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A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse
GYNAECOLOGY
A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse Salomon Zebede, MD, Ashraf Dawood, MD, May Alarab, MD, MSc, Harold Drutz, MD, Danny Lovatsis, MD, MSc Mount Sinai Hospital, University of Toronto, Toronto ON Women’s College Hospital, University of Toronto, Toronto ON
Abstract
Résumé
Objective: To describe a streamlined laparoscopic sacrocolpopexy (LSCP) surgical technique in women with post-hysterectomy vault prolapse and to evaluate the functional outcomes, complication rates, and surgical morbidity within our centre.
Objectif : Décrire une technique chirurgicale simplifiée pour la tenue d’une sacrocolpopexie laparoscopique (SCPL) chez des femmes présentant un prolapsus post-hystérectomie du dôme vaginal et évaluer les issues fonctionnelles, les taux de complication et la morbidité chirurgicale au sein de notre centre.
Methods: We retrospectively reviewed the charts of 180 patients scheduled for LSCP between November 2002 and May 2013 in a tertiary care centre. Patients were followed-up at six weeks, six months, and yearly after surgery. We reviewed patient demographics, preoperative and postoperative symptoms, and perioperative variables. Objective success of the surgery was defined as having a less than stage 2 vault prolapse, and subjective success was defined as the absence of bulge or prolapse symptoms. Success and complication rates were calculated. Results: Of the 180 patients who underwent surgery, 144 patients underwent the procedure as planned and had at least six months of follow-up. At the last follow-up visit, 133 of these 144 patients (92.4%) were free of prolapse symptoms. Several bladder and bowel symptoms showed significant improvement. Anatomical success of vault support was achieved in 140 of 144 patients (97.2%), and 119 patients (82.6%) had no prolapse beyond the hymen. Early complications (within the first 6 weeks) occurred in 8.3% of 162 patients with limited outcome data, and late complications (after 6 weeks) occurred in 11.5% of the 144 patients with long-term data. There were no cystotomies or mesh exposures. Conclusion: At an average of 32 months, this cohort of patients had low prolapse recurrence rates and no reports of cystotomy or mesh erosion. The abridged LSCP technique, as practised in our institution, is safe and effective in the surgical management of posthysterectomy vault prolapse.
Key Words: Laparoscopic sacrocolpopexy, LSCP, mesh, outcomes, post-hysterectomy, prolapse Competing Interests: None declared. Received on July 31, 2015
Méthodes : Nous avons mené une analyse rétrospective des dossiers de 180 patientes qui devaient subir une SCPL entre novembre 2002 et mai 2013 au sein d’un centre de soins tertiaires. Les patientes ont bénéficié d’un suivi à six semaines et à six mois; par la suite, un suivi annuel a été mis en œuvre. Nous avons analysé les caractéristiques démographiques des patientes, les symptômes préopératoires et postopératoires, ainsi que des variables périopératoires. La réussite objective de la chirurgie a été définie comme la constatation subséquente d’un prolapsus du dôme vaginal d’un stade inférieur à 2, tandis que la réussite subjective de cette intervention a été définie comme l’absence de bombement ou de symptômes associés au prolapsus. Les taux de réussite et de complication ont été calculés. Résultats : Parmi les 180 patientes qui ont subi la chirurgie, 144 ont subi l’intervention telle que planifiée et ont bénéficié d’un suivi d’au moins six mois. Au moment de la dernière consultation de suivi, 133 de ces 144 patientes (92,4 %) ne connaissaient aucun symptôme associé au prolapsus. Plusieurs symptômes vésicaux et intestinaux ont connu une atténuation significative. Une réussite anatomique quant au soutien du dôme a été obtenue chez 140 des 144 patientes (97,2 %); de plus, 119 patientes (82.6 %) ne présentaient plus de prolapsus au-delà de l’hymen. Des complications précoces (au cours des six premières semaines) se sont manifestées chez 8,3 % des 162 patientes pour lesquelles nous ne disposions que de données limitées quant aux issues, tandis que des complications tardives (après six semaines) se sont manifestées chez 11,5 % des 144 patientes pour lesquelles nous disposions de données à long terme. Aucun cas de cystotomie ou d’exposition du treillis n’a été constaté. Conclusion : À une moyenne de 32 mois, cette cohorte de patientes présentaient de faibles taux de récurrence du prolapsus et aucun cas de cystotomie ou d’érosion du treillis n’avait été signalé. La technique SCPL simplifiée, telle que pratiquée au sein de notre établissement, est sûre et efficace pour la prise en charge chirurgicale du prolapsus post-hystérectomie du dôme vaginal. Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
Accepted on November 3, 2015 http://dx.doi.org/10.1016/j.jogc.2016.01.006
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J Obstet Gynaecol Can 2016;38(5):446-452
A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse
INTRODUCTION
O
pen sacrocolpopexy, with the use of mesh, has long been considered a successful and safe surgical procedure and has become the standard of care in the management of women with post-hysterectomy vault prolapse.1 However, in the last two decades, minimally invasive surgery has advanced dramatically; laparoscopic sacrocolpopexy (LSCP) provides the potential to combine the success rate of an abdominal approach with the faster recovery time and minimal morbidity associated with a minimally invasive technique.2,3 Unfortunately, the time required to become proficient in the procedure, some technical difficulties in performing the procedure, and the frequent increase in operating time required by an unskilled surgeon have greatly limited its use.4 While adhering to the basic principle of this procedure, many variations in surgical technique have been introduced; however, good quality data to support use of one technique over another are limited.5 Mesh erosion after sacrocolpopexy remains a problem, although generally it is less frequent than with vaginal mesh kits; the average rate for post-hysterectomy patients is 3% to 4%, and when a total hysterectomy or vaginal hysterectomy is performed concomitantly the rate can be up to 16% to 32%.6 Our tertiary care centre uses a surgical technique that avoids the dissection of the peritoneum or bladder from the vaginal wall and peritoneal covering of the mesh. Using this technique, it may be possible to reduce the incidence of cystotomy and mesh erosion or to eliminate these complications entirely and to shorten the surgical time. We describe here our technique and examine the functional outcomes, complication rates, and surgical morbidity of LSCP at our centre, seeking to demonstrate that LSCP using our streamlined surgical technique is a useful alternative in the treatment of post-hysterectomy patients with vault prolapse. METHODS
We reviewed the medical charts of all patients who underwent LSCP performed by a single surgeon (D.L.) between November 2002 and May 2013 at Mount Sinai Hospital or Women’s College Hospital, Toronto, ON. Before surgery, a standardized history was taken and physical examination was performed by a resident or fellow and the attending staff member in the urogynaecology clinic at Mount Sinai Hospital. This included demographic
information (age, parity, BMI, smoking status, history of prolapse or incontinence surgery, route of previous hysterectomy, menopausal status, and previous use of pessary), questions regarding the presence of prolapse symptoms (vaginal bulge or lump), urinary symptoms (stress incontinence, urge incontinence, mixed incontinence, voiding dysfunction), and bowel symptoms (constipation, obstructed defecation, fecal incontinence, rectal prolapse). Physical examination, with the patient in the lithotomy position, was performed by the attending staff member and included objective assessment of the pelvic organ prolapse in each compartment (anterior, apical, and posterior). Patients were asked to perform a Valsalva manoeuvre with maximal effort. The stage of prolapse in each compartment was classified using the simplified pelvic organ prolapse quantification examination described and validated by Swift et al.7e9 Stage 0 to 1 defines prolapse 1 cm or more above the level of the hymen, stage 2 is at the hymen (± 1 cm), stage 3 is more than 1 cm beyond the level of the hymen but without complete vaginal vault eversion, and stage 4 is complete eversion of the vagina. A cough stress test was carried out in all patients in the lying position with manual reduction of the prolapse and a full bladder at the end of urodynamic testing. Urodynamic testing was performed in all patients to assess for any bladder symptoms and to identify “occult” stress incontinence. Urodynamic testing at our institution includes multichannel cystometry, urethral pressure profile, uroflowmetry, and measurement of the postvoidal residual. Surgical Technique
Our standard protocol includes one preoperative dose of intravenous antibiotic and prophylaxis for deep vein thrombosis using subcutaneous lowemoleculareweight heparin. All surgical procedures were performed by a single surgeon (D.L.) with the assistance of urogynaecology fellows in training. A 0-degree 10-mm laparoscope is inserted at the umbilicus, and the patient is then placed in a steep Trendelenburg position. A left lower quadrant 12-mm port is placed and two 5-mm ports are then inserted, one in the right lower quadrant and the other in the left mid-abdomen. Later during the procedure, a 5-mm suprapubic port is placed. The sacral promontory is visualized and the peritoneum is elevated away from the sacrum and incised. Under direct vision, the extraperitoneal tissue is teased open with blunt dissection using laparoscopic scissors and the anterior longitudinal ligament of the spine is exposed at the promontory. Any central blood vessels on the promontory
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are cauterized. The vaginal vault is elevated using a vaginal probe, and a Y-shaped piece of prolene mesh is attached to the anterior and posterior walls.
