Laparoscopic sacral suture hysteropexy for uterine prolapse

This study aims to describe and review a new method of uterine conservation in pelvic reconstruction for women with uterine prolapse. This is a prospective study of women who have undergone laparoscopic sacral suture hysteropexy. Structured questions, visual analogue patient satisfaction score (VAS), and vaginal examination were undertaken. Follow-up was performed by non-surgical reviewers. From July 2001 until August 2003, a total of 81 women underwent laparoscopic sacral suture hysteropexy for uterine prolapse. At a mean of 20.3 months follow-up, 76 women (93.8%) were available for questioning and 57 (70.3%) attended for examination. Sixty-five women (87.8%) had no symptoms of pelvic floor prolapse, 54 women (94.7%) had no objective evidence of uterine prolapse, and 61 women (82.4%) were satisfied with their surgery (VAS≥80%). Laparoscopic sacral suture hysteropexy attaches the posterior cervix to the sacral promontory via the right uterosacral ligament. Follow-up data of laparoscopic sacral suture hysteropexy indicate it to be an effective method in the management of uterine prolapse.     

Laparoscopic uterosacral ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse

This study compares the outcomes of laparoscopic uterosacral ligament uterine suspension (LUSUS) to those of vaginal vault suspension with total vaginal hysterectomy (TVH) for the treatment of symptomatic uterovaginal prolapse. We compared the outcomes of 25 LUSUS to those of 25 TVH with vaginal vault suspension among age-matched controls. No significant complications occurred in either group. EBL and hospitalization duration were significantly less in LUSUS patients (72 cc vs. 227 cc, P < .0001 and 1.05 vs. 1.65 days, P = .002). Vault support, as measured by postoperative pelvic organ prolapse quantitation system point D in the LUSUS group and point C in the TVH group, was better for the LUSUS group (D = –9 vs. C = –7.6, P = .002). No LUSUS group patient underwent reoperation for recurrent apical prolapse as compared to three TVH patients. LUSUS is an effective treatment for appropriately selected women with uterovaginal prolapse who desire uterine preservation     

Urethral profilometry in women with uterovaginal prolapse

The aim of the study was to investigate the continence mechanism in women with uterovaginal prolapse by analysing urethral pressure profiles. Twenty-four women (mean age 59.0±11.9 years, mean parity 3.1±1.6) with prolapse underwent urodynamic evaluation. Urethral pressure profiles were obtained with prolapse and after reduction of the prolapse with a swab stick in the posterior vaginal fornix. After reduction the maximum urethral closure pressure (MUCP) and pressure transmission ratios (PTR) in all four quartiles of the urethra decreased, the position of the MUCP was shifted proximally and the functional urethral length was increased. Thirteen women reported a history of continence and 11 reported incontinence. Ten of 13 women (77%) who reported continence with prolapse were incontinent with their prolapse reduced. In these women, MUCP and PTRs in the first three quartiles of the urethra decreased significantly upon prolapse reduction. In the patients who reported incontinence with prolapse, only the MUCP decreased significantly upon prolapse reduction. Comparisons between the historically continent and incontinent women showed a statistically significant difference only for PTRs in the second and third quartiles of the urethra before prolapse reduction. Because the position of maximum urethral closure pressure before reduction was located in the distal half of the urethra in all patients, we conclude that direct pressure of the prolapsed mass on the urethra (rather than kinking) is the mechanism masking incompetence of the urethral closure mechanism in women with uterovaginal prolapse. The 77% rate of latent incontinence in this series suggests that women with severe pelvic relaxation should undergo careful urogynecologic evaluation before an attempt at surgical correction.Editorial Comment: Masked incontinence associated with genital prolapse is a well known problem for urogynecologists. The causes for this finding, e.g. kinking or compression, are not yet clear. The present study supports the compression theory. To gain a better understanding in the future, two points are important: to find a standard procedure for prolapse repositioning (pessary v speculum v swab stick) and to combine functional and radio- or sonomorphological findings in order to see whether compression and/or kinking occurs and with what consequences.     

Uterine prolapse after pelvic trauma: case report and literature review

Up to date, the connection of pelvic trauma with genital prolapse is not widely recognized. These cases could be classified in a group where disruption of normal anatomy of the pelvis is apparent (i.e., pelvic fracture), and in a second group, where pelvis remains unaffected by the pelvic trauma (i.e., seat belt-related injuries). The aim of the report is to describe the management of a 39-year-old nulliparous patient presenting with stage III uterine prolapse after pelvic trauma; the patient had a history of Mitrofanoff’s procedure for neurogenic bladder followed by closure of the bladder neck and permanent suprapubic urinary catheter for intractable incontinence. The prolapse was managed with a mesh anterior colporraphy combined with sacrospinous hysteropexy. At 3 months follow-up, she is well with no prolapse recurrence.     

