Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy with a minimum of three years follow-up

We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36 months’ follow-up. Median follow-up was 62 months (range 36–84) and mean age was 67 (43–83) years. Mean operating time was 3.1 (2.15–5) h with a median operating time of 2.9 h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3–4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3 years’ follow-up.     

Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse

PURPOSE: Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with durable success rates. However, it is associated with increased morbidity compared with vaginal repairs. We describe a minimally invasive technique of vaginal vault prolapse repair and present our experience with a minimum of 1 year followup. MATERIALS AND METHODS: The surgical technique involves 5 laparoscopic ports: 3 for the da Vinci robot and 2 for the assistant. A polypropylene mesh is attached to the sacral promontory and vaginal apex using polytetrafluoroethylene sutures. The mesh material is then covered by peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction and morbidity with a minimum of 12 months followup. RESULTS: A total of 30 patients with post-hysterectomy vaginal vault prolapse underwent robotic assisted laparoscopic sacrocolpopexy at our institution and 21 have a minimum of 12 months followup. Mean followup was 24 months (range 12 to 36) and mean age was 67 years (range 47 to 83). Mean operative time was 3.1 hours (range 2.15 to 4.75). All but 1 patient were discharged home on postoperative day 1 and the 1 patient left on postoperative day 2. Recurrent grade 3 rectocele developed in 1 patient, 1 had recurrent vault prolapse and 2 had vaginal extrusion of mesh. All patients were satisfied with outcome. CONCLUSIONS: The robotic assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a decreased hospital stay, low complication rates and high patient satisfaction with a minimum of 1 year followup.     

Management of vaginal vault prolapse repair with robotically-assisted laparoscopic sacrocolpopexy

Transabdominal sacrocolpopexy offers an excellent definitive treatment option for patients with high grade vaginal vault prolapse with long-term success rates ranging from 93-99%. However, because it is a transabdominal procedure it is associated with increased morbidity compared with vaginal repairs. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present out initial experience. The surgical technique involves placement of five laparoscopic ports: three for the Da Vinci robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. At the end of the case, the mesh material is the covered by the peritoneum. We also present our initial experience with this technique in 18 consecutive patients. The analysis focused on complications, urinary continence, patient satisfaction, and morbidity. Follow-up was conducted by provider-patient interview. Twenty-five patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. 10/25 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5. (1-12) months and mean age was 66 (47-82) years. Mean total operative time was 3.2 (2.25-4.75) hours. One patient had to be converted to an open procedure secondary to unfavorable anatomy. All but one patient were discharged from the hospital after an overnight stay; one patient left on postoperative day #2. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. One patient developed recurrent grade 3 rectocele, but had no evidence of cystocele or enterocele. We present a novel technique for vaginal vault prolapse repair that combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high patient satisfaction. While our early experience is encouraging, long-term data is needed to confirm these findings and establish longevity of the repair.     

Laparoscopic sacrocolpopexy for the correction of vaginal vault prolapse

BACKGROUND AND PURPOSE: Laparoscopic sacrocolpopexy offers a minimally invasive approach to correcting vaginal vault prolapse. We describe our operative technique and review our experience. PATIENTS AND METHODS: A retrospective study of 10 patients who underwent laparoscopic sacrocolpopexy between February 2000 and June 2002 for posthysterectomy vaginal vault prolapse was performed. Data collected included operative time, complications, hospital stay, and postoperative morbidity. RESULTS: One patient underwent primary laparoscopic repair of an intraoperative bladder injury. Conversion from a laparoscopic to an open procedure was required in one patient because of dense bowel adhesions in the pelvis. The mean analgesic (morphine sulfate equivalent) requirement was 7.3 mg (range 5-21 mg). With a mean follow-up of 16 months (range 5-32 months), prolapse recurred in one patient. CONCLUSION: In the short term, laparoscopic sacrocolpopexy appears to be an effective approach for the treatment of vaginal vault prolapse with minimal postoperative pain and morbidity.     

Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results,quality of life and perioperative outcome—a prospective study with 101 cases

Our prospective study evaluates laparoscopic sacrocolpopexy for vaginal vault prolapse focusing on perioperative data, objective anatomical results using the pelvic organ prolapse quantification (POP-Q) system and postoperative quality of life using the Kings Health questionnaire. One hundred one patients completed the study. Fifty five had laparoscopic supracervical hysterectomy and sacrocolpopexy for uterine prolapse and 46 had laparoscopic sacrocolpopexy for post-hysterectomy prolapse. Median follow-up was 12 months. The subjective cure rate was 93% the objective cure rate (no prolapse in any compartment) according to the International Continence Society classification of prolapse was 98%. The main site of objective recurrence (6%) was the anterior compartment. No apical recurrences and no vaginal mesh erosion occurred. Postoperatively overall quality of life and sexual quality showed significant improvement with less than 1% de-novo dyspareunia. The procedure is recommended for experienced laparoscopic surgeons because of severe intraoperative complications like bladder or rectal injuries.     

Current status of robotics in female urology and gynecology

Currently, there has been limited reporting and research in the female urology and gynecological literature concerning the use of robotics. To date, robotics have been utilized only for the treatment of three benign gynecologic conditions: benign hysterectomy; repair of vesicovaginal fistula; and sacrocolpopexy which is a treatment for posthysterectomy vaginal vault prolapse. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of five laparoscopic ports: three for the daVinci® robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. Thirty-one patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. While our early experience utilizing robotic repairs in female urology and gynecology is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.Financial disclosure of authors: D.S. Elliott: none; G. Chow: none; M. Gettman: none     

Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse

Introduction and hypothesis  

The objective of this study was to report 1 year anatomical and functional outcomes of trocar-guided total tension-free vaginal mesh (Prolift™) repair for post-hysterectomy vaginal vault prolapse with one continuous piece of polypropylene mesh.     

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the “gold standard” procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.     

Will hysterectomy at the time of sacrocolpopexy increase the rate of polypropylene mesh erosion?

Will total abdominal hysterectomy with concomitant sacrocolpopexy lead to polypropylene (Prolene, Ethicon, Somerset, NJ) mesh erosions? Sixty-seven patients demonstrating a stage 2 or more International Continence Society cystocele, rectocele, and uterine prolapse underwent combined sacrocolpopexy and polypropylene mesh fixation and total abdominal hysterectomy. Surgical failure was noted as prolapse of any of the three pelvic compartments with a stage 2 or more recurrence. Sixty-four patients were available for examination, and none demonstrated mesh erosion or recurrent vault prolapse with a median follow-up of 27 months. Four patients experienced a recurrent stage 2 rectocele without any cystoceles or vault prolapse. Performing abdominal hysterectomy with concomitant sacrocolpopexy with polypropylene extensions does not increase the occurrence of synthetic material erosions in the vaginal vault or the anterior or posterior vaginal walls.     

Sacrocolpopexy--a report on 262 consecutive operations.

OBJECTIVES: This report analyses the outcome and complications of 262 consecutive sacrocolpopexy procedures for the repair of vaginal vault prolapse and enterocele. METHODS: From March 1994 to February 2001, 262 patients underwent surgical repair using a standardised retroperitoneal technique. Initially dura mater strips were used and from the 19th patient onwards, Gore-tex soft tissue patch was used to suspend the vaginal apex to the anterior sacral ligament. Halban-type occluding sutures were placed in the pouch of Douglas. All patients were followed up and the minimum duration of follow-up was 16 months. RESULTS: Vaginal vault prolapse was successfully managed in 259 of 262 patients giving a success rate of 98.8%. In addition, 4 patients had a repeat enterocele that required surgical repair. The overall surgical complication rate was low. Erosion of the patch through the vaginal vault occurred in 10 patients, necessitating removal of the patch. Prolapse did not recur in any of these patients. CONCLUSION: Abdominal sacrocolpopexy is a very successful and safe surgical management of vaginal vault prolapse.     

