Full
length
article
Laparoscopic
lateral
suspension
with
mesh
for
apical
and
anterior
pelvic
organ
prolapse:
A
prospective
double
center
study
Liliana
Mereu
a,*
,
Saverio
Tateo
a,
Maurizio
Nicola
D
’Alterio
a,e,
Eleonora
Russo
b,
Andrea
Giannini
b,
Paolo
Mannella
b,
Riccardo
Pertile
c,
Tommaso
Cai
d,
Tommaso
Simoncini
ba
DepartmentofObstetricsandGynecology,SChiaraHospital,Trento,Italy
b
DepartmentofObstetricsandGynecology,UniversityofPisa,Italy
c
ClinicalandEvaluativeEpidemiologyDepartment–TrentoHealthService,Trento,Italy
d
DepartmentofUrology,SChiaraHospital,Trento,Italy
e
UniversityofCagliari,Italy
ARTICLE INFO
Articlehistory: Received26May2019
Receivedinrevisedform8October2019 Accepted17October2019
Availableonlinexxx
Keywords: Apicaldefect Complications
Laparoscopiclateralsuspension Mesh
Pelvicorganprolapse Recurrences
ABSTRACT
Objective:Thepresentstudyanalyzedlong-termoutcomesandcomplicationsoflaparoscopiclateral
suspension(LLS)withmeshtotreatapicalandanteriorpelvicorganprolapse(POP).
Studydesign:Aprospectivecohortstudyon125patientswithvaginalbulgeandapical+/ anterior
prolapsescheduledforLLSwhoconsecutivelyunderwentLLSbetweenApril2013andJanuary2017in
GynecologicDepartmentofSantaChiaraHospitalinTrentoandUniversityofPisa.
ThemainoutcomemeasurewasanatomicandsymptomaticPOPoutcome;thesecondaryoutcomes
measures wererecurrence,reoperation rate,denovo posteriorPOPand complications.Percentage
distributionofthepre-andpostoperativePOP-Qstageswascomparedatmeanfollow-up.Wilcoxon
signedranksumtestwasusedtocomparepreoperativePOP-QstageandpostoperativePOP-Qstageate
meanfollowup,foreachpatient(paireddata)andforeachtypeofprolapse.
Results:120patientswereincludedinthestudy.At2years89%ofpatientswereasymptomaticand
anatomicsuccessratewas94.2%fortheanteriorcompartment,94.9%fortheapicalcompartment.
Concerningposteriorcompartmentprolapse2(1.7%)patientsreferredstage3denovoprolapseduring
follow-up.ThecomplicationrateofClavien-Dindo>3was0,8%.RepeatsurgeryforPOPoccurredin6.4%
ofcases.TheappearanceofPOP-Qrecurrenceswasconcentratedat6monthsfollow-up.BMI>25was
correlatedwithdenovoposteriorcompartmentappearanceduringfollow-up.
Conclusions:LLSforthetreatmentofapicalandanteriorPOPisatechniquewithoptimalresultsintermof
safetyandeffectivenessafter2yearsfollow-up.
©2019ElsevierB.V.Allrightsreserved.
Introduction
POPisafrequentconditionandcanaffectawoman’squalityof life.Inpost-menopausalwomen,theprevalenceof POPis3–6% whendefinedandgradedonsymptomscomparedwith41–50% whenbasedonexamination[1,2].Theanteriorcompartmentisthe mostfrequently reportedsite of prolapse, it is identified twice morethanposteriorandthreetimesmorethanapical compart-mentdefect [3]. Only10–20% ofaffected women,though, seek evaluationfortheircondition[2]. Althoughsurgeryisgenerally
reservedtopatientswithprolapsesymptoms,withadvancestage orafterfailureofconservativetreatments,woman’slifetimeriskof surgeryforPOPis12–19%[4].
TherearevarioussurgicaltechniquesforthecorrectionofPOP: fascialvsmeshrepair, vaginalvsabdominalrouteanddifferent abdominal approaches: laparotomy, laparoscopy, robot-assisted laparoscopy.AftertheFDAwarningof2011and2019concerning POPrepairwithvaginalmesh,trans-abdominalmeshprocedures have reached the more favourable risk-benefit proportion for correction of apical defect. By some, sacrocolpopexy (SCP) is consideredthegoldstandard[2]evenifitcanbeassociatedwith long operative time and learning curve, serious morbidity as vascularanduretericinjuries,lesionsofthesuperiorhypogastric plexus,righthypogastricnerveleadingtodenovoconstipationand evenifrarespondylodiscitisandlumbarpain[5–7].
