Key words abdominocervicopexy - laparoscopic lateral mesh suspension - pelvic organ prolapse
- transperineal ultrasonography - uterus preservation
Schlüsselwörter abdominelle Zervikopexie - laparoskopisch-laterale Suspension mit Netzimplantat -
urogenitaler Deszensus - transperinealer Ultraschall - Erhalt der Gebärmutter
Introduction
Pelvic organ prolapse (POP) is a major health problem which affects the psychological
well-being of women [1 ]. The lifetime risk for POP surgery is reported to be 12.6% and the annual risk is
4.3 per 1000 women [2 ]. Apical prolapse constitutes one of the most important issues in pelvic organ prolapse.
It is known that apical prolapse has a strong association with anterior vaginal wall
defects. Anterior prolapse repairs should usually be accompanied by apical support,
particularly in cases with transverse detachment of the endopelvic fascia from the
cervical apex [3 ]. Laparoscopic lateral suspension with mesh (LLSM) is a promising new technique originally
introduced by Dubuisson et al. [4 ] for the treatment of apical defects and additionally improves anterior defects.
Dubuisson et al. were inspired by the method described by Kapandji [5 ]. The method consisted of laparascopic fixation of the lateral vaginal fornices to
the lateral abdominal wall through subperitoneal tunnels parallel to the ovarian vessels
using a T-shaped polypropylene mesh. This not only suspends the prolapsed pelvic organs
but also reinforces the pubocervical fascia at the apex, thereby improving bladder
symptoms. The technique has since been improved and now has the potential to function
as an alternative to sacrocolpopexy, a globally accepted method for apical prolapse
surgery [6 ], [7 ]. It has been suggested that avoiding the potential risks associated with promontory
dissection is one of the most important features of lateral suspension. Uterus preservation
is the current trend in gynecologic surgery and hence in POP surgery. Uterus preservation
should be offered to appropriate candidates as the primary option to decrease surgical
morbidity and the morbidities associated with re-operation for mesh erosion without
worsening the risk of prolapse recurrence [8 ].
An effective method for the evaluation of pelvic floor anatomy, pelvic floor ultrasonography
is increasingly used for the evaluation of women with pelvic floor dysfunction. The
transperineal approach allows the functional anatomy of the pelvic floor to be assessed
and is also an effective method for the evaluation of objective surgical success [9 ].
Lateral suspension was introduced as an alternative to sacropexy; however, the majority
of the available data in the literature was produced by a single group [6 ], [7 ], [10 ], [11 ], [12 ], [13 ]. External prospective studies are needed to confirm their outcomes. In this prospective
study, we aimed to share our preliminary results for uterus-preserving laparoscopic
lateral mesh suspension (abdominocervicopexy) operations evaluated by transperineal
ultrasonography and subjective assessments.
Materials and Methods
This prospective study was approved by the local clinical research ethics board and
registered with the National Clinical Trials Registry (NCT #03387202). This study
was conducted in a tertiary training and research hospital between November 2016 and
December 2017. We aimed to include 15 patients to establish our initial learning curve
and finally included 17 patients who underwent uterus-preserving laparoscopic lateral
mesh suspension (abdominocervicopexy).
Subjects were eligible if they consented to uterus-preserving lateral abdominocervicopexy
for symptomatic apical pelvic organ prolapse of stage 2 or higher. Patients who preferred
other POP surgical techniques or pessaries were excluded from the study. Hysterectomized
patients and patients with a suspected gynecological malignancy or premalignant lesions
were also excluded. Patients were approached and enrolled at the time of giving their
written consent to surgery. All surgeries were performed by the same surgical team.
Surgical technique
All operations were performed under general anesthesia. Antibiotic prophylaxis with
cefazolin 1 g administered intravenously as a single shot was given to all women at
least 30 minutes prior to surgery. Pneumoperitoneum was achieved with a transumbilical
10-mm trocar. Two ancillary 5-mm suprapubic ports were placed lateral to the inferior
epigastric vessels bilaterally. Laparoscopy was used to incise the vesicouterine fold,
and the bladder was dissected to expose the vaginal wall.
