Laparoscopic Latero-Abdominal Colposuspension: Description of the Technique, Advantages and Preliminary Results - Beyond the Abstract

Currently, laparoscopic sacrocolpopexy is considered the gold standard for pelvic organ prolapse (POP) surgery.1 Several alternative techniques have been described using different anatomical references such as the ileo-pectine ligament,2,3 the round ligament4, or the external oblique muscle aponeurosis.5


In 2007 Dubuisson describes laparoscopic lateral colposuspension.6 Years later, Veit-Rubin describes excellent results associated with the technique.7,8 We present the technique and results obtained in a series of 18 consecutive patients carried out in our institution. We believe it represents a humble contribution to literature in this urogynecology field.

The decision to start the experience with the technique was based on the advantages previously described: technique avoids sacral dissection and fixation of the mesh to the sacrum and does not modify the anatomy of the posterior compartment, minimizing complications such as rectal lesions, constipation, vascular (Iliac vessels) or nerve lesions (hypogastric plexus) and lumbar disc infectious complications.

Suspension techniques have succeeded in restoring the anatomical position of pelvic organs without fixing them to bony or ligamentous pelvic structures. Mesh surgery causes a locally controlled fibrosis and improves pelvic support in the entire compartment where it is implanted.

There are important considerations for the execution of this surgical technique. Recommendations established by the Ibero-American Society of Urogynecology (SINUG) in its consensus document were followed in this series.9 Simplified POP-Q scale was not used in our out-patient clinic due to lack of time. The Baden-Walker scale was used.

We do not use mesh POP surgery in immunosuppressed patients, history of pelvic radiotherapy, or in patients receiving high doses of chronic steroids. The use of topical vaginal estrogens before and after surgery may help improve vaginal irrigation and promote mesh integration. In our center, they are not routinely used. They are indicated only in cases with an atrophic vagina, on lesions of the vaginal mucosa of patients carrying pessaries, or with advanced prolapses.

The technique used is similar to the Dubuisson technique and is fully described in the paper, although the mesh used is different. It is made of polyvinylidene fluoride (PVDF) which has been associated with a lower foreign body reaction10 and allows mesh visualization on nuclear magnetic resonance imaging.11 Fixation of the mesh was also different and was completed by applying 3-4 ml of a synthetic cyanoacrylate glue (Histoacryl/Braun®) using a laparoscopic applicator.12

Once the mesh is fixed, it is important to follow the order of the surgical steps to ensure proper positioning of the vagina. The position of the vagina is checked by both transvaginal and transperitoneal laparoscopic vision before releasing de pneumoperitoneum. The technique allowed a controlled extracorporeal suspension of the vagina through a long tension-free mesh.

Inherent advantages of the technique include the following:

  • Laparoscopic lateral colposuspension does not prevent transobturator tape (TOT) or tension-free vaginal tape (TVT) surgery in patients with concomitant or hidden urinary incontinence.
  • The use of an intravaginal malleable valve simultaneously manipulated from the outside during vesicovaginal plane dissection helps to achieve a more controlled dissection. It is important to avoid inadvertent opening of the vagina or bladder that may subsequently lead to erosion or extrusion of the mesh.
  • In our series, the posterior compartment was not addressed because posterior prolapses were low grade and asymptomatic. However, the laparoscopic lateral colposuspension allows mesh placement in the recto-vaginal plane fixed bilaterally to the levator ani and also allows colpoperineorrhaphy.
  • The round ligament, considered a key anatomic landmark, was easily identified in all cases, even in the patient with a previous hysterectomy. These findings facilitate reproducibility.
  • The technique avoids sacral dissection and mesh fixation to the sacrum, does not modify the anatomy of the posterior compartment, and reduces complications such as rectal lesions, constipation, vascular (Iliac vessels), nervous lesions (hypogastric plexus), and infectious vertebral complications (lumbar discitis).
  • Mesh tension force necessary to vaginal suspension runs through the round ligament path. The technique emulates the natural force vectors and restores the anatomical position of the vagina, considered the central axis of the female pelvis according to integral theory.13
  • In our experience, this technique does not seem to worsen posterior compartment asymptomatic prolapses nor does it predispose to enteroceles.
How to avoid problems?

