From 3D to 2D-4K laparoscopic sacral colpopexy: are we addicted to technology?

OBJECTIVE

A study analyzing perioperative outcomes related to a sudden switch from 3D to 2D-4K technology for laparoscopic sacral colpopexy by expert pelvic surgeons: are we addicted to technology?

MATERIAL AND METHODS

After a sudden transition from 3D to 2D-4K laparoscopic technology, a total of 115 consecutive pelvic prolapse patients who underwent sacral colpopexy from June 2020 to September 2021 were retrospectively assessed from our database. Perioperative parameters, operative times (OT), and intraoperative difficulty scales were assessed. One-year follow-ups were analyzed for the study. Primary endpoints were OT; secondary endpoint was the evaluation of complications linked to this procedure.

RESULTS

We found statistical differences in OT and intraoperative difficulty scales between medians of the last 3D procedures and the first ten 2D-4K surgeries, without differences between operators. Only after more than 20 surgeries, we observed no significant differences between 3D and 2D-4K sacral colpopexy. We observed no statistical differences in terms of anatomic failure, PGI-I, and intra-postoperative complications.

CONCLUSION

The transition of urogynecology from an exclusive vaginal approach to 2D-3D-4K laparoscopy significantly increased the level of technology necessary for surgical treatment of prolapse. This could, as a result, lead to pelvic surgeons becoming increasingly dependent on technology.

Spondylodiscitis after sacral colpopexy: diagnose early to treat earlier

Spondylodiscitis following sacral colpopexy for Pelvic Organ Prolapse (POP) represents a rare complication with severe consequences. Authors performed a literature search, from 2000 to 2022, to set a narrative review of literature. Spondylodiscitis is an uncommon but dangerous side effect of a routine surgical treatment that needs to be identified and treated right away to prevent worsening clinical consequences. Suboptimal dissection of the sacral promontory and/or site infection are associated with spondylodiscitis. When spondylodiscitis is suspected, advanced imaging methods should be used, and surgical excision shouldn't be put off after a failed course of treatment. Authors presented a case-video of a 68-year-old woman who reported severe lower back pain 7 weeks after surgery, in which sacral spondylodiscitis was diagnosed and laparoscopically treated. In this case, a laparoscopic tack and mesh removal from promontory was carried out following the patient's continued lower back pain and the antibiotic therapy's incomplete radiological remission of spondylodiscitis. The patient's radiological findings and symptoms completely resolved two weeks following the procedure.

Quality of Life and Sexual Function after Laparoscopic Posterior Vaginal Plication Plus Sacral Colpopexy for Severe Posterior Vaginal Prolapse

BACKGROUND

Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for women with apical/anterior pelvic organ prolapse (POP). For isolated posterior vaginal prolapse, instead, the literature suggests fascial native tissue repair. This is a retrospective 2-year quality-of-life follow-up study after laparoscopic posterior plication (LPP) combined with LSC in patients with anterior/apical prolapse combined with severe posterior colpocele. The primary endpoint was to evaluate the subjective outcomes quality of life (QoL), sexual function, and patient satisfaction rate. The secondary endpoint was to evaluate perioperative and anatomical outcomes at the 2-year follow-up.

METHODS

A total of 139 consecutive patients with anterior and/or apical prolapse (POP-Q stage ≥ II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥ III) were retrospectively selected from our database among women who underwent, from November 2018 to February 2021, a "two-meshes" LSC. The patients were classified into Group A (81 patients; LSC plus LPP) and Group B (67 patients; LSC alone). The primary endpoint was evaluated using the Patient Global Impression of Improvement (PGI-I), the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the Female Sexual Distress Scale (FSDS), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the EuroQol (EQ-5D). The secondary endpoint was studied using the POP-Q study and an intra-, peri-, and post-operative complications assessment. Two-year follow-up data were analyzed for the study.