percentage for categorical variables. The change in categorical outcomes (proportions) between preoperative and postoperative conditions was assessed using McNemar’s test.
In all cases we used a type 1 (monofilament, macroporous) polypropylene mesh (Surgipro; Covidien Canada, SaintLaurent, QC, and ProLite Mesh; Atrium Medical Corp., Hudson, NH). The anterior arm of the mesh is extended as far as the bladder reflection will allow, but the bladder and the peritoneal reflection are not dissected off the vagina to avoid thinning of the tissues; this decreases the risk of mesh exposure or cystotomy. The posterior arm of the mesh is extended caudally into the cul-de-sac but is simply attached to the middle upper segment of the posterior vaginal wall without caudal dissection to the perineal body. The mesh is sutured to the vaginal walls with fullthickness interrupted sutures of 0 prolene using extracorporeal sliding knots. The anterior arm of the mesh typically measures 4 cm in length and is attached to the anterior vaginal wall using four interrupted sutures; the posterior arm of the mesh usually measures 6 cm and is attached to the posterior vaginal wall using six interrupted sutures. Cystoscopy is routinely performed at this point to ensure that no sutures pass through the bladder. The mesh is then attached to the sacral promontory at the S1 level using a 5-mm ProTak fixation device (Covidien Canada) through an additional 5-mm suprapubic port. A large free space is left behind the mesh to decrease the risk of internal bowel hernia, and the mesh is not covered with peritoneum. All additional procedures, such as vaginal repair or incontinence procedures, are performed subsequently. The procedure is fully described in an online video recording.10
Ethics approval for the study was provided by the Research Ethics Boards of Mount Sinai Hospital and Women’s College Hospital, Toronto, Ontario.
Patients typically returned to our clinic for postoperative visits at six weeks, six months, one year, and annually thereafter. At every postoperative visit, all patients are asked about any medical issues, pelvic floor and urinary symptoms, and overall satisfaction with the outcome (described as “same,” “better,” or “worse”). At each visit a urogynaecological examination is performed, including assessment of the stage of prolapse in each compartment, as previously described. Anatomical failure is recorded if there is apical evidence of stage 2 prolapse or greater. Subjective failure is recorded if the patient reports experiencing a bulge or feeling something falling out. We used SPSS version 22.0 (IBM Corp., Armonk, NY) for descriptive and inferential analysis. All inferential tests were performed using P < 0.05 as the index of significance. Descriptive analysis was conducted by reporting mean and standard deviation for continuous measures or count/
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RESULTS
A total of 189 patients with a clinical diagnosis of symptomatic post-hysterectomy vault prolapse underwent LSCP during the study period. Nine patients were excluded from analysis because of incomplete data, leaving a cohort of 180 patients. Of the 180 patients who underwent surgery, 18 had a modification of the planned procedure because of multiple adhesions, and another 18 had less than six months of follow-up, leaving 144 patients with complete data for analysis. The mean age was 60 ± 8.4 years (range 37 to 82). Patient demographics are described in Table 1. At the last follow-up visit, 140 patients (97.2% of the cohort) had anatomically successful vault support, as defined by stage 0 to 1 prolapse. In 134 patients (93%), the vault was suspended in the upper one third of the vagina. If an anatomically successful outcome was defined as having no prolapse beyond the hymen in any compartment (apical, anterior, or posterior), success was achieved in 119 patients (82.6%). On subjective assessment at the last follow-up visit, 133 patients (92.4%) were free of prolapse symptoms. Only nine patients (6.3%) requested additional treatment for symptomatic prolapse. Of these, four were referred for a vaginal mesh procedure, one underwent anterior vaginal repair, one underwent posterior vaginal repair, one underwent both anterior and posterior vaginal repair, and one underwent an open abdominal sacrocolpopexy. The remaining patient’s prolapse was managed using a pessary. In assessing their overall satisfaction (the same, better, or worse than before surgery) most patients (135; 93.8%) reported feeling better after surgery, eight reported feeling the same, and only one reported feeling worse than before surgery. Preoperatively, all patients experienced prolapse symptoms, specifically reporting a vaginal lump or bulge. One hundred eight patients (60%) reported at least one bladder symptom, and 56 (31.1%) reported at least one bowel symptom. Preoperative and postoperative symptoms are summarized in Table 2. Preoperatively all women had a significant vault descent of stage 2 or more. Anatomical findings during physical examination preoperatively and at the last follow-up visit
A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse
Table 1. Patient Demographics (n [ 180) Characteristic Mean age in years ± SD (range)
60 ± 8.4 (37 to 82)
Mean BMI in kg/m2 ± SD
25.7 ± 3.6
Median parity (range) Type of previous hysterectomy
2 (0 to 8) Vaginal hysterectomy: 88 (48.9%) Laparoscopic assisted vaginal hysterectomy: 8 (4.4%) Total abdominal hysterectomy: 84 (46.7%)
Table 2. Preoperative and Postoperative Symptoms (n [ 144)a Preoperative Stress urinary incontinence
57 (39.6%)
10 (6.9%)
< 0.001
Urge urinary incontinence
46 (31.9%)
14 (9.7%)
< 0.001
Mixed urinary incontinence
19 (13.2%)
2 (2.8%)
< 0.001
Incomplete emptying (PVR > 100 mL)
14 (9.7%)
3 (2.1%)
< 0.01
22 (12.3%)
Bowel symptoms
Postmenopausal, n
166 (92.3%)
Constipation
32 (17.8%)
Previous incontinence procedure, n
50 (27.8%)
Previous anticholinergic medication, n
26 (14.4%) One: 76 Two: 55 Three: 32 Four: 13 Five: 4
Previous POP surgery
At least one previous POP surgery: 133 (73.9%) 2 previous POP surgeries: 29 (16.1%)
POP: pelvic organ prolapse.
