Résultats à long terme de la promontofixation laparoscopique dans les cystocèles de haut grade

Recurrence of Anterior Vaginal Prolapse After Robotic Sacrocolpopexy: Does Cervical Preservation Affect Outcome?

IMPORTANCE

Anterior vaginal prolapse (AVP) is the most common site of recurrence after sacrocolpopexy (SCP). Supracervical hysterectomy helps to prevent mesh exposure, but it is unclear if cervical preservation (CP) affects adequate reduction of AVP.

OBJECTIVE

Our primary objective was to determine the difference in AVP recurrence rates in patients who have undergone SCP with or without CP. Secondary outcomes were composite failure and complications rates.

STUDY DESIGN

This was a retrospective cohort analysis of women who underwent robotic SCP between 2012 and 2019 at Kaiser Permanente Southern California. The first cohort included women with CP (prior or concomitant supracervical hysterectomy). The second included women without CP (prior or concomitant total hysterectomy). Primary outcome was defined as recurrent AVP beyond the hymen. Patients without 12-month follow-up were included in demographic and surgical data analysis only.

RESULTS

The charts of 373 patients with CP and 175 without CP were reviewed. Women with CP were more likely to undergo concomitant anterior repair at the time of SCP (14% vs 6%, P < 0.01); however, rates of AVP recurrence were not significantly different between groups (5% vs 3%, P = 0.26). Median follow-up time was 26 months (interquartile range, 14-38 months). Composite failure was similar between groups (17% vs 11%, P = 0.12). Women with CP were more likely to experience asymptomatic apical failure (6% vs 1%, P = 0.03).

CONCLUSIONS

Cervical preservation at the time of SCP is associated with an increased need for concomitant anterior repair but is not associated with higher rates of AVP recurrence or composite failure.

[Which prostheses to use in mesh sacrocolpopexy? Experimental and clinical study]

BACKGROUND

Sacrocolpopexy is the standard surgical treatment of genital prolapse of the upper vaginal wall. Nowadays, the laparotomy approach is progressively supplanted by the laparoscopic procedure for the same anatomical results. About sacrocolpopexy, to date it still remains details of the technique, which differ with surgical teams maintaining controversy. Among them, the choice of the meshes certainly creates debate.

OBJECTIVES

To state the basic physicochemical principles which are necessary for surgeons to select the most suitable prosthetic material to obtain the most beneficial anatomic and functional outcomes for patients.

MATERIAL AND METHODS

The concepts of prosthetic biocompatibility, strength, shrinkage, deformation and elasticity are discussed. They are illustrated by experimental animal references and also human clinical references.

RESULTS

Macroporous polypropylene and polyester prostheses (pore size>1 mm) are properly integrated. Collagen prosthetic coating improves tissue integration. Absorbable and nonabsorbable ultralight prostheses expose patients to a high risk of recurrence. Multifilament polyester wide pore-side prostheses have less retraction and are more flexible than monofilament polypropylene prostheses.

DISCUSSION AND CONCLUSION

The prosthetic cut-off weight below which the mesh does not offer any guarantee of strength is not precisely known. Moreover, the benefit of weight reduction is not proved. Currently, heavy weight multifilament polyester prostheses with wide pore size, more than 1mm, appear to be the most appropriate meshes for sacrocolpopexy without vaginal incision.

Prevention of complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice

The objective of the study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning adverse events related to surgical procedures involving the use of prosthetic meshes. French and English-language articles from Medline, PubMed, and the Cochrane Database were searched, using key words (mesh; pelvic organ prolapse; cystocele; rectocele; uterine prolapse; complications; adverse event; sacral colpopexy; extrusion; infection). As with any surgery, recommendations include perioperative smoking cessation (Expert opinion) and compliance with the prevention of nosocomial infections (regulatory recommendation). There is no evidence to recommend routine local or systemic estrogen therapy before or after prolapse surgery using mesh, regardless of the surgical approach (Grade C). Antibiotic prophylaxis is recommended, regardless of the approach (Expert opinion). It is recommended to check for pre-operative urinary tract infection and treat it (Expert opinion). The first procedure should be undertaken under the guidance of a surgeon experienced in the relevant technique (Grade C). It is recommended not to place a non-absorbable synthetic mesh into the rectovaginal septum when a rectal injury occurs (Expert opinion). Placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after suturing of a bladder injury if the suture is considered to be satisfactory (Expert opinion). If a synthetic mesh is placed by vaginal route, it is recommended to use a macroporous polypropylene monofilament mesh (Grade B). It is recommended not to use polyester mesh for vaginal surgery (Grade B). It is permissible to perform hysterectomy associated with the placement of a non-absorbable synthetic mesh placed by the vaginal route but this is not routinely recommended (Expert opinion). It is recommended to minimize the extent of the colpectomy (Expert opinion). The laparoscopic approach is recommended for sacral colpopexy (Expert opinion). It is recommended not to place and suture meshes by the vaginal route when a sacral colpopexy is performed (Grade B). It is recommended not to use silicone-coated polyester, porcine dermis, fascia lata, and polytetrafluoroethylene meshes (Grade B). It is recommended to use polyester (without silicone coating) or polypropylene meshes (Grade C). Suture of the meshes to the promontory can be performed using thread/needle or tacks (Grade C). Peritonization is recommended to cover the meshes (Grade C). If hysterectomy is required, it is recommended to perform a subtotal hysterectomy (Expert opinion). Implementation of this guideline should decrease the prevalence of complications related to surgical procedures involving the use of prosthetic meshes.