*Correspondingauthorat:DepartmentofObstetricsandGynecology,Ospedale SantaChiara,TrentoLargoMedaglied’Oro9,38122,Trento,Italy.
E-mailaddress:liliana.mereu@apss.tn.it(L.Mereu).
https://doi.org/10.1016/j.ejogrb.2019.10.026
0301-2115/©2019ElsevierB.V.Allrightsreserved.
ContentslistsavailableatScienceDirect
European
Journal
of
Obstetrics
&
Gynecology
and
Reproductive
Biology
AnalternativeproceduretoSCPthatavoidsdissectionatthe promontorycouldbeLLS.This procedureprovides symmetrical lateraltension-freesuspensionofthecentralmeshpartattachedto the vagina and it can be performed with or without uterus preservation or after hysterectomy. Kapandgji described lateral suspensionthefirsttimein1967[8].ThenDubuissonmodifiedthe techniqueforlaparoscopicapproachin1998[9],totreatanterior andapical compartmentPOP,reportinggood resultsintermof absenceof complicationsandPOPrecurrencesafteroneyearof clinical follow-up [10]. Recently Mini-laparoscopic and Robotic approacheshavealsobeendescribedwithoptimalresultsinterm offeasibility,learningcurveandcomplications[11,12].
TheaimofthisstudywastoanalyzePOPoutcomesandsafetyof LLSforapicalandanteriorPOP.
Materialandmethods
Thisisaprospectivecohortstudyofconsecutivepatientswho underwentLLSforapicalandanteriorPOPbetweenApril2013and January2017attheGynecologicalUnitoftheS.ChiaraHospitalof Trentoand at theDivisionof Obstetricsand Gynecologyof the UniversityofPisa.Inclusioncriteriawere:symptomaticstage2or greater(pointC>-1pelvicorganprolapsequantificationPOP-Q) apicalprolapse(uterovaginalorvaultprolapse)withorwithout anterior compartment prolapse (point Ba > -1 pelvic organ prolapse quantification POP-Q) and without symptomatic or significant posteriorcompartment prolapse (pointBp>1pelvic organprolapsequantificationPOP-Q).
Exclusioncriteria:patientswhounderwentLLSwithabdominal fasciafixationof themesh.Patientswithapical+/-anteriorand posteriorprolapseunderwentsacrocolpopexy.Informedconsent toLLS was obtainedfromall patientsin accordancewithlocal legislation.
InstitutionalReviewBoard approvalwasobtainedfromboth theEthicalCommitteeof AziendaProvincialeServiziSanitariof TrentoandtheUniversityofPisa.
Pre-treatmentevaluationincluded:medicalhistorycollection, pelvic ultrasound, physical examination, clinical evaluation of pelvic organ support assessed by the Pelvic Organ Prolapse QuantificationGradingsystem(POP-Q).Clinicalpatient character-istics including age, BMI, menopausal hormonal status, sexual activity, parity, dyspareunia, bladder dysfunctions, intestinal symptoms such as constipation and fecal incontinence, co-morbidityandpriorsurgeryforPOPwererecorded.Intraoperative parametersincludingconcomitantsurgery,overalloperatingtime, blood loss, conversion rate, post-operative pain, complications, time to discharge and recurrence were recorded as well. The estimatedbloodloss(EBL)wascalculatedbythedifferenceinthe totalamounts ofsuctionedandirrigationfluids.Operativetime was definedas thetime fromskinincisiontotheskinclosure. Perioperative,earlypostoperativecomplications(30days)and late postoperative complications (> 30 days) were recorded. DyspareuniawasrecordedusingaNumericalRatingScale(NRS) from 1 to 10 (dyspareunia > 4 has been considered clinically relevant). Bladderdysfunctionswereclassifiedin urinary stress incontinence,urgeincontinenceandvoidingdysfunction.Postvoid residualvolumemeausrementand urodynamicevaluationhave beenperformedwhenrequiredinrelationtopatients’symptoms [13].TheIncontinenceImpactQuestionaire7(IIQ7)wasusedto assess the impact of UI [14], defecatory functional status was assessed by theWexner constipation score [15]. Intraoperative complications were scored according to Classification of Intra-operative Complications [16] and postoperative complications accordingtothe“Clavien–Dindoclassificationofsurgical compli-cations scale’’ [17]. Mesh-related complications were classified usingtheIUGA/ICScomplicationclassification[18].Postoperative
painassessmentwasperformedusingNRS.Systematic postopera-tive clinical and symptomatic evaluation were performed at 6 weeks,6months,oneand2years.Anatomiccurewasdefineas POP-Q Ba, C, Bp < +1cm, while subjective outcomes were determined by asking to the patients about presence of bulge symptoms.The main outcomesmeasureswere anatomic and symptom outcomes; the secondary outcome measures were recurrence, reoperation rate, de novo posterior POP and complications.