are described in Table 3. Thirty-seven patients (23%) did not return for their last follow-up appointment. The mean (± standard deviation) duration of follow-up was 32.1 ± 25.8 months, with a median of 21 months. In 104 cases, the Surgipro mesh was used, and in 58 cases, the ProLite mesh was used. One hundred eighteen women (72.8%) underwent a concomitant surgical procedure. Intraoperative cystoscopy was performed in 114 patients (70.4%). Eighteen of the procedures (10%) were converted to either an open abdominal sacrocolpopexy (two cases) or a sacrospinous vault suspension (16 cases). In all these cases the indication for conversion was the presence of multiple pelvic adhesions. As noted, 11 of the 18 patients had had at least three or more prior abdominal or pelvic surgical procedures. There were no intraoperative complications. The mean total operating time was 126 ± 43 minutes, including laparoscopic port positioning and concomitant procedures, and the mean surgical blood loss was 112 ± 69 mL. As shown in Table 4, both operating time and surgical
39 (27.1%)
Fecal incontinence Obstructed defecation Sexually active Dyspareunia
Number of previous abdominal or pelvic procedures
McNamara P values
Bladder symptoms
Current smoker, n
Previous pessary, n
Postoperative
Prolapse symptom
13 (9%)
< 0.001
7 (4.9%)
2 (1.4%)
0.18
10 (6.9%)
1 (0.7%)
< 0.01
86 (59.7%)
82 (56.9%)
0.61
14 (16.2%)
6 (7.3%)
0.18
144 (100%)
11 (7.6%)
< 0.001
PVR: post-void residual volume. a Conversion cases and patients with less than 6 months of follow-up were excluded.
blood loss varied widely depending on concomitant procedures. Ninety-seven patients (59%) underwent a concomitant vaginal repair; 84 (52%) underwent an anterior repair, and 75 (46%) underwent a posterior repair. Fifty-eight women (35.8%) underwent outpatient surgery, with an average hospital stay of 9.0 ± 1.0 hours. When surgery was performed on inpatients, the mean duration of hospital stay was 1.2 ± 0.5 days (range 1 to 5). Early postoperative complications (occurring during the first 6 weeks after surgery) occurred in 8.3% of patients, and late complications (occurring more than 6 weeks after surgery) occurred in 11.5%. The details of complications are provided in Table 5. Among patients with early complications, three patients with early voiding dysfunction required use of a Foley catheter for an average of six days. Two patients experienced port-related complications at the site of the 12-mm port. One patient developed a port-site hernia at five weeks after surgery and required surgical intervention for incarceration of the hernia. One patient required blood transfusion after a concomitant tension-free vaginal tape procedure resulted in a retropubic hematoma that was managed conservatively. Three patients developed a postoperative ileus; they received conservative management and were discharged on the fourth postoperative day. In patients with late complications, seven (4.9%) reported stress urinary incontinence symptoms. Three of these
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Table 3. Objective Stage of Preoperative and Postoperative Prolapse
Compartment
Stage 0e1 Preoperative Postoperative n ¼ 180 n ¼ 144
Preoperative n ¼ 180
Postoperative n ¼ 144
Stage 3e4 Preoperative Postoperative n ¼ 180 n ¼ 144
Anterior
34 (18.9%)
126 (87.5%)
23 (12.8%)
13 (9%)
123 (68.3%)
0 (0%)
140 (97.2%)
91 (50.6%)
2 (1.39%)
89 (49.4%)
2 (1.39%)
54 (30%)
133 (92.3%)
47 (26.1%)
7 (4.9%)
79 (43.9%)
4 (2.8%)
Vault Posterior
Stage 2
patients underwent a procedure for incontinence (tensionfree vaginal tape), and the remaining four chose conservative management with pelvic floor exercises. Two patients (1.4%) developed de novo dyspareunia; one chose to undergo expectant management, and the other used vaginal dilators, with resolution of dyspareunia six months after surgery. Two patients presented with small bowel obstruction. One initially underwent conservative management but experienced recurrent hospitalization and requested excision of the mesh four years after surgery. After excision of the mesh, vault prolapse recurred. The second patient presented three months after surgery with small bowel obstruction that required excision of the mesh. Review of the general surgeon’s operative report indicated that the mesh had remained extraperitoneal but had adherent small bowel, requiring excision of a segment of mesh and small bowel. There were no cystotomies, mesh exposures, or suture-related complications in any cases. DISCUSSION
Our findings provide evidence that LSCP, using the abridged technique described here and demonstrated in the online video recording,10 with vaginal repairs when needed, is an effective procedure for the treatment of posthysterectomy vault prolapse. Vault support was provided in 97.2% of patients, and subjective outcomes and patient satisfaction after the procedure also were high, demonstrating outcomes similar to those previously reported.3,11
5 (3.5%)
There have been many variations in these surgical techniques. Some authors recommend extensive dissection of the vesicovaginal space to the level of the urethro-vaginal junction and of the rectovaginal space to the levator ani muscles, but at our institution we prefer to avoid this. As reflected in our results, we have shown that by avoiding this dissection we reduce the risk of perioperative complications (cystotomy, vaginal or bowel perforation) and long-term complications such as mesh erosion and defecatory symptoms. Nevertheless, avoiding the laparoscopic dissection of the vesicovaginal and rectovaginal space will increase the number of patients needing concomitant vaginal repair, as reflected in our results. In a recent cadaver study, Noblet et al. showed that dissection for abdominal sacrocolpopexy may only result in identifying the correct plane between the bladder and vagina in approximately 60% of cases.12 In 30% of their cases, the mesh was located within the split layers of the vaginal wall rather than in the space between the bladder and vagina.12 We believe this is one of the reasons that mesh erosion occurs. In vitro evidence has shown that when the mesh is in direct contact with vaginal smooth muscle cells, it has an atrophic effect on smooth muscle, perhaps due to reduced smooth muscle innervation, and this will lead to a higher risk of mesh erosion.13 Recently the long-term outcomes of the CARE trial were published, reporting an estimated probability of mesh erosion of 9.9% with a tendency for the risk to increase with time.14 In our study there were no cases of
Table 4. Operative Time and Blood Loss for Each Procedure (n [ 162) Number of Procedures
Surgical Procedure Sacrocolpopexy
48
Operative Time (mean ± SD), minutes 104 ± 27
Blood Loss (mL) 64 ± 32
Sacrocolpopexy þ AR and PR
37
119 ± 23
114 ± 47
Sacrocolpopexy þ AR
16
122 ± 22
103 ± 59
Sacrocolpopexy þ PR
12
122 ± 27
100 ± 0
Sacrocolpopexy þ APR þ 2 team sling
25
194 ± 54
225 ± 75
Sacrocolpopexy þ TVT
13
117 ± 35
92 ± 29
Sacrocolpopexy þ TVT þ vaginal repair
7 (4 APR, 2 AR, 1 PR)
150 ± 51
142 ± 38
120 ± 15
137 ± 48
Sacrocolpopexy þ salpingo-oophorectomy
4
AR: anterior repair; PR: posterior repair; APR: anterior and posterior repair; TVT: tension-free vaginal tape.
