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Part IV Uro-gynecology Minimally Invasive Approach in Urogynecology: An Evidence-Based Approach 17 Tatiana Pfiffer Favero and Kaven Baessler Introduction Pelvic organ prolapse is a common condition affecting about 15–30% of parous women in the western world Although it does not represent a life-threatening condition, it may have a considerable impact on the quality of life [1] The most significant symptoms are the feeling and/or the observation of vaginal bulging Obstructed voiding and defecation, dyspareunia, urinary and anal incontinence and pelvic pain are frequently associated complains Usually there are multiple defects of the pelvic floor support system which has to be taken into consideration when planning a surgical approach Minimally invasive techniques in pelvic reconstructive surgery include endoscopic, abdominal and vaginal procedures The correction of all three compartments, anterior, middle and posterior, as well as hysterectomy, continence procedures and mesh applications can be performed using both approaches T P Favero, M.D (*) Abteilung für Gynäkologie, Helios Mariahilf Klinik Hamburg, Stader Straße 203C, 21075 Hamburg, Germany e-mail: Tatiana.Pfiffer@helios-gesundheit.de K Baessler, M.D., Ph.D Franziskus und St Joseph Krankenhäuser, Beckenbodenzentrum, Budapester Straße 15-19, 10787 Berlin, Germany Commonly performed laparoscopic operations are sacrocolpopexy, hysteropexy, uterosacral ligament fixation, Burch colposuspension and paravaginal repair Vaginal approaches comprise anterior and posterior vaginal repairs with and without grafts or meshes, sacrospinous and uterosacral ligament fixation The decision about the most appropriate technique for each patient should include the discussion of whether a hysterectomy will be necessary, potential use of meshes and the need of concomitant continence procedure Factors to be considered are age of the patient, sexual activity, degree of POP, BMI, occupational heavy lifting, the presence of a levator avulsion, presence of cardiac and other comorbidities and particular patient and surgeon preferences and experience of the responsible surgeon The shared decision process should be ideally guided by scientific evidence, balanced with the surgeon’s skills and patient’s preference Although the clinician is responsible for the most appropriate technique, a joint decision with the patient is certainly recommended in order to adjust the procedure with individual needs and expectations Potential advantages of laparoscopic over open abdominal surgery are well known: reduced blood loss, shorter hospital stay and quicker return to activities of daily life, less pain and better aesthetics Particularly with regard to urogynecologic interventions, it allows a broader and better view of the pelvic anatomy for the placement of prostheses and sutures with maximum © Springer International Publishing AG, part of Springer Nature 2018 G G Gomes-da-Silveira et al (eds.), Minimally Invasive Gynecology, https://doi.org/10.1007/978-3-319-72592-5_17 195 196 precision and safety Furthermore, endoscopic procedures may permit the correction of the three different compartments through a single approach Nevertheless, there are some relevant particularities, such as altered appearance of anatomy due to pneumoperitoneum and Trendelenburg positioning, challenging orientation, additional difficulties due to fixed visual axis, loss of depth and magnification with 2D projection Three-dimensional optics and robotic procedures may overcome some of these obstacles Laparoscopic techniques demand a longer learning curve and training in comparison with other routes and should be performed by experienced professionals Anterior Compartment Anterior vaginal wall prolapse (AWP is the most common form of female POP, with 81% of prolapse repairs including the anterior vaginal wall [2] Depending on the site of fascial detachment, cystocele can be central (midline defect of the endopelvic fascia) or lateral (detachment of the pubocervical fascia from the ATFP) A combination of lateral and central defects is also common Surgical repair should address these defects accordingly although there are no studies that differentiated between cystocele defects and repairs ative Tissue Repairs - Anterior N Colporraphy The vaginally performed anterior colporrhaphy has been the standard procedure for the correction of anterior compartment prolapses, with moderate to good results It consists in the opening of the anterior vaginal wall, dissection and plication of the fascia There are some variations of the technique such as separated or continuous stitches, circular or longitudinal suture, one or two layers, fixation or not at the so-called pericervical ring and suburethral plication (so-called Kelly sutures) Usually, one layer of plication is sufficient, though more than one layer may be required in patients with advanced (stage III and T P Favero and K Baessler IV) cystoceles [3] To minimise the risk of recurrence, the detached fascia should be reattached to the supported vaginal apex There is no need to excise the excess vaginal skin, which could