RESULTS

At 2 years, all women showed a statistically significant amelioration of their symptoms on the QoL questionnaires. We found a statistical difference in favor of posterior plication in terms of the PGI-I successful outcome rate (Group A versus B: 85.3% versus 67.1%), FSDS (median 11 versus 21), and PISQ-12 (median 89 versus 62) (p < 0.05 for all comparisons). A significant improvement of all EQ-5D values was observed from baseline to 2-year follow-up, and only for the "pain/discomfort" domains did we observe a significant improvement in LSC plus LPP patients versus LSC alone (p < 0.05). LSC plus LPP women showed, at 2 years, a significant amelioration of their Ap and GH POP-Q points. We observed no statistical differences in terms of intra-post-operative complications or anatomic failure rate between groups.

CONCLUSIONS

Our LPP approach to LSC appears to be a safe, feasible, and effective treatment for advanced pelvic organ prolapse with a significant impact on the patient's general health and sexual quality of life. Adding laparoscopic posterior vaginal plication to "two-meshes" sacral colpopexy is recommended in patients with apical/anterior prolapse and concomitant severe posterior colpocele. This surgical approach, in addition to improving the anatomical results of these patients, is associated with a significant improvement in sexual and quality of life indexes.

Laparoscopic posterior vaginal plication plus sacral colpopexy for severe posterior vaginal prolapse: A randomized clinical trial

AIM

A randomized clinical trial proposing a new laparoscopic prosthetic and fascial approach to severe posterior vaginal prolapse. The primary endpoint was to evaluate the objective and subjective outcomes of our laparoscopic posterior plication (LPP) combined to "two-mesh" sacral colpopexy (laparoscopic sacral colpopexy [LSC]) in severe posterior vaginal prolapse, with a 1-year follow-up. The secondary endpoint was to evaluate the safety of this surgical procedure.

METHODS

This is single-center prospective randomized double-blinded clinical trial. A total of 130 consecutive patients with anterior and/or apical pelvic organ prolapse (POP) (POP-Q stage ≥II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥III) were prospectively assessed for inclusion into the study from November 2018 to January 2020. Patients underwent "two-meshes" LSC and were randomized in Group A (LSC plus LPP) and Group A (LSC alone). Of the 130 included subjects, 8 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using POP-Q study, and subjectively using PGI-I, POPDI-6, and FSDS questionnaires. Complications were assessed intra-, peri-, and postoperatively. Twelve-month follow-ups were analyzed for the study.

RESULTS

We found in LSC plus LPP Group a significant improvement of Ap and genital hiatus POP-Q points. Our subjective study showed, at 12 months, a statistical difference in PGI-I successful outcomes rate in favor of LPP. Also the FSDS resulted significantly much more improved in Group A. We observed no statistical differences in terms of postoperative complications.

CONCLUSIONS

Our LPP approach to LSC could be considered an effective and safe technique to POP patients with severe posterior prolapse.

Vaginal Vault Prolapse in an Elderly Woman

Vaginal vault prolapse is a painful condition in which the vaginal cuff descends. This report presents a case of a 65-year-old obese and diabetic female who was suffering from a third-degree vault prolapse. Conventionally used non-surgical treatments, such as exercises for the pelvic floor, are not as effective as surgical approaches for the treatment of third-degree vault prolapse. Post-hysterectomy vaginal vault prolapse can be treated safely and effectively with abdominal sacral colpopexy using a permanent mesh. Due to several risk factors, such as grand parity, advancing age, and poor lifestyle mainly involving exercise to strengthen pelvic floor musculature, the vaginal route of surgery was employed, which was found to be effective, and thus the treatment was successful. In conclusion, such individualized as well as unique approaches to such rare cases can produce efficacious results.

Abdominal versus robotic sacral colpopexy: A detailed analysis of outcomes

AIMS

Although abdominal sacrocolpopexy (ASC) is considered the gold standard for surgical repair of vaginal vault prolapse, the open surgical approach has significant morbidity. We aim to compare anatomic and functional outcomes in women receiving either robotic-assisted sacral colpopexy (RSC) or ASC for post-hysterectomy prolapse.

