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Laparoscopic Pectopexy with Burch Colposuspension for Pelvic Prolapse Associated with Stress Urinary Incontinence
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Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence L. Pirtea , O. Balint , C. Secoșan , D. Grigoraș , R. Ilina PII: DOI: Reference:
S1553-4650(19)31284-1 https://doi.org/10.1016/j.jmig.2019.10.022 JMIG 3994
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
10 July 2019 4 October 2019 22 October 2019
Please cite this article as: L. Pirtea , O. Balint , C. Secoșan , D. Grigoraș , R. Ilina , Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence, The Journal of Minimally Invasive Gynecology (2019), doi: https://doi.org/10.1016/j.jmig.2019.10.022
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of AAGL.
Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence.
Pirtea L., Balint O., Secoșan C., Grigoraș D., Ilina R.
Pirtea Laurentiu, Associate Professor, MD, PhD and Senior Consultant, University of Medicine and Pharmacy Timișoara Balint Oana, Assistant Professor, MD, University of Medicine and Pharmacy Timișoara Secosan Cristina, Assistant Professor, MD, University of Medicine and Pharmacy Timișoara Grigoras Dorin, Professor, MD, PhD, University of Medicine and Pharmacy Timișoara Senior Consultant and Chief of the Department of Obstetrics and Gynecology Timisoara County Hospital Ilina Razvan, Assistant Professor, MD, PhD and Senior Consultant, University of Medicine and Pharmacy Timișoara
Corresponding author: Balint Oana Postal address: Giuseppe Verdi, no. 6, ap. 18, Timisoara, Romania. E-mail address: [email protected] Phone number: +40740282844 The authors report no conflict of interest with any financial organization regarding the Material discussed in the manuscript.
Abstract
1
Study objective: To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension.
Design: Case report
Settings: University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, România.
Patients: We present the case of a 41 years old women, G1 P1, with no significant medical or surgical history, with a BMI of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele and a positive cough stress test. The pelvic prolapse was classified as POP-Q stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Due to the patient’s obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect and Burch colposuspension for the cure of stress incontinence.
Intervention: The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45o Trendelenburg position. One umbilical 10 mm optical trocar and three 5 mm trocars were used, two inserted 2 cm above and medial to the anterior superior iliac crests and the third at 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a “V” shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesico-vaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 by 15 cm polypropylene mesh, cut in T shape, was introduced in the abdomen. First, the short arm of the “T” was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack™ - ABSTACK30X Fixation Device, Medtronic, UK). In order to use a type of non-absorbable fixation, we decided to also fix the mesh to the cervix stump with three isolated stitches (Silk suture 2.0, Ethicon, USA). Second, with the purpose of ensuring a permanent fixation the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple non2
absorbable tacks on both sides (ProTackTM, Fixation Device, Medtronic, UK). The procedure continued with the complete closure of the peritoneum with vicryl 2.0. Because the patient also had stress urinary incontinence a Burch colposuspension was performed. In order to expose its limits, the urinary bladder was filled with 200 ml of saline. After the incision of the peritoneum the avascular space of Retzius was opened. The dissection continued until the Cooper’s ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant’s intravaginal finger. Two isolated non-absorbable silk stitches (Silk suture 2.0, Ethicon, USA) were placed through the Cooper’s ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction.
Main results: The length of the surgery was 95 minutes with minimal blood loss of about 60 ml. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6 months follow up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix, at 6 cm above the hymenal ring and no urinary incontinence.
Conclusion: Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present and the follow up assessment revealed an effective correction of the prolapse. Further studies are needed in order to conclude the efficiency and safety of this new procedure.
Keywords: pectopexy, pelvic organ prolapse, laparoscopy.
Legend
Case report of a 41 years old women diagnosed with POP-Q stage 3 pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy and Burch colposuspension. The main steps of the procedure are described.
Ethics approval and consent to participate 3
Written informed consent for reporting the case was obtained from the patient prior to the procedure. The procedure was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The Institutional Review Board and Ethical Committee of “Victor Babeş” University of Medicine and Pharmacy Timişoara ruled that approval was not required for this study.