potentially compromise the required tension-free closure Furthermore, excessive excision of the vaginal skin might result in vaginal stenosis There are no conclusive data about which procedure is the most effective, and many studies not describe the employed technique in details Nevertheless, the objective success rate ranges from 37 to 100% [4] Adequate apical support is crucial in reducing the recurrence rate of cystocele Eiber et al demonstrated a reduction of the reoperation rate after 10 years from 20.2% to 11.3% by performing an apical suspension at the time of anterior colporrhaphy [5] Vaginal Paravaginal Repair Already in 1909, White referred to the importance of the paravaginal defects in anterior compartment prolapses [6] DeLancey demonstrated that the dorsal detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment, leads to a prolapse of the anterior vaginal wall [7] Paravaginal defects have been shown to account for 60–80% of anterior compartment prolapse, and its repair offers the chance of a more effective treatment [3] After opening the vaginal mucosa and dissection until the inferior pubic ramus reaching space of Retzius, the endopelvic fascia is sutured to the arcus tendineus fasciae pelvis The sutures are placed from proximal to distal, 2–3 stitches on both sides A cystoscopy is mandatory to rule out suture passage through the bladder and to confirm ureteral patency The success rates for the vaginal paravaginal repair vary from 67 to 100%; nevertheless significant complications have been reported In a total from 145 patients, there were 21 major complications, 18 blood transfusions, bilateral ureteric obstruction, retropubic haematoma requiring surgery, long-term lower extremity neuropathy in and vaginal abscesses [8, 9] Furthermore, it 17 Minimally Invasive Approach in Urogynecology: An Evidence-Based Approach 197 remains open whether additional apical support procedures account for the high success rates Laparoscopic/Robotic Paravaginal Repair Abdominal paravaginal cystocele repair was described by Richardson in 1976 [10] Meanwhile the surgical technique of the laparoscopic repair is well developed However, despite the report of success of 80% [11], there are no conclusive data about the efficacy of this approach The advantages of this procedure compared to the vaginal route include reduced risk for vaginal shortening, safer attachment under vision and the possibility of performing concomitant laparoscopic procedures such as hysterectomy, sacrocolpopexy and/or Burch colposuspension, without the need for a vaginal incision Furthermore, the advantages of the laparoscopy compared to the laparotomy are well known, such as improved visualisation, less risk of bleeding and faster recovery On the other hand, the vaginal route permits the concomitant correction of a central anterior fascial defect However, a sacrocolpopexy with anterior mesh extension to the bladder neck would also correct a median (pulsion) cystocele [12] The laparoscopic access follows the standard procedures The bladder is freed off the pelvic sidewalls by means of blunt and sharp dissection The space of Retzius is exposed, with special attention to avoid the retropubic venous plexus The dissection should be performed to expose the posterior border of the symphysis pubis, Cooper’s ligaments, the white lines and the bladder neck The surgeon places a finger in the vagina to guide the suture placement A nonabsorbable suture is passed through the thickness of the vaginal skin avoiding the epithelium The suture is then passed through the obturator internus fascia, including the white line The suture may also be anchored at the ileopectineal ligament [13] Sutures are placed in an interrupted fashion This procedure is usually performed on both sides depending on the defects Closing the perito- Fig 17.1 Laparoscopic paravaginal repair: the suture is passed through the obturator internus fascia, including the white line, and then anchored at the ileopectineal ligament Sutures are placed in an interrupted fashion neum is not a mandatory step (Figs. 17.1, 17.2, 17.3, and 17.4) A cystourethroscopy is performed to rule out suture passage through the bladder and to confirm ureteral patency The robotic approach is gaining importance; however, little information is available on the efficacy, complications and long-term outcomes Anterior Colporrhaphy with Meshes or Grafts The reinforcement of the anterior vagina wall with grafts has gained importance over the last years These meshes may be biological or synthetic, and the fixation may be by suturing or anchoring systems Several studies and meta- analyses demonstrated better anatomical outcomes with mesh augmentation as compared to native tissues repair alone [14, 15] On the other hand, besides exposures rates, mesh procedures are associated with longer operating times, greater blood loss, higher rates of cystotomy, de novo stress urinary incontinence and prolapse of the apical or posterior vaginal compartment, leading to a higher number of reoperations in comparison with anterior colporrhaphy [14–16] Patient with levator avulsion have a higher risk for recurrence, which