Vaginal sacrospinous fixation: experience in a district general hospital

Clinical Effect of Uterosacral and Cardinal Ligament Fixation versus Sacrospinous Ligament Fixation of Vaginal Vault Prolapse: A Retrospective Analysis

Objective

This study aimed at comparing sacrospinous ligament fixation (SSLF) with uterosacral and cardinal ligament fixation (USCLF) concerning complications and outcomes in patients with pelvic organ prolapse (POP).

Methods

A retrospective analysis was performed on the clinical data of patients with POP stage III or above uterine prolapse treated at Wenzhou People's Hospital from January 2013 to December 2019. Patients were divided into two groups: USCLF group and SSLF group. The perioperative indicators, postoperative complications, pelvic organ prolapse quantification (POP-Q), Pelvic Floor Distress Inventory-20 (PFDI-20), and POP/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) scores of the groups were analyzed and compared.

Results

(1) The operative time and intraoperative blood loss in the USCLF group were lower than those in the SSLF group, with statistical significance (p < 0.05). (2) The incidence of postoperative buttock pain in the SSLF group was 10.7% (6/56), higher than that in the USCLF group (0/56) (Fisher's exact test, p = 0.027). (3) At one year of follow-up, significant improvement in Aa, Ba, C, Ap, and Bp values was observed in both groups (p < 0.05). The values of the Aa and Ba sites in the USCLF group were lower than those in the SSLF group one year after surgery (p < 0.05). (4) The PFDI-20 and PISQ-12 scores of the groups one year after surgery were lower than those before surgery (p < 0.05).

Conclusion

Uterosacral and cardinal ligament suture fixation leads to less bleeding and better postoperative quality of life than preoperative and may be better than SSLF at preventing the recurrence of anterior wall prolapse after surgery.

Comparison of Unilateral and Bilateral Sacrospinous Ligament Fixation Using Minimally Invasive Anchorage

Objective The aim of this study was to determine the effectiveness of a newly developed anchoring system for unilateral sacrospinous ligament fixation (USSLF) and bilateral sacrospinous ligament fixation (BSSLF) procedures.

Material and Methods Ninety-three patients with pelvic prolapse who were treated surgically with the Anchorsure System ^® between 2013 and 2018 were included in the study. USSLF was performed in 52 patients (group 1), and BSSLF was performed in 41 patients (group 2). Pelvic organ prolapse was assessed preoperatively and 6 months postoperatively.

Results There were no significant differences between groups 1 and 2 with regard to age, parity, and demographic characteristics. Anatomical improvement rates were similar, irrespective of the type of SSLF used. No bleeding requiring blood transfusion or organ injuries occurred in any patient. Three patients in the group that received BSSLF developed small asymptomatic cystoceles (grade 1 to 2); there was no recurrence of rectoceles or enteroceles. Mild cystocele was found in 1 patient from the USSLF group. There was no significant difference between the groups with respect to the recurrence of cystocele. Recurrence of vaginal vault prolapse was found in 2 patients from the USSLF group (3.84%). There was no significant difference between the groups with regard to recurrence. Febrile morbidity, clinical outcomes, blood loss, duration of operation, intraoperative complications, and length of hospital stay were similar for the two groups.

Conclusions Unilateral and bilateral SSLF techniques produce similar clinical outcomes. USSLF and BSSLF performed using the new anchoring system are safe and effective methods to treat pelvic organ prolapse.

Is standardised vaginal sacrospinous ligament fixation a safe teaching procedure for residents?

INTRODUCTION AND HYPOTHESIS

Several modifications of sacrospinous ligament fixation (SLF) are described.

METHODS

This study presents a standardised SLF technique. Perioperative course and outcome are compared retrospectively after surgery is performed by experienced surgeons or by residents.

RESULTS

Two hundred three SLF were analysed. Eight residents (LO) operated on 41 patients (5.1 ± 2.2). Six experienced surgeons (SO) operated on 162 patients (27.0 ± 25.7). Mean operating time was 67 ± 33 min. (LO 99 ± 45 min vs. SO 59 ± 22 min, p < 0.05). The overall morbidity rate was 7.8%. There was no significant difference regarding complications and outcomes between SO and LO.

