With the continuous improvement of laparoscopic surgery technology and surgical equipment, laparoscopic surgery in gynecology has brought revolutionary changes in the past 10 years. It has the advantages of small surgical trauma, clear observation of pelvic organs and tissue structures, clear view of the separation of the retroperitoneal space, precise separation of tissues, less bleeding and fast postoperative recovery. In recent years, surgery for pelvic organ prolapse and urinary incontinence can also be done laparoscopically, and more satisfactory results can be achieved. However, this type of surgery is difficult and requires the operator to be very familiar with the anatomical structure of the pelvic floor under the mirror and to be skilled in laparoscopic deep tissue separation and suturing. The methods and efficacy of each type of laparoscopic pelvic reconstructive surgery are outlined here.
(I) Overview of pelvic floor organ prolapse.
Pelvic floor dysfunctional disorders including pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two major categories. Pelvic organ prolapse (POP) includes prolapse of the genital tract as well as bladder bulge, rectal bulge or rectal hernia. Reproductive tract prolapse includes uterine prolapse and anterior and posterior vaginal wall prolapse. Uterine prolapse is defined as the descent of the uterus from its normal position along the vagina, with the ectocervix reaching below the level of the sciatic spine, or even the uterus prolapsing completely outside the vaginal opening, often accompanied by prolapse of the anterior and posterior vaginal walls. Domestic epidemiological surveys in a large sample showed that the incidence of uterine prolapse in married women was 0.04-0.14%, 0.33% in women aged 51-60 years, and 0.71% in women aged 60 years or older. One study found that among the age groups of uterine prolapse, 12.5% were aged 50-59 years and 76.7% were aged ≥60 years or older. The International Continence Society (ICS) defines SUI as an involuntary leakage of urine when the intra-vesical pressure exceeds the maximum intra-urethral pressure without contraction of the detrusor muscle, and this involuntary urine leakage state has adverse effects on social activities and hygiene. Epidemiological surveys in large samples abroad have shown that 12.5% of women suffer from SUI, and the prevalence of SUI in elderly women over 60 years of age is as high as 26.7%. In China, epidemiological surveys of large samples in Fujian and Wuhan showed that the incidence of SUI ranged from 9.1 to 16.3% and 18.5%, respectively, and the incidence increased with the age of women, and the incidence of SUI in elderly women was as high as 29%.
(B) Traditional surgical methods and results of pelvic reconstruction
There are different types of pelvic reconstructive surgery to address the structural defects of different parts of the pelvis. Traditional procedures for stress urinary incontinence include the dissecting MMK procedure (Marshall-Marchetti-Krantz) and bladder neck suspension (Burch procedure); reconstructive procedures for pelvic floor organ prolapse include the transvaginal Mann procedure, anterior and posterior vaginal wall repair, and various transvaginal procedures with the top of the vaginal vault suspended from the sacrospinous ligament, the recto-caudal fascia, or the uterosacral ligament. ligaments. In addition, sacral hysteropexia is performed via dissection, while vaginal closure is rarely performed because patients cannot maintain a normal sexual life after surgery.
In 1999, Benson et al. conducted a randomized prospective study comparing the results of vaginal and cesarean surgery for the correction of severe pelvic organ prolapse and found that 58% of the cesarean surgery results were excellent, compared to 29% in the vaginal group, and the reoperation rate was 16% in the vaginal group and 33% in the feminine group. However, there are also problems with cesarean surgery, mainly the large abdominal incision, the intraoperative interference with the intestine, the long postoperative recovery time, and the high rate of postoperative disease.
Laparoscopic surgery has a small incision and less postoperative pain; the postoperative hospital stay is shorter and recovery is faster. For surgeons skilled in laparoscopic surgery, the success rate of laparoscopic surgery can exceed that of transvaginal surgery and achieve the same results as cesarean surgery. However, laparoscopic pelvic floor reconstruction surgery is relatively difficult, requiring the surgeon 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.