may justify the use of synthetic graft reinforcement [17, 18] (Figs. 17.5 and 17.6) 198 T P Favero and K Baessler Fig 17.2 Laparoscopic paravaginal repair: the posterior suture is passed through the obturator internus fascia, including the white line, correcting the paravaginal defect Fig 17.3 Laparoscopic paravaginal repair, sutures placed on the right side 17 Minimally Invasive Approach in Urogynecology: An Evidence-Based Approach 199 Fig 17.4 Laparoscopic paravaginal repair final aspect Fig 17.5 Surgical approach for the correction of cystocele, based on the underlying defect and considering the available techniques Cystocele Paravaginal defect native tissue repair vaginal laparoscopic/ robotics Midline defect mesh/grafts reinforcement Trocar guided suspension suturing native tissue repair anterior colporrhaphy 200 T P Favero and K Baessler Fig 17.6 Demonstrates actions of anterior repair, Burch colposuspension and mid-urethral sling on the urethra and bladder neck Posterior Compartment The prolapse of the posterior vaginal wall may be due to the herniation of the rectum, colon or small intestine into the lumen of the vagina These conditions can occur isolated or in combination with each other support defects and will commonly be accompanied by a perineal defect and/or a widened genital hiatus [19] Common symptoms are dragging sensation, pelvic heaviness, sexual dysfunction including slack ness at intercourse and difficult and incomplete rectal emptying at defecation frequently requiring digitation [20] Although a rectocele is a frequent finding in patients with defecation disorders, there may be several other causes, such as anismus or paradoxic pelvic floor contraction, intussusception and descending perineum syndrome [21] An interdisciplinary collaboration with coloproctology can be useful, especially if bowel emptying disorders are present without a recognisable rectocele Data are conflicting regarding the efficacy of posterior vaginal repair on improving defaecatory symptoms, and the association is incompletely understood [22, 23] Rectoceles can also be associated with perineal insufficiency, which is usually corrected by means of perineorrhaphy However, no data are available for this operation in the literature The same is true for a concurrent enterocele, which is frequently corrected by “high peritonealisation” or obliteration of the pouch of Douglas [24] Anatomic Considerations The connective tissue between the vagina and the rectum, depending on the anatomical concept, is referred to as the posterior endopelvic fascia, rectovaginal septum, rectal fascia or vaginal muscularis [24] The distal support of the posterior vaginal wall, DeLancey level III, is primarily provided by the perineal body [25, 26] This level of support has strong attachments to the levator ani complex and is thus less susceptible to pelvic pressure transmission that may cause prolapse: it imparts a physical barrier between the vagina and rectum The puborectalis muscle provides a sling of support, enclosing the genital hiatus Disruption of the complex integrity of bony, muscular and connective tissue support may result in posterior vaginal wall prolapse The surgical repair for posterior vaginal prolapse includes midline plication, site-specific technique, graft/mesh augmentation, transanal repair, ventral rectopexy and sacrocolpopexy in which mesh is extended to the distal portion of the posterior vaginal wall and/or perineum The suture material ranges from resorbable polyglactin to non-resorbable sutures The removal of so-called excess vaginal membranes should be more economical to avoid vaginal stenosis [27] idline Plication (Traditional M Posterior Colporrhaphy) This technique was introduced in the nineteenth century Reported anatomic success rates of this technique range from 76 to 96% [19, 28] The posterior vaginal wall is incised in the midline, and flaps are created by dissecting the underlying fibromuscularis layer off the vaginal epithelium Plication of the fibromuscularis in the midline then starts proximally towards the hymen, decreasing the width of the posterior 17 Minimally Invasive Approach in Urogynecology: An Evidence-Based Approach vagina wall and theoretically increasing the strength of this layer The plication of the levator ani muscles used to be a frequent step of the posterior colporrhaphy Although it helps to close the genital hiatus, this is not a normal anatomic position of the levator muscles This may overly constrict the vaginal calibre and cause post-operative pain and dyspareunia while not improving anatomic outcome Thus, in general, levator plication is obsolete [19, 28] Site-Specific Posterior Vaginal Repair After dissection of epithelium off the underlying connective tissue, the defects in the connective tissue are identified by placing a finger in the rectum Any presented discrete breaks in the connective tissue are then approximated and closed using interrupted sutures A midline plication can then be performed over the site-specific repairs, but no levator plication is performed The correction of the rectovaginal fascia defect allows entrapment of faeces on straining in significant