Inabsenceofuterinedisease,hysteropexywasthefirstchoice. LLStechniquedescribedbyDubuissonetal.[19]hasbeenadopted notonlyforthelaparoscopicbutalsoforthemini-laparoscopicand robotic approach [16,20]. In allcases a titanium-coated macro-porouspolypropylenemesh(TiLOOP1Dubuisson)wasused. Statisticalanalysis
Aninitialoverviewof thesamplewas obtainedthroughthe creationofafrequencydistributiontable(absoluteand percent-age) of demographic and clinical variables. The mean standard deviation and median values were presented for the age of patients.
The wilcoxon signed rank sum test was used to compare preoperativePOP-QstageandpostoperativePOP-Qstageatmean follow up, for each patient (paired data) and for each type of prolapse. This statistical test has been chosen because the differencebetweenthetwovariablesisnotnormallydistributed and the variables are ordinal. Mean values and SD are also presentedforeachgroup.
Thesignificanceoftheassociationbetweenthepostoperative POP-Q stageand couplesof times of follow-up (6 weeks vs. 6 monthsand6monthsvs.12months)wasanalyzedwithFisher-s Exacttest,consideringtheassociationsignificantwhenthep-value was<0.05.
The univariate analysis took into account the associations betweenindependentvariables(suchastypeofminimalinvasive approach, BMI classes, ageclasses, parity,hormonal status and priorPOPsurgery)andtheoutcomevariables(typeofrecurrence ofPOP,repeatsurgeryforPOP,surgeryfordifferentsite,surgeryfor complications,vaginalbulge,denovosymptomaticposteriorand asymptomatic POP3): these associations were all invariably studiedwithFisher’sExacttest.
Results
125patientsconsecutivelyunderwenttoLLS;5patientswere excludedbecausesubmittedtoamodifiedLLSwithmeshattached toabdominalfascia.
Patientcharacteristicsandpreoperativesymptomsareshown inTable1.
IndicationtoLLSwas,inallcases,thepresenceofvaginalbulge andapical+/-anteriorprolapse.Apicalprolapse>3waspresent preoperativelyin96(80,6%)patients,anteriorcompartmentdefect >3in86(72.3%)patientsandvaginalbulgeinallcases.
IntraoperativefindingsareshowninTable2.
TheFoleycatheterwasremovedonthemorningaftersurgery. Mean hospital stay was 2.1 days(range 1–10). Mean length of postoperativefollowupwas20months:allpatientshada follow-upat6weeks,6and12months,and89at24months.
Postoperativecomplicationsat1monthoccurredin7cases,2 patientsgrade1:painand vaginitis,1patientgrade2: pyelone-phritisrequiringIVantibioticstherapyand10daysof hospitaliza-tion,1patientsgrade3:1mesherosionrequiringvaginalexcision ofmeshexposure.NogradeIVcomplicationsoccurred.
Concerning urogynecological de novo symptoms: 7 (5.8 %) urgency, 3 (2.5 %) stress urinary incontinence (SUI), 3 (2.5 %)
transient voiding obstruction cases occurred in previously asymptomaticpatients.Nopatientdevelopeddenovo constipa-tion,fecalincontinenceordyspareuniaand11womenwhohad preoperativedyspareuniaimprovedaftersurgery.Urgency incon-tinencewasresolvedwithmedicaltreatment(topicestrogen)and thethreecasesofSUIdidnotrequireanysurgeryatthemoment. At2years89%ofpatientswereasymptomaticandanatomic successratewas94.2%.