As described previously [14 ], a V-shaped 2-cm wide strip was prepared by cutting two edges off a 30 × 30 cm polypropylene
macropore mesh (Parietene™ , Sofradim-Covidien, Trévoux, France) with scissors. We individualized the corner
of the V-mesh by adding a 2 × 2 cm diamond-shaped extension to treat accompanying
anterior wall defects ([Fig. 1 ]). The bottom corner of the diamond-shaped extension of the V-mesh was placed and
fixed on the anterior part of the cervix with a delayed absorbable tacker device (Absorba
Tack™ Covidien, Mansfield, MA, USA). The mesh was tacked to the cervix four to six times.
The anterior corner of the “V” was laid over the vaginal fascia under the bladder
without fixation.
Fig. 1 V-shaped mesh with diamond-shaped extension.
The 3-cm skin incisions were made on either of the abdomen, about 3 – 4 cm superior
and lateral to the anterior-superior iliac spine. Great care was taken to ensure that
the incision sites were at least 2 cm distant from the iliac crest. The abdominal
muscles were then perforated with a laparoscopic grasper and the subperitoneal space
was entered while the visceral peritoneum was left intact. Subperitoneal tunnels were
created by pushing the grasper caudally just above and parallel to the ovarian vessels.
After passing the ovaries, the grasper was directed towards the midline and advanced
through the leaflets of the broad ligament to reach the prepared vesicouterine space.
The arms of the mesh were grasped and pulled throughout the tunnels symmetrically
until the external cervical ostium was suspended just above the level of the ischial
spines. The mesh was then fixed to the fascia of the external oblique muscles by suturing
on each side with 3.0 propylene (Prolene® , Ethicon, Johnson & Johnson Int., Belgium). The remaining 1 cm excess of the arms
was introduced bluntly under the external oblique fascia and left tension free. A
laparoscopic McCall culdoplasty or prophylactic bilateral salpingectomy was performed
concomitantly when needed. The main steps of the Dubuisson technique are shown in
[Fig. 2 ] with minor modifications.
Fig. 2 Dubuission technique with minor modifications. a Preparation of the cervix and vesicovaginal space; b Filling of the bladder to make deep dissection of the vesicovaginal space easier
when treating the anterior prolapse; c Mesh fixation over the cervix with an absorbable tacker; d A subperitoneal tunnel is formed in the direction of the lower third of the round
ligament.
Preoperative and postoperative assessment
Baseline data include demographics, medical history, and physical and sonographic
examinations. A simplified Pelvic Organ Prolapse Quantification grading system (POP-Q)
was used to assess the degree of prolapse [15 ]. Definitions were consistent with ICS 2016 terminology. Stress urinary incontinence
(SUI) was diagnosed by clinical examination which included the cough-stress test in
the supine and standing positions with a 300-ml saline-filled bladder and changes
over 30° in the Q-tip test after a maximum Valsalva maneuver and cough. The severity
of existing nocturia, dyspareunia and constipation were assessed by the clinician
using a non-validated Likert type scale (0 – 3). Nocturia was scored as follows: 0
= no, 1 = one episode, 2 = two to three episodes, 3 = four or more episodes.
Validated versions of the Prolapse Quality of Life (P-QOL) questionnaire [16 ], Pelvic Organ Prolapse Symptom Score (POP-SS) [17 ], Female Sexual Function Index (FSFI) [18 ] and Michigan Incontinence Severity Index (M-ISI) [19 ] were used to assess subjective improvements.
On the second postoperative day the visual analog score (VAS) was used to measure
postoperative pain and the Patient Global Impression of Improvement (PGI-I) questionnaire
[20 ] was used at the last postoperative visit to evaluate the patientsʼ postoperative
improvement. Complications of surgery were assessed using the Clavien-Dindo classification
[21 ].