METHODS

We present a retrospective chart review of all women who underwent ASC and RSC at our institution and had 12-month follow-up (FU). Pelvic organ prolapse quantification (POP-Q) staging was assessed both preoperatively and postoperatively. Perioperative and demographic details were collected from the medical records.

RESULTS

One hundred twenty four women underwent RSC (mean age 63, median FU 16 months). Those in the ASC group (n = 144) were statistically younger (mean age 60) and had longer FU (median 60 months). Both median day of successful voiding trial and discharge day significantly favored RSC. There were no Clavien Grade IV/V complications for either procedure and three RSC procedures were converted to ASC. Both approaches were associated with a significant improvement in POP-Q stage at FU, with few women requiring additional surgery. Overall, 76% of women in each group were dry from stress urinary incontinence. Improvement in storage and emptying indices, dyspareunia, and quality of life measures was observed after both approaches.

CONCLUSION

RSC demonstrates good support of significant vaginal vault prolapse at medium term FU, with shorter hospital stays and low complication rates. Close FU after RSC over a longer period will be needed to fully assess durability of both functional and anatomic outcomes.

New combined surgery for cervical cancer complicated by pelvic organ prolapse using autologous fascia lata: A case report

Radical hysterectomy and immediate sacral colpopexy using autologous fascia lata could be considered a treatment option for cervical cancer complicated by severe and symptomatic pelvic organ prolapse.

Securing Mesh with Delayed Absorbable Suture Does Not Increase Risk of Prolapse Recurrence After Robotic Sacral Colpopexy

Introduction and Objective: Nonabsorbable monofilament suture is traditionally used to secure vaginal mesh for robot-assisted sacral colpopexy (RASC) but can become exposed postoperatively requiring invasive vaginal removal. Polydioxanone delayed absorbable suture may avoid this. We sought to determine the objective and subjective impact of suture choice for mesh fixation. Materials and Methods: A cohort study was undertaken using a prospective registry and subjects were grouped based on type of suture at the time of RASC. Apical failure was defined as C point descent of >2 cm, anterior compartment failure was defined as pelvic organ prolapse quantification (POP-Q) Ba point of >0, and posterior compartment failure was defined as Bp point of >0. Patient-reported outcomes included urogenital distress inventory (UDI)-6 and QoL. Two-tailed t-test and chi-squared were used for analysis. Results: A total of 119 women underwent RASC between 2009 and 2016. Patients had similar preoperative characteristics (Table 1). All POP-Q, UDI-6, and quality of life (QoL) scores improved postoperatively (Tables 1 and 2). Apical failure was noted in 0, anterior failure was noted in 7 (average Ba +1.1 cm in failures), and posterior failure was noted in 4 (mean Bp +1.0 cm) at 16 months' follow-up. Failures in the anterior compartment were much more common in the nonabsorbable monofilament cohort (Table 2). Failures in the apical and posterior compartments were not significantly different between groups. Nine suture erosions were noted in the nonabsorbable monofilament cohort, five requiring excision in the clinic and two in the operating room. Two suture erosions were noted in the delayed absorbable cohort, 0 required excision. Postoperative UDI-6 and QoL scores did not vary significantly between groups (5.3 ± 4.0 vs 5.1 ± 4.0, p = not significant (NS), 2.8 ± 2.0 vs 2.8 ± 2.2, p = NS). [Table: see text] [Table: see text] Conclusion: Securing mesh with delayed absorbable monofilament did not appear to increase risk of failure in patients undergoing RASC and eliminates the need for suture excision postoperatively.

Management of lumbar spondylodiscitis developing after laparoscopic sacrohysteropexy with a mesh: A case report and review of the literature

INTRODUCTION

Lumbar spondylodiscitis is a rare and severe complication of laparoscopic sacrohysteropexy with a polypropylene mesh. However, a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy has not been reported so far. We present a case of lumbar spondylodiscitis following laparoscopic sacrohysteropexy with a mesh. We also discuss 33 cases of lumbar spondylodiscitis following sacral colpopexy and (or) rectopexy with a mesh.