AnatomicalresultsaredetailedinTable3.
Duringthefollowupweobservedthefollowingrecurrences:6 (5%) stage 3 anterior compartment,1 (0.8 %) stage 4 anterior
compartment,5(4.2%)stage3apicalcompartment,1(0.8%)stage 4 apicalcompartment. Concerning posterior compartment pro-lapsewehad2(1.6%)stage3andnostage4denovoprolapses. Vaginal bulging occurred in 14 (11.7 %) cases and de novo symptomaticposteriorprolapsein1(0.8%)women.Atotalof8 (6.7%)patientsunderwentsubsequentSCPbecauseof symptom-atic prolapse: 1 patient for concomitant anterior, apical and posteriorprolapsestage4,6foranteriorandapicalstage3and1 forposteriorstage3.Nopatientunderwentsubsequentsurgeryfor stressincontinence.
Therecurrencesofstage3and4areconcentratedat6months follow-up with a statistical significantly difference from the recurrence at 6 weeks and 12 months (anterior compartment p=0.007, apicalcompartment p=0.001, posteriorcompartment p=0.032).Table4.Nosignificantlydifferencehasbeenfoundat12 and24months.
UnivariateanalysisshowsthatonlyBMI>25iscorrelatedwith de novo posterior compartment appearance during follow up (p=0.0278), while neither patients characteristics nor type of surgeryseemstoinfluenceanteriororapicalprolapserecurrences, vaginal bulge,repeatsurgery for POP,or surgerycomplications (p>0.05).
Discussion
Thepresentseriesof120patientsmirrorsapreviousexperience oftwocentresthatalreadypublishedarticlesonLLSwithmeshin thetreatmentofgenitalprolapse[11,12,20].
Inouropinion,indicationiscrucialforthiskindofcorrection; indeed,asalreadysuggestedbyDubuissonetal,relevantsurgical indicationsarehysteroceleand/orcystocele;theprocedureisnot indicated in case of predominant rectocele, enterocele and/or pelvic floor insufficiency [10,21]. For this reason, we excluded patientswithapicalandposteriordefect,towhomwerecommend SCP,whichprovidesreinforcementintherectovaginalspaceanda posteriordirectionofthevaginalaxis[19]
LLS allows preservation of the uterus, thus providing a significantsurgical,functionalandpsychologicalbenefitinterm ofsafety,reductionofoperativetime,anatomypreservationand patientsatisfaction[10].Inthepresentstudy8patientsunderwent supracervicalhysterectomyforsymptomaticuterinemyomasand 1patientunderwenttotalhysterectomyforabsenceof preopera-tiveendometrialassessment.
LLScanbeperformedwithdifferentapproaches[11,12,21].We did not find statistical difference in term of outcomes among women underwent standard laparoscopy, minilaparoscopy or robotic.
Forallpatientsatitanium-coatedmacroporouspolypropylene mesh(TiLOOP1Dubuisson)wasused:itisahydrophilicmaterial that adheres more stably to the vaginal wall, with an easier manipulation,optimaltissueengraftmentandenhanced biocom-patibility [22–24]. In the present series onlyone (0.8 %) mesh erosion occurred, one month after surgery; the incidence is significantlylowercomparedwiththe4%cumulativeincidenceof mesh erosion reportedin a systematic review after abdominal surgerywithmeshduringa2-yearsfollowup[25]andof4,3% after417laparoscopiclateral suspensionprocedures[14]where bothmicroporouseandmacroporousemeshwasutilized.Itiswell knownthatPolypropyleneis themesh materialthatallowsthe developmentofwell-organized,fibrous,matureconnectivetissue [26–28]andatitaniumlayeroverpolypropyleneseemstoimprove thebenefitsofpolypropylene, asdemonstratedinherniarepair [24],notablyreducingtheriskofextrusionorexposure.
The overall objective success rate of 94 % and the overall subjectivecure rateof 89 %at19months offollow-up inboth anteriorandapicalcompartmentarecomparabletothesuccess Table1
Patients’characteristics.