Pelvic floor ultrasonography was performed by the first author using 3D convex probes
and the Mindray DC-8 PRO ultrasound device (Shenzhen Mindray Bio-medical Electronics
Co. Ltd., China) according to the method described by Shek and Dietz [9 ]. Patients were asked to perform a maximum Valsalva maneuver for at least six seconds
to avoid levator co-activation. Cystoceles were evaluated using the Green classification
[22 ]. Patients with a retrovesical angle (RVA) of more than or below 140° were classified
as Green Type II and III, respectively. RVA was defined as the angle between the proximal
urethra and the trigonal surface of the bladder. The inferior margin of the pubic
symphysis was taken as the line of reference [23 ]. Cystocele and rectocele descent of at least 10 and 15 mm, respectively, below the
pubic symphysis and uterine descent of more than 15 mm at maximum Valsalva were regarded
as significant [9 ], [23 ]. Proximal urethral rotation measurements were obtained at rest and on Valsalva with
introital sonography. The hiatal anteroposterior (AP) diameter which indicates hiatal
ballooning was measured on maximal Valsalva as the shortest distance from the posteroinferior
margin of the pubic symphysis to the anterior margin of the most central aspect of
the puborectalis muscle in the midsagittal view. Cervical length and uterus size were
also measured in each patient.
Outcome measures
The primary outcome measures were anatomical and subjective cure, measured at the
last follow-up visit. Anatomical cure was defined separately for the apical and the
anterior compartment as POP-Q scores for the sites C and Ba of less than − 1 cm, respectively.
Subjective cure was defined as the absence of bulge symptoms with the patient answering
“Never” to question #A1 (A feeling of something coming down from or in your vagina?)
of the POP-SS scale [17 ]. Patient satisfaction was assessed using the PGI-I at the last follow-up and considered
to be satisfactory when the PGI-I was answered with “much better” or “very much better”
[20 ]. Secondary outcome measures were the scores of the P-QOL, POP-SS, FSFI and M-ISI.
Tertiary outcome measures were transperineal pelvic floor ultrasonography results
including anterior compartment mobility and the extent of pelvic organ descent (detailed
in the results), reoperation rate, mesh-related complications and improvements in
constipation, frequency of nocturia, pelvic pain and dyspareunia.
Statistical analysis
SPSS-22 software was used for data analysis. The Kolmogorov-Smirnov test was used
to assess normality. Normally and non-normally distributed paired groups for preoperative
and postoperative outcomes were compared using paired samples t-test and Wilcoxon
signed rank test with Monte Carlo simulation, as appropriate. Variables were reported
by their mean ± standard deviation (SD), median, minimum, maximum values. A p-value
of less than 0.05 was considered significant.
Results
Demographic data including age, body mass index, parity, menopausal status and sexual
activity are summarized in [Table 1 ]. Five patients reported themselves as sexually inactive; in four cases this was
partner-related. The last follow-up visits to assess the outcome measures were in
March 2019. The median follow-up was 23.93 months with a range of 15.3 – 28.8 months
(interquartile range = 3.9).
Table 1 Demographic, pre- and postoperative data.
Age (year, mean ± SD)
52.3 ± 11.7
BMI (kg/m2 ), mean ± SD
29 ± 3.9
Parity, mean ± SD
3.4 ± 2.1
Post-menopausal, n (%)
9 (53)
Sexual activity, n (%)
12 (70.6)
Previous POP surgery, n (%)
2 (11.8)
anterior colporrhaphy
sacrouterine ligament plication, sacrospinous ligament fixation, sacrocervicopexy
Additional surgical procedures, n (%)
6 (35.3)
2 (11.8)
1 (5.9)
1 (5.9)
2 (11.8)
1 (5.9)
1 (5.9)
Operation time (minutes, mean ± SD)
108.8 ± 29.8
Median VAS score at 48 h postop (min-max)
1 (1 – 3)
Postop. complications (Clavien-Dindo), n (%)
0 (0)
1 (5.9)
Re-operation, n (%)
1 (5.9)
Lower urinary tract infection, n (%)
1 (5.9)
De novo stress urinary incontinence, n (%)
0 (0)
De novo overactive bladder, n (%)
2 (11.8)
Exacerbation of existing rectocele, n (%)
0 (0)
De novo constipation, n (%)
1 (5.9)
Mean uterus size was 54.76 ± 13.33 mm (height) × 39.86 ± 11.45 mm (width), and mean
cervical length was 30.61 ± 6.49 mm.
