a
THE JOURNAL OF FEMALE
URINARY INCONTINENCE


Review Articles
 

A Comparison of Laparoscopic and Abdominal Techniques for
The Treatment of Vaginal Vault Prolapse

Paulo Roberto Kawano, João Luiz Amaro.
Departamento de Urologia, Faculdade de Medicina Botucatu, UNESP, Brasil.
 

Pelvic organ prolapse affects about 50% of parous women over 50 years of age, with a lifetime prevalence risk of 30–50%1.  Risk factors  include prior genital prolapse, multipaity, obesity and posthysterectomy patient2.
Traditionally, prolapse is treated surgically but most procedures, such as vaginal hysterectomy, are associated with recurrent prolapse such that up to a third of patients require further surgery1,3. Vault prolapse is a particular problem following hysterectomy and the incidence varies from 0.2% to 45%1,3. Vault prolapse has an incidence of 11.6% after hysterectomy for pelvic organ prolapse compared with 1.8% when performed for other reasons1,4. Prolapse occurs in equal numbers after abdominal or vaginal hysterectomies and symptoms are not dependent on the stage of the prolapse5.
The treatment can be conservative with physiotherapy and pessaries or surgical.  More than 40 different techniques for the treatment of vaginal vault prolapse have been described5,6 for the surgical management of apical defects, but none of them have been found to be superior to the others1,7. The main aim of pelvic floor reconstructive surgery is to correct anatomical defects while maintaining or restoring bladder, bowel and sexual function.
In the last five years, sacrocolpopexy has become a common choice for suspending the vault following prolapse1. Abdominal sacrocolpopexy is well described in the literature1,8,9,10, and this procedure has traditionally been performed abdominally with a non-absorbable mesh sutured to the upper two-thirds of the posterior vaginal wall suspended from the presacral ligaments1. The mesh can be made completely of synthetic material, autologous or heterologous material5.  Common complications of abdominal sacrocolpopexy include bleeding, infections and mesh-related problems (Table1), with erosions or loosening reported in about of 2% of cases5. Unfortunately there is no standard definition of recurrence about vault prolapse.  Mostly a prolapse extending beyond the hymen or the onset of fresh symptoms in any patient is regarded as recurrence (Table 2).  In the same way, the definitions used for objective cure rate vary, that difficult the comparison of the final results among the different studies (Table 3).
Although the abdominal sacrocolpopexy is the gold standard for surgical repair of apical prolapse2,8,10,23,25,26, this is a major surgical procedure, performed through a large abdominal incision and carrying with it all of the attendant risks and complications, and long recovery period.  With the advancement of laparoscopic surgery techniques, another less invasive option is laparoscopic sacrocolpopexy. Early reports of laparoscopic reconstructive surgery have been promising5,27,28 with the procedure performed safely and achieving results comparable to an open technique2 (Table 4). The laparoscopic surgery was done exactly the same way as the open technique. Patient recovery is greatly enhanced; usually requiring significantly shorter hospital stays than open procedures of the past.
Many studies demonstrate the feasibility of laparoscopic sacrocolpopexy, but there are no randomized comparisons of laparoscopic and open sacrocolpopexies.  A few complications are reported with laparoscopic technique with good anatomical function without recurrence is recorded in various articles 5,27,28,35,38.
Cosson et al30,40 reported that 62 of 63 (94%) women followed up demonstrated no evidence of clinical prolapse at 12 months. Nezhat28 observed a cure rate of 100% in 15 women at 3 – 40 months. Ross reported no apical prolapse recurrence in 15 of 19 (79%) patients 1 year after surgery; 2 (13%) developed recurrent paravaginal defects and 3 (20%) developed rectoceles27. Dorsey and Sharp32 reported 100% satisfactory apical suspension in 9 women, although the length of follow-up was not reported. After a maximum of 2 to 3 months follow-up, Drent33 reported a 100% successful rate in 5 women, although success was not defined. 
In many of the articles searched, complications were not included in outcomes reported. Complication rates are rarely assessed completely in retrospective studies and may differ in various articles.  Cosson et al30 reported 1 had a rectal injury, 2 had bladder injuries, and 3 underwent reoperations for bleeding complications, including 1 perioperative hemorrhage requiring conversion to laparotomy.  Ross27 observed similar injuries. In Nezhat’s study22, 1 of 15 patients required conversion to laparotomy for presacral bleeding. Cosson et al41 in a separate publication, reported the complication of staple erosion into the vagina after stapling mesh to the vagina and, subsequently, do not recommend using staples on this site.   Oguchi et al42,58 with nine patients underwent this procedure don’t experienced peri or post-operative complications.  Salvatore43 in a retrospective review analysis of 100 women underwent laparoscopic genital prolapse repair observed one conversion (due to a technical problems) and a total 4% rate of mesh vaginal erosion.
Laparoscopic sacrocolpopexy is a minimally invasive treatment for vault prolapse and offers a high quality of life to patients5, with shorter hospitalization, better hemostasis, and less pain than the open procedure44.   Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy45
Larger trials with careful follow-up are needed to understand whether, for this particular surgery, the laparoscopic and open approaches are similar in durability and complication rates.



