Chapter Outline
Indications for Minimally Invasive Prolapse Surgery
Operative Technique for Laparoscopic Sacral Colpopexy
Laparoscopic Uterosacral Ligament Vaginal Vault Suspension
Moschcowitz and Halban Procedure
Laparoscopic Enterocele Repair
Laparoscopic and Robotic Retropubic Surgical Procedures
Cost of Minimally Invasive Prolapse and Continence Surgery
Introduction
Since laparoscopic retropubic urethropexy was introduced in 1991, laparoscopic access and techniques have been applied to most abdominal and numerous vaginal route surgical procedures for urinary incontinence and pelvic organ prolapse. Adoption of laparoscopic sacral colpopexy has increased in the past decade, especially with the application and Food and Drug Administration (FDA) approval of robotic assistance for gynecologic procedures in 2005. Laparoscopic surgery has possible advantages, including improved anatomic visualization of the peritoneal cavity, presacral space, and space of Retzius, which can be attributed to laparoscopic magnification, insufflation effects, and improved hemostasis. Other potential advantages over open surgery include shortened postoperative hospitalization resulting in potential cost reduction, decreased postoperative pain, more rapid recovery and return to work, and better cosmetic appearance of smaller incisions. Despite these many potential advantages, laparoscopy has a prolonged learning curve for suturing and technically difficult retroperitoneal dissections. Consequently, this can lead to increased operating time early in the surgeon’s experience, with a potential for greater hospital cost secondary to increased operating time and use of disposable surgical instruments. Additionally, widespread adoption of traditional laparoscopic surgery for urinary incontinence and prolapse procedures may have been further thwarted by inadequate instructional experience in residency and fellowship and the introduction of minimally invasive vaginal midurethral slings and apical suspension mesh kit procedures. Robotic-assisted laparoscopy offers the novice laparoscopic surgeon a means of becoming facile with minimally invasive surgical techniques. There are currently few well-designed studies comparing the learning curves for skill acquisition in minimally invasive prolapse and incontinence surgery. The literature regarding minimally invasive prolapse and incontinence procedures predominantly consists of retrospective cohort studies from surgeons subspecializing in advanced laparoscopy. Comparative, adequately powered studies regarding conventional or robotic-assisted laparoscopic surgery for prolapse and stress urinary incontinence are rare.
Indications for Minimally Invasive Prolapse Surgery
The indications for laparoscopic repair of enterocele, vaginal apical prolapse, rectal prolapse, and perineocele are identical to those for vaginal and abdominal routes. The choice of conventional laparoscopic or robotic-assisted laparoscopic access is determined by the surgeon, patient preference, the laparoscopic skill of the surgeon, and, occasionally, the patient’s insurance coverage. Additional factors that should be considered include a history of pelvic or anti-incontinence surgery, previous failed transvaginal colpopexy, a shortened vagina, concern for severe abdominopelvic adhesions, patient age and weight, need for concomitant pelvic surgery, and the patient’s ability to undergo general anesthesia.
The surgeon needs to carefully consider the effects of intra-abdominal CO 2 insufflation and its hemodynamic and metabolic effects in patients with chronic obstructive pulmonary, cardiovascular, and chronic renal diseases ( ). One should be wary of patients with contraindications to increases in intracranial pressure and patients who are potentially hypovolemic preoperatively, as a laparoscopic or robotic procedure may be contraindicated. These concerns are particularly amplified in prolonged minimally invasive cases ( ). An exhaustive review of the physiologic effects of pneumoperitoneum is beyond the scope of this chapter.
Trendelenburg position also causes some difficulty in ventilating the patient and contributes greatly to hemodynamic changes ( ). Prolonged Trendelenburg position increases chest wall resistance and dead space, consequently decreasing the alveolar-arterial diffusion of oxygen. Pulmonary compliance and functional residual capacity are reduced; these effects are often more pronounced in obese patients ( ). The cephalad displacement of the diaphragm and carina can cause the endotracheal tube to become displaced into the mainstem bronchus and upper airway and pulmonary interstitial edema can also result. In addition, pneumoperitoneum and Trendelenburg position can contribute to a reduction in the femoral venous flow and can increase the perioperative risk of venous thromboembolic events. Finally, corneal abrasion, despite use of protective eye tape, has been reported in 3% of patients in a case series of 1500 patients from a single institution ( ). These authors thought that the steep Trendelenburg position places the patient at risk for coming into contact with the monitoring cables. They proposed using eye patches over the eye tape to prevent this and noted a reduction in their corneal abrasion rates.