Mesh problems occur when the expectations of the surgical technique are not discussed considering the patient's expectations, when mesh loses its biomechanical characteristics after the implant or when the execution of the technique is suboptimal.

The quality of the results depends on the patient's risk factors, the characteristics of the mesh, and the experience and expertise in the execution of the technique.

Risk factors

  • Patients over 80 years old have shown a higher incidence of de novo urge urinary incontinence, infravesical obstruction, and pelvic organ prolapse (POP) surgery failures compared to women aged 65-80. Vaginal atrophy is associated with extrusion and sexual dysfunction.
  • Previous failed POP surgery is associated with poorer reconstructive results in relation to poorer quality connective tissue.
  • Mesh surgery has shown worse results in patients with high-grade prolapses, obesity, pathology that involves pelvic floor chronic stress (asthma), and in patients with connective tissue diseases.
  • Smoking and diabetes have been associated with an increased risk of erosion due to abnormal microcirculation phenomena.
Mesh surgery should be discussed after evaluating individualized risk factors and considering possible results adapted to the patient's expectation.

Mesh characteristics

Light or ultra-light meshes with better porosity and lower density (75-200 microns), are associated with a lower risk of complications14,15 and retain anisotropic properties after implantation.17,18

The main objective is to maintain mesh biomechanical properties and avoid the vaginal "stress-shielding" phenomenon or mesh contraction.19-21 It is important to check vaginal consistency during first outpatient clinic visit after surgery.

Experience and expertise of the surgeon

Expertise refers to the knowledge necessary to perform a task, is a structured process that, once applied, allows a result to be predicted. Experience refers to the number of times a task is performed. The goal is to gain expertise through experience and generate a technique that provides predictable, optimal, and reproducible results.

Dissection should be performed in the correct anatomical space (vesicovaginal plane), suboptimal or insufficient exposure of the vagina should be avoided. When fixation of the mesh and vaginal suspension are performed with excessive tension, it can cause ischemia, postoperative pain, and dyspareunia. Inadvertent vaginal or bladder injuries can lead to erosion and/or mesh extrusion.

After completing vesicovaginal plane dissection it is important to ensure adequate hemostasis before implanting the mesh to reduce the risk of hematomas and future complications such as infection, pain or dyspareunia. Application of thermal energy on the mesh should be avoided.

Mesh must be fixed completely unfolded and without tension over the entire vaginal surface. The size of the mesh must be adapted to the anatomy of each patient to avoid generating foreign body granuloma in unnoticed areas that increase the risk of complications (dyspareunia or post-operative pain). In this series, we avoid fixing the mesh with running stitches that can produce greater ischemia to the vagina and compromise the mesh integration process. The use of synthetic glues has been associated with good results, saving surgical time, and showing a safe profile in POP mesh surgery.12

Execution of the pre-peritoneal tunnel is done with simultaneous laparoscopic vision in order to identify the external iliac vessels and avoid vascular intraoperative complications. It also allows identifying and passing under the round ligament of the uterus, a fundamental anatomical landmark of the technique.

It is important to respect the order of the surgical steps. Once the placement of the mesh is completed, the vagina is suspended and the prolapse is reduced, the ends of the mesh are fixed extracorporeally at the skin level to maintain the position of the vagina. Vaginal tamponade or pessary is placed and the peritoneum is closed. The last step of the laparoscopic procedure is to release pneumoperitoneum, then the mesh is sectioned at the skin level. The correct sequence of these steps guarantees a correct position of the vagina.

Vaginal tamponade is maintained until the following day of surgery and the patient remains at rest until it is removed. The following day, vaginal tamponade and bladder catheter are removed and the patient begins to walk. This guarantees an adequate orientation of the vagina during the first hours of mesh integration, critical for achieving good surgical results. It is advisable to have sexual rest for 6 weeks and to evaluate the results at 1, 6, and 12 months of follow-up checking the absence of "vaginal stress shielding". In our opinion, the orderly execution of the technique is crucial to obtain adequate postoperative results.

