The use of laparoscopy in pelvic floor reconstruction surgery should be evaluated objectively
Laparoscopic techniques have been widely used in the surgical treatment of benign gynecological tumors, ectopic pregnancy, endometriosis, and early malignant tumors. In recent years, laparoscopy has been used in the surgical treatment of pelvic organ prolapse and urinary incontinence, and has achieved certain clinical efficacy. In order to judge the value of laparoscopy in the surgical treatment of pelvic floor diseases more objectively, the following is a brief discussion of the methods and clinical effects of laparoscopic pelvic reconstructive surgery commonly used at home and abroad.
1. Laparoscopic bladder neck suspension (Burch procedure)
Stress urinary incontinence is a common disease in gynecology and is mostly treated surgically for moderate and severe patients. One of the previously used surgical procedures is bladder neck suspension (Burch procedure), which was used clinically in the 1960s and involves suspending the tissue on both sides of the anterior vaginal wall or bladder neck from Cooper’s ligament, thereby lifting the bladder neck and narrowing the angle between the bladder and the posterior angle of the urethra for the purpose of treating stress urinary incontinence. 1991 was the year when Drs. Vancailllie and Dr. Schuessler performed the first laparoscopic suspension of Cooper’s ligament with good results. Laparoscopic Burch procedure has been widely used because it is not open, has less postoperative pain, faster recovery of bladder function, fewer days of indwelling urinary catheter, and has a cure rate similar to that of open Burch procedure. However, in recent years, the tension-free midurethral suspensory banding (TVT) and transconjunctival midurethral suspensory banding applied to clinical practice have been widely recognized by urologists and gynecologists for their ease of operation, even fewer complications, and positive near-term and long-term outcomes. Therefore, the Burch procedure has a tendency to be replaced. Some scholars observed 72 female patients with stress urinary incontinence, 36 cases treated with TVT and 36 cases treated with laparoscopic Burch procedure, with a mean follow-up of 20.6±8 months after surgery, and the recurrence rate of stress urinary incontinence was 3.2% in the TVT group and 18.8% in the laparoscopic group. It indicates that the recurrence rate of laparoscopic Burch procedure is higher. Therefore, laparoscopic Burch surgery is not currently advocated for the treatment of patients with stress urinary incontinence alone, and is recommended for other gynecologic conditions combined with stress urinary incontinence, which are treated with laparoscopic surgery along with Burch surgery.
2. Laparoscopic lateral paravaginal repair
Patients with anterior vaginal wall bulge are divided into central and parietal defects. The central defect is mainly due to a defect in the pubocervical fascia, which can be repaired clinically with a patch (Mesh) reinforcement. Shull et al [1] found that there are three types of paravaginal defects during autopsy and surgery: (1) the pelvic tendon arch is torn away from the surface of the anal raphe and the internal closing muscle; (2) the pelvic tendon arch is still attached to the lateral pelvic wall and the pubocervical fascia is separated from the arch; (3) part of the pelvic tendon arch is attached to the pelvic wall and the other part is attached to the pubocervical fascia. (3) the pelvic fascial tendon arch is partly attached to the pelvic wall and partly to the pubocervical fascia. Any of these types of defects will result in decreased lateral support of the anterior vaginal wall, resulting in anterior and lateral wall bulge. Laparoscopic repair of the lateral vaginal wall has just been performed in recent years. The main method is to examine laparoscopically the separation of the lateral pelvic fascia from the lateral vaginal wall (from the level of the pubic bone to the sciatic spur), determine the extent of the lateral vaginal defect, separate the lateral pelvic wall at the Retzius gap to expose the pelvic fascial tendon arch (white line), and close the closed hole with 0/2 non-absorbable sutures. The sutures are sutured with 0/2 non-absorbable sutures, firstly from the sciatic spine towards the pubic symphysis, not through the vaginal mucosa, with an interval of 1-2 cm between each stitch and 3-5 stitches on each side, so that the paravaginal defect is completely repaired. Cystoscopy should be performed after the suturing to understand any damage to the bladder and urethra and the sutures.
Possible complications of laparoscopic lateral paravaginal repair may lead to injury bleeding of blood vessels in the closed area, bladder injury, urethral injury, rectal injury, postoperative Retzius gap hematoma or abscess when separating and exposing the pelvic lateral wall of the Retzius gap. Too tight sutures or sutures through the bladder and urethra can lead to postoperative dysuria and vesicovaginal fistula.