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A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse
Table 5. Complication Rates
Complication
Early: First Six Postoperative Weeks (n ¼ 162)
Late: Six Weeks Postoperatively to Last Follow-Up Visit (n ¼ 144)
Urinary tract Urinary tract infection
4
1
Voiding dysfunction
3
0
De novo stress urinary incontinence
0
7
De novo urge urinary incontinence
0
3
De novo overactive bladder
0
2
Port-related complication Port hernia
1
0
Hematoma
1
0
Small bowel obstruction
0
2
Ileus
2
0
Severe constipation
1
1
Postoperative fever
1
0
Blood transfusion
1
0
De novo dyspareunia
0
2
14
16
Gastrointestinal
Other
Total
Clavien-Dindo Classification of Postoperative Complications I (no treatment)
8
9
II (need for pharmacological treatment)
5
3
performing a sacral colpoperineopexy is associated with no improvement and even worsening of defecatory symptoms.5 Many surgeons believe that peritoneal covering of the mesh will decrease the risk of bowel complications, but this remains controversial. Muller et al. conducted a retrospective review comparing patients who had reperitonealization of the mesh with those who did not and found that reperitonealization of the mesh was not associated with a reduction of bowel complications.15 Elneil et al. also reported that they did not find an increase in complication rates after performing 121 sacrocolpopexy procedures without burying the mesh and patient follow-up for a median of 19 months.16 In our cohort, bowel complications occurred at a rate of 3% (3 cases of ileus managed conservatively, and 2 cases of small bowel obstruction necessitating surgical intervention). This rate is similar to that reported in other studies in which the mesh is covered by peritoneum.17 Our study provides further evidence that omitting reperitonealization of the mesh is safe. In an era in which reducing costs and improving the quality of care are priorities, we believe that these can be achieved by reducing operating time and moving some procedures to an ambulatory setting without compromising quality. With the surgical technique described in this study, we were able to reduce operating time and to perform procedures in an ambulatory setting. In our cohort, 58 of the cases (35.8%) were performed successfully in an ambulatory setting with same-day discharge. We assume that this would result in significant cost savings, although further cost analysis is required for confirmation.
mesh erosion, and we believe that this was related to avoiding the dissection of the visceral peritoneum.
Pelvic organ prolapse usually is part of complex pelvic floor dysfunction, with coexisting bladder and bowel symptoms. In our cohort, 60% of patients experienced at least one bladder symptom and 30.1% experienced at least one bowel symptom. Our findings demonstrate a significant reduction in both bladder and bowel symptoms after surgery. However, because of the retrospective nature of the study, we were able to collect data only on the presence or absence of symptoms. We recognize that using validated questionnaires preoperatively and postoperatively is the best means of measuring any subjective data, and having not done so is a weakness of this study. An additional limitation of this study, inherent in any retrospective study, is the lack of information about patients lost to follow-up and how this could have affected the findings.
In a review, Parkes et al. noted that there is evidence suggesting that dissection of the posterior vaginal wall and
Nevertheless, this study has several strengths. First, patients had intermediate- to long-term follow-up. Any
IIIa (intervention under local anaesthesia) IIIb (intervention under general anaesthesia)
1 (port hernia)
5 (3 TVT for de novo SUI, 2 for bowel obstruction)
IV (intensive care due to single or multiorgan failure)
0
0
V (death)
0
0
TVT: tension-free vaginal tape; SUI: stress urinary incontinence.
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patients with less than six months of follow-up were excluded from the outcomes analysis but not from the analysis of perioperative data or complications. A second strength is the uniformity of the surgical technique. Variations in the surgical technique, as well as a mix of procedures, including any type of promontory fixation (hysteropexy, cervicopexy, and sacrocolpopexy) and concomitant hysterectomy, will give an imprecise understanding of the success rate or complications for a specific procedure. CONCLUSION
LSCP, using the technique described in this study, is a highly effective procedure for treating post-hysterectomy vault prolapse. After an average of 32 months, patients had good objective and subjective results and a significant reduction in pelvic organ prolapse symptoms. Complication and recurrence rates in our cohort were low, with no mesh erosion or cystotomy. Because the procedure may be performed on an outpatient basis, using our streamlined technique, it can provide significant cost savings.
REFERENCES 1. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2013;4:CD004014. 2. Freeman RM, Pantazis K, Thomson A, Frappell J, Bombieri L, Moran P, et al. A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J 2013;24:377e84. 3. Ganatra AM, Rozet F, Sanchez-Salas R, Barret E, Galiano M, Cathelineau X, et al. The current status of laparoscopic sacrocolpopexy: a review. Eur Urol 2009;55:1089e103. 4. Coolen AL, van Oudheusden AM, van Eijndhoven HW, van der Heijden TP, Stokmans RA, Mol BW, et al. A comparison of complications between open
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abdominal sacrocolpopexy and laparoscopic sacrocolpopexy for the treatment of vault prolapse. Obstet Gynecol Int 2013;2013:528636. 5. Parkes IL, Shveiky D. Sacrocolpopexy for treatment of vaginal apical prolapse: evidence-based surgery. J Minim Invasive Gynecol 2014;21:546e57. 6. Lee RK, Mottrie A, Payne CK, Waltregny D. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Eur Urol 2014;65:1128e37. 7. Swift SE, Morris S, McKinnie V, Freeman R, Petri E, Scotti RJ, et al. Validation of a simplified technique for using the POPQ pelvic organ prolapse classification system. Int Urogynecol J 2006;17:615e20. 8. Parekh M, Swift S, Lemos N, Iskander M, Freeman B, Arunkalaivanan AS, et al. Multicenter inter-examiner agreement trial for the validation of simplified POPQ system. Int Urogynecol J 2001;22:645e50. 9. Lemos N, Korte JE, Iskander M, Freeman R, Arunkalaivanan A, Rizk D, et al. Center-by-center results of a multicenter prospective trial to determine the inter-observer correlation of the simplified POP-Q in describing pelvic organ prolapse. Int Urogynecol J 2012;23:579e84. 10. Dawood A, Zebede S, Alarab M, Drutz H, Lovatsis D. A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse. Available at: http://www.youtube.com/watch?v¼u4Cq4N y0Pgw. Accessed on June 6, 2014. 11. Sarlos D, Kots L, Ryu G, Schaer G. Long-term follow-up of laparoscopic sacrocolpopexy. Int Urogynecol J 2014;25:1207e12. 12. Noblett K, Brueseke T, Lin F, Rosenblatt P. Comparison of location of mesh placed transvaginally vs mesh placed abdominally at the time of sacrocolpopexy. Int Urogynecol J 2015;26:79e83. 13. Jallah Z, Liang R, Feola A, Barone W, Palcsey S, Abramowitch SD, et al. The impact of prolapse mesh on vaginal smooth muscle structure and function [epub ahead of print]. BJOG http://dx.doi.org/10.1111/1471-0528.13514. [Epub ahead of print]. 14. Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013;309:2016e24. 15. Muller M, Jacobs K, Abernethy M, Mueller E. Outcomes following minimally invasive sacrocolpopexy. Poster 11 presented at: AUGS 34th Annual Scientific Meeting, October 16e19, 2013; Las Vegas, NV. 16. Elneil S, Cutner AS, Remy M, Leather AT, Toozs-Hobson P, Wise B. Abdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series. BJOG 2005;112:486e9. 17. Warner WB, Vora S, Alonge A, Welgoss JA, Hurtado EA, von Pechmann WS. Intraoperative and postoperative gastrointestinal complications associated with laparoscopic sacrocolpopexy. Female Pelvic Med Reconstr Surg 2012;18:321e4.