Is hysterectomy or the use of graft necessary for the reconstructive surgery for uterine prolapse?

The aim of this study was to evaluate whether hysterectomy or the use of graft is necessary for the reconstructive surgery for uterine prolapse. One hundred sixty-eight patients were categorized into the 3 groups: group I, abdominosacral colpopexy with mesh and hysterectomy (n = 63); group II, abdominosacral uteropexy with mesh (n = 35); group III, abdominal uterosacrocardinal colpopexy and hysterectomy (n = 70). Perioperative and postoperative complications, functional outcomes, and anatomical recurrences were assessed. The median follow-up was 36 months in all surgery groups. In the complication rates and functional outcomes, no difference was noted, except for operation time (longer in group I, p = 0.001) and hemoglobin loss (greater in group II, p = 0.002). There was a significant difference in the cumulative anatomical cure rates (p < 0.0001). The risk of recurrence in group III was 6.2 times higher than in group I. In conclusion, the use of graft, rather than hysterectomy, might be necessary for the reconstructive surgery for uterine prolapse.     

The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse

The objective of this study was to assess the effectiveness of sacrospinous ligament fixation of the uterus as a primary treatment of uterovaginal prolapse. In this observational study, 133 women underwent a sacrospinous hysteropexy. Data were obtained from their medical records, and standardized questionnaires about urogenital symptoms and quality of life were used. All women were invited for gynecological examination, using the Pelvic Organ Prolapse Quantification score. Ninety-nine women responded by returning the questionnaire (mean age, 59.2 and follow-up time, 22.5 months); 60 of these women underwent gynecologic examination. Eighty-four percent of women were highly satisfied about the outcome of the procedure. Serious complications were rare. The recurrence rate of descensus uteri that needed surgical treatment was 2.3%. The recurrence of cystoceles after surgery was 35%, but there were no differences in urogenital symptoms between women with or without a cystocele.     

Analysis of risk factors associated with surgical failure of sacrospinous suspension for uterine or vaginal vault prolapse

The goal of this study was to analyze the potential risk factors determining surgical failure after sacrospinous suspension for uterine or vaginal vault prolapse. Each woman underwent a detailed history taking and a vaginal examination before treatment. Follow-up evaluations were at immediate post-operation, 1 week, 1 to 3 months, 6 months, 9 months, and annually after the operation. The surgical failure rate (27/168) following sacrospinous suspension was 16.1%. Using multivariable logistic regression, women with the presence of C or D point stage I at immediate post-operation were a significant risk factor for surgical failure after sacrospinous suspension (odds ratio, 35.34; 95% confidence interval, 8.75–162.75; p < 0.001). The success rate during the 18-month follow-up decreased significantly in women with the presence of C or D point stage I at immediate post-operation than stage 0. Although the sample size of women with symptomatic uterine or vaginal vault prolapse is small, impaired correction of anatomic defects is a significant risk factor for surgical failure of sacrospinous suspension.     

Uterine prolapse in a young nulligravida with scleroderma and premature ovarian failure

We report a case of pelvic organ prolapse quantification (POPQ) stage III uterine prolapse in a 25-year-old nulligravida. Premature ovarian failure was diagnosed after 1 year of amenorrhea. Localized scleroderma was noticed on her thigh and lower back. We discuss the possible role of scleroderma and ovarian failure on the occurrence of uterine prolapse in light of the literature.     

Abdominal hysterectomy and Burch colposuspension for uterovaginal prolapse

The recurrence rate for prolapse in patients who underwent abdominal hysterectomy and sacrocolposuspension for genital prolapse were determined. Patient records were reviewed and 58 patients who had undergone abdominal hysterectomy for genital prolapse and sacrocolposuspension with mesh were included. The patients median age was 47.0 years and parity 3. Preoperatively, 25 patients (43%) presented with bladder symptoms, 17 (29%) with bowel symptoms and 45 (78%) with something protruding through the vagina. All patients underwent hysterectomy, of which 51 (88%) were subtotal. Colposuspension was performed by inserting a mesh from the mid-vagina to the sacrum (S1). A Burch colposuspension was performed in 50 patients (87%). The median follow-up was 20 months. Six patients (10%) developed recurrent prolapse, of which five (9%) underwent repeat surgery. There were no mesh erosions. The recurrence rate for prolapse was low, indicating that abdominal hysterectomy with sacrocolposuspension is an excellent option for uterovaginal prolapse.Editorial Comment: It has long been felt that the optimal route for hysterectomy in patients with uterovaginal prolapse was via the vaginal approach. While this may be the most facile way to accomplish the hysterectomy, it may not be the best way to re-support pelvic defects and prevent recurrent prolapse. The aim of this paper is to determine if an abdominal approach to hysterectomy and correction of pelvic defects successfully corrects the defects and prevents recurrence of pelvic prolapse. This is a question worthy of study. Unfortunately, the study population and the procedures performed were too diverse to answer this question.     