Primary outcomes
Preoperative Ba, C, Bp and vaginal length (VL) measurements were 17.59 ± 13.13 mm,
36.65 ± 12.52 mm, − 1.05 ± 13.41 mm and 96.62 ± 12.36 mm, respectively. Anatomical
cure was 100% for the apical compartment and 88.2% for the anterior compartment, with
one symptomatic and one asymptomatic case with stage 2 cystocele ([Table 2 ]). There was no significant improvement in the posterior compartment (p = 0.5). Ba
and C points were significantly improved, and vaginal lengthening was 10.14 ± 4.19 mm
([Table 3 ]). The Bp point was not significantly changed by the operation (p = 0.053), although
an average ascent of 5.72 ± 11.27 mm was observed.
Table 2 Objective cure. Pre- and postoperative distribution of prolapse stage according to
anatomic compartments.
Preoperative, n (%)
Postoperative, n (%)
p (z)
Wilcoxon signed rank test with Monte Carlo simulation
* p < 0.05
Apical
< 0.01 (− 3.7)*
0 (0)
17 (100)
0 (0)
0 (0)
2 (11.8)
0 (0)
6 (35.3)
0 (0)
9 (52.9)
0 (0)
Anterior
< 0.01 (− 3.6)*
1 (5.9)
11 (64.7)
3 (17.6)
4 (23.5)
6 (35.3)
2 (11.8)
5 (29.4)
0 (0)
2 (11.8)
0 (0)
Posterior
0.5 (− 1)
11 (64.7)
12 (70.6)
5 (29.4)
4 (23.5)
1 (5.9)
1 (5.9)
Enterocele
0.25 (− 1.4)
15 (88.2)
17 (100)
2 (11.8)
0 (0)
Table 3 Pre- and postoperative POP-Q measurements.
95% CI
(mm)
Mean
SD
SEM
Lower
Upper
p
Paired t-test
* postoperative
SD: standard deviation; SEM: standard error of the mean; CI: confidence interval;
VL: vaginal length
Ba & Ba*
24.53
10.19
2.47
19.29
29.77
0.000
C & C*
69.82
14.42
3.5
62.41
77.24
0.000
Bp & Bp*
5.72
11.27
2.73
− 0.08
11.51
0.053
VL & VL*
− 10.14
4.19
1.02
− 12.3
8
0.000
Symptomatic recurrence was seen in 1 patient with cystocele and rectocele who was
treated with anterior and posterior colporrhaphy one year after the operation. There
was no de novo SUI or exacerbation of the existing rectocele. De novo overactive bladder
was seen in two patients and resolved with short-term anticholinergic therapy and
behavioral changes. De novo constipation was seen in one patient who was diagnosed
by general surgeons with inflammatory bowel disease and treated successfully with
the appropriate medical therapy. Sterile pyuria was seen in one patient in the early
postoperative period and successfully treated with antibiotic therapy without any
recurrence.
16 out of 17 patients answered “Never” to the “A feeling of something coming down
from or in your vagina?” question, indicating the absence of bulge symptoms. All patients
reported an improvement in their condition. Improvement after the operation was reported
as “very much better” by 88.2% of the patients and “much better” by the remaining
11.8%. Subjective cure and patient satisfaction rates were 94.12 and 100%, respectively.
