Laparoscopic Sacrocolpopexy for Pelvic Organ Prolapse: Surgical Technique and Outcomes

Roberto Nucciotti1, Fabio Massimo Costantini1
  • 1 Ospedale Misericordia (Grosseto)

Objective

Abdominal sacrocohysteropexy is the gold standard treatment for pelvic organ prolapse (POP) and can be performed laparoscopically. The demand for treatment of pelvic floor disorders has been projected to increase significantly in the coming years, as Western countries are experiencing a rapid increase in the geriatric demographic. The prevalence of pelvic organ prolapse (POP), defined as stage ≥2 prolapse using the Pelvic Organ Prolapse Quantification (POP-Q) examination, was reported to be 37% in the general population and increased to 64.8% in an older population of women with a mean age of 68 yr . . To evaluate the surgical outcome, complications and benefits of laparoscopic single promonto-fixation for patients with pelvic prolapse.

Materials and Methods

POP surgery aims to restore physiologic anatomy as well as to preserve lower urinary tract, intestinal, and sexual functions.We perform a posterior dissection down to the levator muscles and an anterior dissection down to the trigone.  a transperitoneal placement of a 100% polyester mesh on the anterior vaginal wall and a posterior mesh on the levator ani muscle . The posterior mesh, "butterfly" shaped is sutured to the levator muscles, to the rectum above the anorectal junction and to the uterosacral ligaments. The anterior mesh is sutured to the vagina and the isthmus/cervix and attached to the promontory with a tension measured through a vaginal exam.

Results

A total of 243 patients were operated from 2005 to 2015. Their mean age was 63 (range 35–78), average follow-up was 14.6 months, the mean operating time was 102 minutes. There were 2 conversions due to anesthetic or surgical difficulties. Follow up was done by a postal questionnaire and physical examination at 6 months and then yearly. 96% were satisfied with the results of their operation and no patients complained of sexual dysfunction. There was a 2% recurrence rate of prolapse, 0 vaginal erosions. Perioperative complications were one vaginal effraction . The mean hospital stay was 3 days (2–5) . We observed no retraction of the mesh and no dyspareunia. With this type of conformation of the posterior mesh we have significantly reduced the dischezia compared to double promonto-fixation.

Discussions

Laparoscopic promonto-fixation is feasible and highly effective technique that offers good long-term results with complication rates similar to open surgery, with the added benefits of minimally invasive surgery We consider unnecessary remove uterus and promontory attached of the posterior mesh, reducing the risk of erosion, constipation and dischezia. De novo urgency was observed in 10 patients (10.5%) who had had previous high-grade cystocele (five with concomitant prolapse of other compartments). The symptoms were treated with short-term anticholinergic medications and always resolved in the first few weeks after surgery. Laparoscopic approach was developed to reduce surgical invasiveness and was shown to achieve similar results compared with the open approach . However, the procedure is technically challenging, particularly because of the need to perform intracorporeal sutures in a limited space, and is characterised by relatively long operative times.

Conclusion

With this technique we performed a complete treatment for severe prolapse by a minimally invasive approach with a low rate of recurrence at this point. Our technique of RASC with implant of polypropylene meshes is associated with low morbidity and good long-term results in the treatment of all types of POP. High BMI and previous abdominal or vaginal surgery, including previous treatments for POP, do not represent a contraindication for this surgical approach. Our study is limited by its retrospective and noncomparative design. Furthermore, we relied only on the Baden-Walker classification for assessment of POP without using the International Continence Society organ prolapse classification and did not obtain information about QoL after surgery. We are also aware that the use of interviews before data analysis rather than standardised questionnaires or mandatory follow-up examinations might have led to an underestimation of symptoms or asymptomatic POP recurrences. Further prospective and comparative studies are needed to confirm these findings.

References

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By: Filip Claerhout, Dirk De Ridder, Jan Paul Roovers, Heidi Rommens, Federico …
Issue: 6, Volume: 55, Pages: 1459 – 1468, Published: 2009
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By: Francois Rozet, Eric Mandron, Carlos Arroyo, Henry Andrews, Xavier Cathelineau, …
Published: 2014
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By: Richard K. Lee, Alexandre Mottrie, Christopher K. Payne, David Waltregny
Issue: 6, Volume: 65, Pages: 1128 – 1137, Published: 2014

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