Transvaginal uterosacral ligament hysteropexy: a retrospective feasibility study

Introduction and hypothesis

Uterine-sparing procedures could be attractive in patients concerned about preservation of fertility and change in corporeal image and sexuality. Transvaginal uterosacral hysteropexy can provide an alternative mesh-free technique for uterine suspension. This study aimed to evaluate the feasibility of transvaginal uterine suspension to uterosacral ligaments in terms of operative data, complications, midterm efficacy, and patient satisfaction.

Materials and methods

This retrospective study analyzed the first 20 cases of transvaginal hysteropexy through bilateral high uterosacral ligaments (modified Shull technique) performed in our Institution.

Results

Mean follow-up was 33.2 months. The procedure was performed in 84?±?19 min ,and blood loss was 228?±?139 ml. Three mild complications (15 %) were observed. Recurrence [Pelvic Organ Prolapse Quantification system (POP-Q) stage ≥ II was observed in five patients (25 %), and three of them (15 %) required reintervention. Mean Patient Global Impression of Improvement score was “much improved.” Two woman (40 %) who had not fulfilled their childbearing desire obtained a pregnancy. Both underwent elective caesarean section at term.

Conclusions

Transvaginal uterosacral hysteropexy appears a feasible mesh-free technique for apical support. This procedure can be indicated in women with the desire of preserving fertility or who prefer a uterine-sparing surgical option.

     

Transvaginal native-tissue repair of enterocele

Introduction and hypothesis

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

Methods

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

Results

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

Conclusions

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

     

Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesis

Posthysterectomy vaginal vault prolapse repair represents a challenge for urogynecologists. Surgical management can be successfully achieved with native tissue using a vaginal approach with uterosacral ligament (USL) suspension. However, severe complications have been described, mainly related to ureteral injury.

Methods

A 57-year-old woman with symptomatic stage 2 vaginal vault prolapse underwent transvaginal USL suspension according to the described technique.

Results

Surgical procedure was successfully achieved without complications. Final examination revealed excellent apical support and preservation of vaginal length. However, ureteral damage represents the major pitfall of USL suspension. This step-by-step video tutorial may represent an important tool to improve surgical know how and minimize the risk of ureteral injury.

Conclusion

Transvaginal USL suspension provides an effective technique for apical support without the use of prosthetic materials. Intimate understanding of pelvic anatomy, direct visualization of ureter, and proper suture positioning are the key points to minimize the risk of complications.

     

Laparoscopic hysteropexy: 10 years’ experience

Introduction and hypothesis

Uterine prolapse is common and has traditionally been treated by vaginal hysterectomy. Increasingly, women are seeking uterine-preserving alternatives. Laparoscopic hysteropexy offers resuspension of the uterus using polypropylene mesh. We report on 10 years’ experience with this technique.

Methods

All hysteropexy procedures in our unit since 2006 were reviewed. Primary outcome was safety of hysteropexy, as assessed by intraoperative and major postoperative complications. Secondary outcomes were measures of feasibility, including operating time, length of stay, conversion to alternative procedures, change in point C, patient satisfaction, and repeat apical prolapse surgery.

Results

Data were available for 507 women. Complications were rare (1.8%) with no evidence of any mesh exposure. Mean operating time was 62.5 min and median length of stay 2 nights. In 17 patients (3.4%), hysteropexy was abandoned. There was a mean change in point C of 7.9 cm and 93.8% of patients felt that their prolapse was “very much” or “much” better. Of these women, 2.8% have had repeat apical surgery.

Conclusions

To our knowledge, this is the largest series to date, describing 10 years’ experience with laparoscopic hysteropexy. The surgical technique appears to be safe, with low complication rates, which supports the choice of appropriately selected women to opt for uterine preservation surgery as an alternative to hysterectomy for the management of uterine prolapse.

     

Sacrospinous hysteropexy: review and meta-analysis of outcomes

Introduction

Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery.

Methods

Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration’s Review Manager software to perform meta-analysis of randomized controlled studies and observational studies.

Results

Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n?=?651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76–5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41–2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy.

Conclusion

Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.

