Pelvic Organ Prolapse
The laparoscopic approach has been increasingly used in POP surgery.
Sacrocolpopexy(SCP) is considered a gold standard and is associated with vascular complications (6.7%), intestinal obstruction (4.7%), constipation (1-2%) and infectious lumbar discitis (8 cases).
Initial series of laparoscopic lateral colposuspension (LCS) demonstrated good anatomical and functional results with high patient satisfaction (Veit-Rubin2017).
Objective: To describe an alternative mesh fixation method for LCS, report preliminary results, advantages, and limitations.
On July 2018, LCS (Dubuisson-technique) experience was started in our department.
Symptomatic predominantly anterior and/or apical compartment prolapses associated or not with lower-degree posterior compartment prolapse.
Frequency and severity of urinary, anorectal, genital and sexual symptoms were assessed. Simplified POP-Q system, bi-manual examination, and cervix cytological screening were used.
Preoperative workup included urinalysis, gynecological and urinary ultrasounds. Post-voided residuals were systematically measured. Urine culture was used to rule out UTI if suggested by urinalysis. Urodynamics were performed in high-grade prolapses associated with LUTS or when results would alter planned treatment.
The patient’s preferences and expectations were considered. Informed consent was obtained.
A four trocar transperitoneal pure laparoscopic approach and conventional laparoscopic material were used.
A 7x4cm polyvinylidene fluoride MRI visible mesh was employed. Mesh fixation was done using a colored cyanoacrylate tissue adhesive and barbed sutures for mesh reperitonealization.
Pre, intra and postoperative variables were assessed.
Surgeries were video-recorded and reviewed in February 2019. SonyVegas Pro11® was used for video edition and GIMP® for image edition.
Ten Patients were included with symptomatic stageIII anterior compartment prolapses. No symptomatic posterior compartment prolapses were identified.
Two patients referred urgency without incontinence. Neither evident nor occult stress urinary incontinence (SUI) was identified (prolapse manual reduction). Anti-incontinence surgery was not performed.
Four patients referred slow and/or incomplete micturition. Urodynamic investigations revealed abnormally high post-void residuals on 3 patients (>150ml) and 1 BOO. Neither detrusor overactivity nor underactivity was demonstrated.
Voiding cystometry ruled out other causes of voiding dysfunction. Defecatory or sexual dysfunctions were not preoperatively identified.
Nine patients were coitally active and 1 inactive (With plans to become active). Coexistent pelvic pathology was previously ruled out. The uterus was preserved and hysterectomies were not performed.
The median age was 69+-7 years. All procedures were laparoscopically completed.
Median surgical time was 55±21 min. The median estimated blood loss was 22+-16ml.
Neither intraoperative nor postoperative complications were identified.
The length of hospital stay was 24h.
All patients referred return to normal activities on the first visit to the outpatient clinic (one month after surgery). All patients referred absence of vaginal bulge (Subjective patient-reported outcomes).
Satisfactory anatomical and functional results were obtained at 6 months of follow-up. Neither enterocele nor de-novo-SUI was reported. LUTS remission was achieved. Relapses were not identified and no further surgery was needed.
Satisfactory MRI mesh visualization was obtained and post-operative complications were not identified.
LCS advantages are:
- Minimal risk of complications associated with sacral dissection (neuro-vascular, ureteral, and constipation)
- Decrease surgical time by reducing mesh reperitonealization.
- Symmetrical tension-free vaginal suspension is achieved. Uterosacral ligaments attachments and postero-lateral orientation of the vagina (DeLancey Level-I) are emulated.
- Acceptable patient-reported satisfaction was achieved.
The technique is associated with good anatomical and functional results. Reestablish quality of life with minimal complications.
Multicentric, prospective and randomized trials are needed to compare alternative techniques with gold-standard. Longer follow-up is needed.
Alternative mesh fixation method theoretically brings less ischemia to the vagina, especially in the postero-lateral planes, associated with poorer irrigation. This method might bring a lesser risk of mesh extrusion.
Mesh MRI-visualization represented a valuable tool to rule-out complications.
Video-surgical review is considered a useful tool to optimize techniques in our department.