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

The minimally invasive sacrospinous fixation under visual guidance: An anatomical study

OBJECTIVE

Sacrospinous fixation is the gold standard procedure for management of apical pelvic organ prolapse by the vaginal route. However, there may be a relevant risk of neurovascular injury due to the proximity of neurovascular structures. We propose an anatomical study concerning the sacrospinous ligament with a new innovative minimally invasive technology using both a suture capturing device and a chip-on-the-tip endoscope to perform sacropinous fixation.

STUDY DESIGN

Bilateral sacrospinous fixation was performed in three female cadavers, in the course of the anatomical study conducted with a specific device (the Suture Capturing I Stitch™ Device) under real time visual guidance with a chip-on -the-tip endoscope, the NanoScope™ system.

RESULTS

Identification of ischial spine and sacrospinous ligament as well as feasibility of sacrospinous fixation under NanoScope™ control were always possible on both sides.

CONCLUSIONS

This new innovative minimally invasive technology using both a suture capturing device and a chip-on-the-tip endoscope is relevant and could be an advantage in terms of safety and better placement of the suture on the sacrospinous ligament.

Anterior sacrospinous ligament fixation by the vaginal route in ten steps

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery. Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences. The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure. In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.

Comparison between anterior and posterior vaginal approach in apical prolapse repair in relation to anatomical structures and points of fixation to the sacrospinous ligament in fresh postmenopausal female cadavers

INTRODUCTION AND HYPOTHESIS

The high prevalence of pelvic organ prolapse (POP) in women requires attention and constant review of treatment options. Sacrospinous ligament fixation (SSLF) for apical prolapse has benefits, high efficacy, and low cost. Our objective is to compare anterior and posterior vaginal approach in SSLF in relation to anatomical structures and to correlate them with body mass index (BMI).

METHODS

Sacrospinous ligament fixation was performed in fresh female cadavers via anterior and posterior vaginal approaches, using the CAPIO®SLIM device (Boston Scientific, Natick, MA, USA). The distances from the point of fixation to the pudendal artery, pudendal nerve, and inferior gluteal artery were measured.

RESULTS

We evaluated 11 cadavers with a mean age of 70.1 ± 9.9 years and mean BMI 22.4 ± 4.6 kg/m². The mean distance from the posterior SSLF to the ischial spine, pudendal artery, pudendal nerve, and inferior gluteal artery were 21.18 ± 2.22 mm, 17.9 ± 7.3 mm, 19.2 ± 6.8 mm, and 18.9 ± 6.9 mm respectively. The same measurements relative to the anterior SSLF were 19.7 ± 2.7 mm, 18.6 ± 6.7 mm, 19.2 ± 6.9 mm, and 18.3 ± 6.7 mm. Statistical analysis showed no difference between the distances in the two approaches. The distances from the fixation point to the pudendal artery and nerve were directly proportional to the BMI.

CONCLUSIONS

There was no difference in the measurements obtained in the anterior and posterior vaginal approaches. A direct correlation between BMI and the distances to the pudendal artery and pudendal nerve was found.

Anterior bilateral sacrospinous ligament fixation with concomitant anterior native tissue repair: a pilot study

INTRODUCTION AND HYPOTHESIS

Anterior bilateral sacrospinous ligament fixation (ABSSLF) was first described in 2000 but only evaluated in a limited number of studies. However, due to the FDA's ban on transvaginal mesh, interest in this technique has re-emerged. The SSLF procedure is known for its inherent high risk for anterior compartment failure; hence, in our center we started performing a preemptive concomitant anterior repair with the intention to reduce such risk. The aim of this study was to review the feasibility and clinical outcomes of this innovative technique.

METHODS

We performed a retrospective cohort study of all the women who had an ABSSLF and a concomitant anterior native tissue repair between May 2019 and July 2020 in a tertiary hospital in France. Our primary endpoint was surgical feasibility, while as secondary endpoints we wanted to explore the perioperative morbidities and clinical outcomes associated with this technique.

RESULTS

A total of 50 women were operated on in the studied period. The median follow-up time was 10 [8.5] months. It was feasible to perform the combined ABSSLF and concomitant anterior native tissue repair in all cases. The most frequent perioperative complications reported were urinary tract infection (14%) and difficulty in resuming voiding (16%). Anatomical and functional results were improved. The rate of anterior compartment recurrence was 37%.