Secondary outcomes
A significant improvement after surgery was seen for all subjective measures and their
sub-domains (p < 0.05, [Table 4 ]).
Table 4 Comparison of pre- and postoperative quality of life scales.
Preoperative
Postoperative
p (z)
Mean ± SD
Min-Max
Mean ± SD
Min-Max
Wilcoxon signed rank test with Monte Carlo simulation
P-QOL: Prolapse Quality of Life; POP-SS: Pelvic Organ Prolapse – Symptom Score; FSFI:
Female Sexual Function Index; M-ISI: Michigan Incontinence Severity Index
P-QOL
General health perceptions
2.47 ± 0.94
1 – 4
1.18 ± 0.81
0 – 2
0.003 (− 2.84)
Prolapse impact
3.71 ± 0.59
2 – 4
1.06 ± 0.43
0 – 2
0.000 (− 3.78)
Bladder functions
31.30 ± 9.66
14 – 48
17.65 ± 5.16
11 – 30
0.000 (− 3.50)
Bowel functions
15.89 ± 5.50
6 – 25
8.71 ± 4.95
0 – 20
0.000 (− 3.16)
Role limitations
6.65 ± 2.03
2 – 8
2.18 ± 0.53
2 – 4
0.000 (− 3.47)
Physical limitations
10.70 ± 6.70
2 – 75
2.47 ± 0.80
2 – 4
0.000 (− 3.55)
Social limitations
6.30 ± 2.08
2 – 8
2.12 ± 0.33
2 – 3
0.000 (− 3.57)
Personal relationships
9.23 ± 2.89
3 – 12
1.76 ± 1.68
0 – 5
0.000 (− 3.64)
Emotions
8.94 ± 2.33
5 – 12
3.59 ± 0.94
3 – 6
0.000 (− 3.42)
Sleep/Energy
5.94 ± 1.78
2 – 8
2.71 ± 1.26
2 – 7
0.000 (3.54)
Severity measures
11.82 ± 3.90
5 – 16
4.59 ± 0.87
4 – 7
0.000 (− 3.63)
POP-SS
Total
20.89 ± 5.74
9 – 28
5.06 ± 4.66
0 – 17
0.000 (− 3.62)
FSFI
Desire
2.05 ± 1.30
1.2 – 5.4
3.4 ± 1.39
1.2 – 6
0.011 (− 2.46)
Arousal
1.90 ± 1.27
0 – 3.9
3.45 ± 1.85
0 – 5.7
0.015 (− 2.41)
Lubrication
2.12 ± 1.61
0 – 4.8
4.15 ± 1.69
0 – 6
0.001 (− 2.94)
Orgasm
1.80 ± 1.60
0 – 4.4
3.73 ± 1.74
0 – 6
0.001 (− 2.94)
Satisfaction
2.50 ± 1.62
0 – 5.2
4.17 ± 1.27
1.2 – 5.6
0.024 (− 2.25)
Pain
2.00 ± 1.76
0 – 5.2
5.10 ± 1.70
0 – 6
0.001 (− 2.94)
Total
12.37 ± 7.36
1.2 – 26.5
24 ± 7.98
6.4 – 34.6
0.001 (− 2.98)
M-ISI
Stress urinary incontinence
3.18 ± 3.20
0 – 10
1.29 ± 2.31
0 – 6
0.002 (− 2.82)
Urge urinary incontinence
6.06 ± 3.70
0 – 12
2.00 ± 2.55
0 – 9
0.000 (− 3.53)
Pad use
3.88 ± 1.80
0 – 6
1.71 ± 1.86
0 – 5
0.002 (− 3.02)
Bother score
2.53 ± 2.37
0 – 7
0.71 ± 1.26
0 – 4
0.013 (− 2.4)
Severity score
13.12 ± 6.48
1 – 25
5.00 ± 5.76
0 – 20
0.000 (− 3.52)
The POP-SS question #8 (The symptom most frequently reported as causing the most bother)
was answered with #7 (A feeling that your bowel has not emptied completely) by two
patients (11.8%) while remaining 15 (88.2%) answered the question with “not applicable”.
