Laparoscopic sacrocolpopexy: demonstration of a nerve-sparing technique

Intraoperative Fluorescent Navigation of the Ureters, Vessels, and Nerves during Robot-Assisted Sacrocolpopexy

In this study, we aimed to demonstrate the feasibility and safety of navigating the ureters, middle sacral artery (MSA), and superior hypogastric nerve (SHN) using indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during robot-assisted sacrocolpopexy (RSCP). Overall, 15 patients who underwent RSCP for apical vaginal prolapse were retrospectively enrolled. All patients underwent cystoscopic intraureteric instillation of 5 cc ICG (2.5 mg/mL) before RSCP and intravenous injection of 3 cc ICG during presacral dissection and mesh fixation. In all patients, the fluorescent right ureter was clearly identified in real time. The MSA was visualized on ICG-NIRF images in 80% (13/15) of patients. The mean time from ICG injection to MSA visualization was 43.7 s; the mean duration of the arterial phase was 104.3 s. Fluorescent SHN was detected in 73.3% (11/15) of patients. The time from ICG injection to SHN fluorescence was 48.4 s; the duration of fluorescence was 177.2 s. There was no transfusion, iatrogenic ureteral injury, or bowel or urinary dysfunction. Our results indicated that intraoperative ureter, MSA, and SHN mapping using ICG-NIRF images during RSCP is a valuable and safe technique to avoid iatrogenic ureteral, vascular, and neural injuries and to simplify surgical procedures. Nonetheless, further studies are required.

Lateral extension and attachment of mesh to the lateral vagina during laparoscopic sacrocolpopexy: a modified technique aimed at lowering recurrences in the anterior vaginal compartment. A surgical video

PURPOSE/OBJECTIVE

Laparoscopic sacrocolpopexy has been demonstrated to be the gold standard of prolapse surgery in cases with apical defect. Most recurrences seem to occur in the anterior compartment, especially if a paravaginal defect is present. To reduce the incidence of anterior recurrence after laparoscopic sacrocolpopexy we modified our previous published technique by placing the anterior mesh not only deep under the bladder but also laterally and fixing it to the lateral edge of the vagina. With this video article, we would like to show and explain our modified technique and demonstrate how lateral mesh placement can be easily and safely performed using laparoscopy.

METHODS

The video demonstrates our modified technique with lateral extension and fixation of the anterior mesh to the lateral vagina during laparoscopic sacrocolpopexy in a patient with severe uterine prolapse (grade III) and a large cystocele (grade III). Special emphasis is given to the topographical anatomy of the paravaginal space and the surgical technique of lateral fixation.

RESULTS

This modified new technique shows excellent perioperative results in more than 100 cases without any occurrences of lesions of the ureters. Our initial experience also shows very good anatomical results in all three compartments.

CONCLUSIONS

Paravaginal dissection and exposure of the ureters to extend the mesh placement and fixation to the lateral border of the vagina in the anterior compartment during laparoscopic sacrocolpopexy seem to be feasible and safe, helping to significantly reduce the risk of anterior recurrences. Prospective data are needed to evaluate this interesting technique.

Medium term anatomical and functional outcomes following modified laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

We evaluated the anatomical and functional outcomes following modified laparoscopic sacrocolpopexy (LSC) utilizing deep dissection of the vaginal walls and distal mesh fixation at the anterior and posterior compartments. We hypothesized that anatomical and functional outcomes improve after this modified LSC technique.

METHODS

This was a retrospective study of all women (n = 240) who underwent LSC for pelvic organ prolapse (POP) from January to December 2017 in a tertiary center. POP-Q staging, validated questionnaires (International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] and Pelvic Floor Distress Inventory Questionnaire-Short Form), and uroflowmetry were used to evaluate the anatomical and functional outcomes. Statistical analyses were performed using McNemar test and repeated measures analysis of variance with Fisher's least significant difference post hoc (p < 0.05).

RESULTS

The anatomical success rate is 96%, with a prolapse recurrence rate of 3.8% at 3-year follow-up. Bulge symptoms and anatomical compartments were significantly improved after LSC. Clinically, there were significant improvements after LSC in voiding dysfunction and bowel symptoms. Also, there was a significant increase in stress urinary incontinence and non-significant decrease in mixed urinary incontinence and urge urinary incontinence. ICIQ-SF and Colorectal-Anal Distress Inventory 8 scores were significantly lower after LSC, signifying improvement in incontinence and bowel symptoms.

CONCLUSION

Our modified LSC technique is safe and effective in restoring level 1 and level 2 supports, without adverse effects on urinary and bowel function. Bladder and bowel symptoms have also been found to keep improving over time.

Functional outcome after laparoscopic nerve-sparing sacrocolpopexy: a prospective cohort study

INTRODUCTION

To date sacrocolpopexy is regarded as the reference standard treatment for primarily apical compartment prolapse and multicompartment prolapse. Most bladder and bowel dysfunction improves postoperatively after sacrocolpopexy; however, de novo bowel or de novo bladder dysfunction can occur. The inferior hypogastric nerve is commonly known among pelvic surgeons. However, the inferior hypogastric nerve and its fine fibers are difficult to identify; iatrogenic lesion is commonly tolerated although this can lead to bladder, bowel and sexual dysfunction. This study was performed to assess the functional outcome after nerve-sparing sacrocolpopexy.

MATERIAL AND METHODS

From 2014 to 2016 all women undergoing a laparoscopic sacrocolpopexy for apical or multicompartment prolapse stage >2 were included in this prospective study. Laparoscopic sacrocolpopexy was performed using the nerve-sparing approach. Objective outcome was assessed by preoperative and postoperative POP-Q changes. De novo bladder and de novo bowel dysfunction were subjectively and objectively evaluated.

RESULTS

In all, 137 women were included. Significant objective improvement for point Aa and C (p < 0.0001) preoperatively to postoperatively was seen. The posterior compartment remained unchanged with point Ba -2. De novo overactive bladder and de novo bladder outlet obstruction with elevated postresidual volume were seen for both in 0.7% (1/137). De novo stress urinary incontinence was seen in 0.7% (5/137). De novo constipation was seen in 5%, bowel incontinence in 0% and resolution of pre-existing obstipation in 14.5%. De novo laxative use (9%) in the first 12 weeks was the most common postoperative problem.

CONCLUSION

We could demonstrate that when a nerve-sparing technique is applied for sacrocolpopexy low de novo bladder (18%) and de novo bowel dysfunction can be seen.

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the "gold standard" procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.