Laparoscopic sacrocolpopexy versus transvaginal mesh for recurrent pelvic organ prolapse

Both expert surgeons agree with the following: (1) Surgical mesh, whether placed laparoscopically or transvaginally, is indicated for pelvic floor reconstruction in cases involving recurrent advanced pelvic organ prolapse. (2) Procedural expertise and experience gained from performing a high volume of cases is fundamentally necessary. Knowledge of outcomes and complications from an individual surgeon’s audit of cases is also needed when discussing the risks and benefits of procedures and alternatives. Yet controversy still exists on how best to teach new surgical techniques and optimal ways to efficiently track outcomes, including subjective and objective cure of prolapse as well as perioperative complications. A mesh registry will be useful in providing data needed for surgeons. Cost factors are also a consideration since laparoscopic and especially robotic surgical mesh procedures are generally more costly than transvaginal mesh kits when operative time, extra instrumentation and length of stay are included. Long-term outcomes, particularly for transvaginal mesh procedures, are lacking. In conclusion, all surgery poses risks; however, patients should be made aware of the pros and cons of various routes of surgery as well as the potential risks and benefits of using mesh. Surgeons should provide patients with honest information about their own experience implanting mesh and also their experience dealing with mesh-related complications.     

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.     

Robotic-assisted laparoscopic sacrocolpopexy for stage III pelvic organ prolapse

Introduction and hypothesis

Abdominal sacrocolpopexy is the gold standard treatment for pelvic organ prolapse and can be performed laparoscopically. Robotic assistance allows optimal dissection and placement of the prosthesis. We present a video of our technique along with the results on 90 patients.

Methods

We perform a posterior dissection down to the levator muscles and an anterior dissection down to the trigone. The meshes are made of polyester (mersuture®). The posterior mesh is sutured to the levator muscles, to the rectum above the anorectal junction, below the uterosacral ligaments, and to the isthmus/cervix. The anterior mesh is sutured to the vagina and the isthmus/cervix and attached to the promontory with a tension measured through a vaginal exam.

Results

We operated on 90 patients. There was an additional procedure in 71 cases (either subtotal hysterectomy, adnexectomy, adhesiolysis, or rectopexy). The mean operative time was 246 min (180–415). Perioperative complications were one vaginal effraction and a case of sigmoidal perforation during an adhesiolysis. Early complications were two cases of bowel hernia through port sites. The mean hospital stay was 3.48 days (2–11). The mean follow-up is 15.6 months (range 1–45). Six patients have a persistent stage II prolapse. We observed no retraction of the prosthesis and no dyspareunia.

Conclusions

With this technique we performed a complete treatment for severe prolapse by a minimally invasive approach with a low rate of recurrence at this point.     

腹腔镜阴道骶骨固定术治疗女性盆腔器官脱垂的40例分析

目的探讨腹腔镜阴道骶骨固定术(laparoscopic sacrocolpopexy,LSC)治疗女性盆腔器官脱垂(pelvic organ prolapse,POP)的可行性和临床疗效。 方法选取首都医科大学附属北京安贞医院2015年1月至2017年12月因POP进行子宫切除并LSC治疗患者40例,采用POP-Q分期法和盆底功能障碍问卷表(PFDI-20)、盆底功能影响问卷表(PFIQ-7)、性功能调查问卷评分(PISQ-31)评价解剖及功能疗效。患者年龄45～77岁,平均(60.8±1.4)岁;孕1～4次,平均(2.8±0.7)次;产1～3次,平均(1.7±0.5)次。 结果手术时间130～330 min,平均(215.2±7.6)min;术中出血量20～300 ml,平均(82.3±9.2)ml;术后住院时间3～19 d,平均(6.6±0.4)d;术后阴道长度7.0～8.5 cm,平均7.5 cm;术后例随访8～21个月,平均11个月;术后客观无脱垂复发,客观治愈率为100%,术后自觉症状较术前改善,正常恢复性生活,主观满意度100%。 结论LSC在女性盆腔器官脱垂的治疗中客观治愈率高,术后性生活满意,有一定的临床疗效。     

Uterus-sparing vaginolaparoscopic sacrocolpopexy for apical pelvic organ prolapse

Introduction and hypothesis

Our aim was to evaluate the safety, feasibility, and effectiveness of a vaginolaparoscopic sacrocolpopexy (VLS) technique for treating apical pelvic organ prolapse (POP).

Materials and methods

This was a prospective interventional case series (design classification: Canadian Task Force II3) performed in the endoscopic unit of a tertiary care referral facility and university hospital. We assessed 15 symptomatic parous women with stage ≥2 apical POP according to the POP Quantification (POP-Q) classification. Interventions comprised posterior colpotomy with mesh fixation to the uterosacral ligaments and the back of the uterus that was further fixed to the anterior longitudinal ligament of the sacrum using a tacker via laparoscopy.