Surgical Anatomy
Thorough knowledge of the anatomy of the anterior abdominal wall is mandatory for safe and effective trocar insertion. The umbilicus is approximately at the L3 to L4 level, and the aortic bifurcation is at L4 to L5. In obese women, the umbilicus is caudal to the bifurcation. Thus, for maximal safety, the intraumbilical trocar should be introduced at a more acute angle toward the pelvis in thin women and closer to 90° in obese women. However, it is important not to track too far caudally in the subcutaneous tissue so that pelvic visualization is optimized. The left common iliac vein courses over the lower lumbar vertebrae from the right side and may be inferior to the umbilicus ( ). The common iliac arteries course 5 cm before bifurcating into the internal and external iliac arteries. The ureter crosses the common iliac artery at or above this bifurcation.
The superficial epigastric artery, a branch of the femoral artery, courses cephalad and can be transilluminated, although this can be difficult in patients with darker skin color. The inferior epigastric artery branches from the external iliac artery at the medial border of the inguinal ligament and runs laterally to and below the rectus sheath at the level of the arcuate line ( Fig. 21.1 B ). Two inferior epigastric veins accompany this artery. Computed tomography (CT) studies of abdominal wall vasculature show that, above the pubic symphysis, the inferior and superficial epigastric vessels are 5.6 ± 1.0 cm and 5.5 ± 2.0 cm from the midline, respectively ( ). At the level of the umbilicus, the superficial epigastrics and circumflex iliacs are 4.6 ± 1.4 cm and 10.7 ± 1.7 cm from the midline, respectively ( ). The inferior epigastric vessels course along the parietal peritoneum and are lateral to the medial umbilical folds but medial to the deep inguinal ring. These can be identified where the round ligament enters the inguinal canal. The median umbilical ligament, the embryonic urachus, is attached to the apex of the bladder and extends to the umbilicus. The urachus remains patent in some women and may be somewhat vascular.
The medial umbilical folds and the peritoneum overlying the obliterated umbilical arteries are the lateral landmarks of dissection of the parietal peritoneum during transperitoneal surgery into the space of Retzius. The upper margin of the undistended bladder dome lies several centimeters above the pubic symphysis. When the bladder is filled with 300 mL of fluid, however, the upper margin of the bladder dome is approximately 3 cm above the pubic symphysis. The important laparoscopic landmarks for surgery in the space of Retzius include: Cooper’s ligaments, the accessory or aberrant obturator veins, the obturator neurovascular bundles (which are 3-4 cm above the arcus tendineus fasciae pelvis; Fig. 21.2 ), the bladder neck (delineated by placing vaginal traction on the Foley bulb), and the arcus tendineus fasciae pelvis and arcus tendineus levator ani, which both insert into the pubic bone ( Figs. 21.2 and 21.3 ).
When considering the anatomy of the repair of pelvic organ support, a surgeon must keep in mind the three levels of support of the vagina. The upper fourth of the vagina (level I) is suspended by the cardinal/uterosacral complex, the middle half (level II) is attached laterally to the arcus tendineus fasciae pelvis and the medial aspect of the levator ani muscles, and the lower fourth (level III) is fused to the perineal body. The endopelvic fascia (also referred to as the anterior pubocervical fascia and posterior rectovaginal fascia) contributes to the integrity of the wall of the vagina. All pelvic support defects—whether anterior, apical, or posterior—represent a break in the continuity of the endopelvic fascia and/or a loss of its suspension, attachment, or fusion to adjacent structures. The goals of pelvic reconstructive surgery are to correct all defects, thus reestablishing vaginal support at all three levels, and to maintain or restore normal visceral and sexual function.