(C) The procedure and efficacy of laparoscopic pelvic floor reconstruction surgery
1. Laparoscopic bladder neck suspension (Burch procedure)
The Burch procedure involves elevating the anterior vaginal wall or bladder neck to its original level by suspending it from the Cooper’s ligament to reduce the angle between the bladder and the posterior urethra. The main purpose is to treat stress incontinence of types I and II. However, this procedure is not suitable for type III stress incontinence (i.e., combined with urethral sphincter function defects).
The procedure was performed under intravenous general anesthesia with a head-down-arm-high position (Trendelenger’s position) and an 18-gauge Foley balloon urinary catheter was routinely placed preoperatively. Four laparoscopic puncture channels were designed. The peritoneal incision was made at the upper edge of the bladder base at 2 cm, and the anterior peritoneal layer was cut from the umbilical artery on one side to the umbilical artery on the other side to fully free the anterior bladder space, and it was appropriate to fill the bladder with 200-300 ml of fluid in patients with difficulty in revealing the bladder. The retropubic space is then continued down to open the Retzius space, exposing the pubic bone and bilateral Cooper’s ligaments to the bladder neck. The vessels within this gap are clearly visible and should be avoided; if there is injury, bipolar electrocoagulation can be used to stop the bleeding. The bladder is pushed back medially with a noninvasive pulling hook while the vaginal wall tissue is grasped with a grasping forceps on the opposite side to completely separate the bladder from the vagina and storm the anterior wall of the **** tract. At this point, a finger is inserted into the vagina to identify the urethral-vesical connection through the balloon urethra, and the Cooper’s ligament is first sutured with a 2/0 non-absorbable needle suture, passing through the full length of Cooper’s ligament as far as possible to enhance its resistance to tension and exiting in the direction of its longitudinal axis. The surgeon places the middle finger of the left hand inside the vagina to expose the urethral-vesical junction and the suture entry point in the anterior vaginal wall, avoiding the bladder, and avoiding penetration of the vaginal mucosa. The sutures should be tightened and knotted after the needle is removed. The knot should be tightened so that the urethral-vesical junction does not form an acute angle. The first suture must be 1 cm outside the urethrocystic junction, and then the second suture in turn should be suspended with an interval of about 1 cm between each stitch, and the peritoneum should be closed intermittently with absorbable thread. Postoperative cystoscopy should be performed to observe whether the urethra is patent and whether the bladder and urethra were mistakenly sutured during the suturing. it is not necessary to routinely suture and close the peritoneal reflex of the bladder after Burch suspension. Postoperative drainage is usually not required to be placed in the pelvis. Sometimes a drain may be placed in the Retzius interval to prevent postoperative hematoma formation.
The Burch procedure is performed by raising the position of the bladder neck and urethra, narrowing the posterior angle of the urinary bladder, increasing the resistance of the bladder neck, and increasing bladder neck control when abdominal pressure increases to improve control of urinary overflow. In recent years, with the development of laparoscopic technology, laparoscopic Cooper’s ligament suspension has more unique advantages of less trauma and faster recovery, and its efficiency rate can reach 95%. A randomized controlled comparison of open and laparoscopic burch surgery by Carey MP showed that there was no difference in patient satisfaction at 6 months, 24 months and 3-5 years postoperative follow-up, with longer operative time in the laparoscopic group (87 minutes in the laparoscopic group; 42 minutes in the open group). Moehrer et al. (2003) showed that the overall surgical success rate was 85%-100% in the open group and 85%-96% in the laparoscopic group. Urodynamic findings showed lower power in the laparoscopic group than in the open group, with no statistical difference. In our hospital, 61 cases of Burch surgery were followed up for 6 months-28 months, and the efficacy of open versus laparoscopic comparison was similar (cure rate 91%, 88%). Laparoscopic Burch surgery has the advantages of less trauma, lower postoperative morbidity and faster recovery. The reported incidence of complications varies widely, ranging from 6.3% to 23.8%. The main complications include bladder injury, overactive bladder, pelvic hematoma, postoperative co-infection, dysuria and urinary retention, and postoperative morbidity.