     

Repair of a vesicouterine fistula following cesarean section

Introduction and hypothesis

Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

Methods

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

Results

No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

Conclusions

Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

     

Transvaginal levator myorrhaphy for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesis

Posthysterectomy vaginal vault prolapse repair represents a surgical challenge. Surgical management can be successfully achieved with native-tissue repair through levator myorrhaphy. Despite low morbidity, levator myorrhaphy is not a common procedure. The aim of the video is to provide anatomic views and surgical steps necessary to achieve a successful transvaginal levator myorrhaphy for vaginal vault prolapse repair.

Methods

A 72-year-old woman with symptomatic stage IV vaginal vault prolapse was admitted for transvaginal levator myorrhaphy according to the described technique.

Results

Surgical repair was successfully achieved without complications. The final examination revealed good apical support and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know how.

Conclusions

Transvaginal levator myorrhaphy provides an alternative technique for apical support without using prosthetic materials. This technique can be indicated when abdominal approach or synthetic device are not recommended or when peritoneum opening may be challenging. However, due to its possible constricting effect, it should be reserved to sexually inactive patients.

     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

     

Male Fertility Preservation

Purpose of Review

With improvements in cancer treatment outcomes and an increase in cancer survivorship, understanding the importance of fertility preservation options prior to undergoing cancer treatment is essential. Therefore, we review herein the effect of cancer and its treatment on male fertility, the rationale for sperm cryopreservation, options for sperm retrieval, ART outcomes, and experimental options.

Recent Findings

Recent data update fertility outcomes with newer cancer therapies and provide longitudinal insight into survivor paternity with and without fertility preservation. Likewise, updated ART outcomes and future preservation options are discussed.

Summary

The effect of cancer and its treatment on spermatogenesis is well established. Sperm cryopreservation is the best pre-treatment insurance for the opportunity of future fertility. Post-therapy patients may also achieve fertility restoration with ART, using cryopreserved or freshly obtained sperm. Meanwhile, utilization of cryopreserved testicular stem cells for future transfer or for in vitro maturation represents exciting alternatives on the horizon.

     

Hysteropexy: an Option for the Repair of Pelvic Organ Prolapse

Purpose of Review

Women have an estimated 12.6% lifetime risk of undergoing surgery for pelvic organ prolapse in the USA (Wu et al. in Obstet Gynecol 123(6): 1201–6, 2014). Surgical repair of uterovaginal prolapse most commonly includes hysterectomy and vaginal vault suspension; however, the value of concomitant hysterectomy is uncertain, and there appears to be growing interest in uterine conservation. Multiple procedures have evolved using a variety of approaches. The aim of this paper is to review uterine sparing (hysteropexy) prolapse repair techniques and outcomes.

Recent Findings

Several randomized controlled trials (RCT) have shown comparable success rates for apical compartment support with sacrospinous hysteropexy as compared to vaginal hysterectomy with uterosacral ligament suspension, with shorter hospitalization and quicker return to work. (Detollenaere et al. in BMJ 351: h3717, 2015); (Dietz et al. in Int Urogynecol J Pelvic Floor Dysfunct 21(2): 209–16, 2010). Available data suggest vaginal mesh hysteropexy is as effective as vaginal mesh with hysterectomy, with lower rates of mesh exposure. (Maher et al., 2017) To date, no RCTs have been published comparing sacral hysteropexy to hysterectomy with sacral colpopexy. Overall, there is a higher reoperation rate for sacral hysteropexy and a higher mesh exposure rate for hysterectomy with sacral colpopexy. (Maher et al., 2017) No RCTs have been published comparing hysteropexy surgical approaches.

Summary

Although hysteropexy data is expanding, there is a need for more information regarding long-term surgical durability, appropriate patient selection, and whether one approach is superior to another.

     

A rat hysteropexy model for evaluating adhesion formation and comparison of two different structured meshes

Introduction and hypothesis

Peritonization of mesh during sacrohysteropexy is generally advocated to prevent adhesions to the viscera; however, randomized clinical trials are lacking, and peritonization may not be completely possible in a laparoscopic hysteropexy procedure. Our main objective was to describe a basic experimental rat sacrohysteropexy model. We hypothesized that even when peritoneal closure was omitted, using composite mesh would result in less adhesions to the viscera.