Operative Technique for Laparoscopic Sacral Colpopexy
Operative Setup and Instrumentation
Patent positioning is particularly important for laparoscopic and robotic cases. In our cases, the patient is usually placed on a disposable piece of egg crate foam that is secured to the operative table under the torso to prevent the patient from slipping toward the head of the bed with steep Trendelenburg position. A gel pad (AliGel or Overlay Pad, AliMed, Inc., Dedham, MA) or bean bag (Olympic Vac-Pac Marlin Medical, Bayswater North, VIC, Australia) are other options for slippage prevention. A padded strap can be placed across the chest to further secure the patient (Alistrap, AliMed, Inc., Dedham, MA). Shoulder braces are another option, but these have been associated with brachial plexus injuries in some cases. Careful attention is paid to extremity positioning to prevent peripheral nerve injuries. The arms are tucked with the draw sheet with the wrist in a neutral, thumbs-up position. If needed, padding of the ulnar prominence and sled arm boards are used to further secure the arms. Ideal stirrups for combined laparovaginal cases are the Allen ® stirrups and Yellofins ® (Allen Medical Systems, Acton, MA) that have levers that can quickly convert the patient from low to high lithotomy position while preserving the sterility of the field. The lateral knee near the fibular prominence is typically padded to minimize risk of nerve injury in thin patients.
The operating room setup for laparoscopic pelvic surgery is shown in Figure 21.4 . The monitor screens should be placed laterally to the legs in direct view of the surgeon standing on the opposite side of the table. The scrub nurse should be in the center if two monitor screens are used; otherwise, the scrub nurse is located behind one surgeon and the electrosurgical unit or the harmonic scalpel on the opposite side. After the three-way Foley catheter and uterine manipulator (if needed) have been placed, the vaginal tray with cystoscope is set aside, if needed, for later use.
A sterile pouch attached to each thigh is equipped with commonly used instruments, such as unipolar scissors, bipolar cautery, graspers, and laparoscopic blunt-tipped dissectors. Additionally, a laparoscopic cholecystectomy drape can be placed over the laparoscopic-assisted vaginal hysterectomy drape to provide troughs for instruments on either side of the abdominal field. The irrigation should be set up before making incisions for trocars.
For the standard suturing technique, the needle holder preference is determined by comfort of the surgeon. Conventional and 90-degree self-righting German needle holders (Ethicon Endo-Surgery, Inc., Cincinnati, OH) have ratchet spring handles. The Storz Scarfi needle holder and notched assistant needle holder (Karl Storz Endoscopy, El Segundo, CA) are most similar to conventional needle holders used during laparotomy. However, the handles are difficult to maintain and may pop open after extended use. The needle holder tips may become magnetized, which hampers needle grasping. Disposable suturing devices, such as the Endo-stitch (Covidien Surgical, Dublin, Ireland), have been introduced, but extracorporeal knot-tying is preferred because of technical facility and the ability to hold more tension on the suture. The choice of an open-ended or close-ended knot pusher for extracorporeal knot-tying depends on surgeon preference. Other options for knot-tying include various premade knots, such as clinch knots that do not require knot pushers and intracorporeal knots.
Some surgeons have chosen to avoid knot-tying altogether by securing the mesh with a barbed suture (Quill by Angiotech, Vancouver, B.C. and V-Loc by Covidien, Boulder, CO) and using a tacking device to tack the mesh into the anterior longitudinal ligament. The use of barbed sutures is currently under investigation and is being compared to the conventional laparoscopic or robotic-assisted suturing approach ( ). Although the use of barbed suture could greatly improve efficiency, there are potential risks of bowel obstruction with the use of barbed suture to close the peritoneum and vaginal cuff. Currently, tacking devices are not routinely used in sacral colpopexy. Lumbosacral osteomyelitis and spondylodiscitis are rare but devastating complications of sacral colpopexy. Less than 30 cases are currently reported in the literature, and most are related to sutures, not tacks, placed in the presacral space ( ). Bone tacks, however, may penetrate the intervertebral disc or disc space to a greater depth than suture and could, theoretically, lead to lumbosacral osteomyelitis and spondylodiscitis.
