"Standardized" apical fixation - laparoscopic bilateral uterosacral ligament replacement: defined material of defined shape at defined fixation sites.

Ludwig S1, Mallmann P1

Research Type


Abstract Category

Continence Care Products / Devices / Technologies

Abstract 640
Surgical Video 2
Scientific Podium Video Session 32
Friday 31st August 2018
15:38 - 15:47
Hall B
Anatomy Mixed Urinary Incontinence Surgery Pelvic Organ Prolapse
1. University of Cologne, Germany

Sebastian Ludwig



In contrast to the established gold-standard (sacrocolpopexy, sacrospinous fixation) for apical fixation, the so called cervicosacropexy and vaginosacropexy (laCESA and laVASA) are clearly defined surgical procedures and restore urinary continence. The uterosacral ligaments (USL) are replaced bilaterally with a minimum of material between the cervix / vaginal vault and the sacral vertebra at the level of S1. Since the bony dimensions in the female small pelvis are nearly identical alloplastic tapes of defined lengths (9cm) and shape (width 0.4cm) were used to replace the USL. Therefore, the results are comparable and can be performed identically by different surgeons.
The objective of this study was the implementation of a laparoscopic apical fixation in the treatment of pelvic organ prolapse and urinary incontinence.
In laCESA, subtotal hysterectomy was performed by dissecting the uterus above the origin of the USL at the cervix. In laVASA, the peritoneum over the vaginal vault was opened along the running scar. The polyvinylidene-fluoride (PVDF) ligament-replacement structure was sutured to the cervix or vaginal vault. The peritoneum over the first sacral vertebra (attachment of the USL) was blunt-opened and the USLs were "tunneld" towards cervix/vault on both sides and the PVDF-structure was placed into the peritoneal fold. The PVDF ligament-replacement structure was attached with three titanium helices to the prevertebral fascia of S1 on each side. The peritoneum above the cervix or vaginal vault was closed.
Urinary incontinence symptoms were documented according to validated questionnaires, objective outcome according to POP-Q system.
So far, 160 patients underwent laCESA and laVASA. Median operating time was 89 minutes (32-194min). At 4 months, in 76% and 100% of patients urinary continence and apical prolapse were restored. No mesh erosion appeared.
The advantage of laCESA and laVASA lies in the comprehensible surgical technique (clearly defined technique) and the minimal amount of material used (no polypropylenes). 
The possibility of a short operating time and short hospitalisation depict this laparoscopic bilateral USL replacement as one treatment alternative in patients with apical prolapse suffering from UI.
The CESA and VASA surgical techniques are techniques to restore apical vaginal prolapse and urinary incontinence as already described. laCESA and laVASA with fixation at physiological landmarks with a minimum of material contributes to the established surgical treatment options for genital prolapse and urinary incontinence.
Funding None Clinical Trial No Subjects None
17/01/2021 07:10:56