PATIENT CONCERNS

A 46-year-old woman with 3 previous vaginal deliveries underwent laparoscopic mesh sacrohysteropexy for stage III uterine prolapse. One month after surgery, the patient developed persistent symptoms, such as stiffness of the lumbosacral portion, low back pain (LBP), persistent swelling, pain between the right iliac crest and the buttock, inability to bend down, and pain in the right lower limb. Symptoms were alleviated by a nonsteroidal anti-inflammatory drug. However, in the last 7 days, symptoms worsened and she was unable to stand or walk. The patient had very limited leg mobility.

DIAGNOSIS

Blood routine examination, erythrocyte sedimentation rate, C-reactive protein, and magnetic resonance imaging (MRI) of the lumbar spine indicated lumbar pyogenic spondylodiscitis.

INTERVENTIONS

Removal of mesh and hysterectomy via laparoscopy were performed immediately, and antibiotics were given simultaneously. However, on the basis of MRI findings and persistent symptoms, debridement, laminectomy, spinal canal decompression, bone grafting, and internal fixation via pedicle screw placement were performed 5 months after laparoscopic sacrohysteropexy.

OUTCOMES

All symptoms were alleviated 5 days after the operation. The patient could stand in the erect position and raise her lower limbs within 2 weeks. She could resume her normal activities within 2 months after the operation, and her X-ray appeared normal.

CONCLUSION

Persistent LBP and radiating pain may be the signals of lumbar spondylodiscitis. MRI is the gold standard diagnostic examination for lumbar spondylodiscitis. Awareness of symptoms, such as LBP and radiating pain symptoms, timely diagnosis, mesh removal, and referral to orthopedists are important to prevent more severe complications. Surgical practice needs to be improved further and any other infections should be treated immediately as the most likely causes of lumbar spondylodiscitis are related to the mesh and other infections.

Robot-assisted surgery for the management of apical prolapse: a bi-centre prospective cohort study

OBJECTIVE

Robot-assisted surgery is a recognised treatment for pelvic-organ prolapse. Many of the surgical subgroup outcomes for apical prolapse are reported together, leading to a paucity of homogenous data.

DESIGN

Prospective observational cohort study (NCT01598467, clinicaltrials.gov) assessing outcomes for homogeneous subgroups of robot-assisted apical prolapse surgery.

SETTING

Two European tertiary referral hospitals.

POPULATION

Consecutive patients undergoing robot-assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS).

METHODS

Anatomical cure (simplified Pelvic Organ Prolapse Quantification, sPOPQ, stage 1), subjective cure (symptoms of bulge), and quality of life (Pelvic Floor Impact Questionnaire, PFIQ-7).

MAIN OUTCOME MEASURES

Primary outcome: anatomical and subjective cure.

SECONDARY OUTCOMES

surgical safety and intraoperative variables.

RESULTS

A total of 305 patients were included (RASC n = 188; RSHS n = 117). Twelve months follow-up was available for 144 (RASC 76.6%) and 109 (RSHS 93.2%) women. Anatomical success of the apical compartment occurred for 91% (RASC) and in 99% (RSHS) of the women. In all compartments, the success percentages were 67 and 65%, respectively. Most recurrences were in the anterior compartment [15.7% RASC (symptomatic 12.1%); 22.9% RSHS (symptomatic 4.8%)]. Symptoms of bulge improved from 97.4 to 17.4% (P < 0.0005). PFIQ-7 scores improved from 76.7 ± 62.3 to 13.5 ± 31.1 (P < 0.0005). The duration of surgery increased significantly for RSHS [183.1 ± 38.2 versus 145.3 ± 29.8 (P < 0.0005)]. Intraoperative complications and conversion rates were low (RASC, 5.3 and 4.3%; RSHS, 0.0 and 0.0%). Four severe postoperative complications occurred after RASC (2.1%) and one occurred after RSHS (1.6%).