Trocar Placement
Incisions are made depending on the anatomy of the umbilicus. Many variations of the accessory trocar sites have been described. We use two additional trocars: a 5/12 mm disposable trocar with reducer in the right lower quadrant (if knot-tying from the right) lateral to the right inferior epigastric vessels and a reusable 5 mm port or an additional 5/12 mm disposable trocar, with reducer in the left lower quadrant lateral to the left inferior epigastric vessels. Trocars are placed laterally to the rectus muscle, approximately 3 cm medial to and above the anterior superior iliac spine. One or two additional 5 mm ports are placed at the level of the umbilicus, lateral to the rectus muscle for simultaneous suturing and/or retraction ( Fig. 21.1 A ). Based on an anatomic study by , we know that ilioinguinal and iliohypogastric nerve entrapment during fascial closure may be reduced if the ports are placed at least 2 cm cephalad to the anterior superior iliac spines. An additional 5 mm port may be placed on the principal surgeon’s side so that he or she can operate with two hands. Both reusable and disposable ports may be secured with circumferential screws to prevent port slippage. In addition, both 5 and 10 mm balloon ports exist (Kii Fios First Entry with Advanced Fixation Cannula, Applied Medical, Rancho Santa Margarita, CA), where insufflation of a circumferential intraperitoneal balloon helps to maintain the port’s intraperitoneal location with port manipulation and instrument exchanges. Port placement is shown in Figure 21.1 A .
Intraperitoneal Anatomy Assessment
After the insertion of a 0-degree laparoscope (5 or 10 mm) through a respective 5 or 10 mm intraumbilical or infraumbilical cannula followed by intra-abdominal insufflation, an inspection of the peritoneal cavity is performed, delineating the inferior epigastric vessels just lateral to the medial umbilical folds, abdominal and pelvic organs, pelvic adhesions, and coexisting abdominal or pelvic pathology. Two additional trocars (5/12 mm disposable trocars) are placed under direct visualization in the right and left lower quadrants, lateral to the inferior epigastric vessels, and one or two additional 5 mm ports are placed at the level of the umbilicus, lateral to the rectus muscle, as previously noted.
After the placement of the ancillary ports, the key anatomic landmarks of sacral colpopexy are noted: the middle sacral artery and vein; the sacral promontory with anterior longitudinal ligament; the aortic bifurcation and the vena cava (at the L4 to L5 level); the right common iliac vessels and right ureter (at the right margin of the presacral space); and sigmoid colon, which is at the left margin. The left common iliac vein is medial to the left common iliac artery and can be damaged during dissection or retraction.
The anatomic landmarks for laparoscopic rectocele repair, ventral rectopexy, and laparoscopic sacral colpopexy/colpoperineopexy include the rectovaginal septum, made up of Denonvilliers’ fascia, and its lateral attachment to the medial aspect of the levator ani muscles. Denonvilliers’ fascia is the endopelvic fascia attached superiorly to the uterosacral cardinal ligament complex, laterally to the superior fascia of the levator ani muscle, and inferiorly to the perineal body. The rectovaginal septum is the posterior point of attachment of the sacral colpopexy mesh. Rectovaginal fascia, rectovaginal septum, and Denonvilliers’ fascia are synonymous. The pubocervical fascia is the anterior point of mesh attachment during sacral colpopexy. During a sacral colpoperineopexy, the dissection is carried down to the perineum and bilateral levator ani muscles to which the inferior and lateral segments of a T-shaped mesh are attached.
Procedure
After a careful appraisal of relevant vascular and visceral anatomy is obtained, dissection of the peritoneum between the vaginal apex and rectum is performed to delineate the rectovaginal space and fascia ( Fig. 21.5 ). Anterior dissection is performed (taking care to avoid damage to the bladder) if a mesh is to be sutured to the pubocervical fascia or if enterocele repair is needed. A vaginal obturator (frequently an end-to-end anastomosis (EEA) sizer), sponge stick, or equivalent vaginal manipulator is used for delineation of the vaginal apex or rectum. An EEA sizer is frequently placed in the rectum to aid in the posterior dissection. Some surgeons prefer a Lucite stent (Marina Medical, Sunrise, FL) that is circumferentially uniform for ease of suturing to the vaginal muscularis.