The urologist dedicated to POP surgery must be trained in prosthetic surgery. The synthetic mesh is considered an implant and the surgeon must be trained in the management of possible complications.9

Considering the aging population, prevalence of POP, and the interest in preserving body image and sex life beyond menopause, laparoscopic lateral colposuspension represented a therapeutic alternative to the gold standard. The sample is limited and comes from a single center; therefore, the conclusions are not definitive. Prospective, randomized, and multicenter studies with greater samples and longer follow-up are necessary to obtain definitive conclusions regarding laparoscopic sacrocolpopexy as the gold standard.

Written by: José Vicente Baldissera, MD, Urologist, Hospital de Dénia-Marina Salud, Dénia, Alicante, Spain

References:

  1. Baessler, Kaven, Corina Christmann‐Schmid, Christopher Maher, Nir Haya, Tineke J. Crawford, and Julie Brown. "Surgery for women with pelvic organ prolapse with or without stress urinary incontinence." Cochrane Database of Systematic Reviews 8 (2018).
  2. Banerjee, Carolin, and Karl Günter Noé. "Laparoscopic pectopexy: a new technique of prolapse surgery for obese patients." Archives of gynecology and obstetrics 284, no. 3 (2011): 631-635.
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  6. Dubuisson, J. B. "403: Recipe and Artfulness Optimizing Repair of POP by Laparoscopic Lateral Suspension." Journal of Minimally Invasive Gynecology 14, no. 6 (2007): S143.
  7. Veit-Rubin, Nikolaus, Jean-Bernard Dubuisson, Angèle Gayet-Ageron, Sören Lange, Isabelle Eperon, and Jean Dubuisson. "Patient satisfaction after laparoscopic lateral suspension with mesh for pelvic organ prolapse: outcome report of a continuous series of 417 patients." International Urogynecology Journal 28, no. 11 (2017): 1685-1693.
  8. Veit-Rubin, Nikolaus, Jean Dubuisson, Florin Constantin, Sören Lange, Isabelle Eperon, Victor Gomel, and Jean-Bernard Dubuisson. "Uterus preservation is superior to hysterectomy when performing laparoscopic lateral suspension with mesh." International Urogynecology Journal 30, no. 4 (2019): 557-564.
  9. Martinez, A. Martín, C. Muller-Arteaga, P. Blasco Hernandez, B. Padilla-Fernandez, R. Martínez García, C. Errando-Smet, E. Vicente Palacio et al. "DOCUMENTO DE CONSENSO DE SINUG SOBRE EL USO DE MALLAS EN EL TRATAMIENTO DEL PROLAPSO GENITAL."
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  14. García-Ureña, Miguel Ángel, Vicente Vega Ruiz, Antonio Díaz Godoy, Jose María Báez Perea, Luis Miguel Marín Gómez, Francisco Javier Carnero Hernández, and Miguel Ángel Velasco García. "Differences in polypropylene shrinkage depending on mesh position in an experimental study." The American journal of surgery 193, no. 4 (2007): 538-542.
  15. Gonzalez, Rodrigo, Kim Fugate, David McClusky, E. Matt Ritter, Andrew Lederman, Dirk Dillehay, C. Daniel Smith, and Bruce J. Ramshaw. "Relationship between tissue ingrowth and mesh contraction." World journal of surgery 29, no. 8 (2005): 1038-1043.
  16. Feola, Andrew, Steven Abramowitch, Zegbeh Jallah, Suzan Stein, William Barone, Stacy Palcsey, and Pamela Moalli. "Deterioration in biomechanical properties of the vagina following implantation of a high‐stiffness prolapse mesh." BJOG: An International Journal of Obstetrics & Gynaecology 120, no. 2 (2013): 224-232.
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