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Laparoscopic treatment of genitourinary prolapse

Authors

Abstract

The description of the laparoscopic treatment of genitourinary prolapse covers all aspects of the surgical procedure used for the management of genital prolapse.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, dissection, posterior prosthesis, closure, promontory, vesico-vaginal dissection, anterior mesh, promontory fixation, repair of peritoneum, drainage/closure.
Consequently, this operating technique is well standardized for the management of this condition.

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Publication

2001-12

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E-publication

WeBSurg.com, Dec 2001;1(12).
URL: http://www.websurg.com/doi-ot02en244.htm

Laparoscopic treatment of genitourinary prolapse

1. Introduction

Genitourinary prolapse is a frequent pathology in postmenopausal women. It is characterized by a deformation of the vagina caused by the prolapse of pelvic or abdominal organs. This prolapse results from weakness or damage to the natural aponeurotic or muscular support mechanisms.

2. Anatomy

• Regional anatomy

Thorough knowledge of pelvic anatomy is essential for laparoscopic management of prolapse. This includes:
- position of the vagina in relation to the other pelvic organs;
- position of the promontory in relation to the iliac vascular pedicles and the ureter;
- location of the levator ani muscles.

• Vagina

1. Rectouterine (Douglas) pouch
After introducing the trocars into the peritoneal cavity, the parietal aspect of the peritoneum is incised:
- posteriorly, at the back of the rectouterine (Douglas) pouch to dissect the rectovaginal space, and laterally to expose the levator ani muscles;
- anteriorly, at the junction of the uterine isthmus and the anterior vaginal cul-de-sac, or opposite the fornix of the vagina in the case of a hysterectomy, to dissect the vesicovaginal space.

• Promontory

1. Anterior longitudinal ligament
2. Ureter
3. Median presacral vessels
The exposure of the anterior longitudinal ligament must follow the topography of the promontory with respect to the iliac vascular pedicles and the ureter. Care must be taken not to injure these organs during suturing of the prosthetic material.

• Levator ani muscles

1. Rectum
2. Puborectal muscle
3. Pubococcygeus muscle
4. Iliococcygeus muscle
Knowledge of the location of the levator ani muscles, the orientation of their fibers and their position with respect to the rectum, anal sphincter complex and vagina is essential.

3. Indications

Indications
Laparoscopy can be performed to treat symptomatic genitourinary prolapse. The aim of the treatment is to control the clinical manifestations and to prevent complications.
Symptomatic prolapse:
- feeling of pelvic heaviness or fullness and low back pain;
- perception of a lump at the opening of the vulva;
- mucosal erosions.
Complications caused by prolapse:
- urinary tract infections;
- chronic bladder retention;
- bladder instability;
- dilatation of the upper urinary tract;
- renal insufficiency.

Contraindications
Anesthesia:
The contraindications are essentially those for general anesthesia.
Coagulation disorders:
Coagulation studies must be normal before operating.
Abdominal surgery:
It is possible to perform the procedure laparoscopically despite previous abdominal surgery. Laparoscopic adhesiolysis is mandatory in these cases.
Radiotherapy:
A history of radiotherapy in the pelvic region is not a contraindication, although it makes the dissection more difficult.

4. Preop period

• Physical examination

The diagnosis of genitourinary prolapse is purely clinical. There are several forms, depending on the organ involved. These different forms of prolapse are rarely isolated, but are combined in varying degrees.
1. Ureterocele:
On physical examination, the ureter and the bladder deform the anterior vaginal wall.
2. Cystocele:
On physical examination, the bladder deforms the anterior vaginal wall.
3. Rectocele:
On physical examination, the rectum deforms the posterior vaginal wall.
4. Hysterocele:
On physical examination, the uterus drops down, dragging along the vaginal vault.
5. Elytrocele:
On physical examination, the rectouterine pouch deforms the vaginal vault or the posterior vaginal wall.

• Clinical grades

Three grades of prolapse can be seen on physical examination. Grade 3 prolapse causes obvious physical discomfort. Grades 1 and 2 are generally asymptomatic. They are usually observed during physical examination in patients who consult for urinary incontinence.
Grade 1 is descent within the vagina.
Grade 2 is descent of the cervix to the introitus.
Grade 3 is descent of the uterus outside the introitus.

• Anesthetic work-up

The respiratory and cardiac conditions of the patient must permit general anesthesia. Coagulation studies must be normal and the urinalysis results negative before the procedure. The patient is informed of the operative risks and of the potential need for intraoperative conversion to an open procedure.

• Additional exams

A resting
B straining
1. cystocele
2. rectocele
Urodynamic studies are often performed, especially in cases of coexisting incontinence.
MRI is used more commonly than colpocytogram for morphological exploration of the prolapse.

5. Management

Management
Management of prolapse should comply with the following principles:
- repositioning of the organs while respecting their anatomical relationships;
- restoration or preservation of urinary and anal continence;
- maintenance of coital function;
- good long-term results.

Prolapse repair
Prolapse repair can be performed via 2 different approaches (Scali and Blondon, 1974):
- the high transabdominal approach;
- the low transvaginal approach.
Advocates of the transabdominal procedure have developed a laparoscopic approach (Cosson et al., 2000; Paraiso et al., 1999; Wattiez et al., 2001) to avoid a wide incision on the anterior abdominal wall.

Common objectives
The following objectives are shared by both conventional and laparoscopic abdominal procedures:
- interpose non-absorbable mesh between the anterior vaginal wall and the bladder, and between the posterior vaginal wall and the rectum. This material replaces the weakened means of natural support of the vagina, preventing recurrent prolapse.
- solidly attach this mesh to the anterior longitudinal ligament, at the level of the promontory. This tension-free attachment should reposition the vagina and restore its normal shape.