CONCLUSIONS

This is the largest reported prospective cohort study on robot-assisted apical prolapse surgery. Both procedures are safe, with durable results.

TWEETABLE ABSTRACT

European bi-centre trial concludes that robot-assisted surgery is a viable approach to managing apical prolapse.

Comparison between laparoscopic uterus/sacrocolpopexy and total pelvic floor reconstruction with vaginal mesh for the treatment of pelvic organ prolapse

AIM

To compare total pelvic floor reconstruction with vaginal mesh (TVM) and laparoscopic uterus/sacrocolpopexy (LSC) for the treatment of pelvic organ prolapse (POP).

METHODS

Six hundred and seventy patients with POP stage 3 and 4 underwent LSC (n = 350) or TVM (n = 320) at the West China Second Hospital, Sichuan University between January 2011 and December 2016. Retrospective analysis was done to compare the POP-Q value before operation and 6 months, 5 years after operation, also compare the, patient global impression of change (PGI-C), pelvic floor distress inventory (PFDI-20) and pelvic floor impact questionnaire (PFIQ-7). Patients were followed for a median 36 months. Thirty-five patients in the LSC and 37 in the TVM groups were lost to follow-up.

RESULTS

Preoperative POP value and disease course were similar (P = 0.075). The LSC group was younger (52.8 ± 6.8 vs. 63.9 ± 8.7 years, P = 0.037). Intraoperative bleeding was smaller in the LSC group (74.4 ± 33.2 vs. 150.4 ± 80.3 mL, P < 0.01), with longer operation time (130.0 ± 34.1 min vs 100.4 ± 40.4 min, P < 0.035). The patients were followed for 10-60 months (median, 36 months). Postoperative PISQ-12 (P < 0.01) was better in the LSC group. PFDI-20 and PFIQ-7 were improved after operation in both groups. Objective satisfaction (94.9% vs 91.9%, P > 0.05) and recurrence rate (8.4% vs 5.1%, P = 0.064) were similar. No infection or fistula occurred after operation in both groups. The complication rate of intraoperative bladder injury and postoperative perineal pain in LSC group was lower than those in the TVM group (P < 0.05).

CONCLUSION

LSC showed no serious adverse events and led to higher postoperative satisfaction than TVM in selected patients. Nevertheless, treatment should be selected in accordance with the willingness and condition of each patient.

Postoperative urinary retention after pelvic organ prolapse repair: Vaginal versus robotic transabdominal approach

AIMS

Postoperative urinary retention has been reported in 13-32% of patients that undergo pelvic organ prolapse (POP) repair. The purpose of our study was to compare rates of urinary retention between transvaginal and robotic transabdominal approaches and identify risk factors for postoperative urinary retention following POP repair.

METHODS

Medical records of patients that underwent POP repair were reviewed. Surgeries included transvaginal high uterosacral ligament suspension (HUSLS) and robotic-assisted sacral colpopexy (RASCP). All patients underwent a retrograde fill voiding trial (RGVT) postoperatively. Demographics, comorbidities, preoperative urodynamic findings, and surgical procedures were compared between women that passed their RGVT and those that did not.

RESULTS

Out of 484 patients reviewed, 333 underwent POP repair with a transvaginal HUSLS and 151 underwent RASCP. Postoperative urinary retention was identified in 128 (26.4%) patients where 113 underwent transvaginal HUSLS and 15 underwent RASCP. The odds ratio (OR) of postoperative urinary retention following transvaginal HUSLS was 3.26 (CI 1.72-6.18; P < 0.001) compared to RASCP. Older age was also a risk factor for postoperative urinary retention (OR 1.03, CI 1.01-1.05; P = 0.012). While parity, preoperative post-void residual (PVR), and rates of concomitant transvaginal anterior/posterior repair were significantly higher in patients that developed postoperative urinary retention on univariate analysis, these factors did not demonstrate significance on multivariate analysis.