CONCLUSIONS

Operation time was longer but outcomes were identical, and morbidity rate was not increased in the group of resident surgeons. In comparison to literature, complication rate was low. SLF should be part of residency programmes.

[How to manage multicompartment pelvic organe prolapse?]

Repair of pelvic organ prolapse by vaginal route may use native tissues or meshes, which have been in extensive use over the last decades. Traditional surgery, and particularly sacrospinous fixation, has been proven to be effective with long term follow-up with well-known specific risks that could be avoided by skilled surgeons on condition that he observes basic vaginal surgery rules. This surgery is still recommended as first choice in patients over 70 years old with high-grade prolapse. Nevertheless recurrence rate after high-grade cystocele repair using native tissues as been reported between 30 and 50% depending on the technique used. Mesh repair and particularly the use of mesh kits is a valid option in case of prolapse with cystocele behind the hymen, specifically in case of paravaginal defect. Meshes use is licit in patients with prolapse recurrence as well. In contrast, spread use of transvaginal meshes in young patients with grade 3 or 4 prolapse whom tissues have a poor quality, has to be considered very carefully because of the lack of knowledge about long term results and sexual outcome.

Laparoscopic sacrocervicopexy for the treatment of uterine prolapse: a retrospective case series report

STUDY OBJECTIVE

To evaluate apical support in patients desiring uterine preservation with pelvic organ prolapse who underwent laparoscopic sacrocervicopexy.

DESIGN

Retrospective case series report (Canadian Task Force classification III).

SETTING

Academic community teaching hospital.

PATIENTS

Forty consecutive women who underwent laparoscopic sacrocervicopexy.

INTERVENTIONS

Synthetic mesh was used to attach the distal uterosacral ligaments and posterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory.

MEASUREMENTS AND MAIN RESULTS

Pelvic organ prolapse quantification system measurements were used and apical support was evaluated using point C. Mean C was -1.13 (+9 to -4) preoperatively, -5.28 (-3 to -13) at 6 weeks postoperatively, -5.26 (-3 to -8) at 6 months postoperatively, and -4.84 (-3 to -7) at 1 year postoperatively.

CONCLUSION

Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation.

Vaginal vault prolapse: Choice of operation

The surgeon who faces a patient with vaginal vault prolapse is dealing with a complex and intriguing challenge. Part of the complexity is due to the lack of standardization and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus all aspects of the prolapse pathology and the patient's lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for an individual patient. In this chapter we present the vaginal and abdominal approaches for the correction of vaginal vault prolapse, with discussion of the surgical outcomes and complications for each technique. A comprehensive comparison of the various techniques is offered on the basis of current published literature. In addition, we focus on various controversies, including the prevention of vault prolapse at the time of hysterectomy, issues regarding uterine preservation, the management of overt or occult concomitant stress incontinence, and the place-if any-for combined anti-incontinence procedures at the time of prolapse surgery. New minimally invasive techniques for vault prolapse are also reviewed. We emphasize areas that call for further research and for standardized outcome criteria.

Vaginal surgical approach to vaginal vault prolapse: considerations of anatomic correction and safety

PURPOSE OF REVIEW

Pelvic organ prolapse is a common problem in women and often requires surgical management. Vaginal vault prolapse requires significant expertise. The pelvic reconstructive surgeon should be familiar with various methods of repair, including the vaginal approach, in order to provide appropriate individualized patient care. The safety of procedures should be balanced against the need for anatomic correction.

RECENT FINDINGS

Vaginal surgical approaches such as sacrospinous suspension, although shown in the past to have slightly less success than abdominal approaches such as sacral colpopexy, continue to have good safety and efficacy profiles, and may be used in appropriately selected patients. Randomized clinical trials are still required to compare different vaginal procedures such as sacrospinous and uterosacral ligament suspension. A new minimally invasive transperineal approach, posterior intravaginal slingplasty, requires further evaluation before being used in routine clinical practice.

SUMMARY

Posthysterectomy prolapse of the apical vaginal compartment frequently requires a surgical solution. This may be approached via the abdominal, vaginal or combined route. A vaginal approach, being less invasive, may be the safer option if carefully performed. The gynecologic surgeon must balance the advantages of anatomic correction (e.g. with sacrospinous vault suspension) against the advantages of a potentially safer yet less anatomically correct procedure (e.g. colpocleisis). The surgical approach must be individualized for every patient.