2. Laparoscopic lateral paravaginal repair
Laparoscopic lateral paravaginal repair is used to repair defects in the lateral vaginal wall. The extent of the paravaginal defect is determined by first examining the separation of the lateral pelvic fascia from the lateral vaginal wall (from the level of the pubic bone to the level of the sciatic spur), and then separating the lateral pelvic wall at the Retzius gap to expose the pelvic fascia tendon arch (white line). For lateral paravaginal repair, sutures are placed with 0/2 non-absorbable sutures to close the internal muscles of the foramen ovale and the paravaginal fascia, first from the sciatic spine towards the pubic symphysis in a sequential manner, without penetrating the vaginal mucosa, with 1-2 cm intervals between each stitch and 3-5 stitches on each side to completely repair the paravaginal defect. Cystoscopy should be performed at the end of suturing to understand any damage to the bladder and urethra and the sutures.
When separating and exposing the pelvic lateral wall of Retzius gap to expose the pelvic fascial tendon arch, there is a risk of injury bleeding from blood vessels in the closed area, bladder injury, urethral injury, rectal injury, postoperative Retzius gap hematoma or abscess, etc. Too tight sutures or sutures through the bladder and urethra can lead to postoperative urinary difficulties and vesicovaginal fistula.
3. Laparoscopic uterosacral ligament shortening and fixation
Uterosacral ligament shortening and fixation has been accepted by most patients in recent years, with the advantage of maintaining the integrity of the supporting structures of the pelvic floor and preserving the patient’s uterus. The procedure is performed laparoscopically, making it less traumatic and painful, with a rapid postoperative recovery.
Anesthesia and position are the same as before, firstly, the course of bilateral ureters is clarified, then the peritoneum of the pelvic wall is opened, the bilateral ureters are freed and the bilateral sacral ligaments are pushed away to avoid damage to the ureters when the sacral ligaments are sutured; a 0-gauge non-absorbable thread is used and stitches are inserted 2 cm below the sacral attachment of the sacral ligaments, and purse-string sutures are performed along both sides of the uterosacral ligaments, the rectovaginal septum and the posterior vaginal wall or the vaginal part of the cervix. The uterosacral ligament is shortened. The folded and shortened uterosacral ligament is sutured at the level of the vaginal part of the cervix, the cervix is fixed on both sides of the sacral ligament, and the suture is then tied. After completion of the uterosacral ligament shortening and fixation, the uterosacral ligaments on both sides are intermittently sutured, tightened and ligated to close the rectal fossa of the uterus. If ureteral distortion occurs after suturing the uterosacral ligament, the pelvic lateral peritoneum medial to the sacral ligament is opened, and the ureter is freed and pushed away to allow its natural course.
The key to the success of laparoscopic uterosacral ligament shortening and fixation lies in the selection of the indication, as the presence of a defective or weak sacral ligament and the presence of chronic cough affect the cure rate. Maher CF reported that 21% of patients had recurrence of symptoms at 12 months follow-up. In contrast, Hannah G reported a recurrence rate of 5.3% at 20.3 months of follow-up.
4. Laparoscopic uterosacral ligament-vaginal vault suspension
Suspension of the uterosacral ligament-vaginal vault can be accomplished by cesarean, transvaginal, or laparoscopic surgery. The position of the ureter and the uterosacral ligament can only be determined by palpation during transvaginal surgery, but can be visualized laparoscopically. The pubocervical and rectovaginal fascia are first freed, and the uterosacral ligament and rectovaginal septum are sutured with a 0-gauge nonabsorbable suture 1 cm above the sciatic spine and secured with sutures on each side through the vaginal vault.
Mckinney reported a 97% cure rate in 70 cases of uterosacral ligament-vaginal vault suspension. Ostrzenski analyzed the clinical outcomes of 16 transvaginal and 11 laparoscopic uterosacral ligament-vaginal vault suspensions. The mean operative time in the transvaginal group was 222 min and the cure rate was 69% at 36 months after surgery, whereas the mean time for laparoscopic surgery was 200 min and the cure rate was 91% at 42 months after surgery. According to Lin LL, who summarized the data of 133 patients undergoing laparoscopic uterosacral ligament-vaginal vault suspension, the cure rate was 87.2% with a recurrence rate of 12.8% and an overall complication rate of 2.25% at a follow-up of 2.0-7.3 years.