Allpatients (n=120) Caucasianethnicity,n(%) 120(100) Age(years),meanSD(median) 609.85(61) BMI(kg/m2 )<25,n(%) 66(55) BMI(kg/m2 )>25,n(%) 59(49.1) Parity,n(%) Nulliparous 1(0.8) Multiparous 119(99.21
Numberofvaginaldeliveries,n(%)
One 42(35) Twoormore 81(67.2) Menopausal,n(%) 100(83.3) HRT,n(%) 7(5.8) Sexualactivity,n(%) 96(80) Dyspareunia>4,n(%) 11(9.1) Voidingobstruction,n(%) 4(3.3) StressIncontinence,n(%) 0(0) Urgencyincontinence,n(%) 11(9.1) Constipation,n(%) 0(0) Fecalincontinence,n(%) 0(0) PriorPOPsurgery,n(%) 13(10.8) Priorurinaryincontinencesurgery,n(%) 3(2.5) Priorhysterectomy,n(%) 7(5.8) BMI=BodyMassIndex.
HRT=HormoneReplacementTherapy.
Voidingobstructionincludessymptomsofhesitancy,weakstream,incomplete empyting. Table2 Surgicalfindings. Allpatients(n=120) Approaches Standardlaparoscopy,n(%) 40(33.3) Mini-laparoscopy,n(%) 20(16.6) Roboticassistedlaparoscopy,n(%) 60(50.0)
Suspension Hystero 105(87.5) cervical 8(6.6) Vaginalvault 7(5.8) Anteriormesh,n(%) 120(100%) Posteriormeshn,(%) 0(0%) Concomitantprocedures,n(%) 45(37.5) Totalhysterectomy,n 1 Subtotalhysterectomy,n 7 Myomectomy,n 2 Salpingoophorectomy,n 12 Salpingectomy,n 7 Cervicalamputation 7 Stapledtransanalrectalresection,n 2 Hysteroscopicpolipectomy,n 2
Adhesiolysis,n 5
Meanoperativetime,mean(range) 120(63-280) Intraoperativecomplications,n(%) 0(0) Conversiontolaparotomyn,(%) 0(0)
ratefollowingSCP(97.7%and92%respectively)[6].Postoperative vaginalbulgewasreportedby11%ofpatients.Itisabetterresultif compared with 21.6 % described in 417 laparoscopic lateral suspensionproceduresforanterior,apicalandposteriorprolapse byVeit-Rubin[29].Only8patients(6.6%)repeatedsurgeryforPOP during two years of follow-up, which is consistent with the findingsofseveralinvestigatorswhoreportedre–operationrates from3.4–11%[29,30].Theselowratesofobjectiveand symptom-atic prolapse recurrences indicate excellent outcomes of this techniqueforthetreatmentofapicalandanteriordefectaccording tothecriteriadescribedbyBarberetal.[2].
Withregardtotheposteriorcompartment,wefounddenovo posteriorprolapsein3(2.5%)patients;1denovosymptomaticand 2denovo posteriorPOP-Q>3.Two patientsunderwentsurgery duringfollow-up forsymptomatic posteriorprolapse (onewith
concomitantapicalandanteriorPOPandonewithonlyposterior POP).
Wefoundanassociationbetweenappearanceofpostoperative POPandtimetofollowup,therecurrenceofanteriorandapical prolapseandtheappearanceofasymptomaticstage1/2posterior prolapse were detected significantly more often during the 6 month-followupvisit.
TheunivariateanalysisrevealsthatonlyBMI>25isrelatedtode novoposteriorcompartmentdefect>2,whilethetypeofsurgical approach, age, parity, menopausal hormonal status, prior POP surgery seem not to have a significant association with POP recurrence,reinterventionorPOPsymptoms.Thesefindingssuggest thatwecouldconsideraconcomitantpreventativecorrectionofthe posteriorcompartmentinselectedgroupsofpatientsorwecould adviseweightlosspriortosurgicalPOPcorrection.
Table3
Pre-andpostoperativePOP-Qstageatmeanfollowup.