If exposure of the sacral promontory and presacral space is not adequate, the bed should be airplaned to the left and a reusable triangle retractor (Snowden Pencer, Tucker, GA) or fan retractor (Origin Medsystems, Menlo Park, CA) can be placed through an ancillary port. Suture can also be passed through several sigmoid epiploica and brought through the left lower quadrant lateral to the left lower quadrant port site with a Carter Thomason suture carrier. Both suture ends are secured with minimal tension at the skin surface with a Kelly clamp, retracting the sigmoid laterally. Once the sigmoid is adequately retracted, the peritoneum overlying the sacral promontory is incised longitudinally with laparoscopic scissors and extended to the cul-de-sac. A laparoscopic dissector or hydrodissection is used to expose the periosteum of the sacral promontory. If blood vessels are encountered during the dissection, coagulation or clip placement is used to achieve hemostasis. Some surgeons prefer to first dissect the presacral space, thus eliminating the most technically difficult portion of the procedure. A Halban procedure or Moschcowitz culdoplasty may be performed based on surgeon preference or when a deep cul-de-sac is noted. When a concomitant culdoplasty is performed, it is completed after posterior mesh placement. Performance of a culdoplasty is controversial because review of the literature shows no improved cure or decreased risk of recurrence with concomitant culdoplasty at the time of sacral colpopexy ( ).
A 15 × 4 to 5 cm lightweight, macroporous, polypropylene mesh is introduced through a 5/12 mm port. The mesh is sutured anteriorly to the vaginal apex with two to three pairs of sutures. Efficiency of mesh arm placement may be improved by first placing the suture, and then back-threading the mesh through the suture ends at the abdominal surface. We typically use 2-0 polydioxanone distally, closest to the bladder base, followed by continued use of 2-0 polydioxanone or 2-0 polypropylene more proximal to the vaginal apex. A second piece of mesh of similar dimension is passed into the abdomen and secured on the posterior vaginal apex and rectovaginal septum, with three to four similar rows of 2-0 polypropylene. Alternatively, some surgeons like to place the posterior mesh first. When we do this, we first place the most distal posterior suture, thread the mesh at the abdominal surface, and tie down these sutures. We then place the posterior apical sutures, which helps to retract the mesh out of the visual field and facilitates placement of the additional, more distal, posterior sutures. When a Y-shaped mesh is used, it is easier to first suture the anterior portion so that the cephalad portion of the mesh may be retracted anteriorly while the posterior rows of sutures are being placed. Finally, when placing a T-shaped posterior mesh for colpoperineopexy, we typically suture the larger, T-shaped piece of mesh to the posterior wall of the vagina and perineum. The smaller, rectangular piece of mesh is then sutured to the anterior vaginal wall. We then sew both pieces together into the vaginal apex and trim the excess anterior mesh (note that a 15-18 cm mesh length may be required for laparoscopic sacral colpoperineopexy). The sutures are tied extracorporeally as they are placed. Care is taken to place the stitches through the entire thickness of the vaginal wall, excluding the epithelium. The surgeon sutures the mesh to the longitudinal ligament of the sacrum at the level of S1 in two rows of no. 0 or 2-0 polypropylene sutures ( Fig. 21.6 ). A vaginal examination is performed assuring that no undue tension has been placed on the mesh. Titanium tacks or hernia staples may also be used to attach the mesh to the anterior longitudinal ligament of the sacrum. The redundant portion of the mesh is excised, and the peritoneum is reapproximated over the mesh with a no. 2-0 polyglactin suture. If the mesh remains exposed, sigmoid epiploic fat may be sutured over it.
If a hysterectomy is performed before sacrocolpopexy, a supracervical hysterectomy is advised to minimize risk of mesh erosion or exposure ( ). If contraindications for supracervical hysterectomy exist, a double layered closure of the vaginal apex is recommended. In addition, care should be taken to avoid affixing the mesh to the apical suture line in order to decrease risk of mesh erosion. The technique for sacrohysteropexy is discussed in detail in Chapter 26 .
A concomitant midurethral sling or laparoscopic Burch colposuspension is performed if the patient has urethral hypermobility with urodynamic stress incontinence. A paravaginal defect repair is performed, if needed, to treat anterior vaginal wall defects. If rectal prolapse is present, a rectopexy with or without sigmoid resection can be performed laparoscopically with or without robotic assistance. We perform these combined cases with our colorectal surgery colleagues.