Methods

Twenty in-bred female virgin Wistar Hannover rats were used in this study. Standardized hysteropexy procedure and adhesion model is described step by step with two different mesh materials: polypropylene and a composite polyester. Mesh was anchored between the posterior cervix and anterior longitudinal ligament of the lumbar vertebrae. Macroscopic adhesion scores and histopathological tissue reaction was investigated.

Results

Macroscopically, the surface area involved in adhesions was similar between groups. However, adhesions in the polypropylene group were more dense, required sharp dissection for lysis, and yielded higher total macroscopic adhesion scores (p < 0.001). Histologically, a more pronounced host inflammatory response was encountered in the polyester group (p < 0.001).

Conclusions

We describe a rat hysteropexy model and a previously established uterine adhesion model. Adhesion scores in the composite mesh group were lower, and bowel involvement was not seen. Our findings are promising, and further research investigating antiadhesive composite mesh use for hysterosacropexy would be appropriate, especially when peritoneal closure is omitted.

     

Laparoscopic sacral hysteropexy versus laparoscopic sacrocolpopexy with hysterectomy for pelvic organ prolapse

Introduction and hypothesis

Treating pelvic organ prolapse (POP) with uterine conservation and sacral hysteropexy has uncertain subjective and objective outcomes. We sought to compare laparoscopic sacral hysteropexy with laparoscopic sacrocolpopexy/total laparoscopic hysterectomy (TLH with LSC).

Methods

Clinical data of 34 patients who underwent TLH with LSC and 65 patients who underwent laparoscopic sacral hysteropexy performed by the same group of surgeons between January 2008 and December 2013 were reviewed retrospectively. The primary outcome was subjective satisfaction rate based upon validated questionnaire (Patient Global Impression of Change [PGI-C]). Secondary outcomes were: anatomical cure, impact on quality of life based upon validated questionnaires (pelvic floor distress inventory-short form 20 [PFDI-20], Pelvic Floor Impact Questionnaire 7 [PFIQ-7], and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 [PISQ-12]), surgical complications, and cost.

Results

After a mean follow-up of 33 months, the subjective satisfaction rate was significantly higher in the TLH with LSC cohort (92.3 % vs 100 %; p?<?0.001). The POP-Q scores in both groups were significantly improved postoperatively. However, the anatomical cure in the two groups (72.3 % vs 88.2 %; p?=?0.07) did not differ significantly The postoperative PFIQ-7 and PFDI-20 scores were significantly better in the TLH with LSC cohort than in the laparoscopic sacral hysteropexy cohort (p?=?0.043 and p?=?0.035 respectively).

Conclusions

Relative to laparoscopic sacral hysteropexy, the TLH with LSC approach provides similar anatomical results, excellent patient satisfaction, and improved quality of life scores.

     

Is it possible to preserve lumbar lordosis after hybrid stabilization? Preliminary results of a novel rigid–dynamic stabilization system in degenerative lumbar pathologies

Purpose of the study

To evaluate the results of a novel rigid–dynamic stabilization technique in lumbar degenerative segment diseases (DSD), expressly pointing out the preservation of postoperative lumbar lordosis (LL).

Materials and methods

Forty-one patients with one level lumbar DSD and initial disc degeneration at the adjacent level were treated. Circumferential lumbar arthrodesis and posterior hybrid instrumentation were performed to preserve an initial disc degeneration above the segment that has to be fused. Clinical and spino-pelvic parameters were evaluated pre- and postoperatively.

Results

At 2-year follow-up, a significant improvement of clinical outcomes was reported. No statistically significant difference was noted between postoperative and 2-year follow-up in LL and in disc/vertebral body height ratio at the upper adjacent fusion level.

Conclusions

When properly selected, this technique leads to good results. A proper LL should be achieved after any hybrid stabilization to preserve the segment above the fusion.

     

Bladder Preservation Therapy: Review of Literature and Future Directions of Trimodal Therapy

Purpose of the Review

This review targets the latest literature on bladder preservation therapy with emphasis on trimodal therapy (TMT), highlighting its role in the management of muscle invasive bladder cancer (MIBC) and outlining future directions in bladder preservation research.

