A 5-Year Single-Center Experience on Laparoscopic Sacrocolpopexy

Pedro Miguel Baltazar, João Pina, Raquel João, Hugo Pinheiro, Pedro Melo Rocha, Ana Meirinha, Miguel Almeida, Natália Martins, Frederico Ferronha, Ciprian Muresan, José Paulo Patena Forte, Luís Campos Pinheiro

Urology Department, Centro Hospitalar Lisboa Central, Lisbon, Portugal

Head of Department: Prof. Dr. Luís Campos Pinheiro

Hypothesis / Aims of Study:

Interpretation of Results / Concluding Message:

Study Design, Materials and Methods:

Review of Surgical Results:

Revision of the Laparoscopic Sacrocolpopexies performed at the Urology Department of the Centro Hospitalar Lisboa Central in the last 5 years (n = 28):

#201

Hypothesis: The pelvic organ prolapse is a frequent pathology in multiparous postmenopausal women, associated with changes in quality of life, bladder, bowel, and sexual dysfunctions. The preference by a laparoscopic approach for pelvic pavement reconstruction in woman with pelvic organ prolapse has increased in the last decades due to a better visualization of the pelvic anatomy and a better access for the prosthesis fixation. The laparoscopic sacrocolpopexy is a well-accepted technique for the uterine and apical prolapses with excellent surgical results, high satisfaction rates and low complication rates. Aims of Study: Review and describe the most important aspects of the laparoscopic sacrocolpopexy procedure; Review the surgical indications, associated procedures and possible outcomes of laparoscopic sacrocolpopexy; Report the surgical experience of the Centro Hospitalar Lisboa Central Urology Department in the last 5 years; Assess the clinical and functional outcomes for sexual, bladder and bowel domains.

Laparoscopic sacrocolpopexy is a well-accepted procedure for correction of complete pelvic organ prolapse; The principal complication was the development of stress urinary incontinence; The global satisfaction and the quality of life levels were high; Our results confirm the efficacy of this procedure, the low long-term morbidity rate, high satisfaction level and good clinical and functional outcomes in sexual, bladder and bowel domains.

The pelvic organ prolapse was quantified by the “Pelvic Organ Prolapse Quantification Scale” (POP-Q); The functional outcomes was assessed by the “International Consultation in Incontinence Questionnaire for Vaginal Symptoms” (ICIQ-VS) and directed questions; A database was kept prospectively in the last 5 years for all laparoscopic sacrocolpopexies.

Laparoscopic Sacrocolpopexy – Surgical Procedure:

Dissection of Vesicovaginal space: With the help of a vaginal valve, the peritoneum overlying the vaginal vault is cut and dissected toward the vesicovaginal septum by folding the bladder and exposing the anterior wall of the vagina.

Dissection of rectovaginal space: The rectum must be pulled forward toward the sacrum to identify the rectovaginal septum; The peritoneum over the vaginal vault should be sectioned and dissected toward the rectovaginal septum.

Dissection of the promontory: Must be performed until the periosteum, taking care to identify the sacred vessels, right ureter and left common iliac vein that crosses the sacred promontory on the midline.

Dissection and opening of the right lateral peritoneum: From the promontory to the vaginal vault, taking care to identify the right ureter, inferior hypogastric nerve and internal iliac vessels.

Peritoneal closure: Start covering the prosthesis fixed to the vaginal vault (Vicryl® 0) and then proceed to the closure of the right lateral peritoneum, covering the entire prosthesis with peritoneum.

Prosthesis fixation in sacral promontory: The prosthesis is fixed with 1-2 points of a non-resorbable suture (2/0) encompassing the periosteum. It is important to perform a tension-free prosthesis fixation.

Prosthesis fixation in vesicovaginal space and in the levator ani muscle: The two anterior prosthetic arms are fixed with a non-resorbable sutures (2/0).

Preparation of prosthesis: We use a polypropylene mesh in a "Y shape" presenting an arm for fixing to the vesicovaginal space, another arm for fixing to the rectovaginal space and a longer trailing arm for fixing to the sacral promontory.

Preoperative Procedures - Vaginal application of estrogens one

month prior to surgery for improving trophism and healing;

- Place the patient in lithotomy;

- Place the arms along the body to decrease the risk of brachial plexus injuries;

- Catheterize patient with a 14Fr Foley;

- Establish pneumoperitoneum with a Veress needle;

- Make a 15-20º Trendelenburg position to rule out intestinal loops of the pelvic cavity;

- Placement of laparoscopic trocars arranged as follows: • A 10-12mm trocar for the30º optic in

umbilicus; • A 5mm trocar in the right iliac fossa; • A 5mm trocar in the right flank; • A 10mm trocar in the left flank.

Postoperative Period

- Avoid violent activities in the next 3 months;

- Perform a high-fiber diet and good hydration in order to avoid constipation;

- Sexual activity should not be started before the sixth week.

