Hypothesis / aims of study
Abdominal sacrocolpopexy with concomitant hysterectomy is often considered gold standard treatment for utero vaginal prolapse. The sacrocolpopexy has been performed for many years with several modifications. Ongoing innovations and developments in minimally invasive surgery led to the introduction of laparoscopic and later robotic-assisted laparoscopic approaches to abdominal sacrocolpopexy. The laparoscopic approach has potential advantages in terms of reduced morbidity, shorter hospital stay and convalescence. Laparoscopic sacrocolpopexy requires extensive tissue dissections, manipulations and suturing, laparoscopic surgery skills. Surgeons witl less experinece in laparoscopic pelvic surgery and suturing can results in supoptimal, time consuming and difficult operations susceptive to complications.
Vaginally assisted laparoscopic sacrocolpopexy (VALS) is a combined surgical approach where a vaginal hysterectomy is initially performed, followed by a transvaginal placement of a synthetic mesh and is concluded with a laparoscopic suspension of the vaginal vault on the sacral promontory. von Pechmann et al. first described the procedure and showed the safety and shortterm anatomical outcomes in a pilot study.
The objective of this study was to compare the short-term anatomic outcomes, complication rates, and operative times of patients with uterovaginal prolapse undergoing VALS with those of patients undergoing abdominal sacrocolpopexy
Study design, materials and methods
This is a prospective cohort study comparing VALS method to abdominal sacrocolpopexy with concurrent hysterectomy in patients advanced symptomatic utero vaginal prolapse stage 3 or 4 according to Pelvic Organ Prolapse Quantification (POP-Q) system. We recorded operation times, anesthesia time, estimated blood loss, outcomes, peroperative and postoperative complications.
The VALS procedure consists of two steps.First, vaginal hysterectomy performed, anterior vaginal wall dissected up to bladder neck starting from initial vaginal incision, posterior vaginal wall dissected from rectum starting from initial vaginal incision up to distal third of posterior vaginal wall. Two 15 cm long, 3 cm wide type 1 polypropylene meshes transfixed to anterior and posterior vaginal wall with 4-6 polyglactin suture to each wall. The sutured meshes are placed inside the pelvic cavity and the vaginal vault is closed with absorbable polyglactin suture. Mid urethral sling and/or perineoplasty were performed vaginally before laparoscopy. Laparoscopy was performed with one intraumbilical (10 mm), 3 lateral abdominal (5 mm) trocars. The sacral promontory is identified and the overlying peritoneum
is opened up to vaginal cuff laterally to the rectum and medially to the right uterosacral ligament. Two meshes fixated to anterior longitudinal ligament of the sacrum with with two separate 3/0 polypropylene sutures without tension. The mesh was then reperitonealized with absorbable interrupted extracorporeal sutures.
Abdominal sacrocolpopexy was performed via Pfannenstiel incision after total or subtotal abdominal hysterectomy. Sacrocolpopexy was performed similiar to laparoscopic scarocolpopexy.
Twenty one women underwent VALS, and 24 women underwent abdominal sacrocolpopexy. The mean follow up was 22 months for AS group and 13 months for VALS group. Hospitalization duration was shorter for the VALS group (median 2 (1-3)days ) than As group (median 3 (2-8) days) (p<0.0001). There was no signiﬁcant difference in peroperative complication rate omplication rates (12.5% vs none, p=0.09), blood loss (mean hemoglobin loss in VALS 1.7 g/dl, AS 1.6g/dl, p=0.7) postoperative complication rates (20.8% vs 4.8%, P = 0.1), mesh extrusion rates (12.5% vs 4.8%,p=0.3), and recurrence (%4.2 vs none, p=0.3). The mean total operative time and anesthesia time were similiar (operation times; VALS group 134.8 ±45.4, AS group minutes 151.2 ±40.1, anestheisia time; VALS group 181.3 ±45.4, As group 183.9 ±44.3 (p=0.8)).
Interpretation of results
VALS is a alternative for conventional abdominal sacrocolpopexy with similiar complication and less hospitalization.b