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: The Franciscan laparoscopic bone anchor inserter

Background A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed.Methods We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse.Results Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum.Conclusion Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.     

Laparoendoscopic single-site (LESS) sacrocolpopexy: feasibility and efficacy of knotless procedure performed with conventional instruments

The aim of this paper was to report a case of a patient with stage IV vaginal vault prolapse treated by laparoendoscopic single-site (LESS) sacrocolpopexy using an Alexis retractor and a surgical glove attached to three trocars through a 3.5-cm umbilical incision. Only conventional laparoscopic instruments were used for intrabdominal dissection of vagina and peritoneum. The mesh was fixed to the vaginal fornix and to the sacral periosteum from the promontory using running sutures hold in the extremities by polymer clips. The posterior peritoneum was closed over the mesh. LESS sacrocolpopexy performed with conventional instruments is a difficult but feasible and efficient technique to treat vaginal vault prolapse that respects the principles of conventional laparoscopic or open repairs. Alexis retractor associated with knotless sutures are technical options that simplify LESS reconstructive surgical maneuvers.     

Transvaginal strangulated small intestinal hernia after abdominal sacrocolpopexy: case report and literature review

Purpose

To report a case of transvaginal small intestinal hernia following abdominal sacrocolpopexy and review this clinical presentation in the current literature.

Methods

A review of our case and a literature review of vaginal evisceration were carried out.

Results

The patient underwent sacrocolpopexy and a Burch procedure. Six months later, a recurrent enterocele through a 1 cm defect in the vaginal vault was diagnosed. Several weeks later she presented with an incarcerated and strangulated loop of small intestine extending beyond the introitus. This required an urgent exploratory laparotomy, ileocecal resection, and vaginal vault closure. Postoperatively, she experienced gradual prolapse recurrence and is currently successfully managed with a pessary. Risk factors that include vaginal atrophy, chronic constipation, and previous pelvic surgery may have contributed to the evisceration, mesh erosion, and may have caused the breakdown in the vaginal vault mucosa ultimately responsible for the evisceration. In addition, placement of the sacrocolpopexy mesh without tension, and utilization of an interposition graft to reinforce the weakened vaginal vault tissue, are aspects of the surgical procedure that may influence outcomes. At the time of evisceration repair, the best approach to resuspend the vaginal vault, and prevent recurrent prolapse or evisceration, is currently unknown.

Conclusion

Vaginal evisceration is a potential complication of abdominal sacrocolpopexy. Early recognition and treatment of this complication is critical, and prolapse recurrence may occur even after surgical repair.     

Laparoscopic sacrocolpopexy: operative times and efficiency in a high-volume female pelvic medicine and laparoscopic surgery practice

Introduction and hypothesis

There has been a trend toward robotic sacrocolpopexy in the United States despite longer operating times and higher costs compared with traditional laparoscopy. The current study objective was to evaluate incision to closure times of laparoscopic sacrocolpopexy in a urogynecologic practice with extensive experience in the laparoscopic approach for pelvic reconstruction.

Methods

We conducted a single-center retrospective evaluation of consecutive patients undergoing laparoscopic sacrocolpopexy for vaginal vault prolapse using a permanent polypropylene Y-mesh over a 1-year period. Standard operative technique for sacrocolpopexy was used. Four to six sutures were placed on the anterior leaflet of the mesh, and six to eight sutures were placed posteriorly. Two sutures were placed in the presacral ligament. Mesh was retroperitonealized with a running 2–0 monocryl suture. Primary outcomes were total operating time and time to complete laparoscopic sacrocolpopexy.

Results

One hundred and twenty-seven consecutive patients with an average age of 60.04?±?10.14 years, body mass index (BMI) 25.79?±?4.52 kg/m², underwent laparoscopic sacrocolpopexy for vaginal vault prolapse. Ninety-two patients had other procedures performed intraoperatively: laparoscopic-assisted vaginal hysterectomy, laparoscopic paravaginal repair, laparoscopic enterocele repair, and/or laparoscopic enterolysis. Mean total operative time for all laparoscopic procedures completed was 107.45 ± 34.00 min. The average time to perform sacrocolpopexy, including incision and closure, was 52.78 ± 13.09 min.