Equipment Needed

- 1 10/12 mm and 3 5mm trocars; - 1 bipolar forceps (Ultracision®/Ligasure®); - 1 Metzenbaum monopolar scissors; - 1 vaginal valve; - 1 aspiration and irrigation system; - 1 atraumatic grasping forceps double action jaw; - 2 needle-holders; - 1 “Y shape” polypropylene mesh.

Surgical Procedure

Questions Answers Yes (n, (%)) No (n, (%))

Are you globally satisfied with the results obtained with the

surgery?

27 (96,4%) 1 (3,6%)

Would you choose again to perform this surgical procedure? 27 (96,4%) 1 (3,6%)

Table 5. Qualitative assessment of the satisfaction rates of patients submitted to laparoscopic sacrocolpopexies.

0

2

4

6

8

10

12

14

16

0 1 2 3 4 5 6 7 8 9 10

15

4 3

4

1 0 0

1 0 0 0 N

um

ber

of

Pat

ien

ts (

n)

Overall, how much do your vaginal symptoms interfere with your daily activities?

Quantitative Assessment of Health Related Quality of Life (HR-QoL)

Graphic 1. Quantitative assessment of the health related quality of life according to the International Consultation in Incontinence Questionnaire for Vaginal Symptoms (ICIQ-VS).

Assessment of Patients Satisfaction

Postoperative Complications N (n, (%)) Erosion of vaginal vault by the prothesis 1 (3,6%)

Occasional pain in the lower abdominal quadrants 1 (3.6%)

Development of a enterocutaneous fistula 1 (3,6%)

Rectocele recurrence 1 (3,6%)

Development of stress urinary incontinence 5 (17,9%)

Table 3. Postoperative complications ocurred.

Perioperative Complications N (n, (%)) Vesical perforation 2 (7,1%)

Intestinal perforation 1 (3,6%)

Table 2. Perioperative complications occurred.

Associated Procedures N (n, (%)) Placement of a "TOT" prothesis 13 (46,4%)

Subtotal Histerectomy 14 (50,0%)

Table 4. Associated procedures performed in the same surgical time.

Date Age

(Years)

PxBx POP-Q Previous

Histerectomy

Concomitant Subtotal

Histerectomy

Concomitant Placement

of a “TOT” Prothesis

Surgery Time

(min)

Hospital

Stay

(Days)

Perioperative

Complications

Postoperative Complications HR-QoL

(ICIQ-VS)

(0-10) 08-01-10 83 P2B3 IV/IV 265 6 1

04-01-11 69 P2B1 III/IV 225 2 0

18-02-11 65 P3B2 III/IV 145 4 0

21-11-11 63 P1B1 III/IV 235 6 Development of stress urinary incontinence 2

21-11-11 63 P2B2 III/IV 190 5 0

30-01-12 52 P1B1 III/IV 180 4 Development of stress urinary incontinence 2

19-03-12 69 P2B2 IV/IV 250 7 0

16-05-12 55 P1B1 IV/IV 325 2 Development of stress urinary incontinence 3

30-05-12 67 P3B3 III/IV 295 2 0

06-06-12 60 P2B2 III/IV 295 2 Vesical perforation Rectocele recurrence 4

21-11-12 44 P1B1 IV/IV 365 4 1

14-01-13 65 P3B3 III/IV 245 5 0

02-04-13 67 P2B2 IV/IV 200 3 Development of stress urinary incontinence 3

08-04-13 65 P2B2 IV/IV 185 5 0

27-05-13 65 P2B1 III/IV 290 22 Intestinal perforation Development of a enterocutaneous fistula 7

12-06-13 64 P2B2 III/IV 147 3 0

19-09-13 68 P2B2 III/IV 280 4 Development of stress urinary incontinence 3

22-09-13 77 P2B1 III/IV 260 4 1

22-09-13 75 P3B3 III/IV 260 4 0

25-10-13 58 P2B2 IV/IV 300 9 1

30-10-13 69 P3B4 III/IV 190 3 0

18-12-13 76 P2B2 IV/IV 380 4 0

11-11-13 54 P6B3 III/IV 215 3 Vesical perforation Erosion of vaginal vault by the prothesis 3

20-01-14 51 P1B1 III/IV 210 3 0

29-01-14 57 P1B2 IV/IV 280 4 0

24-02-14 59 P1B1 III/IV 180 3 0

10-03-14 74 P1B1 III/IV 295 3 Occasional pain in the lower abdomen 2

24-03-14 59 P2B2 III/IV 210 3 0

Average 63,5 - - - - - 248 4,7 - - -

Table 1. Data review of surgical interventions. PxBx - Number of pregnancies and births; POP-Q - Quantitative assessment of the degree of urogenital prolapse ("Pelvic Organ Prolapse Quantification Scale"); SUI - Stress Urinary Incontinence; HR-QoL – Health-Related Quality-of-life; ICIQ-VS - "International Consultation in Incontinence Questionnaire for Vaginal Symptoms".

Surgical Complications

Other Surgical Procedures performed in the same Surgical Time

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