A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse Salomon Zebede, MD, Ashraf Dawood, MD, May Alarab, MD, MSc, Harold Drutz, MD, Danny Lovatsis, MD, MSc Mount Sinai Hospital, University of Toronto, Toronto ON Women’s College Hospital, University of Toronto, Toronto ON
Abstract
Résumé
Objective: To describe a streamlined laparoscopic sacrocolpopexy (LSCP) surgical technique in women with post-hysterectomy vault prolapse and to evaluate the functional outcomes, complication rates, and surgical morbidity within our centre.
Objectif : Décrire une technique chirurgicale simplifiée pour la tenue d’une sacrocolpopexie laparoscopique (SCPL) chez des femmes présentant un prolapsus post-hystérectomie du dôme vaginal et évaluer les issues fonctionnelles, les taux de complication et la morbidité chirurgicale au sein de notre centre.
Methods: We retrospectively reviewed the charts of 180 patients scheduled for LSCP between November 2002 and May 2013 in a tertiary care centre. Patients were followed-up at six weeks, six months, and yearly after surgery. We reviewed patient demographics, preoperative and postoperative symptoms, and perioperative variables. Objective success of the surgery was defined as having a less than stage 2 vault prolapse, and subjective success was defined as the absence of bulge or prolapse symptoms. Success and complication rates were calculated. Results: Of the 180 patients who underwent surgery, 144 patients underwent the procedure as planned and had at least six months of follow-up. At the last follow-up visit, 133 of these 144 patients (92.4%) were free of prolapse symptoms. Several bladder and bowel symptoms showed significant improvement. Anatomical success of vault support was achieved in 140 of 144 patients (97.2%), and 119 patients (82.6%) had no prolapse beyond the hymen. Early complications (within the first 6 weeks) occurred in 8.3% of 162 patients with limited outcome data, and late complications (after 6 weeks) occurred in 11.5% of the 144 patients with long-term data. There were no cystotomies or mesh exposures. Conclusion: At an average of 32 months, this cohort of patients had low prolapse recurrence rates and no reports of cystotomy or mesh erosion. The abridged LSCP technique, as practised in our institution, is safe and effective in the surgical management of posthysterectomy vault prolapse.
Key Words: Laparoscopic sacrocolpopexy, LSCP, mesh, outcomes, post-hysterectomy, prolapse Competing Interests: None declared. Received on July 31, 2015
Méthodes : Nous avons mené une analyse rétrospective des dossiers de 180 patientes qui devaient subir une SCPL entre novembre 2002 et mai 2013 au sein d’un centre de soins tertiaires. Les patientes ont bénéficié d’un suivi à six semaines et à six mois; par la suite, un suivi annuel a été mis en œuvre. Nous avons analysé les caractéristiques démographiques des patientes, les symptômes préopératoires et postopératoires, ainsi que des variables périopératoires. La réussite objective de la chirurgie a été définie comme la constatation subséquente d’un prolapsus du dôme vaginal d’un stade inférieur à 2, tandis que la réussite subjective de cette intervention a été définie comme l’absence de bombement ou de symptômes associés au prolapsus. Les taux de réussite et de complication ont été calculés. Résultats : Parmi les 180 patientes qui ont subi la chirurgie, 144 ont subi l’intervention telle que planifiée et ont bénéficié d’un suivi d’au moins six mois. Au moment de la dernière consultation de suivi, 133 de ces 144 patientes (92,4 %) ne connaissaient aucun symptôme associé au prolapsus. Plusieurs symptômes vésicaux et intestinaux ont connu une atténuation significative. Une réussite anatomique quant au soutien du dôme a été obtenue chez 140 des 144 patientes (97,2 %); de plus, 119 patientes (82.6 %) ne présentaient plus de prolapsus au-delà de l’hymen. Des complications précoces (au cours des six premières semaines) se sont manifestées chez 8,3 % des 162 patientes pour lesquelles nous ne disposions que de données limitées quant aux issues, tandis que des complications tardives (après six semaines) se sont manifestées chez 11,5 % des 144 patientes pour lesquelles nous disposions de données à long terme. Aucun cas de cystotomie ou d’exposition du treillis n’a été constaté. Conclusion : À une moyenne de 32 mois, cette cohorte de patientes présentaient de faibles taux de récurrence du prolapsus et aucun cas de cystotomie ou d’érosion du treillis n’avait été signalé. La technique SCPL simplifiée, telle que pratiquée au sein de notre établissement, est sûre et efficace pour la prise en charge chirurgicale du prolapsus post-hystérectomie du dôme vaginal. Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
Accepted on November 3, 2015 http://dx.doi.org/10.1016/j.jogc.2016.01.006
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J Obstet Gynaecol Can 2016;38(5):446-452
A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse
INTRODUCTION
O
pen sacrocolpopexy, with the use of mesh, has long been considered a successful and safe surgical procedure and has become the standard of care in the management of women with post-hysterectomy vault prolapse.1 However, in the last two decades, minimally invasive surgery has advanced dramatically; laparoscopic sacrocolpopexy (LSCP) provides the potential to combine the success rate of an abdominal approach with the faster recovery time and minimal morbidity associated with a minimally invasive technique.2,3 Unfortunately, the time required to become proficient in the procedure, some technical difficulties in performing the procedure, and the frequent increase in operating time required by an unskilled surgeon have greatly limited its use.4 While adhering to the basic principle of this procedure, many variations in surgical technique have been introduced; however, good quality data to support use of one technique over another are limited.5 Mesh erosion after sacrocolpopexy remains a problem, although generally it is less frequent than with vaginal mesh kits; the average rate for post-hysterectomy patients is 3% to 4%, and when a total hysterectomy or vaginal hysterectomy is performed concomitantly the rate can be up to 16% to 32%.6 Our tertiary care centre uses a surgical technique that avoids the dissection of the peritoneum or bladder from the vaginal wall and peritoneal covering of the mesh. Using this technique, it may be possible to reduce the incidence of cystotomy and mesh erosion or to eliminate these complications entirely and to shorten the surgical time. We describe here our technique and examine the functional outcomes, complication rates, and surgical morbidity of LSCP at our centre, seeking to demonstrate that LSCP using our streamlined surgical technique is a useful alternative in the treatment of post-hysterectomy patients with vault prolapse. METHODS