rectocele with 18% post-operatively needing vaginal digitation to defaecate and 18% experiencing post-operative dyspareunia [19, 28] Furthermore, lower success rates following the discrete site-specific repair (70%) as compared to the midline fascial plication (86%) were described [29] raft or Mesh Augmentation G of Posterior Vaginal Repair Graft and mesh augmentations may be performed to reinforce the posterior colporrhaphy or as a substitute for the so-called fascia without the plication of the fascia and may be fixed to the sacrospinous ligament and to the perineum Although there is variation in the surgical technique, typically, after creating vaginal flaps, the dissection is extended bilaterally to the pelvic sidewall A midline colporrhaphy or site-specific repair is then typically performed The graft or mesh is then placed over the repair and anchored along the sidewall The vaginal epithelium is then closed over the graft or mesh 201 Other techniques employ mesh kits with transischiorectal passage of trocars to attach the mesh through the sacrospinous ligaments However, there are no data to support any routine use The posterior intravaginal sling technique was withdrawn because of severe mesh complications mainly related to the multifilament mesh [30] To date no study has shown any benefit to graft or mesh overlay or augmentation of a vaginal suture repair for posterior vaginal wall prolapse [14, 19, 31] The use of biological implants has so far shown no advantages compared to posterior vaginal plastic surgery On the contrary, the posterior plastic was superior to the augmented surgeries and halved the recurrence risk in the meta-analysis with all comparative randomised and non-randomised controlled trials: RR 0.58; 95% CI 0.41–0.84 [11] Therefore, the use of xenografts (biological implants) is to be dispensed within the posterior compartment due to missing advantages acrocolpopexy with Extension S of Mesh Posteriorly The technique is a modification of sacrocolpopexy with extension of the posterior mesh down to the distal posterior vaginal wall and/or the perineal body or levator ani muscle on both sides, while correcting a coexisting apical defect The procedure can be performed through laparoscopic or robotic-assisted routes The presacral space is opened, and the peritoneal dissection is extended posteriorly from the apex, entering the rectovaginal space Dissection is continued to the perineal body or levator ani muscle The mesh is then attached to the posterior vaginal wall distally, levator ani muscle and to the anterior longitudinal ligament of the sacrum in a tension-free fashion The peritoneum is then typically closed over the mesh, burying it completely The success rates for rectoceles vary from 45 to 90% [32–35] While modified abdominal sacrocolpopexy results have been reported, data on how these results would compare to traditional transvaginal repair of posterior vaginal wall prolapse is lacking 202 Transanal Repair of Rectocele Three trials have evaluated transanal versus transvaginal repairs of rectoceles Each trial had slightly different inclusion criteria Based on these three trials, we can conclude that the results for transvaginal repair of rectocele are superior to transanal repair of rectocele, in terms of subjective and objective outcomes [16] Post-operative enterocele was significantly less common following vaginal surgery as compared to the transanal group Functional outcome based on a modified obstructed defecation syndrome patient questionnaire was better after transperineal repair compared to transanal repair Middle Compartment The apical prolapse is represented not only by uterine or vaginal vault prolapse, but it is also co-responsible for approximately 60% of the bladder prolapse [36, 37] There is growing recognition that adequate support for the vaginal apex is an essential component of a durable surgical repair for women with advanced prolapse [5] To correct the apex, there are several good options with relatively high success rates They can broadly be separated into those performed transvaginally and those performed abdominally Nowadays, the abdominal approach is gradually being replaced by conventional laparoscopic or even robotically assisted laparoscopic techniques The apical suspension procedures include both non-mesh (native tissue) procedures and mesh repairs The individual woman’s surgical history and goals, as well as her individual risks for surgical complications, prolapse recurrence and de novo symptoms affect surgical planning and choice of procedure for apical POP The surgical repair of defects in the middle compartment (Level according to DeLancey [25]) may be performed as a single operation for uterine or vaginal vault prolapse but may be of particular importance as it frequently supplements the correction in the anterior or posterior compartment T P Favero and K Baessler Sacrospinous Ligament Suspension (SSLS) This technique was first described in 1958 [38] for vaginal vault prolapse and is one of the most popular and widely reported native tissue transvaginal procedures for correcting apical prolapse The vaginal apex or uterus may be