Conclusion

This retrospective evaluation provides further evidence that traditional laparoscopic sacrocolpopexy should be considered a primary therapy for vaginal vault prolapse.

     

A Retrospective Comparison of Abdominal Sacrocolpopexy with Burch Colposuspension versus Sacrospinous Fixation with Transvaginal Needle Suspension for the Management of Vaginal Vault Prolapse and Coexisting Stress Incontinence

The objective of this study was to compare the surgical outcome of abdominal sacrocolpopexy and Burch colposuspension with sacrospinous fixation and transvaginal needle suspension in the management of vaginal vault prolapse and coexisting stress incontinence. One hundred and seventeen women with vaginal vault prolapse and coexisting stress incontinence were surgically managed over a 7-year period. The first 61 consecutive women who underwent sacrospinous fixation and transvaginal needle suspension comprised the vaginal group, and the following 56 consecutive women who underwent abdominal sacrocolpopexy and Burch colposuspension comprised the abdominal group. Office records were reviewed to assess the presence of recurrent prolapse and urinary incontinence during postoperative follow-up. Objective follow-up was available for 101 women. Mean duration of follow-up was 24.0 ± 15 months for the vaginal group, and 23.1 ± 12.6 months for the abdominal group. The incidence of recurrent prolapse to or beyond the hymen (33% vs. 19%, P = 0.0505) and lower urinary tract symptoms (26% vs. 13%, P = 0.0506) were significantly higher in the vaginal group than in the abdominal group. Our data suggest that the combined abdominal approach has a lower incidence of recurrent prolapse and lower urinary tract symptoms than the combined vaginal approach in managing vaginal vault prolapse and coexisting stress incontinence.     

Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse after failed transvaginal polypropylene mesh surgery

Introduction and hypothesis

A prospective case series to assess the safety and efficacy of laparoscopic sacrocolpopexy for the surgical management of recurrent pelvic organ prolapse (POP) after transvaginal polypropylene mesh prolapse surgery.

Methods

Between January and December 2010, women with post-hysterectomy recurrent prolapse (≥ stage 2 POP-Q) after transvaginal polypropylene mesh prolapse surgery were included. Perioperative morbidity and short-term complications were recorded and evaluated. Surgical outcomes were objectively assessed utilising the Pelvic Organ Prolapse Quantification system (POP-Q), the validated, condition-specific Australian Pelvic Floor Questionnaire (APFQ) and the Patient Global Impression of Improvement (PGI-I) at 12 months.

Results

All 16 women in this study had undergone surgery with trocar-guided transvaginal polypropylene mesh kits. In 75% the recurrent prolapse affected the compartment of prior mesh surgery with the anterior (81%) and apical (75%) compartment prolapse predominating. At a mean follow-up of 12 months, all women had resolution of awareness of prolapse, had < stage 2 POP-Q on examination and high levels of satisfaction on PGI-I post surgery. There were no serious peri- or postoperative complications.

Conclusions

This preliminary study suggests that laparoscopic sacrocolpopexy for recurrent prolapse after failed transvaginal mesh surgery is feasible and safe. Further widespread evaluation is required.     

Abdominal sacral colpopexy with Mersilene mesh.

INTRODUCTION: This study focussed on abdominal sacral colpopexy with Mersilene mesh to correct total vaginal vault prolapse. Our aim was to describe and explain our operative modifications. MATERIALS AND METHODS: From 1992 and 1999, we performed sacrocolpopexy on 25 patients for vaginal vault prolapse. We proposed a change by interposing a mesh between the vaginal vault and the sacral promontory shaped as an inverted 'V'. RESULTS: No intraoperative or postoperative complications were encountered; to date the outcome of all patients was satisfactory. CONCLUSION: Based on the results of the follow-up, this new surgical approach of abdominal sacral colpopexy can be considered as effective surgery for vaginal vault prolapse.     