   
   
   
   
   
   
   
   
   
   
   
   
 

Table 1: Complications after abdominal sacrocolpopexy 5 (N = 1571)*

 

Complication

 

Classification

 

n

 

%

 

Haemorrhage

 

 

Haemorrhage/blood transfusion

 

31

 

2.0

Abdominal wall haematoma; seroma

16

1.0

Infection

 

Cystitis

92

5.9

Fever, secondary healing, dehiscence, abscess

88

5.6

Damage to pelvic organs

Bladder perforation, rectal perforation, intestinal lesions

24

1.6

Urological problems

Kinking of ureters, voiding disorders, urinary incontinence, urgency

30

1.9

Graft/mesh

Erosion, dislocation of mesh

31

2.0

Other reasons for relaparatomy

Ileus, subileus, incisional hernia, vesico-vaginal fistula, other

45

2.9

Medical problems

DVT, phlebitis, cardiac fibrillation, pulmonary embolism, MI, colitis, GI bleeding, pulmonary malventilation

17

1.1

Others

Vaginal discharge, nerve damage

10

0.4

* No complications specified for 437 patients.

   
   
   
   
   
   
   
   
   
   

Table 2: Recurrence after abdominal sacrocolpopexy (N = 2008) 5.

.

Anatomical site

n

%

Recurrence (vault)

37

1.9

Enterocele

24

1.2

Cystocele

44

2.3

Rectocele

80

4.1


   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
 

Table 3: Success cure rates in abdominal sacrocolpopexy 5.

AUTOR

PATIENT

FOLLOW UP (months)

 SUCCESS RATE (%)

Snyder and Krantzl 11

147

43

93

Sullivan et al 12

236

64

100

Culligan et al 13

245

61.2

85

Brizzolara et al 14

124

36

98

Timmons et al 10

163

33

99

Lecuru et al 15

203

32,5

86,7-100

De Vries et al 16

101

48

32

Occelli et al 17

271

66

97,7

Patsner et al 18

175

12

97

Lindequer et al 19

262

16

99

Medina et al 20

97

19

90

Hardiman et al 21

80

47

99

Collopy et al 22

89

56,7

100

Brubaker et al 23

62

75,6

94

Lefranc et al 24

85

126

90,6


   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

Table 4: Outcome after laparoscopic vault prolapse operations


AUTHOR

YEAR

PATIENT

FOLLOW UP
(weeks or months)

SUCCESS RATE (%)

Dujardin et al 29

2002

168

NE

98

Cosson et al 30

2002

77

11,4 m

94

Lindeque et al 19

2002

262

NE

98,8

Elliott et al 31

2004

20

5,1 m (1-12 m)

NE

Nezhat et al 28

1994

15

3 a 40 m

100

Ross et al 27

1997

19

12 m

100

Doresy e Sharp et al 32

1995

9

NE

100

Drent et al 33

2001

5

2 a 3 m

100

Mahendran et al 34

1996

29

6s a 6 m

NE

Carter et al 35

2001

8

6 m

100

Seman et al 36

2003

73

24 m

90

Lee et al 37

2000

12

12 a 36 m

92

Fedelle et al 38

1997

12

9 a 28 m

100

Dubuisson et al 39

1999

35

5 (±4,5 m)

NE

   
   
   
   
   
   
   
   
   
   
   
   
References
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