[Laparoscopic surgery in the treatment of urogenital prolapse. Current status]

Urogenital prolapse is an emerging problem because of the increasing life expectancy of populations. Nearly 42% of women between 15 and 97 years have a pelvic floor disorder (PFD). On the basis of Medline search, we present the main laparoscopical techniques to treat PFD: Burch, sacrocolpopexy, lateral suspension, uterosacral suspension, paravaginal repair, the benefits of laparoscopic surgery, its success rates and complications, and response to various questions that frequently arise about some techniques: should we perform a hysterectomy? Should we make a paravaginal repair? Should we treat prophylactically a stress urinary incontinence? What type of mesh should we use? What to prefer: staples or sutures? Is the posterior mesh necessary?

Anterior sacrospinous ligament fixation associated with paravaginal repair using the Pinnacle device: an anatomical study

INTRODUCTION AND HYPOTHESIS

The objective of this paper is to study the reproducibility and anatomical risks of anterior sacrospinous ligament (SSL) fixation associated with paravaginal repair using the Pinnacle device (Boston Scientific).

METHODS

Simplified bilateral anterior SSL fixation associated with paravaginal fixation through the arcus tendineus fascia pelvis (ATFP) was performed on five fresh cadavers using the Pinnacle device. Cadaver dissection was then performed by open pelvic surgery.

RESULTS

Eight SSL and ten ATFP were available for analysis. SSL fixations were optimal in four cases, too superficial in three cases, and too high in one case. Mean distance between SSL fixation and ischial spine was 18.6 mm (range 10 to 30 mm). Mean distance between SSL fixation and pudendal nerve was 6.5 mm (range 0 to 15 mm). ATFP fixations were optimal in five cases, good in four cases, and too superficial in one case. In one case (10%), the middle arm of the prosthesis was in contact with the ureter and traction on that arm resulted in ureteral kinking.

CONCLUSIONS

Anterior SSL fixation associated with paravaginal repair using the Pinnacle™ device was not reproducible every time in this cadaver study. These results confirm the need for specific training before starting anterior SSL fixations.

[Laparoscopic promontofixation]

OBJECTIVES

The pathology of the pelvic floor, including the urinary incontinence, the anal incontinence and the genital prolapse, is very dominant, concerning approximately a third of the adult women. It is fundamental that this musculature supports a good function, because of the weakness of the pelvic floor produces urinary incontinence, cysto and rectocele, genital prolapses and sexual dysfunctions. The above mentioned pathology can be corrected by laparoscopic promontofixation, whatever the previous history of pelvic surgery, including the placing of prosthetic material. In this article we describe the above mentioned intervention.

MATERIAL AND METHODS

Preoperative care is standardized and is accompanied by antibiotic prophylaxis, preventive antithrombotic treatment and in the event of a history of pelvic surgery, a digestive preparation. Positioning of the patient must plan a 30° Trendelenbourg position. After the introduction the trocars, initial surgery comprises anterior dissection of promontory after incision of the posterior peritoneum with the patient placed beforehand in a Trendelembourg position. After that, we make interrectovaginal dissection to free the whole posterior surface of the vagina. This is followed by the installation of a posterior mesh pre-cut in an arc. After intervesical vaginal dissection, the anterior prosthesis comprising a precut polyester mesh is fixed avoiding excess traction. The end of the surgery involves careful reperitonization of all the prosthetic parts. Possible specific surgical complications are vascular and visceral wounds. RESULTS Y CONCLUSIONS: The technique allows the correction of the dysfunction of the pelvic floor and incontinence with good anatomical and functional results. Postoperative secondary haemorrhage and gastrointestinal occlusion may occur. Occurrence of an inflammatory syndrome and low back pain suggests spondylodicitis and MRI should be performed. Vaginal erosion on the prosthesis may occur after several months and seems relatively independent of the prosthetic material used.

[Mini-invasive posterior sacrospinous ligament fixation using the CAPIO needle driver: an anatomical study]

OBJECTIVE

To study anatomical risks after posterior sacrospinous ligament fixation using the CAPIO needle driver.

SUBJECTS AND METHODS

A simplified bilateral posterior sacrospinous ligament fixation was performed on seven fresh female cadavers using the CAPIO needle driver. Cadavers were installed in gynaecologic position then dissected by the abdominal route. The posterior sacrospinous ligament fixation was performed after a posterior vaginal wall incision on the midline and a simplified dissection of both pararectal fossae. The abdominal dissection was focused on the sacrospinous ligament area. We measured the distance between the neurovascular elements adjacent to the sacrospinous ligament from the suture site.

RESULTS

Thirteen sacrospinous ligaments were available for analysis. The mean length (+/-SD) of the ligament was 51+/-9.2 mm and the mean width at the level of fixation (+/-SD) was 23.5+/-5.7 mm. No rectal injury was observed. Fixations were in the deeper (ligament) and medium (muscle) part of the SSL in eight (61%) and five (39%) cases respectively. The ischial spine was 21.6 mm (range: 13-30). The mean distances between fixation and pudendal nerve and artery were 16.1 mm (range: 4-32) and 20 mm (range: 12-37) respectively.

CONCLUSION

Mini-invasive posterior sacrospinous ligament fixation using the CAPIO needle driver seemed to be reproducible with low anatomical risks. However, the fixation should be at least at 20 mm medially to the ischial spine in order to reduce neurological risks.

[Informing a patient about surgical treatment for pelvic organ prolapse]

Inform consent is a major objective in the relation patient-physician. Patient's information becomes doubt when it is insufficient. To answer to medical persons asking about patient's information, pretreatment clinical and paraclinical assessment will be discussed. Reflexion delay, surgical alternative therapy and pre-operatory examination will be exposed. Several critical situations, such as associated hysterectomy, patient's comorbidity (tobacco, obesity) or synthetic mesh reinforcement have to be well-known to inform patient about failures and outcomes.