Laparoscopic management of uterine prolapse with cystocele and rectocele using "Gynemesh PS"

OBJECTIVE: Our department performed laparoscopic correction of uterine or vault prolapse with cystocele and rectocele using the "Gynemesh PS." The aim of this study was to evaluate the surgical outcomes and perioperative morbidity after a laparoscopic operation. MATERIALS AND METHODS: From August 2004 to September 2005, we performed laparoscopic pelvic floor repairs in 6 cases of vault prolapse and 15 cases of uterine prolapse at the Department of Obstetrics and Gynecology at the Kyungpook National University Hospital (Daegu, Korea). Uterine and vault prolapse were repaired by laparoscopic rectocele and cystocele repair using the Gynemesh PS, uterosacral ligament suspension, paravaginal repair, and Burch colposuspension. In uterine prolapse, we also carried out a subtotal hysterectomy. The stage of prolapse was classified by means of the pelvic organ prolapse quantification (POPQ) system. RESULTS: The mean age, Q-index, and parity were 64 years (range, 47-79), 24.6 (range, 18.7 approximately 27.8), and 5 (range, 3 approximately 10), respectively. Mean operation time was 141 minutes (range, 90 approximately 211). Mean estimated blood loss was 53 mL (range, 20 approximately 80). Mean hospital stay was 5 days (range, 3 approximately 9 days). There were no major complications, but postoperative voiding difficulty developed in 1 case. Mean preoperative POPQ stage was 3 and immediate, 6-week, 3-month, 6-month, and 1-year postoperative POPQ score was 0. Mean follow-up period was 7.5 months (range, 3 approximately 13). The objective success rate was 100%. CONCLUSIONS: Laparoscopic pelvic floor repair is an effective procedure and enables us to combine the advantages of laparotomy with the low morbidity of the vaginal route. In Europe, the sacrocolpopexy was more popular, but uterosacral ligament suspension is the most natural anatomic repair of defects and, hence, the least likely to be predisposed to future defects in the anterior or posterior vaginal wall or to compromise vaginal function. However, further studies are required on the long-term efficiency and reliability in order to evaluate the value of this technique.     

Laparoscopic sacrocolpopexy for post-hysterectomy vaginal vault prolapse

Laproscopic sacrocolpopexy offers a minimally invasive approach to correct post-hysterectomy vaginal vault prolapses. Herein we present our surgical technique and results. Through the transperitoneal approach, the retroperitoneal space was dissected along the right edge of the rectum and a polypropylene mesh is sutured to the vaginal apex and the anterior longitudinal ligament of the sacrum. We sutured the mesh to the sacrum with 2-0 PDS. To prevent bleeding from the pre-sacral vessels, occasionally we used a bone anchor system, Straight-In, in sacral fixation. Nine patients underwent this operation since August 19, 2005. The patient's age ranged from 48 to 78 years old. The median operation time was 250 minutes and the blood loss was 80.7 ml. The median post-operative hospital stay was 8.3 days. We experienced no peri- or post-operative complications. The vagina was well fixed post-operatively in all patients. Laparoscopic sacrocolpopexy is a minimally invasive treatment for vault prolapse and offers a high quality of life to patients.     

Use of a bidirectional barbed suture in robot-assisted sacrocolpopexy

Abdominal sacrocolpopexy is an effective and durable surgical procedure that is conventionally reserved for management of vaginal vault prolapse. With the availability of robotic technology in recent years, sacrocolpopexy has become more commonly performed in a minimally invasive fashion. Peritoneal closure can be a tedious and time-consuming step in robot-assisted sacrocolpopexy. We describe a novel technique utilizing a bidirectional barbed suture to re-approximate the peritoneum in robot-assisted sacrocolpopexy, making the procedure more time-efficient.