In China, Xu Huicheng et al [2] observed the clinical results of 74 cases of anterior vaginal wall bulge treated by laparoscopic paravaginal repair (LPVR), and the average follow-up was 14 months (6-30 months) after surgery. Seven cases had a recurrence of anterior vaginal wall bulge (POP-Q stage I) and did not receive further surgical treatment. The subjective cure rate was 94.6% and the objective cure rate was 90.5%. The authors concluded that LPVR is a safe and effective treatment for anterior vaginal wall bulge with paravaginal defects with satisfactory clinical results, and that the procedure is less invasive and has rapid recovery.
According to related reports, it is believed that PVR has the following two problems: (1) PVR surgery focuses on reinforcing the anterior pelvis, but changes the force points of the pelvic floor, making other pelvic floor areas prone to prolapse or dysfunction, such as mid-pelvic or posterior pelvic prolapse; (2) the recurrence rate is high after surgery, and scholars at home and abroad agree that the poor long-term results of paravaginal repair are due to the fact that it is difficult to perform suture reinforcement on the original already weak or defective It is difficult to maintain the long-term effect by suture reinforcement on the already weak or defective tissues, and the result will be improved if reinforcement such as patch can be applied. Therefore, laparoscopic paravaginal repair is one of the methods to treat paravaginal defects, but it is not the ideal procedure.
3. Laparoscopic anterior sacral vaginal fixation
Anterior sacral vaginal fixation is mainly used to treat mid-pelvic defects, including uterine prolapse and vaginal vault prolapse, by three surgical routes: transvaginal surgery, transabdominal surgery and laparoscopic surgery. Advantages of the laparoscopic route: (1) laparoscopic pneumoperitoneum allows expansion of the potential pelvic gaps, a clear surgical view and exposure of the anatomical abnormalities of the pelvic fascia; (2) laparoscopy allows clear identification of the intrapelvic fascia; (3) compared with the transvaginal and transabdominal routes, the surgical wound is small and less traumatic.
Laparoscopic anterior sacral vaginal fixation is similar to transabdominal anterior sacral vaginal fixation method. The specific surgical procedure involves first pushing up the top of the vagina and laparoscopically incising the peritoneal retrusion at the top of the vagina anteriorly and posteriorly, respectively, to expose the rectovaginal fascia and the top of the pubocervical fascia. The lateral retroperitoneum is then opened along the right side of the sigmoid colon to the sacral promontory, exposing the anterior sacral ligament. A patch is placed, usually trimmed and sutured in a “Y” shape, with the lower end sutured to the vesico-vaginal fascia and recto-vaginal fascia, respectively, and the upper end sutured to sacrum 2-3, with the vaginal break elevated. Finally, the lateral retroperitoneum was sutured and the patch was embedded.
Regarding the efficacy of surgery, Xu Xexian et al [3], a domestic scholar, applied laparoscopic Mesh intrapelvic fascia repair sacral fixation for vaginal vault prolapse with bladder and rectal bulge, with 6-10 months postoperative follow-up, improvement in bowel and urinary function, and normal sexual function at 6 months postoperatively without recurrent cases. It is considered that laparoscopic Mesh intrapelvic fascia repair sacral fixation is an effective procedure for the treatment of vault prolapse with varying degrees of bladder and rectal distention, which is minimally invasive and safe. Foreign follow-up results also show that sacral fixation is the procedure with the lowest recurrence rate and the best recovery of sexual, bladder, and rectal function compared with sacrospinous ligament fixation, transabdominal sacral fixation, and high sacral ligament vaginal vault suspension, making it the gold standard procedure for vault prolapse [4].
However, laparoscopic anterior sacral vaginal fixation also has operational problems such as long operative time, difficulty in exposing the anterior sacral area, technical difficulty in performing vaginal fascia and anterior sacral sutures laparoscopically, and in addition, after vaginal vault suspension, urinary incontinence may occur postoperatively due to the change in the direction of the vaginal axis. The author observed a limited number of clinical cases and found that 2 cases presented with postoperative spasmodic abdominal pain before defecation, which relieved on its own after defecation, and the symptoms lasted for 1-2 weeks with gradual relief, and it remains to be seen whether there is patch irritation or influence on the peristalsis of the sigmoid colon and rectum. For the more concerned problem in the anterior sacral area, it usually does not cause major bleeding as long as the suture site is accurate. Therefore, for patients with severe mid-pelvic defects, laparoscopic presacral vaginal fixation can be considered with positive outcomes, but attention should be paid to surgical complications and patient quality of life.