5. Laparoscopic anterior sacral vaginal fixation
The important anatomical landmarks of the sacroanterior colpopexy are the sacral promontory, the anterior longitudinal ligament, and the aortic bifurcation at the level of L4 to L5, the right common iliac vessels in the right anterior sacral space, and the left sigmoid colon. In addition to the usual 3 punctures, one additional 5-mm puncture trocar is placed at the right rectus abdominis muscle external edge, flat to the umbilicus. The peritoneum around the ectopic vaginal fornix is first separated to expose 3-4 cm of the posterior vaginal wall, and a 3 cm × 10 cm or 3.5 cm × 12 cm “T” or “Y” polypropylene patch (polypropylene mesh) is sutured with a 0-gauge nonabsorbable thread. The polypropylene mesh is spread and sutured to the posterior vaginal wall (3-6 stitches) at one end, and the other end is sutured to the anterior sacral capsule and the anterior longitudinal ligament. The anatomical position of the vagina is restored without excessive stretching. After fixation, the patch is placed in the right side of the retroperitoneal rectal space and the retroperitoneum is closed to prevent postoperative patch erosion. Extra care should be taken with the important vessels and ureters surrounding this surgical area.
Nezhat et al. reported that the average operative time for laparoscopic anterior sacral vaginal fixation was 170 min (105-320 min) with an average intraoperative bleeding of 226 ml (50-800 ml) and one case was converted to caesarean section due to bleeding from the anterior sacral vessels, while the cure rate was 100% in the remaining cases. A controlled cohort study by Paraiso MF reported that there was no significant difference in complications and reoperation rates between laparoscopic and open anterior sacral vaginal fixation, with longer operative time but less bleeding and shorter hospital stay in the laparoscopic group.
(iv) Perspectives of laparoscopic pelvic floor repair
Laparoscopic surgery has a history of 103 years, and with the continuous improvement of surgical instruments and equipment and the continuous improvement and maturation of surgical techniques, laparoscopic examination and surgery has become the most widely used, most effective and most promising “minimally invasive gynecological” surgery, replacing most traditional gynecological caesarean sections. The most prominent advantages of laparoscopic surgery are: small incision, less disturbance to the abdominal cavity, less postoperative pain, less intraoperative bleeding, shorter hospital stay, faster postoperative recovery, and less impact on the nervous system, digestive system, and immune system. Laparoscopy allows the operator to determine the pelvic anatomy more clearly, especially the deep pelvic structures, such as the presacral space and the retropubic space. Increased intra-abdominal pressure can reduce intraoperative bleeding. For surgeons skilled in laparoscopic surgery, the success rate of laparoscopic surgery can exceed that of transvaginal surgery, achieving the same results as cesarean surgery. However, there are still certain disadvantages in laparoscopic pelvic floor reconstruction surgery, such as the need for deep pelvic floor tissue separation using laparoscopy, which requires a high degree of intracavitary suturing. As a result, laparoscopic surgical technique is more demanding and requires a steeper learning curve and longer operative time. There is a corresponding increase in the cost of the procedure due to the longer operative time.
All types of pelvic floor reconstructive surgery and stress urinary incontinence procedures performed laparoscopically are essentially similar to those performed by cesarean section. For surgeons skilled in pelvic floor reconstruction surgery and laparoscopic surgery, laparoscopic pelvic floor reconstruction surgery can better reconstruct the normal anatomy, improve clinical symptoms, and restore and maintain normal sexual life and bowel and urinary function. The current literature on the evaluation of the effectiveness of laparoscopic pelvic floor repair is mostly retrospective, and the indicators for evaluating the postoperative cure rate are not uniform. In order to more objectively assess the clinical effects of laparoscopic pelvic floor reconstruction surgery, a large sample of prospective, randomized controlled studies on its safety and efficacy are still needed.