Recent Findings

TMT is the most promising bladder preservation treatment modality. Comparable results to contemporary radical cystectomy series are seen in properly selected patients. A multidisciplinary team approach is critical in the management of these patients. Future research is directed at the integration of immunotherapy into the treatment protocol.

Summary

TMT, involving maximal transurethral resection followed by chemoradiation, is an attractive alternative to radical cystectomy with urinary diversion in carefully selected patients with muscle invasive disease. In the absence of randomized trial (RCT), comparison between TMT and cystectomy, based on retrospective data from large centers, suggests comparable oncological outcomes, with a favorable impact on quality of life.

     

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

Aim

We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.

Material and methods

We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.

Conclusion

This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

     

Vaginal cystocele repair and hysteropexy in women with anterior and central compartment prolapse: efficacy and safety after 30 months of follow-up

Introduction and hypothesis

The aim of this study was to assess the safety and efficacy of vaginal native tissue repair and uterine suspension after a follow-up of at least 1 year.

Methods

We included all consecutive women with an anterior vaginal prolapse of stage II or higher and a concomitant uterine prolapse of stage II who underwent this surgical procedure. We considered women with a descensus with maximum point of less than ?1 in any compartment as objectively cured. Overall success was defined as no prolapse symptoms, together with a Patient Global Impression of Improvement (PGI-I) score of 2 or less, prolapse of stage lower than II, and no need for other surgery.

Results

A total of 102 patients underwent this surgical procedure during the study period and met all the inclusion criteria for statistical analysis. The mean follow-up was 31 ± 8.2 months; no patient was lost to follow-up. Five patients (4.9%) showed postoperative complications. In terms of subjective outcomes, at the last available follow-up, failure of this surgical procedure was seen in 2% of patients. The objective cure rate and the overall cure rate were the 95.1%. No significant deterioration in objective cure rates was observed over time (p = 0.6).

Conclusions

Vaginal repair and hysteropexy appear to be an effective and safe option for women with advanced uterovaginal prolapse.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Sacrospinous ligament fixation for hysteropexy: does concomitant anterior and posterior fixation improve surgical outcome?

Introduction and hypothesis

Uterine preservation in uterine prolapse is an option for young patients. We hypothesized that sacrospinous hysteropexy (SSH) with anchorage to both the anterior and posterior cervix (SSH-ap) would have a better outcome than SSH with anchorage to the posterior cervix only (SSH-p).

Methods

This was a retrospective study including 75 patients who underwent SSH at Chang Gung Memorial Hospital between March 2008 and August 2013. Five were excluded due to incomplete data. Of the remaining 70 patients, 35 underwent SSH-p between March 2008 and June 2011, and 35 underwent SSH-ap between June 2010 and August 2013. The primary outcome was the objective anatomical result, and a successful outcome was considered anatomical correction (POP-Q stage 1 or less) of anterior and apical prolapse. Subjective outcome was evaluated using the POPDI-6 questionnaire, and a patient response of “No or mild abdominal organ falling out sensation” together with “No or mild heaviness” was considered to indicate a successful outcome. Anterior fornix and cervical diameter measurements were included. The secondary outcome was quality of life according to the UDI-6, IIQ-7, POPDI-6, and PISQ-12 questionnaires. The 3-year outcome was used for comparison.

Results

The subjective overall cure rates were significantly different between the SSH-p and SSH-ap groups (74.3% and 94.3%, respectively; p = 0.023). However, the objective overall cure rates were not significantly different (74.3% and 82.9%, respectively).

Conclusion

Anchorage of the anterior cervix and vaginal wall together with the usual posterior anchorage yield better subjective outcomes and apical suspension at 3 years after surgery than anchorage of the posterior cervix and vaginal wall only. The cervix position affected the subjective outcome. Concurrent trachelectomy did not affect the outcome.

     

Skene’s gland cyst: a simple marsupialization technique

Introduction and hypothesis

We present a simple approach to the marsupialization of a Skene’s gland cyst.

Methods

Our technique facilitates suture placement to exteriorize the cyst wall to efficiently treat a distal Skene’s gland cyst and reduce the risk of recurrence.

Conclusion

Marsupialization is an accepted option for the surgical management of Skene’s gland cyst. This technique is an effective and streamlined approach to Skene’s gland marsupialization.