We reviewed the medical charts of all patients who underwent LSCP performed by a single surgeon (D.L.) between November 2002 and May 2013 at Mount Sinai Hospital or Women’s College Hospital, Toronto, ON. Before surgery, a standardized history was taken and physical examination was performed by a resident or fellow and the attending staff member in the urogynaecology clinic at Mount Sinai Hospital. This included demographic
information (age, parity, BMI, smoking status, history of prolapse or incontinence surgery, route of previous hysterectomy, menopausal status, and previous use of pessary), questions regarding the presence of prolapse symptoms (vaginal bulge or lump), urinary symptoms (stress incontinence, urge incontinence, mixed incontinence, voiding dysfunction), and bowel symptoms (constipation, obstructed defecation, fecal incontinence, rectal prolapse). Physical examination, with the patient in the lithotomy position, was performed by the attending staff member and included objective assessment of the pelvic organ prolapse in each compartment (anterior, apical, and posterior). Patients were asked to perform a Valsalva manoeuvre with maximal effort. The stage of prolapse in each compartment was classified using the simplified pelvic organ prolapse quantification examination described and validated by Swift et al.7e9 Stage 0 to 1 defines prolapse 1 cm or more above the level of the hymen, stage 2 is at the hymen (± 1 cm), stage 3 is more than 1 cm beyond the level of the hymen but without complete vaginal vault eversion, and stage 4 is complete eversion of the vagina. A cough stress test was carried out in all patients in the lying position with manual reduction of the prolapse and a full bladder at the end of urodynamic testing. Urodynamic testing was performed in all patients to assess for any bladder symptoms and to identify “occult” stress incontinence. Urodynamic testing at our institution includes multichannel cystometry, urethral pressure profile, uroflowmetry, and measurement of the postvoidal residual. Surgical Technique
Our standard protocol includes one preoperative dose of intravenous antibiotic and prophylaxis for deep vein thrombosis using subcutaneous lowemoleculareweight heparin. All surgical procedures were performed by a single surgeon (D.L.) with the assistance of urogynaecology fellows in training. A 0-degree 10-mm laparoscope is inserted at the umbilicus, and the patient is then placed in a steep Trendelenburg position. A left lower quadrant 12-mm port is placed and two 5-mm ports are then inserted, one in the right lower quadrant and the other in the left mid-abdomen. Later during the procedure, a 5-mm suprapubic port is placed. The sacral promontory is visualized and the peritoneum is elevated away from the sacrum and incised. Under direct vision, the extraperitoneal tissue is teased open with blunt dissection using laparoscopic scissors and the anterior longitudinal ligament of the spine is exposed at the promontory. Any central blood vessels on the promontory
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are cauterized. The vaginal vault is elevated using a vaginal probe, and a Y-shaped piece of prolene mesh is attached to the anterior and posterior walls.
percentage for categorical variables. The change in categorical outcomes (proportions) between preoperative and postoperative conditions was assessed using McNemar’s test.
In all cases we used a type 1 (monofilament, macroporous) polypropylene mesh (Surgipro; Covidien Canada, SaintLaurent, QC, and ProLite Mesh; Atrium Medical Corp., Hudson, NH). The anterior arm of the mesh is extended as far as the bladder reflection will allow, but the bladder and the peritoneal reflection are not dissected off the vagina to avoid thinning of the tissues; this decreases the risk of mesh exposure or cystotomy. The posterior arm of the mesh is extended caudally into the cul-de-sac but is simply attached to the middle upper segment of the posterior vaginal wall without caudal dissection to the perineal body. The mesh is sutured to the vaginal walls with fullthickness interrupted sutures of 0 prolene using extracorporeal sliding knots. The anterior arm of the mesh typically measures 4 cm in length and is attached to the anterior vaginal wall using four interrupted sutures; the posterior arm of the mesh usually measures 6 cm and is attached to the posterior vaginal wall using six interrupted sutures. Cystoscopy is routinely performed at this point to ensure that no sutures pass through the bladder. The mesh is then attached to the sacral promontory at the S1 level using a 5-mm ProTak fixation device (Covidien Canada) through an additional 5-mm suprapubic port. A large free space is left behind the mesh to decrease the risk of internal bowel hernia, and the mesh is not covered with peritoneum. All additional procedures, such as vaginal repair or incontinence procedures, are performed subsequently. The procedure is fully described in an online video recording.10
Ethics approval for the study was provided by the Research Ethics Boards of Mount Sinai Hospital and Women’s College Hospital, Toronto, Ontario.
