Hypothesis / aims of study
New minimally invasive surgical techniques for the reconstruction of pelvic organ static and pelvic floor function with individually designed tape implants may minimize postoperative complication rates and lower recurrence risk of pelvic floor dysfunction and/or prolapse. Herein, we present our first results of female pelvic organ prolapse correction with a new surgical technique.
Study design, materials and methods
We conducted a prospective single-arm study approved by the local ethical committee. The study was performed in accordance with the Declaration of Helsinki and written informed consent was obtained from all patients prior to the surgical procedure. The study included 38 women (median age, 60 years [range: 42-79 years]) with apical and anterior vaginal wall prolapse that was managed by Sacrouterin Ligament Augmentation (SULA) with Anterior Transobturator Tapes (ATOTs) by the same experienced surgeon. The preoperative vaginal status was assessed with POP-Q as stage II-IV by the International Continence Society (ICS) system. Polypropylene non-absorbable mesh (60g/m2; 10 cm x 15 cm) was used to individually design tape implants. Two pairs of tape implants were inserted transobturatorly (suburethral and subvesical) through two dermal incisions with Tunneller (Tyco). For sacrouterin ligament augmentation two apical tape implants were inserted completely tension free in the direction of both sacrouterin ligaments. SULA with ATOTs were used with or without vaginal hysterectomy (27 (median age, 62 years [range: 48-79 years]) and 7 cases (median age, 49 years [range: 42-62 years]), respectively). In 4 cases (median age, 65 years [range: 54-77 years]) ATOTs was used for correction of vaginal cuff prolapse. The postoperative ICS stage was assessed on day 5, at 3 and 12-months after surgery.
Interpretation of results
In contrast to other currently used methods for the treatment of pelvic organ prolapse, where apical tapes are attached directly, around or through the sacrospinous ligament, SULA enables completely tension free insertion of two apical tapes in the direction of both sacrouterin ligaments. Therefore, during sexual intercourse tape implants stay far away from the sacrospinous ligaments (out of the penetration line), which not only successfully minimizes the risk of postoperative dyspareunia, but may also lower the rate of postoperative complications (such as tape material extrophy) to the level of TVT-O procedures. Secondly, aesthetic advantage is provided by placing only one surgical incision access on each thigh, (hiding the incision in skin folds). Both pairs of transobturator tapes are separately inserted through the same surgical incision. Importantly, suburetral and subvesical part of the tapes stay medially connected, but remain flat, so that they do not twist into a string until passing transobturatorly. Transobturator tapes connect both tendieus archs and serve as good anchors for apical tapes, which individually move laterally into the paravesicular space before being inserted tension free in an upward direction parallel to the sacroutein ligaments. SULA with ATOTs can also be used to support the pelvic organs in case of lateral pubocervical fascia and apical cardinal and sacrouterin ligament defects.