Results

The main outcome was a significant postoperative improvement in prolapse and resultant improvement in quality of life (QoL) after VLS. Six patients required concomitant reconstructive procedures. Mean operative time for the vaginal phase was 8.54?±?3.10 (7–12) min and 32.36?±?8.2 (27–41) min. for the laparoscopic phase Mean duration of VLS ranged from 30 to 50 min. At the 6-months follow-up, the procedure was successful in 14 of 15 patients (93.34%); one woman (6.66%) presented with recurrence at a lower stage. Neither mesh complications nor sacral ostitis were encountered. There was significant improvement in vaginal symptoms, sexual well-being, QoL, and clinical staging after the procedure.

Conclusion

By eliminating all forms of intraperitoneal suturing, performing a posterior colpotomy, and the advent of tackers without evidence of sacral ostitis, VLS seems to be a simple, feasible, effective, and fast approach for treating POP.

     

Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse after failed transvaginal polypropylene mesh surgery

Introduction and hypothesis

A prospective case series to assess the safety and efficacy of laparoscopic sacrocolpopexy for the surgical management of recurrent pelvic organ prolapse (POP) after transvaginal polypropylene mesh prolapse surgery.

Methods

Between January and December 2010, women with post-hysterectomy recurrent prolapse (≥ stage 2 POP-Q) after transvaginal polypropylene mesh prolapse surgery were included. Perioperative morbidity and short-term complications were recorded and evaluated. Surgical outcomes were objectively assessed utilising the Pelvic Organ Prolapse Quantification system (POP-Q), the validated, condition-specific Australian Pelvic Floor Questionnaire (APFQ) and the Patient Global Impression of Improvement (PGI-I) at 12 months.

Results

All 16 women in this study had undergone surgery with trocar-guided transvaginal polypropylene mesh kits. In 75% the recurrent prolapse affected the compartment of prior mesh surgery with the anterior (81%) and apical (75%) compartment prolapse predominating. At a mean follow-up of 12 months, all women had resolution of awareness of prolapse, had < stage 2 POP-Q on examination and high levels of satisfaction on PGI-I post surgery. There were no serious peri- or postoperative complications.

Conclusions

This preliminary study suggests that laparoscopic sacrocolpopexy for recurrent prolapse after failed transvaginal mesh surgery is feasible and safe. Further widespread evaluation is required.     

Clinical and urodynamic assessment in patients with pelvic organ prolapse before and after laparoscopic sacrocolpopexy

Introduction and hypothesis

We hypothesized that patient-reported urinary symptoms and urodynamic evaluation improve after laparoscopic sacrocolpopexy (LSC) despite deeper vesicovaginal space dissection.

Methods

This was a retrospective study of women with pelvic organ prolapse who underwent LSC from January 2013 to January 2016 in a tertiary center. Urinary function was clinically evaluated using the International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF), the Overactive Bladder Symptom Score (OABSS) and the Pelvic Floor Distress Inventory Questionnaire- – Short Form 20 (PFDI-20). Urodynamic assessment was performed before and 6 months after surgery. The Wilcoxon signed-ranks test and the McNemar test were applied with p?<?0.05 considered significant.

Results

A total of 155 patients were included in the study. Of these, 46 had urodynamic assessment before and after LSC. There were significant improvements after LSC in urodynamic storage phase parameters (higher volume at first desire, higher volume at strong desire, and larger bladder capacity) and voiding phase parameters (higher Q _max, higher Q _ave, lower P _det Q _max, increased voided volume and reduced postvoid residual urine volume). Clinically, there was a significant increase after LSC in stress urinary incontinence and a significant reduction in urgency urinary incontinence, overactive bladder and voiding dysfunction.

Conclusions

Apart from increased stress urinary incontinence, there was an improvement in overall urinary function in terms of patient-reported symptoms and urodynamics, despite deep vesicovaginal space dissection. Hence, LSC is a viable surgical option for pelvic organ prolapse, restoring both level 1 and level 2 support without detrimental effects on urinary function.

     

Optimism in women undergoing abdominal sacrocolpopexy for pelvic organ prolapse

BACKGROUND: Although studies suggest that optimism can predict health outcomes, the relationship has not been tested in women with pelvic organ prolapse (POP). This study sought to explore the relationship between optimism, prolapse severity, and symptoms before operation; and examine whether optimism predicts postsurgical functional status, treatment satisfaction, and treatment success. STUDY DESIGN: Data from the randomized Colpopexy and Urinary Reduction Efforts (CARE) study, in which stress continent women undergoing sacrocolpopexy to repair stage II to IV POP completed a baseline assessment of optimism and validated symptom and quality-of-life measures at baseline and 24 months. Relationships between optimism and demographics, clinical status, and functional and quality-of-life outcomes were assessed. RESULTS: Of 322 Colpopexy and Urinary Reduction Efforts study participants, 305 (94.7%) completed 24-month followup interviews. At baseline, there were no notable differences in optimism with respect to POP stage or history of earlier operations for prolapse or urinary incontinence. At baseline, women with greater optimism reported markedly better physical and mental functioning (p 相似文献   

Mini-laparoscopic sacrocolpopexy for apical and posterior female pelvic organ prolapse

Aim of the video

Mini-laparoscopic surgery is the future for most laparoscopic procedures. Although already applied in some gynaecological surgical interventions, this video is to our knowledge the first publication on the use of the mini-laparoscopic approach to sacrocolpopexy for apical and posterior pelvic organ prolapse following total hysterectomy.