Robotic Sacral Colpopexy
The robotic sacral colpopexy is performed using a technique similar to the laparoscopic sacral colpopexy. The da Vinci ® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) is currently the only widely used robotic surgical system in the United States. The four-armed da Vinci ® S and the da Vinci ® SI systems are currently the most commonly used. The da Vinci ® Surgical System has three components: the patient cart (operative robot), surgeon console, and the vision cart. An example of robotic operative room arrangement is depicted in Figure 21.7 .
The robotic approach to sacral colpopexy differs from the laparoscopic approach on a few parameters: trocar locations, docking the robotic patient cart, and use of intracorporeal knot tying. Five trocars are placed in a shallow “W” formation ( Figs. 21.1 B and 21.8 ): two of the 8 mm robotic ports are placed bilaterally, 9 cm lateral and inferior from the umbilicus, and the third robotic trocar is placed in the left lower quadrant, 9 cm lateral to the more medial left-sided port. A 12 mm umbilical trocar is used for the laparoscope, and an 8 mm assistant trocar is placed 9 cm lateral to the right-sided robotic trocar. This trocar size allows introduction and removal of suture with SH needles and does not require fascial closure, thus decreasing the risk of postoperative pain. The robotic trocars are placed approximately 9 cm apart to minimize risk of robotic arm collision ( Fig. 21.8 ). In addition, care should be taken to assure that the robotic trocars’ black remote center, a fixed point around which the robotic arm articulates, is just above the peritoneum. After the robotic trocars are safely placed and the patient is placed in maximal Trendelenburg position (about 30°), the robotic patient cart is docked under the instruction of the bedside surgeon ( Fig. 21.9 ). Although many methods of robotic patient cart docking have been described, we feel that parallel docking on the patient’s left side allows easy access for vaginal manipulation and results in minimal issues with robotic arm collision ( Fig. 21.10 ). After first affixing the camera arm, the other robotic arms are connected to the robotic trocars with care taken to position arms to minimize risk of robotic arm collisions. A 30° angle between the instruments arms and camera is good, but a 45° angle is usually better. Positioning the fourth robotic arm (arm 3) at the most left lateral trocar is usually done last, because of the need for its horizontal and, often, inferior angle to the patient ( Fig. 21.10 ).
We typically place the robotic Monopolar scissors in arm 1, a bipolar instrument, either a PK ® Dissecting Forceps or a Bipolar Forceps in arm 2 and a Prograsp in arm 3 for the initial dissection. If a hysterectomy is being performed, the Tenaculum Forceps can be placed in arm 3, rather than the Prograsp; however, this is only necessary for large uteri with fibroids. Once the initial dissection for the sacral colpopexy is done, we typically use a SutureCut needle driver in arm 1, needle driver in arm 2 and Prograsp in arm 3 to suture robotically with 8-in monofilament 2-0 or 0 polypropylene and polydioxanone, as described above in our discussion of laparoscopic sacral colpopexy.
There are a few points of caution for robotic-assisted laparoscopic surgery. (1) There is no haptic feedback with the robotic system, so the surgeon has to pay close attention to visual cues when placing tension on tissues or suture. (2) Once the robotic system is docked, the patient bed position cannot be changed without first removing instruments and undocking the robotic arms. (3) The tip of the robotic endoscopic camera becomes very hot and must be cleaned outside of the peritoneal cavity. (4) The ability to clutch, exchange instruments, focus the camera, and ability to use monopolar and bipolar energy modalities differs between the different generations of da Vinci ® Robotic Surgical Systems. Consequently, a surgeon should be comfortable with the features of the particular robotic system before its use.
Clinical Results: Subjective and Objective Cure
In the recent update of the Cochrane review of surgical management of pelvic organ prolapse, stated that abdominal sacral colpopexy had lower rates of recurrent vaginal apex prolapse (3.5% versus 15%; relative risk (RR), 0.23; 95% confidence interval (CI), 0.07-0.77), reduced grade of residual prolapse (5.7% versus 20%; RR, 0.29; 95% CI, 0.09-0.97), and less dyspareunia (16% versus 36%; RR, 0.39; 95% CI, 0.18-0.86), when compared with vaginal sacrospinous colpopexy. Abdominal sacral colpopexy, however, was associated with a longer operative time (mean difference (MD), 21 min, 95% CI, 12-30), longer time to recovery (MD, 8.3 days; 95% CI, 3.9-12.7), and was more expensive (weight MD, USD $1334; 95% CI, $1027-$1641) than the non-mesh augmented vaginal approach. Well-designed randomized trials included in the meta-analysis by , and compared laparoscopic sacral colpopexy with either robotic (Paraiso), open (Freeman), or total vaginal mesh (Maher). The details of these trials and their findings are discussed below and summarized in Table 21.1 .