suspended to the sacrospinous ligament either unilaterally or bilaterally, using an extraperitoneal approach The fixation can be performed with resorbable and non-resorbable sutures The reported apical success rates of unilateral sacrospinous fixation of vaginal vault are between 79 and 97%, on average 92% Recurrences in the anterior compartment are more common, between 10 and 30%, on average 21% In the posterior compartment, recurrences occur significantly less frequently, 0–11%, an average of 6% [39, 40] Unilateral buttock/gluteal pain occurs in 3–15% of patients and typically resolves within 6 weeks after surgery [41] Although infrequent, serious complications associated with SSLS include life-threatening haemorrhage from sacral or pudendal vascular injury with an overall transfusion rate from 2% [42] Uterosacral Ligament Suspension (USLS) The vaginal or laparoscopic sacrouterine ligament fixation consists of the fixation of the vaginal apex or the uterus to the uterosacral ligaments as high as possible using an intraperitoneal surgical approach The normal vaginal axis is to be restored McCall’s operation also includes obliteration of the pouch of Douglas Bob Shull proposed a modification where the sutures are transvaginally placed sequentially through the uterosacral ligaments and united with the anterior and posterior vaginal sheaths or vaginal fascia [43] There are no different anatomical results whether the fixation is performed with resorbable or non-resorbable filaments [39, 41] However, erosions may vary from to 22% in women who 17 Minimally Invasive Approach in Urogynecology: An Evidence-Based Approach 203 Fig 17.7 Laparoscopic fixation of the vaginal apex to the uterosacral ligaments with obliteration of the pouch of Douglas received non-resorbable filaments Systematic reviews showed an apical success rate ranging from 85 to 98% [44, 45] The laparoscopic fixation of the vaginal apex to the uterosacral ligaments (Fig. 17.7) has some advantages, such as no use of meshes, less erosion when performing a concomitant total hysterectomy, higher suture position, better visualisation of the ureters (Fig. 17.8), less interaction with radio- or chemotherapy in case of malignancies needing further treatments, potentially less complications when compared to meshes, like erosion, mesh retraction, vaginal discharge, pelvic pain and dyspareunia Rardin reported a lower ureteral risk of injury (0 vs 4%) by the laparoscopic procedure in a direct comparison with the vaginal access with simultaneous vaginal hysterectomy [46] There are some retrospective studies and reviews that have examined the laparoscopic fixation of the uterosacral ligaments after simultaneous hysterectomy, and the reported apical failure rates were between 11 and 13% [46–50] Despite some promising results, there is still no standard technique for the laparoscopic approach, and the outcomes from vaginal USLS cannot be extrapolated to L-USLS An intraoperative cystoscopy is recommended for the detection of disturbed urine passage Other possible complications include transfusion- requiring bleeding (1.3%), bladder (0.1%) or rectum (0.2%) injury In addition, nerve entrapment can cause numbness and pain in the area of S2–4 in about 4% of the patients [45] Fig 17.8 Representation of the sacrocolpopexy Sacrocolpopexy Originally, sacrocolpopexy was an operation for the fixation of the vaginal vault However, it was developed further in order to correct defects in the anterior and/or posterior compartment by placing mesh anteriorly between the vagina and the bladder as well as posteriorly between the vagina and the rectum, possibly down to the levator ani Traditionally, sacrocolpopexy has been performed via a laparotomy, but the use of minimally invasive approaches, both laparoscopic and robotic, has become the norm over the last decade (Fig. 17.8) Laparoscopic Sacrocolpopexy (LSC) The dissection follows three phases: sacral promontory (opening of the retroperitoneum), anterior vaginal wall and rectovaginal septum (posterior vaginal wall) Appropriate sutures are placed to attach the anterior arm of the typically Y-shaped mesh to the anterior vaginal wall and the posterior arm to the posterior vaginal wall If required, the posterior arm extends to the level of the levator ani muscle or is attached to it on both sides The proximal end of the mesh is attached to the anterior longitudinal ligament at the promontory or S1 by means of stiches or mechanical suture A systematic review of studies with original data ... concomitant SUI: anterior colporrhaphy or anterior mesh repair, 17 Minimally Invasive Approach in Urogynecology: An? ?Evidence- Based Approach Study or Subgroup Altman 20 11 Hiltunen 20 07 Rudnicki 20 14... expectations and consequently the satisfaction of the patient about treatment (Fig. 17 .20 ) 17 Minimally Invasive Approach in Urogynecology: An? ?Evidence- Based Approach 21 3 Genital Prolapse Minimally Invasive. .. International Publishing AG, part of Springer Nature 20 18 G G Gomes-da-Silveira et al (eds.), Minimally Invasive Gynecology, https://doi.org/10.1007/97 8-3 -3 1 9-7 25 9 2- 5 _17 195 196 precision and safety Furthermore,