腹腔镜下子宫腹壁悬吊术治疗子宫脱垂的疗效分析

目的 探讨腹腔镜下子宫腹壁悬吊术治疗子宫脱垂的临床效果.方法 回顾性分析2015-01-2019-05间郑州大学第一附属医院收治的76例要求保留子宫的子宫脱垂患者的临床资料,其中研究组40例行腹腔镜下子宫腹壁悬吊术,对照组36例行腹腔镜下子宫骶骨岬悬吊术.对2组患者的手术情况及治疗效果进行比较分析.结果 研究组手术时间...     

Rectus fascia colpopexy in posthysterectomy vaginal prolapse: Analysis of 18 cases

Posthysterectomy prolapse of the vaginal vault is a complicated and uncommon occurrence in gynecology. The treatment is surgical and may be either vaginal or abdominal. The great variety of techniques described indicates that there is disagreement about the ideal route or technique to be used. The authors present their experience in surgical correction using colpopexy with rectus abdominal muscle fascia.Editorial Comment: This surgical procedure was originally described by Te Linde in 1962 and later modified by Alves de Lima and Valente. The value of this study is in the relatively long follow-up of 3 years. The authors document minimal complications and good results. It is actually surprising that they did not see postprocedure enteroceles owing to the markedly anterior placement of the vaginal axis.     

Follow-up of prolapse surgery in rural Nepal

Pelvic organ prolapse (POP) is a significant problem in Nepal. Surgical treatment is scarcely available and little is known of the results of POP surgery on women living under burdensome circumstances. The aim of our study was to set up a follow-up program in rural Nepal and evaluate POP surgery. In 2004 and 2006, 74 women with a POP from remote areas around Dhulikhel Hospital underwent prolapse surgery. Together with local contacts men, a plan was made to implement a follow-up program. All the operated patients were invited to a follow-up visit in March 2007. Thirty-three (45%) patients attended the follow-up: 85% (n = 28) found the effect of the procedure an improvement. A satisfactory anatomic outcome was found in 93% (n = 32). A remarkable finding was the reduction in physical labour after the surgical procedure in 50% of the follow-up cases. Some adjustments in the follow-up program may contribute to a higher participation.     

Transverse cystocele repair with uterine preservation using native tissue

The goals of this study were to describe the surgical procedure of the transverse cystocele repair with uterine preservation using native tissue and to examine the surgical complications and short-term anatomical outcomes of this operation. Patients who underwent transverse cystocele repair with uterine preservation at our institution were identified by retrospective chart review for the interval from January 2001 to September 2006. Sixty-nine patients were identified. Median point for first postoperative visit was 6.1 weeks (range 3-101 weeks). Average age was 66.6 +/- 13.1 years (range 33-89). Patients undergoing this procedure had no intraoperative complications and high frequency of initial anatomic success (defined as Baden-Walker halfway system grade 0 or 1 for anterior compartment) during a relatively short follow-up interval. Preoperatively, bladder grade averaged 2.6 with postoperative grade averaging 0.02. Based on our initial anatomical findings, we conclude that this surgical approach has merit for a subset of patients with adequate uterine support.     

Small bowel preservation for intestinal transplantation: a review

Intestinal transplantation has become the therapy of choice for patients with intestinal failure and life‐threatening complications from total parenteral nutrition. Results, however, remain inferior as compared with other transplant types with the quality of the organ graft as the most important factor of outcome after transplantation. The intestine is extremely sensitive to ischemia. Unfortunately, a relatively long ischemic preservation period is inevitable. The current standard in organ preservation [cold storage (CS) with University of Wisconsin solution] was developed for kidney/liver preservation and is suboptimal for the intestinal graft despite good results for other organs. This review aimed at appraising the results from the use of previously applied and recently developed preservation solutions and techniques to identify key areas for improvement. As the studies available do not reveal the most effective method for intestinal preservation, an optimal strategy will result from a synergistic effect of different vital elements identified from a review of published material from the literature. A key factor is the composition of the solution using a low‐viscosity solution to facilitate washout of blood, including amino acids to improve viability, impermeants and colloids to prevent edema, and buffer for pH‐homeostasis. Optimizing conditions include a vascular flush before CS and luminal preservation. The most effective composition of the luminal solution and a practical, clinically applicable optimal technique are yet to reach finality. Short‐duration oxygenated arterial and/or luminal perfusion have to be considered. Thus, a tailor‐made approach to luminal preservation solution and technique need further investigation in transplant models and the human setting to develop the ultimate technique meeting the physiologic demands of the intestinal graft during preservation.     