FSFI was only administered to the 12 sexually active patients (70.6%) as appropriate.
Of the five preoperatively sexually inactive patients, four were inactive due to partner-related
problems and the remaining one returned to sexual activity postoperatively, but her
data were not included in the statistical analysis.
Tertiary outcomes
No mesh-related complications were seen in any of the patients during the follow-up
periods. Mean operation time was 108.8 ± 29.8 minutes. Only one patient was classified
as Clavien-Dindo grade IV due to a misunderstanding by the anesthesiology team about
the need for intensive care due to a false suspicion of CO2 embolism. That was the only case of conversion to laparotomy. Significant blood loss
was not observed in any cases. SUI was present in four patients preoperatively. All
were stress test-positive after the operation and were later treated using a mid-urethral
sling in a double-step procedure. However, patient-reported scales indicated significant
improvements in subjective stress and urge scores ([Table 4 ]).
A significant improvement was seen in patientsʼ nocturia and dyspareunia scores but
not the constipation scores. The nocturia scores of the patients were 2.00 ± 0.94
and 0.59 ± 0.62 pre- and postoperatively, respectively (p = 0.000). Pre- and postoperative
dyspareunia scores of the patients were 2.06 ± 1.30 and 0.00 ± 0.00, respectively
(p = 0.000). Constipation scores of the patients were 0.59 ± 0.80 and 0.35 ± 0.49
pre-and postoperatively (p = 0.102).
Transperineal and introital pelvic floor ultrasonography measurements are given in
[Table 5 ]. Urethral mobility was reduced by 6.24 ± 11.95° postoperatively (p = 0.047). All
patients were classified according to their retrovesical angle measurements (RVA).
58.8% of the patients were classified as Green type II (RVA ≥ 140°) with an average
of 161 ± 15.06°, and 41.2% of the patients were classified as Green type III (RVA
< 140°) with an average of 108.29 ± 31.11°. RVA on maximum Valsalva was reduced by
27 ± 47.2° after the operation (p = 0.032).
Table 5 Pelvic floor ultrasonography measurements.
Preoperative (mean ± SD)
Postoperative (mean ± SD)
p
UR: urethral rotation; RVA: retrovesical angle; HD: hiatal AP diameter on “Valsalva”
and “at rest”.
B, C and R indicate the extent of bladder, cervix and rectum descent on maximal Valsalva
of at least six seconds. A minus sign signifies a position below the posterior inferior
margin of the pubis on ultrasound.
UR (°)
28.12 ± 16.57
21.88 ± 12.53
0.047
RVA (°)
131.29 ± 41.38
104.35 ± 34.15
0.032
HDv (mm)
68.20 ± 10.92
64.40 ± 6.80
0.039
HDr (mm)
71.57 ± 9.12
68.45 ± 7.71
0.012
B (mm)
16.41 ± 13.75
− 3.89 ± 13.71
0.000
C (mm)
26.30 ± 13.50
− 28.90 ± 8.51
0.000
R (mm)
1.67 ± 8.53
3.15 ± 12.05
0.565
The most descended points of the bladder and cervix over the pubic symphysis on maximal
Valsalva measured by transperineal ultrasound improved significantly after the operation
by 20.3 and 55.2 mm respectively (p = 0.000). The hiatal AP diameter on Valsalva decreased
significantly from 68.2 ± 10.92 mm to 64.4 ± 6.8 mm before and after the operation
(p = 0.039). In contrast, the anorectum of the patients was observed to be descended
by 1.48 ± 10.4 mm on maximum Valsalva but did not reach the level of statistical significance
(p = 0.565).