4. Laparoscopic uterosacral ligament shortening and fixation
Laparoscopic uterosacral ligament shortening and fixation is mainly aimed at patients with uterine prolapse without sacral ligament defect or weakness, in order to achieve the purpose of suspending the prolapsed uterus. It is mainly suitable for patients with prolapse who require preservation of the uterus without lesions of the uterus and cervix. Laparoscopic uterosacral ligament shortening and fixation is performed by shortening the sacral ligaments by tying consecutive sutures on each side and then tying the two sides together to elevate the uterus or vaginal vault. Liang Zhiqing et al [5] performed laparoscopic uterosacral ligament shortening and fixation in 32 patients with uterine prolapse, and after 4 to 28 months of follow-up of all patients, 23 cases (72%) were cured; 7 cases (22%,) were effective, and 2 cases recurred. The foreign literature reports that 21% of the patients had recurrence of symptoms at 1-year follow-up. The recurrence rate in the last 2 years was only 5.3%, which shows that the effect of surgery may be closely related to the operator’s surgical experience and the selection of surgical indications.
Since uterosacral ligament shortening and fixation mainly relies on its own sacral ligament to strengthen and elevate the uterus, the indications should be selected for patients without sacral ligament defects or weakness, otherwise the surgical results will be affected. In addition, because the surgical operation is mainly performed near the sacral ligament, care should be taken to avoid damaging the ureter and rectum, and it is recommended to free the ureter during the operation, separate the rectum pars distalis, and fully expose the sacral ligament before suturing.
5. laparoscopic sacrospinous ligament suspension
At present, sacrospinous ligament suspension is still a common surgical method in China, but the sacrospinous ligament is located in the posterior lateral wall of the pelvis, and its position is deeper, so it is difficult to expose it by transvaginal surgery, and it is mainly sutured by palpation, and it is easy to damage the sciatic nerve and internal pubic vessels and sacral plexus vessels during suturing. Laparoscopic sacrospinous ligament fixation retains the advantages of open retropubic surgery, while the surgery is less invasive, less painful, quicker in postoperative recovery, and more acceptable to patients.
There are two surgical routes for laparoscopic sacrospinous ligament suspension: anterior and retroperitoneal. The anterior peritoneal route exposes the sacrospinous ligament by separating the retropubic space, and the retroperitoneal route exposes the sacrospinous ligament by opening the retroperitoneum on both sides of the anterior sacrum. The advantages of the anterior peritoneal route over the posterior peritoneal route are: (1) Burch operation and paravaginal repair can be performed simultaneously. (2) The operation is far away from the ureter and less likely to damage the ureter and vascular plexus. Therefore, the anterior peritoneal route is currently chosen.
For the specific surgical approach, the peritoneum is opened laparoscopically 1 to 2 cm above the pubic symphysis, and to avoid injury to the bladder, the paravaginal space is separated sufficiently, backward to the sciatic spine. After the sciatic spine is clearly identified, the sacrospinous ligament can be clearly exposed by bluntly separating posteriorly and medially with a separator forceps. Sutures are selected with nonabsorbable sutures, and the sacrospinous ligament and sacrospinous ligament cervical attachment are sutured and knotted to lift the vaginal apex [6].
This surgical procedure is not performed clinically and requires a complex surgical operation and more experience to identify the anatomy of the pelvic floor. It is recommended that for clinicians with limited laparoscopic experience, a transvaginal route for sacrospinous ligament suspension should be performed.
In conclusion, with the continuous improvement of surgical instruments and equipment and the continuous improvement and maturation of surgical techniques, laparoscopic surgery has become the most widely used, most effective and most promising “minimally invasive gynecologic” surgery. The outstanding advantage of laparoscopy in pelvic floor surgery is that it enables the operator to determine more clearly the anatomical structures of the pelvic floor, especially the deep pelvic structures, such as the anterior sacral space, the posterior pubic space, the sacrospinous ligament of the pelvic floor, and the pelvic fascial tendon arch. In addition, the results of laparoscopic pelvic floor reconstruction are relatively similar to those of vaginal or open surgery. However, laparoscopic pelvic floor reconstruction surgery is still difficult, requiring the operator to be very familiar with the anatomical structure of the pelvic floor under the mirror and skilled in laparoscopic deep tissue separation and suturing skills. It is not suitable for surgeons who are not yet proficient in laparoscopic skills. Therefore, in the absence of a “gold standard surgical approach” for pelvic floor reconstruction surgery, laparoscopic pelvic floor reconstruction surgery should be carried out scientifically and carefully, paying attention to both the surgical results and the quality of life of the patient, and choosing the appropriate treatment method by combining the clinician’s own technical level and medical conditions.