POP-Q Preoperativen(%) Postoperative
atanaverageof20monthsn(%)
p-valueWilcoxonsigned ranksumtest PointBa 0 1(0.8) 88(73.3) < 1cm 7(5.8) 15(12.5) 1cmto1cm 20(16.6) 10(8.4) <0.0001 >1cmto<(TVL-2)cm 69(57.6) 6(5) (TVL-2)cm 23(191) 1(0.8) Mean(SD) 2.9(0.8) 0.5(0.9) PointC 0 0(0.0) 109(90.8) < 1cm 0(0.0) 3(2.5) 1cmto1cm 37(30.8) 2(1.6) <0.0001 >1cmto<(TVL-2)cm 48(40.0) 5(4.1) (TVL-2)cm 35(29.1) 1(0.8) Mean(SD) 3.0(0.8) 0.2(0.7) PointBp 0 75(62.5) 72(60.0) < 1cm 40(33.3) 26(21.6) 1cmto1cm 5(4.1) 20(16.6) >1cmto<(TVL-2)cm 0(0.0) 2(1.6) 0.02 (TVL-2)cm 0(0.0) 0(0.0) Mean(SD) 0.4(0.6) 0.6(0.8) Table4
DenovoappearanceofPOPduringfollow-up.
ComparisonbetweenPostoperative6weeksand Postoperative6months
ComparisonbetweenPostoperative6monthsand Postoperative12months Postoperative 6weeks,(n=120)n(%) Postoperative 6months (n=120)n(%) Postoperative 6months(n=120)n(%) Postoperative 12months (n=120)n(%) PointBa < 1cm 13(10.8%) 4(3.3%) 4(3.3%) 5(4.1%) 1cmto1cm 10(8.3%) 6(5%) 6(5%) 2(1.6%) >1cmto<(TVL-2)cm 0(0.0%) 6(5%) 6(5%) 0(0.0%) (TVL-2)cm 0(0.0%) 1(0.8%) 1(0.8%) 0(0.0%)
p-valueFisher’sExacttest 0.007 0.11
PointC
< 1cm 7(5.8%) 0(0.0%) 0(0.0%) 1(0.8%)
1cmto1cm 3(2.5%) 2(1.6%) 2(1.6%) 0(0.0%)
>1cmto<(TVL-2)cm 0(0.0%) 5(4.1%) 5(4.1%) 0(0.0%)
(TVL-2)cm 0(0.0%) 1(0.8%) 1(0.8%) 0(0.0%)
p-valueFisher’sExacttest 0.001 0.011
PointBp
< 1cm 16(13.3%) 9(7.5%) 9(7.5%) 2(1.6%)
1cmto1cm 4(3.3%) 12(10%) 12(10%) 3(2.5%)
>1cmto<(TVL-2)cm 0(0.0%) 1(0.8%) 1(0.8%) 0(0.0%)
(TVL-2)cm 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%)
Theseresultssuggestthatthesuspensionaxisofalateralmesh doesnotleadtoenteroceleorPouchofDouglasherniainpatients treatedforapicalandanteriorprolapse;theidentification,during thefollowupofa19%ofasymptomaticposteriorPOP-Q=2would demonstratethatLLSrevealsthepresenceofpre-existingposterior defect rather than determines its appearance. While vaginal sacrospinousorsacrocolpopexyclearlydivertthephysiologicaxis ofthevagina,LLSseemsnottochangevaginalanatomy[31].Wedo notknowwhetherornotthe"correct"vaginalaxisimpactspainor sexual function. As these anatomic considerations are merely hypothesises,furtherstudiesareneededtoclarifytheseaspects. Theabsenceofdyspareuniaafterthissurgicalprocedureseems topreservethenormalsexualfunction.Duringthefollowupwe alsofoundalowrate(10%)ofurinarysymptomsandnodenovo intestinalsymptomssuchasconstipationandfecalincontinence. In our cohort of patients who underwent standard LLS, postoperativeClavien-Dindograde3complicationsoccurredonly in1/119(0.8%)ofcases.
Thelowincidenceofpostoperativecomplicationsandthehigh successrateofthistechniqueprovidereasontoconsiderLLSasan optiontotreatapicalandanteriorPOP.
ThisisthefirststudyonLLSwithaclinicalfollowupoftwo years(meanfollowupof 20months); themajorityof previous studies on LLS have a 12 month-follow-up with objective evaluation[19,21], whiletheonlystudywithameanfollowup of 7.2 years is based on telephone interviews on patients’ satisfaction[10,28].