Risk factors for uterine prolapse in Nepal

Uterine prolapse is a significant public health problem in Nepal. The aim of this study was to determine the prevalence of uterine prolapse and to define possible risk factors for this disease in the Kathmandu Valley of Nepal. This clinical report consists of an analysis of data from Dr. Iwamura Memorial Hospital and Research Center (IMHARC) in Bhaktapur, between July 1 and September 30, 2006. This analysis was restricted to a sample that included all women with complaints of uterine prolapse (second- or third-degree prolapse) diagnosed and treated at the IMHARC. During a 3-month period, 96 women were diagnosed and treated with uterine prolapse. The median age at the time of clinical presentation was 50 years, and the median maternal weight was 45 kg. In average, the women gave birth to four children vaginally. Most of the affected women were smoking, and most of them were postmenopausal. Thirty-five percent of the affected patients had a chronic obstructive pulmonary disease (COPD), 16% suffered from hypertension and 5% had diabetes mellitus. The majority of the women with uterine prolapse were of Newari origin (84%), and nearly all patients reported that they were working heavily during pregnancy as well as in the postpartum period (87%). We found several risk factors for uterine prolapse in Nepal. Especially extensive physical labor during pregnancy and immediately after delivery, low availability of skilled birth attendants, smoking while having COPD and low maternal weight due to lack of nutritious food are mainly responsible for this common disease. In our opinion, extensive information, prevention programs and early management of genital prolapse should be the first steps to reduce this significant social and public health problem in Nepal.     

游离子宫动脉的腹腔镜全子宫切除术68例临床分析

目的探讨腹腔镜下游离阻断子宫动脉的全子宫切除术的临床效果。方法2004年1月-2006年6月,对68例子宫良性病变在腹腔镜下游离出子宫动脉后钛夹夹闭,阻断子宫动脉行全子宫切除术。结果68例手术均获成功,无中转开腹,无手术并发症发生。其中1例游离双侧子宫动脉失败,双极电凝后完成手术（有2次剖宫产手术史）。术中同时行盆腔粘连分离术18例,单侧或双侧附件切除术14例,卵巢囊肿剔除术8例,阑尾切除术1例,胆囊切除术1例。手术时间90-185 min,（112.6±27.5）min,每侧子宫动脉的分离时间3-15 min,（5.2±3.4）min,术中出血量50-150 ml,（86.5±39.6）ml,术后肠功能恢复时间18-48 h,（27.3±4.8）h,术后病率4.4%（3/68）,术后住院时间4-7 d,（5.1±1.8）d。术后随访2-6个月,（3.5±1.6）月,3例术后1-2个月时阴道点滴出血,经抗感染、止血等治疗5-7天治愈。结论腹腔镜下游离阻断子宫动脉的全子宫切除术安全、可行、有效、并发症少,值得临床推广应用。     

Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse

Due to the anatomic proximity of the urinary and genital tracts, iatrogenic ureteral injury during pelvic organ prolapse repairs is a serious complication that we have managed in increasing number at our institution. However, few centers have reported on their experience with ureteric injuries associated with gynecologic reconstructive surgery. These ureteral injuries may lead to much morbidity, in particular the formation of ureterovaginal fistula, and the potential loss of renal function especially when diagnosed postoperatively. It is necessary, therefore, for surgeons to have a thorough knowledge of ureteral anatomy and to take precautions to prevent such injuries. The purpose of this article is to review this pertinent anatomy and the key principles of management of ureteric complications of transvaginal surgery for pelvic organ prolapse. The present study illustrates the application of our treatment algorithm based on the time of presentation and the patient condition.     

Nerve preservation in tension-free vaginal mesh procedures for pelvic organ prolapse: a cadaveric study using fresh and fixed cadavers

The aims of this study were, using fixed and fresh cadavers, to clarify how closely the pelvic splanchnic nerve, levator ani nerve (LAN), and sacrospinous ligament (SSL) are located and to examine how to avoid nerve injury during the posterior tension-free vaginal mesh procedure (TVMP), in which mesh is applied through the SSL. Macroscopic dissection of fixed cadavers demonstrated that the LAN crossed the inside of the SSL at a point 0–18 mm medial to the ischial spine and entered the muscle at a point 12–26 mm inferior to the ischial spine and 40–55 mm anterolateral to the coccyx. Dissection after TVMP of fresh cadavers revealed that the point of penetration of mesh through the SSL was close to the LAN. To preserve the LAN, penetration of the SSL should be within 5 mm of the lower margin at a point 20–25 mm medial to the ischial spine.