CONCLUSIONS

Transvaginal HUSLS demonstrates a 3.26 OR for postoperative urinary retention compared to the robotic transabdominal approach. Older age is also a significant risk factor whereas parity, preoperative PVR, and rates of concomitant transvaginal anterior/posterior repair were not significant risk factors on multivariate analysis.

Lumbosacral Osteomyelitis and Discitis with Phlegmon Following Laparoscopic Sacral Colpopexy

Lumbosacral osteomyelitis and discitis are usually a result of hematogenous spread; rarely it can result from direct inoculation during a surgical procedure. Bacteria may also track along implanted devices to a different location. This is a rare complication seen from pelvic organ prolapse surgery with sacral colpopexy. A 67-year-old female developed increasing lower back pain four months following a laparoscopic sacral colpopexy. Imaging revealed lumbar 5-sacral 1 (L5-S1) osteomyelitis and discitis with associated phlegmon confirmed by percutaneous biopsy and culture. The patient was treated conservatively with antibiotics, but required laparoscopic removal of the pelvic and vaginal mesh followed by twelve weeks of intravenous antibiotics. The patient has experienced clinical improvement of her back pain. This is an uncommon complication of sacral colpopexy, but physicians must be vigilant and manage aggressively to avoid more serious complications and permanent deficit.

Multidisciplinary Approach to the Treatment of Concomitant Rectal and Vaginal Prolapse

Rectal prolapse and vaginal prolapse have traditionally been treated as separate entities despite sharing a common pathophysiology. This compartmentalized approach often leads to frustration and suboptimal outcomes. In recent years, there has been a shift to a more patient-centered, multidisciplinary approach. Procedures to repair pelvic organ prolapse are divided into three categories: abdominal, perineal, and a combination of both. Most commonly, a combined minimally invasive abdominal sacral colpopexy and ventral rectopexy is performed to treat concomitant rectal and vaginal prolapse. Combining the two procedures adds little operative time and offers complete pelvic floor repair. The choice of minimally invasive abdominal prolapse repair versus perineal repair depends on the patient's comorbidities, previous surgeries, preference to avoid mesh, and physician's expertise. Surgeons should at least be able to identify these patients and provide the appropriate treatment or refer them to specialized centers.

Increased morbidity in combined abdominal sacrocolpopexy and abdominoplasty procedures

INTRODUCTION AND HYPOTHESIS

This study was performed to determine whether abdominoplasty combined with abdominal sacrocolpopexy (ASC + A) increases perioperative morbidity compared with ASC alone. We hypothesized that patients undergoing combined procedures would have increased complications.

METHODS

This was a multicenter, retrospective cohort study of all women undergoing ASC + A from 2002 to 2010 at Washington Hospital Center and Johns Hopkins University. We selected two women undergoing ASC alone for comparison with each ASC + A patient. Baseline demographics, surgical data, length of hospitalization, and perioperative complications were recorded. The primary outcome was any major complication within 6 weeks of surgery, including intraoperative complications, pulmonary embolism (PE), deep venous thrombosis (DVT), cardiac compromise, intensive care unit (ICU) admission, reoperation, and readmission. Surgical data and minor complications were also compared.

RESULTS

Twenty-six ASC + A patients and 52 ASC patients were identified. There were no significant differences in baseline characteristics between groups. Patients with ASC + A had longer operating times (337 vs 261 min, p < 0.01), more intravenous fluid administration intraoperatively (4,665 vs 3181 ml, p < 0.01), and longer hospital stays (3.7 vs 2.7 days, p < 0.01). Major complications occurred in 23 % of the ASC + A group compared with 12 % of the ASC group (p = 0.20). The ASC + A group had greater declines in hematocrit levels and higher rates of PE, ICU admission, and blood transfusion, all of which were statistically significant.

CONCLUSIONS

ASC + A increases length of stay and perioperative complications, such as PE, ICU admission, and blood transfusion, compared with ASC alone. Surgeons should consider recommending interval abdominoplasty due to increased morbidity risk with a combined procedure.