Weakness of the present study is the presence of different minimalinvasive approachesand differencesin typeof sutures utilized.A multicenterrandomizedcontrolledstudyis ongoing, comparingstandardizedLLSand SCPforthetreatmentofapical defects.
Conclusion
ThisseriesofLLSwithmeshproceduresforthetreatmentof anteriorandapicalprolapseperformedbytwoinstitutionsshowed thatthetechniqueisfeasibleandreproduciblewithoptimalresults intermofsafetyandeffectiveness,after2yearsfollowup.However, randomizedcontrolledstudiesareneededtoclarifyifthistechnique canbeconsideredanalternativeinthetreatmentofPOP.
Founding
No foundingsourcessupportingtheworkorinstitutional or corporateaffiliationsoftheauthors.
DeclarationofCompetingInterest None.
Acknowledgements None.
References
[1]Nygaard I, Barber MD, Burgio KL,KentonK, Meikle S,Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311–6.
[2]BarberMD,MaherC.Apicalprolapse.IntUrogynecolJ2013;24:1815–33. [3]NeumanM,LavyY.Conservationoftheprolapseduterusisavalidoption:
mediumtermresultsofaprospectivecomparativestudywiththeposterior intravaginal slingoplastyoperation.IntUrogynecolJPelvicFloorDysfunct 2007;18:889–93.
[4]SmithFJ,HolmanCD,MoorinRE,TsokosN.Lifetimeriskofundergoingsurgery forpelvicorganprolapse.ObstetGynecol2010;116:1096–100.
[5]VieillefosseS,ThubertT,DacheA,HermieuJF,DeffieuxX.Satisfaction,quality oflifeandlumbarpainfollowinglaparoscopicsacrocolpopexy:suture vs. tackers.EurJObstetGynecolReprodBiol2015;187:51–6.
[6]HiggsA,ChuaHL,SmithAR.Longtermreviewoflaparoscopicsacrocolpopexy. BJOG2005;112:1134–8.
[7]PropstK,Tunitsky-BittonE,SchimpfMO,RidgewayB.Pyogenic spondylo-discitisassociatedwithsacralcolpopexyandrectopexy:reportoftwocases andevaluationoftheliterature.IntUrogynecolJ2014;25:21–31.
[8]KapandjiM.Treatmentofurogenitalprolapsebycolpo-hystmo-cydtopexy with transverse strip and crossed, multiple layer, ligamento-peritoneal douglasorraphy.AnnChir1967;21:321–8.
[9]DubuissonJB, ChapronC.Laparoscopic iliaccolpo-uterinesuspension for treatmentofgenitalprolapse,usingtwomeshes.Anewoperativetechnique.J GynecolSurg1998;14:153–9.
[10]Veit-RubinN,DubuissonJB,Gayet-AgeronA,LangeS,EperonI,DubuissonJ. Patientsatisfactionafterlaparoscopiclateralsuspensionwithmeshforpelvic organprolapseoutcomereportofacontinuousseriesof417patients.Int UrogynecolJ2017;28:1685–93.
[11]MereuL,TerrenoE,DalpràF,TateoS.Mini-laparoscopiclateralsuspension repairofapicalpelviorganprolaps.GynecolSurg2017;(suppl1):ES26–273. [12]SimonciniT,RussoE,MannellaP,GianniniA.Robotic-assistedapicallateral
suspension for advanced pelvic organ prolapse: surgical technique and perioperativeoutcomes.SugEndosc2016;30:5647–55.
[13]CassandraL,CarberryMD,TulikangasPaulK,RidgewayBeriM,CollinsSarahA, RonyAA.Americanurogynecologicsocietybestpracticestatement:evaluation andcounselingofpatientswithpelvicorganprolapse.FemalePelvicMed ReconstrSurg2017;23:281–7.
[14]ShumakerSA,WymanJF,UebersaxJS,McClishD,FantlJA.Health-related quality of life measures for women with urinary incontinence: the IncontinenceImpactQuestionnaireandtheUrogenitalDistressInventory. ContinencePrograminWomen(CPW)ResearchGroup.QualLifeRes1994;3 (October5):291–306.
[15]AgachanF,ChenT,PfeiferJ,ReissmanP,WexnerSD.Aconstipationscoring systemtosimplifyevaluationandmanagementofconstipatedpatients.Dis ColonRectum1996;39(June6):681–5.