CONCLUSIONS

ABSSLF with a concomitant anterior native tissue repair is feasible and relatively safe for treating anterior and apical pelvic prolapse. However, anterior compartment failure rate is still a limitation. Further larger studies with long-term anatomical and functional results comparing this technique to alternative transvaginal surgical approaches are needed.

A review of six sacrospinous suture devices

BACKGROUND

The sacrospinous ligament is frequently accessed blindly during vaginal vault suspension with risk to inferior gluteal vessels. This article examines the vascular safety of six devices currently used for this purpose using cadaveric examination.

METHOD

Devices were evaluated for cost and for their ability to reliably avoid vessels behind the sacrospinous ligament by applying each to the traditionally described location, two fingerbreadths medial to the right ischial spine. We selected the five predissected, preserved pelves and right hemipelves where vessels remained attached.

RESULTS

The i stitch(®) was seen to penetrate coccygeal branches of inferior gluteal artery. The Capio(®) , Caspari(™) and Endostitch(®) remained confined within all, including thin, ligaments. The Miya(®) hook and Deschamp(®) impinged upon but deflected vessels behind thin ligaments.

CONCLUSIONS

VascuIar anatomy behind the sacrospinous ligament is enormously variable. Suture placement two fingerbreadths medial to the spine does not guarantee safety. The ligament may be thin in the elderly, who are unlikely to cope with haemorrhage yet who may represent a growing proportion of those requiring surgery. For vascular safety, the ideal device is compact. It impresses and enfolds but does not penetrate behind the ligament. The sharp penetrating component that carries suture should traverse the shortest distance at the shallowest depth allowing adequate bite. This was satisfied by the Caspari(®) , Capio(®) and less so by Endostitch(®) . The i stitch(®) was not safe in thin ligaments. The Deschamp(®) and Miya(®) devices may be a good compromise for the developing world where cost is important.

Vaginal sacrospinous colpopexy using the Capio suture-capturing device versus traditional technique: feasibility and outcome

PURPOSE

This study compares the feasibility and outcome of sacrospinous colpopexy for treating vaginal vault prolapse (VVP) performed by either the traditional technique or a simplified procedure using the Capio™ suture-capturing device.

MATERIALS AND METHODS

Eighty-six patients with VVP were included in the study. Forty-two patients were treated by traditional sacrospinous colpopexy (TSC group) and 44 patients were treated by the modified technique using the Capio device (CSC group). Additional procedures were performed to restore concomitant pelvic floor defects.

RESULTS

The mean (±SD) total operative time was significantly lower in the CSC group (71.7 ± 24.5 min) than in the TSC group (105.5 ± 31.5 min; p < 0.001); the intraoperative blood loss was higher in the TSC group than in the CSC group. In the CSC group, the mean operative time required to perform sacrospinous colpopexy was 21.4 ± 3.2 min. In patients who underwent only sacrospinous colpopexy, the time required to perform surgery was significantly lower in the CSC group (20.9 ± 3.3 min) than in the TSC group (39.1 ± 5.2 min; p < 0.001). There was no significant difference in the incidence of surgical complications between the two study groups. The objective and subjective success rates at 3-year follow-up were 88.1 and 92.9 % in the TSC group while in the CSC group they were 86.4 and 92.9 %.

CONCLUSION

The modified technique of sacrospinous ligament fixation using the Capio device reduces the operative time and blood loss when compared to the traditional technique.

Feasibility and outcome of vaginal paravaginal repair using the Capio suture-capturing device

INTRODUCTION AND HYPOTHESIS

This investigation describes the feasibility and outcome of vaginal paravaginal repair (VPVR) performed using the Capio suture-capturing device.

METHODS

This prospective study included 36 women with paravaginal fascial defects, symptomatic stage II to IV anterior vaginal wall prolapse, and uterine prolapse equal or more than stage 2. VPVR was performed using the Capio device. In addition, anterior colporrhaphy, posterior colporrhaphy, and vaginal hysterectomy were performed.

RESULTS

The mean time required to perform the VPVR was 12.9 min (range, 11-18 min). The median blood loss during the VPVR was 35 ml (range, 20-65 ml). There were no major intraoperative complications. At 2-year follow-up, the rate of recurrent anterior vaginal wall prolapse (stage ≥ 2) was 8.6%.

CONCLUSIONS

VPVR performed using the Capio device is associated with minimal dissection of the tissues, blood loss, and operating time and has low recurrence rate at 2-year follow-up.

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.