Methods

The concept of mini-laparoscopic sacrocolpopexy presented in this video article was performed on 12 women with post-hysterectomy apical and posterior pelvic organ prolapse using mini-laparoscopic instruments and ports of 3 mm in diameter combined with a 12-mm umbilical port. Surgery was performed with the same principles as for the conventional laparoscopic procedure.

Results

The mean operating time was 70 min (SD?±?12). The tensile strength of the mini-laparoscopic instruments allowed appropriate manipulation of tissue consistent with that of conventional instruments. No difficulties or complications were experienced in comparison to a conventional technique. All patients were discharged from hospital on day 1 postoperatively.

Conclusions

The effectiveness, safety and feasibility of the mini-laparoscopic surgical technique was applied to sacrocolpopexy. Because of the initial favourable experience, the mini-laparoscopic sacrocolpopexy could become more widely used in the future.

     

改良腹腔镜阴道骶前固定术治疗重度盆腔器官膨出及其并发症的处理和预防

1962年,Lane报道了经腹骶骨阴道固定术（Abdominal Sacrocolpopexy）治疗阴道穹窿膨出,之后这种术式就在临床逐渐应用起来。其后逐渐发展出保留子宫的骶骨固定术。被认为是治疗重度盆腔器官脱垂的经典金标准。随着人类寿命的延长和对生活质量要求的提高,腹腔镜手术已应用于该手术,因手术区域受限和诸多的镜下缝合延长了手术时间,增加了腔镜下手术的难度。     

Abdominal mesh sacrocolpopexy for recurrent triple‐compartment pelvic organ prolapse

OBJECTIVE

To report the short‐ and intermediate‐ term outcome of safety and efficacy after abdominal‐mesh sacrocolpopexy (MSC) for recurrent anterior, posterior and vault (‘triple‐compartment’) pelvic organ prolapse (POP).

PATIENTS AND METHODS

In a database review we identified non‐neurogenic women who had MSC for recurrent triple‐compartment POP and with a ≥6‐month cystographic follow‐up. The preoperative evaluation included a history, physical examination, Urogenital Distress Inventory (UDI‐6) and visual analogue quality‐of‐life (QoL) questionnaires, urodynamic studies, and a standing lateral voiding cysto‐urethrogram (VCUG) with rest‐strain views. All surgery as performed by the same surgeon, using polypropylene (Marlex) mesh. Perioperative data, the VCUG at 6 months, and interval pelvic examinations were recorded.

RESULTS

Between 2000 and 2006, 29 postmenopausal women (Caucasian, mean age 64 years, sd 11) underwent MSC. The mean (sd , range) operative duration was 228 (75, 170–340) min, the estimated blood loss 150 (100) mL and the inpatient stay 3 (1) days. At a mean (sd ) follow‐up of 23 (16) months, the physical examination showed no evidence of POP of grade ≥2, with mean POP‐Quantification scores of ?2.8 (0.4), ?2.9 (0.4) and ?9.3 (0.8) for points A_a, A_p and C, respectively. Two patients (8%) had evidence of grade ≥2 cystocele at the 6‐month VCUG. After MSC, four of the six UDI and the QoL scores were significantly lower at the last follow‐up than at baseline, with no change in sexual or defecatory function.

CONCLUSIONS

The objective and subjective improvement at the short and intermediate follow‐up after MSC suggest that this is a safe and effective treatment for recurrent triple‐compartment POP.     

Long-term outcomes after totally robotic sacrocolpopexy for treatment of pelvic organ prolapse

Purpose

This study evaluated the feasibility, safety, effectiveness, and long-term results of pelvic organ prolapse surgery using the Da Vinci^® robotic system.

Methods

During a 7-year period, 52 consecutive patients with pelvic organ prolapse underwent robotic-assisted abdominal sacrocolpopexy. Clinical data were retrospectively collected and analyzed.

Results

All but two of the procedures were successfully completed robotically (96 %). Median operative time was 190 (range, 75–340) mins. There was no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 5 days. The median follow-up was 42 months. Five recurrent prolapses (9.6 %) were diagnosed.

Conclusions

Our experience indicates that using the Da-Vinci^® robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse with good long-term results.