| Author (year) | Study Type | Comparison Groups (N) | Mean OR Time (min) | Hospital Stay (days) | Length of Follow-up | Cure: Objective | Cure: Subjective | Comments |
|---|---|---|---|---|---|---|---|---|
| RT multicenter | LSC (26) | 144 ± 28 ∗ | 3.2 ± 1.1 ∗ | 12 months | NS | NS | Equivalence trial for both POP-Q point C and PGI-I “much better” response | |
| ASC (27) | 131 ± 44 | 4.1 ± 1.6 | −6.65 cm ± 1.2 | PGI-I | ||||
| −6.63 cm ± 1.4 | P-QOL | |||||||
| SF-36 | ||||||||
| RC | RSC (23) | 44.2 ± 6 months | NS | NS | Obj cure: ≤stage I apical prolapse, C ≤ −5, total vaginal length of ≥7 cm | |||
| ASC (28) | (33-55) | 100% | PFDI-20 | |||||
| 100% | PFIQ-7 | |||||||
| PISQ-12 | ||||||||
| RC multicenter | RSC (218) | 206 min ∗ | 1.2 ∗ | 7.6 ∗ | 94.1% ∗ | Obj cure: POP-Q < stage II | ||
| LSC (213) | 81.1% | |||||||
| ASC (400) | 234 min | 2.8 | 10.8 months | 75.9% | ||||
| RC | RSC (65) | NS | NS | 3 months | NS | Obj cure: stage 0/I for Ba, Bp, or C | ||
| LSC (23) | 334 | 1 (1-5) | 87.1% | |||||
| (205-537) | 1 (1-3) | 91.3% | ||||||
| 325 | ||||||||
| (219-451) | ||||||||
| RT | RSC (40) | 227 ± 47 § | NS | 12 months | NS | NS | ||
| LSC (38) | 162 ± 47 | 43 ± 37 | Apical stage | PFDI-20 | ||||
| 34 ± 11 h | 0/I: 88% | PFIQ-7 | ||||||
| Apical stage | PISQ-12 | |||||||
| 0/I: 91% | EQ-5D | |||||||
| AAS | ||||||||
| RT | LSC (53) | 97 § (36-280) | 2 (2-10) ¶ | 24 months | 77% § | NS | Obj cure: Aa, Ba, C, Bp, Ap <−1 cm | |
| TVM (55) | 3 (2-6) | 43% | APFQ | |||||
| P-QOL | ||||||||
| 50 (30-96) | ||||||||
| RC | LSC (44) | NS | 35.4 § | 7.4 months ¶ | NS | NS | Obj cure: C > 1/2 of TVL, no need for re-operation or pessary use | |
| ASC (41) | 183 | 63.3 h | 10.6 months | 100% apical | 91% | |||
| 168 | 93% anterior | |||||||
| 93% posterior | 95% | |||||||
| 100% apical | Anterior/posterior success Aa, Ba, Ap, Bp < − .5 | |||||||
| 88% apical | ||||||||
| 93% posterior | ||||||||
| RC | RSC 73 | 328 ± 55 § | 1.3 ± 0.8 § | 6 weeks | C: −9 ¶ | Point C more improved for RSC, no difference in other POP-Q points | ||
| ASC 105 | 225 ± 61 | 2.7 ± 1.4 | (−10 to −8) | |||||
| C: -8 | ||||||||
| (−9 to −8) | ||||||||
| RC | LSC (56) | 269 ± 65 § | 1.8 ± 1 § | 13.5 ± 12 months | NS | No significant difference in total reoperations for recurrent prolapse between groups | ||
| ASC (61) | 218 ± 60 | 4 ± 1.8 | 15.7 ± 18 months |
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