Post-hoc statistical power was assessed using G*Power v. 3.1. (Heinrich Heine University,
Düsseldorf, Germany). If the postoperative changes in C and Ba points are taken as
the primary outcome measures; the power of this analysis (n = 17) was found to be
100% for both outcomes, with effect sizes of 4.84 and 2.41, respectively, for C and
Ba points and an alpha error of 0.05.
Discussion
A wide variety of surgical techniques are used to correct POP, and sacrocolpopexy
has been widely accepted as the gold standard for apical prolapse surgery [24 ]. However, there are major disadvantages associated with this procedure, including
the risk of major pelvic vessel or ureteral injury and sacral discitis [25 ], [26 ]. We believe that the sacropexy technique places the uterus in a more posterior position
than its normal anatomical position, leaving the anterior compartment unsupported
against intraabdominal pressure, which may lead to urge symptoms and de novo anterior
prolapse. Because of the aforementioned issues, we preferred to use a lateral suspension
operation for POP surgery. In this study, uterus-preserving laparoscopic lateral suspension
(abdominocervicopexy) with mesh operation was found to be effective to correct simultaneous
apical and anterior compartment prolapse ([Fig. 3 ]).
Fig. 3 a, b Preoperative vaginal examination, c postoperative vaginal examination.
In the original Dubuisson technique, a T-shaped mesh is sutured to the lateral vaginal
fornices, and the arms of the mesh are suspended from the vaginal apex towards the
lateral abdominal wall between the leaflets of the broad ligament and pulled outside
the abdomen at a point 3 – 4 cm superior and lateral to the anterior superior iliac
spines through a subperitoneal tunnel.
This brilliant technique has not only been shown to be safe and effective in many
studies but also provides a more normal anatomical correction [6 ], [7 ]. We have previously made some modifications to this technique [14 ]: firstly, the cervix was used as the anchoring point instead of the vaginal fornices
in order to imitate the cardinal ligament and with the hope of decreasing the risk
of mesh detachment and erosion. Secondly, we used a delayed absorbable tacker system
instead of suturing in order to decrease the operation time. Thirdly, we fixed the
arms of the mesh to the external oblique muscle fascia with Prolene stitches to reduce
the risk of failure. In addition, instead of a T-shaped mesh we used a V-shaped mesh
prepared from an ordinary 30 × 30 cm macropore polypropylene mesh such as those used
by Ceci et al. and also sutured the arms of the mesh to the external oblique muscle
fascia [27 ]. We individualized the shape of the mesh with a diamond-shaped extension and prepared
a V-shaped mesh for cases with a large additional cystocele and laid the edge of the
“V” over the vaginal fascia under bladder without fixation to avoid vaginal mesh erosion.
Recently, the results of the largest series of laparoscopic lateral suspensions with
mesh was published by Veit-Rubin et al. A total of 417 patients were operated on.
The anatomical success rate was 93.6% for the apical and 91.6% for the anterior compartment,
and the subjective cure rate was 78.4% in their first year. They also reported that
over 85% of patients rated their situation as improved and that this satisfaction
was associated with the absence of concomitant hysterectomy. Their mesh exposure rate
was 4.3% and the reoperation rate was 7.3% [7 ].
In the current study, the uterus was preserved in all 17 of the operated patients.
The anatomical success rate for the apical and anterior compartments was 100 and 88.2%,
respectively, and the subjective cure and patient satisfaction rates were 94.12 and
100%, respectively. The discrepancy between the subjective cure rate and the patient
satisfaction rate could be related to the study size, the preservation of the uterus
as suggested by the results of Veit-Rubin et al. [13 ] or the slightly different operative technique. We have not seen any patient with
mesh exposure and we only re-operated one patient who underwent anterior and posterior
colporrhaphy.
Veit-Rubin et al. reported recovered sexual activity for 13.1% of patients at 1 year
after surgery [7 ]. This was comparable with our results. Mean total FSFI score increased from 12.37 ± 7.36
to 24 ± 7.98 postoperatively (n = 12, p < 0.05, [Table 4 ]). In addition, one sexually inactive patient returned to sexual activity after the
operation.