Patients typically returned to our clinic for postoperative visits at six weeks, six months, one year, and annually thereafter. At every postoperative visit, all patients are asked about any medical issues, pelvic floor and urinary symptoms, and overall satisfaction with the outcome (described as “same,” “better,” or “worse”). At each visit a urogynaecological examination is performed, including assessment of the stage of prolapse in each compartment, as previously described. Anatomical failure is recorded if there is apical evidence of stage 2 prolapse or greater. Subjective failure is recorded if the patient reports experiencing a bulge or feeling something falling out. We used SPSS version 22.0 (IBM Corp., Armonk, NY) for descriptive and inferential analysis. All inferential tests were performed using P < 0.05 as the index of significance. Descriptive analysis was conducted by reporting mean and standard deviation for continuous measures or count/
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RESULTS
A total of 189 patients with a clinical diagnosis of symptomatic post-hysterectomy vault prolapse underwent LSCP during the study period. Nine patients were excluded from analysis because of incomplete data, leaving a cohort of 180 patients. Of the 180 patients who underwent surgery, 18 had a modification of the planned procedure because of multiple adhesions, and another 18 had less than six months of follow-up, leaving 144 patients with complete data for analysis. The mean age was 60 ± 8.4 years (range 37 to 82). Patient demographics are described in Table 1. At the last follow-up visit, 140 patients (97.2% of the cohort) had anatomically successful vault support, as defined by stage 0 to 1 prolapse. In 134 patients (93%), the vault was suspended in the upper one third of the vagina. If an anatomically successful outcome was defined as having no prolapse beyond the hymen in any compartment (apical, anterior, or posterior), success was achieved in 119 patients (82.6%). On subjective assessment at the last follow-up visit, 133 patients (92.4%) were free of prolapse symptoms. Only nine patients (6.3%) requested additional treatment for symptomatic prolapse. Of these, four were referred for a vaginal mesh procedure, one underwent anterior vaginal repair, one underwent posterior vaginal repair, one underwent both anterior and posterior vaginal repair, and one underwent an open abdominal sacrocolpopexy. The remaining patient’s prolapse was managed using a pessary. In assessing their overall satisfaction (the same, better, or worse than before surgery) most patients (135; 93.8%) reported feeling better after surgery, eight reported feeling the same, and only one reported feeling worse than before surgery. Preoperatively, all patients experienced prolapse symptoms, specifically reporting a vaginal lump or bulge. One hundred eight patients (60%) reported at least one bladder symptom, and 56 (31.1%) reported at least one bowel symptom. Preoperative and postoperative symptoms are summarized in Table 2. Preoperatively all women had a significant vault descent of stage 2 or more. Anatomical findings during physical examination preoperatively and at the last follow-up visit
A Streamlined Surgical Approach to Laparoscopic Sacrocolpopexy for Post-Hysterectomy Vault Prolapse
Table 1. Patient Demographics (n [ 180) Characteristic Mean age in years ± SD (range)
60 ± 8.4 (37 to 82)
Mean BMI in kg/m2 ± SD
25.7 ± 3.6
Median parity (range) Type of previous hysterectomy
2 (0 to 8) Vaginal hysterectomy: 88 (48.9%) Laparoscopic assisted vaginal hysterectomy: 8 (4.4%) Total abdominal hysterectomy: 84 (46.7%)
Table 2. Preoperative and Postoperative Symptoms (n [ 144)a Preoperative Stress urinary incontinence
57 (39.6%)
10 (6.9%)
< 0.001
Urge urinary incontinence
46 (31.9%)
14 (9.7%)
< 0.001
Mixed urinary incontinence
19 (13.2%)
2 (2.8%)
< 0.001
Incomplete emptying (PVR > 100 mL)
14 (9.7%)
3 (2.1%)
< 0.01
22 (12.3%)
Bowel symptoms
Postmenopausal, n
166 (92.3%)
Constipation
32 (17.8%)
Previous incontinence procedure, n
50 (27.8%)
Previous anticholinergic medication, n
26 (14.4%) One: 76 Two: 55 Three: 32 Four: 13 Five: 4
Previous POP surgery
At least one previous POP surgery: 133 (73.9%) 2 previous POP surgeries: 29 (16.1%)
POP: pelvic organ prolapse.
are described in Table 3. Thirty-seven patients (23%) did not return for their last follow-up appointment. The mean (± standard deviation) duration of follow-up was 32.1 ± 25.8 months, with a median of 21 months. In 104 cases, the Surgipro mesh was used, and in 58 cases, the ProLite mesh was used. One hundred eighteen women (72.8%) underwent a concomitant surgical procedure. Intraoperative cystoscopy was performed in 114 patients (70.4%). Eighteen of the procedures (10%) were converted to either an open abdominal sacrocolpopexy (two cases) or a sacrospinous vault suspension (16 cases). In all these cases the indication for conversion was the presence of multiple pelvic adhesions. As noted, 11 of the 18 patients had had at least three or more prior abdominal or pelvic surgical procedures. There were no intraoperative complications. The mean total operating time was 126 ± 43 minutes, including laparoscopic port positioning and concomitant procedures, and the mean surgical blood loss was 112 ± 69 mL. As shown in Table 4, both operating time and surgical
39 (27.1%)
Fecal incontinence Obstructed defecation Sexually active Dyspareunia
Number of previous abdominal or pelvic procedures
McNamara P values
Bladder symptoms
Current smoker, n
Previous pessary, n
Postoperative
Prolapse symptom
13 (9%)
< 0.001
7 (4.9%)
2 (1.4%)
0.18
10 (6.9%)
1 (0.7%)
< 0.01
86 (59.7%)
82 (56.9%)
0.61
14 (16.2%)
6 (7.3%)
0.18
144 (100%)
11 (7.6%)
< 0.001
PVR: post-void residual volume. a Conversion cases and patients with less than 6 months of follow-up were excluded.
blood loss varied widely depending on concomitant procedures. Ninety-seven patients (59%) underwent a concomitant vaginal repair; 84 (52%) underwent an anterior repair, and 75 (46%) underwent a posterior repair. Fifty-eight women (35.8%) underwent outpatient surgery, with an average hospital stay of 9.0 ± 1.0 hours. When surgery was performed on inpatients, the mean duration of hospital stay was 1.2 ± 0.5 days (range 1 to 5). Early postoperative complications (occurring during the first 6 weeks after surgery) occurred in 8.3% of patients, and late complications (occurring more than 6 weeks after surgery) occurred in 11.5%. The details of complications are provided in Table 5. Among patients with early complications, three patients with early voiding dysfunction required use of a Foley catheter for an average of six days. Two patients experienced port-related complications at the site of the 12-mm port. One patient developed a port-site hernia at five weeks after surgery and required surgical intervention for incarceration of the hernia. One patient required blood transfusion after a concomitant tension-free vaginal tape procedure resulted in a retropubic hematoma that was managed conservatively. Three patients developed a postoperative ileus; they received conservative management and were discharged on the fourth postoperative day. In patients with late complications, seven (4.9%) reported stress urinary incontinence symptoms. Three of these
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Table 3. Objective Stage of Preoperative and Postoperative Prolapse
Compartment
Stage 0e1 Preoperative Postoperative n ¼ 180 n ¼ 144
Preoperative n ¼ 180
Postoperative n ¼ 144
Stage 3e4 Preoperative Postoperative n ¼ 180 n ¼ 144
Anterior
34 (18.9%)
126 (87.5%)
23 (12.8%)
13 (9%)
123 (68.3%)
0 (0%)
140 (97.2%)
91 (50.6%)
2 (1.39%)
89 (49.4%)
2 (1.39%)
54 (30%)
133 (92.3%)
47 (26.1%)
7 (4.9%)
79 (43.9%)
4 (2.8%)
Vault Posterior
Stage 2
patients underwent a procedure for incontinence (tensionfree vaginal tape), and the remaining four chose conservative management with pelvic floor exercises. Two patients (1.4%) developed de novo dyspareunia; one chose to undergo expectant management, and the other used vaginal dilators, with resolution of dyspareunia six months after surgery. Two patients presented with small bowel obstruction. One initially underwent conservative management but experienced recurrent hospitalization and requested excision of the mesh four years after surgery. After excision of the mesh, vault prolapse recurred. The second patient presented three months after surgery with small bowel obstruction that required excision of the mesh. Review of the general surgeon’s operative report indicated that the mesh had remained extraperitoneal but had adherent small bowel, requiring excision of a segment of mesh and small bowel. There were no cystotomies, mesh exposures, or suture-related complications in any cases. DISCUSSION