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Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence L. Pirtea , O. Balint , C. Secoșan , D. Grigoraș , R. Ilina PII: DOI: Reference:
S1553-4650(19)31284-1 https://doi.org/10.1016/j.jmig.2019.10.022 JMIG 3994
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
10 July 2019 4 October 2019 22 October 2019
Please cite this article as: L. Pirtea , O. Balint , C. Secoșan , D. Grigoraș , R. Ilina , Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence, The Journal of Minimally Invasive Gynecology (2019), doi: https://doi.org/10.1016/j.jmig.2019.10.022
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc. on behalf of AAGL.
Laparoscopic pectopexy with Burch colposuspension for pelvic prolapse associated with stress urinary incontinence.
Pirtea L., Balint O., Secoșan C., Grigoraș D., Ilina R.
Pirtea Laurentiu, Associate Professor, MD, PhD and Senior Consultant, University of Medicine and Pharmacy Timișoara Balint Oana, Assistant Professor, MD, University of Medicine and Pharmacy Timișoara Secosan Cristina, Assistant Professor, MD, University of Medicine and Pharmacy Timișoara Grigoras Dorin, Professor, MD, PhD, University of Medicine and Pharmacy Timișoara Senior Consultant and Chief of the Department of Obstetrics and Gynecology Timisoara County Hospital Ilina Razvan, Assistant Professor, MD, PhD and Senior Consultant, University of Medicine and Pharmacy Timișoara
Corresponding author: Balint Oana Postal address: Giuseppe Verdi, no. 6, ap. 18, Timisoara, Romania. E-mail address: [email protected] Phone number: +40740282844 The authors report no conflict of interest with any financial organization regarding the Material discussed in the manuscript.
Abstract
1
Study objective: To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension.
Design: Case report
Settings: University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, România.
Patients: We present the case of a 41 years old women, G1 P1, with no significant medical or surgical history, with a BMI of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele and a positive cough stress test. The pelvic prolapse was classified as POP-Q stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Due to the patient’s obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect and Burch colposuspension for the cure of stress incontinence.
Intervention: The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45o Trendelenburg position. One umbilical 10 mm optical trocar and three 5 mm trocars were used, two inserted 2 cm above and medial to the anterior superior iliac crests and the third at 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a “V” shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesico-vaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 by 15 cm polypropylene mesh, cut in T shape, was introduced in the abdomen. First, the short arm of the “T” was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack™ - ABSTACK30X Fixation Device, Medtronic, UK). In order to use a type of non-absorbable fixation, we decided to also fix the mesh to the cervix stump with three isolated stitches (Silk suture 2.0, Ethicon, USA). Second, with the purpose of ensuring a permanent fixation the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple non2
absorbable tacks on both sides (ProTackTM, Fixation Device, Medtronic, UK). The procedure continued with the complete closure of the peritoneum with vicryl 2.0. Because the patient also had stress urinary incontinence a Burch colposuspension was performed. In order to expose its limits, the urinary bladder was filled with 200 ml of saline. After the incision of the peritoneum the avascular space of Retzius was opened. The dissection continued until the Cooper’s ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant’s intravaginal finger. Two isolated non-absorbable silk stitches (Silk suture 2.0, Ethicon, USA) were placed through the Cooper’s ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction.
Main results: The length of the surgery was 95 minutes with minimal blood loss of about 60 ml. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6 months follow up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix, at 6 cm above the hymenal ring and no urinary incontinence.
Conclusion: Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present and the follow up assessment revealed an effective correction of the prolapse. Further studies are needed in order to conclude the efficiency and safety of this new procedure.
Keywords: pectopexy, pelvic organ prolapse, laparoscopy.
Legend
Case report of a 41 years old women diagnosed with POP-Q stage 3 pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy and Burch colposuspension. The main steps of the procedure are described.
Ethics approval and consent to participate 3
Written informed consent for reporting the case was obtained from the patient prior to the procedure. The procedure was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The Institutional Review Board and Ethical Committee of “Victor Babeş” University of Medicine and Pharmacy Timişoara ruled that approval was not required for this study.
4