[16]RosenthalR,HoffmannH,ClavienPA,BucherHC,Dell-KusterS.Definitionand classificationofintraoperativecomplications(CLASSIC):Delphistudyand pilotevaluation.WordJSurg2015;39:1663–71.
[17]ClavienPA,BarkunJ,deOliveiraML,etal.TheClavien–Dindoclassificationof surgicalcomplications:five-yearexperi-ence.AnnSurg2009;250:187–96. [18]HaylenBT,FreemanRM,SwiftSE,CossonM,DavilaGW,DeprestJ,etal.An
InternationalUrogynecologicalAssociation(IUGA)/InternationalContinence Society(ICS)jointterminologyandclassificationofthecomplicationsrelated directlytotheinsertionofprostheses(meshes,implants,tapes)andgraftsin femalepelvicfloorsurgery.NeurourolUrodyn2011;30(January):2–12. [19]DubuissonJB,YaronM,WengerJM,JacobS.Treatmentofgenitalprolapseby
laparoscopiclateralsuspensionusingmesh:aseriesof73patients.JMinim InvasiveGynecol2008;15:49–55.
[20]DalpràF,MereuL,DelPezzoC,NozzaE,PerinE,TateoS.Laparoscopicprotesic lateralsuspensionforgenitalprolaps:amodifiedapporach.GynecolSurg 2013;10(suppl1):S1–S151.
[21]DubuissonJ,EperonI,DällenbachP,DubuissonJB. Laparoscopicrepairof vaginal vault prolaps by lateral suspension mesh. Arch Gynecol Obstet 2013;287:307–12.
[22]Schug-PassC,TammeC,TannapfelA,KöckerlingFA.Lightweight polypropyl-enemesh(TiMesh)forlaparoscopicintraperitonealrepairofabdominalwall hernia:comparisonofbicompatibilitytheDualMeshinanexperimentalstudy usingtheporcinemodel.SurgEndosc2006;20:402–9.
[23]Horstman R, Hellwing Classen C, Röttgermann S, Palmes D. Impact of polypropyleneusingpure,mixed,andtitanium–coatedmeshes.WorldJSurg 2006;30:1747–9.
[24]KockerlingF,Schug-PassC.Whatdoweknowabouttitanizedpolypropylene meshes?Anevidence-basedreviewoftheliterature.Hernia2014;18:445–57. [25]DallenbachtP,DeOliveiraSS,MarrasL,BoulvainM.Incidenceandriskfactor formesherosionafterlaparoscopicrepairofpelvicorganprolapsebylateral suspensionwithmesh.IntUrogynecolJ2016;27:1347–55.
[26]DavilaGW,DrutzH,DeprestJ.Clinicalimplicationsofthebiologyofgrafts: conclusionsofthe2005IUGAgraftsroundtable.IntUrogynecolJPelvicFloor Dysfunct2006;17(Suppl1):S51–5.
[27]LeTH,KonL,BhatiaNN,OstergardDR.Updateontheutilizationofgraftsin pelvicreconstructionsurgeries.CurrOpinObstetGynecol2007;19(5):480–9. [28]Veit-RubinN,DubuissonJB,LangeS,EperonI,DubuissonJ.Uterus-preserving laparoscopiclateralsuspensionwithmeshforpelvicorganprolapse:a patient-centeredoutcomereportandvideoofacontinuousseriesof245patients.Int UrogynecolJ2016;27:491–3.
[29]MiedelA,TegerstedtG,MorlinB,HammarstromM.A5-yearprospective follow-upstudyofvaginalsurgeryforpelvicorganprolaps.IntUrogynecolJ PelvicFloorDysfunct2008;19:1593–601.
[30]DiwadkarGB,BarberMD,FeinerB,MaherC,JelovsekJE.Complicationand reoperationratesafterapicalvaginalprolapsesurgicalrepair:asystematic review.ObstetGynecol2009;113:267–373.
[31]SzeEH,MeranusJ,KohliN,MiklosJR,KarramMM.Vaginalconfigurationon MRIafterabdominalsacrocolpopexyandsacrospinousligamentsuspension. IntUrogynecolJPelvicFloorDysfunct2001;12:375–9.