Our findings provide evidence that LSCP, using the abridged technique described here and demonstrated in the online video recording,10 with vaginal repairs when needed, is an effective procedure for the treatment of posthysterectomy vault prolapse. Vault support was provided in 97.2% of patients, and subjective outcomes and patient satisfaction after the procedure also were high, demonstrating outcomes similar to those previously reported.3,11
5 (3.5%)
There have been many variations in these surgical techniques. Some authors recommend extensive dissection of the vesicovaginal space to the level of the urethro-vaginal junction and of the rectovaginal space to the levator ani muscles, but at our institution we prefer to avoid this. As reflected in our results, we have shown that by avoiding this dissection we reduce the risk of perioperative complications (cystotomy, vaginal or bowel perforation) and long-term complications such as mesh erosion and defecatory symptoms. Nevertheless, avoiding the laparoscopic dissection of the vesicovaginal and rectovaginal space will increase the number of patients needing concomitant vaginal repair, as reflected in our results. In a recent cadaver study, Noblet et al. showed that dissection for abdominal sacrocolpopexy may only result in identifying the correct plane between the bladder and vagina in approximately 60% of cases.12 In 30% of their cases, the mesh was located within the split layers of the vaginal wall rather than in the space between the bladder and vagina.12 We believe this is one of the reasons that mesh erosion occurs. In vitro evidence has shown that when the mesh is in direct contact with vaginal smooth muscle cells, it has an atrophic effect on smooth muscle, perhaps due to reduced smooth muscle innervation, and this will lead to a higher risk of mesh erosion.13 Recently the long-term outcomes of the CARE trial were published, reporting an estimated probability of mesh erosion of 9.9% with a tendency for the risk to increase with time.14 In our study there were no cases of
Table 4. Operative Time and Blood Loss for Each Procedure (n [ 162) Number of Procedures
Surgical Procedure Sacrocolpopexy
48
Operative Time (mean ± SD), minutes 104 ± 27
Blood Loss (mL) 64 ± 32
Sacrocolpopexy þ AR and PR
37
119 ± 23
114 ± 47
Sacrocolpopexy þ AR
16
122 ± 22
103 ± 59
Sacrocolpopexy þ PR
12
122 ± 27
100 ± 0
Sacrocolpopexy þ APR þ 2 team sling
25
194 ± 54
225 ± 75
Sacrocolpopexy þ TVT
13
117 ± 35
92 ± 29
Sacrocolpopexy þ TVT þ vaginal repair
7 (4 APR, 2 AR, 1 PR)
150 ± 51
142 ± 38
120 ± 15
137 ± 48
Sacrocolpopexy þ salpingo-oophorectomy
4
AR: anterior repair; PR: posterior repair; APR: anterior and posterior repair; TVT: tension-free vaginal tape.
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Table 5. Complication Rates
Complication
Early: First Six Postoperative Weeks (n ¼ 162)
Late: Six Weeks Postoperatively to Last Follow-Up Visit (n ¼ 144)
Urinary tract Urinary tract infection
4
1
Voiding dysfunction
3
0
De novo stress urinary incontinence
0
7
De novo urge urinary incontinence
0
3
De novo overactive bladder
0
2
Port-related complication Port hernia
1
0
Hematoma
1
0
Small bowel obstruction
0
2
Ileus
2
0
Severe constipation
1
1
Postoperative fever
1
0
Blood transfusion
1
0
De novo dyspareunia
0
2
14
16
Gastrointestinal
Other
Total
Clavien-Dindo Classification of Postoperative Complications I (no treatment)
8
9
II (need for pharmacological treatment)
5
3
performing a sacral colpoperineopexy is associated with no improvement and even worsening of defecatory symptoms.5 Many surgeons believe that peritoneal covering of the mesh will decrease the risk of bowel complications, but this remains controversial. Muller et al. conducted a retrospective review comparing patients who had reperitonealization of the mesh with those who did not and found that reperitonealization of the mesh was not associated with a reduction of bowel complications.15 Elneil et al. also reported that they did not find an increase in complication rates after performing 121 sacrocolpopexy procedures without burying the mesh and patient follow-up for a median of 19 months.16 In our cohort, bowel complications occurred at a rate of 3% (3 cases of ileus managed conservatively, and 2 cases of small bowel obstruction necessitating surgical intervention). This rate is similar to that reported in other studies in which the mesh is covered by peritoneum.17 Our study provides further evidence that omitting reperitonealization of the mesh is safe. In an era in which reducing costs and improving the quality of care are priorities, we believe that these can be achieved by reducing operating time and moving some procedures to an ambulatory setting without compromising quality. With the surgical technique described in this study, we were able to reduce operating time and to perform procedures in an ambulatory setting. In our cohort, 58 of the cases (35.8%) were performed successfully in an ambulatory setting with same-day discharge. We assume that this would result in significant cost savings, although further cost analysis is required for confirmation.
mesh erosion, and we believe that this was related to avoiding the dissection of the visceral peritoneum.
Pelvic organ prolapse usually is part of complex pelvic floor dysfunction, with coexisting bladder and bowel symptoms. In our cohort, 60% of patients experienced at least one bladder symptom and 30.1% experienced at least one bowel symptom. Our findings demonstrate a significant reduction in both bladder and bowel symptoms after surgery. However, because of the retrospective nature of the study, we were able to collect data only on the presence or absence of symptoms. We recognize that using validated questionnaires preoperatively and postoperatively is the best means of measuring any subjective data, and having not done so is a weakness of this study. An additional limitation of this study, inherent in any retrospective study, is the lack of information about patients lost to follow-up and how this could have affected the findings.
In a review, Parkes et al. noted that there is evidence suggesting that dissection of the posterior vaginal wall and
Nevertheless, this study has several strengths. First, patients had intermediate- to long-term follow-up. Any
IIIa (intervention under local anaesthesia) IIIb (intervention under general anaesthesia)
1 (port hernia)
5 (3 TVT for de novo SUI, 2 for bowel obstruction)
IV (intensive care due to single or multiorgan failure)
0
0
V (death)
0
0
TVT: tension-free vaginal tape; SUI: stress urinary incontinence.
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patients with less than six months of follow-up were excluded from the outcomes analysis but not from the analysis of perioperative data or complications. A second strength is the uniformity of the surgical technique. Variations in the surgical technique, as well as a mix of procedures, including any type of promontory fixation (hysteropexy, cervicopexy, and sacrocolpopexy) and concomitant hysterectomy, will give an imprecise understanding of the success rate or complications for a specific procedure. CONCLUSION
LSCP, using the technique described in this study, is a highly effective procedure for treating post-hysterectomy vault prolapse. After an average of 32 months, patients had good objective and subjective results and a significant reduction in pelvic organ prolapse symptoms. Complication and recurrence rates in our cohort were low, with no mesh erosion or cystotomy. Because the procedure may be performed on an outpatient basis, using our streamlined technique, it can provide significant cost savings.
REFERENCES 1. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2013;4:CD004014. 2. Freeman RM, Pantazis K, Thomson A, Frappell J, Bombieri L, Moran P, et al. A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J 2013;24:377e84. 3. Ganatra AM, Rozet F, Sanchez-Salas R, Barret E, Galiano M, Cathelineau X, et al. The current status of laparoscopic sacrocolpopexy: a review. Eur Urol 2009;55:1089e103. 4. Coolen AL, van Oudheusden AM, van Eijndhoven HW, van der Heijden TP, Stokmans RA, Mol BW, et al. A comparison of complications between open
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