Pelvic Organ Prolapse
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Cristina Gutiérrez Ruiz
Sacrocolpopexy can be considered the “gold standard” in the correction of vaginal vault prolapse, however it depends on the experience of the surgeon.
During sacrocolpopexy, sigmoid colon and sacral promontorium should be identified and care should be taken to avoid damaging the right ureter, presacral veins, hypogastric nerve and sigmoid colon in the sacral area. Some well-known disadvantages of the technique are : extended surgical time, long learning curves, postoperative defecation disorders and pelvic pain.
Laparoscopic pectopexy is a novel method of vaginal prolapse repair that offers clear practical advantages compared with laparoscopic sacropexy. This technique uses the iliopectineal ligament on both sides for the mesh fixation, so there is no restriction caused by the mesh. The mesh follows natural structures (round and broad ligaments) without crossing sensitive spots, such as the ureter or bowel. This surgical modifications help reduce the complications of the sacrocolpopexy, operation time and learning curve.
59 years-old female patient with Steinert disease and previous hysterectomy plus double adnexectomy, complaining of voiding dysfunction due to vaginal vault prolapse requiring CIC (Clean Intermittent Catheterization) for bladder emptying.
The physical examination showed vaginal vault prolapse stage 3. The Pelvic Organ Prolapse Quantification System (POP-Q) is shown above
Urodynamics Study: Bladder Outlet Obstruction due to vaginal vault prolapse.
Due to high anesthetic risk involving her muscular dystrophy and her altered anatomical condition, laparoscopic pectopexy was proposed.
The surgery was performed using standard laparoscopic equipment with 4 trocars of 10-mm and 5-mm. The optical access was placed via infraumbilical trocar, and the working devices were introduced through a pararectal, left, and right incisions as usual.
In this particular case with the uterus missing, we opened the peritoneal layer along the theoretical direction of both round ligaments towards the pelvic wall. The dissection begins at the right external iliac vein. We exposed an approximately 3-cm segment of the right iliopectineal ligament (Cooper ligament) adjacent to the insertion of the ileopsoas muscle.
We must take care of the obturator nerve, situated caudal to our dissection field. Vaginal apex was prepared for mesh placement and the anterior and posterior wall of the vaginal peritoneum were dissected.
The vaginal apex was fixed with absorbable suture material. The mesh ends were attached to both iliopectineal ligaments using nonabsorbable suture material of polyvinylidene fluoride (PVDF) pulled up to the intended tension-free position. A hammock-like fixation of the vaginal apex was performed. Finally, we covered the mesh with peritoneum using absorbable suture material in a continuous suturing technique.
Total surgical time was 120 minutes, with no subsequent surgical or anesthetic complications. The patient was discharged at 48h. The anterior and middle prolapse was minimally invasively resolved. Voiding dysfunction disappeared and no constipation was observed in the follow up.
According to our experience, laparoscopic pectopexy offers a feasible, safe, and comfortable alternative for apical prolapse surgery with shorter surgical time.
Noé KG, Schiermeier S, Alkatout I, Anapolski M. Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study. J Endourol. 2015 Feb;29(2):210-5. doi: 10.1089/end.2014.0413. Epub 2014 Nov 20. PMID: 25350228; PMCID: PMC4313410.Karsli A, Karsli O, Kale A. Laparoscopic Pectopexy: An Effective Procedure for Pelvic Organ Prolapse with an Evident Improvement on Quality of Life. Prague Med Rep. 2021;122(1):25-33. doi: 10.14712/23362936.2021.3. PMID: 33646939.
Continence 2S2 (2022) 100310DOI: 10.1016/j.cont.2022.100310