Huang et al. reported a higher incidence of voiding dysfunction, weaker pelvic floor
support and a more caudally positioned bladder neck in patients with Green type III
cystoceles [28 ]. In those patients, the proximal urethra can be rotated as much as with Green type
II cystoceles, resulting in urethral kinking. Urethral mobility was reduced by 22.2%
(6.24 ± 11.95°) after the operation (p = 0.047) in the current study. RVA on maximum
Valsalva was reduced by 27 ± 47.2° postoperatively (p = 0.032). Changes in the retrovesical
junction might have been largely caused by tissue suspension during fixation and may
depend on the type of the cystocele, therefore there may be no direct surgical effect.
The change in RVA should be interpreted with caution and cannot be generalized. In
this study, it was found that laparoscopic lateral suspension supported the bladder
base well and restored the normal anatomy with correction of the retrovesical angle
([Fig. 4 ]).
Fig. 4 Transperineal ultrasonography of the pelvic floor. a Preoperative status: cystourethrocele; b Postoperative correction of anterior prolapse at rest; c Postoperative correction of anterior prolapse on maximal Valsalva. B: bladder; SP:
pubic symphysis; U: urethra. Arrows indicate the mesh fixed to the cervix and laid
over the anterior vaginal wall. Note the corrected retrovesical angle.
The integral theory proposed that bladder symptoms originate predominantly from damaged
suspensory ligaments and fascia rather than from the bladder itself [29 ]. Defects in the structures supporting and stretching the vesicovaginal fascia membrane
are the cause of several functional urinary symptoms. The loss of support by the trampoline
membrane that specifically corresponds to the trigone mainly triggers a premature
micturition reflex including nocturia and urge symptoms. Hence it was hypothesized
that supporting the anterior and apical compartments would improve those symptoms.
The results of the present study were in accordance with the integral theory, with
improved voiding dysfunction and urge symptoms as measured by validated questionnaires
and a significant decrease in nocturia episodes and dyspareunia. We think that LLSM
mimics the cardinal ligament and partially supports the bladder base.
Andrew et al. retrospectively analyzed imaging data from their large and varied POP
surgery series to assess changes in the levator hiatus area [30 ]. POP repair led to minimal but significant shortening in the three-dimensional hiatal
area by 9% measured by transperineal ultrasound. In the current study, the two-dimensional
hiatal anteroposterior diameter was found to be shortened by 4.36%, with a mean of
3.12 ± 4.57 mm, comparable to the results of Andrew et al. Although the rarity of
additional posterior compartment surgeries may explain this limited shortening, we
believe that shortening of the hiatal AP diameter might be explained by the relief
of pressure exerted on the levator muscles following correction of the prolapse and
the reinstatement of normal anatomy.
The small study size is the major limitation of the present study. On the other hand,
this study was carried out to establish our learning curve for the LLSM operation.
This study had three major strengths. Firstly, it was developed as a prospective longitudinal
study. Moreover, to the best of our knowledge, this is the first time transperineal
ultrasonography was used to evaluate the results of a lateral suspension operation.
Finally, unlike most of previous studies, urge symptoms (as measured by POP-QOL and
M-ISI) and frequency of nocturia were also assessed as outcomes after prolapse surgery.
Significant improvements in both were demonstrated.
Conclusion
Uterus-preserving laparoscopic lateral suspension (abdominocervicopexy) with mesh
operation was found to be safe and effective with high patient satisfaction rates
and simultaneous correction of apical and anterior prolapse. Significant improvements
in patientsʼ quality of life, frequency of nocturia, urge symptoms and extent of dyspareunia
were observed. Pelvic floor ultrasound outcomes may be useful when comparing this
approach with other surgical techniques.
Clinical Trials Registry
NCT #03387202