Specific objectives
The specific objectives of the laparoscopic approach are:
- attach the mesh in a minimal fashion to the posterior vaginal wall, to avoid the risk of vaginal necrosis;
- interpose graft material between the rectum and the vagina using a lateral attachment of the mesh on the levator ani muscles.

6. Operating room

• Patient

- general anesthesia;
- supine position;
- 30° Trendelenburg;
- perineum on the edge of the table to enable manipulation of the ribbon retractor;
- legs abducted to make the perineum accessible and to facilitate the positioning of the laparoscopic unit between the legs;
- prophylactic antibiotics are administered during anesthetic induction;
- urinary catheter.

• Team

1. The surgeon stands on the patient's left.
2. The assistant stands on the patient's right.
If needed, a second assistant manipulates the ribbon retractor and stands between the patient's legs or on the surgeon's left when acting as scrub nurse.
3. The scrub nurse stands on the surgeon's left with the instrument table to his or her left, or
between the patient's legs if acting as second assistant. If acting as first assistant, the scrub nurse
stands opposite the surgeon on the patient's right, with the instrument table to his or her right.
4. The anesthesiologist stands at the patient's head.

• Equipment

The operating table must be designed for a 30° Trendelenburg position.
Prolapse repair is often combined with surgical treatment for urinary incontinence. When a vaginal approach is required for this, the table must be equipped for a lithotomy position. If the patient’s legs can be easily attached to movable stirrups without contaminating the operative field, the initial draping can be maintained throughout the operation. Otherwise, the patient is repositioned after the prolapse repair, and re-draped.

7. Trocar placement

• Landmarks

Four trocars are usually necessary. The important landmarks are as follows:
- umbilicus;
- pubis;
- right anterior-superior iliac spine;
- left anterior-superior iliac spine.

• Trocar placement

The sizes and positions of the trocars are as follows:
A: 10 mm, infra-umbilical position
B: 5 mm, halfway between the umbilicus and the pubic symphysis
C: 5 mm, in the left iliac fossa, 2 to 3 cm medial to the anterior-superior iliac spine
D: 5 mm, in the right iliac fossa, 2 to 3 cm medial to the anterior-superior iliac spine

8. Instruments

• Instruments

The instrumentation required for laparoscopic surgery is placed on the sterile instrument table to the right of the assistant or to the left of the scrub nurse, and includes the following:
1. two atraumatic graspers (one flat fenestrated and one narrow pair);
2. flat fenestrated bipolar forceps, which can also be used for grasping;
3. monopolar curved scissors;
4. laparoscopic needle holder;
5. suction-irrigation system;
6. urinary catheter;
7. specific ribbon retractor (flat, metal, rigid, 25 mm wide and 20 cm long, with one rounded endovaginal tip and one triangular tip);
8. non-absorbable mesh, either precut and preshaped, or cut to fit;
9. non-absorbable 0 braided suture, 26 mm needle, absorbable suture for the reconstruction of the peritoneum;
10. ultrasonic dissectors (optional).

• Position of instruments

The instruments are placed in the trocars as follows:
A: laparoscope
B: monopolar scissors or ultrasonic dissectors or needle holder
C: grasper or bipolar grasper
D: grasper or suction device

9. Exposure

• Rectouterine (Douglas) pouch

1. Uterus
2. Posterior vaginal wall
3. Rectouterine pouch
4. Rectum
The sigmoid colon is mobilized at the level of the intersigmoid recess to expose the rectouterine pouch. In rare cases, it is attached to the abdominal wall.
To expose the promontory, it is necessary to retract the sigmoid mesocolon towards the left.

• Suspension of the uterus

The body of the uterus is suspended from the anterior abdominal wall with nylon 0 suture passed through the wall. This, along with the ribbon retractor, achieves tenting of the uterosacral ligaments and exposure of the anterior surface of the rectouterine pouch.

• Trendelenburg position

The Trendelenburg position maintains the intestinal loops outside the pelvic cavity.

10. Dissection

• Objective

The inter-recto-vaginal dissection is the first step of the operative procedure. It is performed to dissect free the following structures:
- the rectum on its anterior and lateral surfaces down to the anal canal;
- the posterior vaginal wall;
- the levator ani muscles.

• Median dissection

1. Uterosacral ligaments
2. Posterior vaginal wall deformed by the valve
3. Rectum
The ribbon retractor introduced into the posterior vaginal cul-de-sac should be anteverted as far as possible to stretch the uterosacral ligaments. The exposed peritoneum is opened from one uterosacral ligament to the other in a V-shaped incision. A grasper retracts the inferior margin of the incised peritoneum, allowing access to an avascular plane that corresponds to the rectovaginal fascia. The dissection should be begun in a median plane, in contact with the posterior vaginal wall.

• Lateral dissection

1. Rectum
2. Laterorectal space
The lateral dissection is begun in contact with the uterosacral ligament to find the posterolateral wall of the vagina.
The space thus created enables the surgeon to perform a lateral dissection at a distance from the rectum and to gain access to the posterior portion of the levator ani muscles covered by their aponeurosis. This operative step requires a progressive dissection of the fatty laterorectal tissue, with care taken not to injure the hemorrhoidal vessels. In case of injury, a bipolar grasper should be used to perform hemostasis.

• Exposure of the levator ani muscles

1. Levator ani muscles
2. Rectum
Access to the levator ani muscles must be wide to anchor the prosthetic strip adequately.
The dissection is begun in contact with the pubococcygeus portion of the levator ani muscle and is pursued to the left of the rectum anteriorly and medially, to expose the pubococcygeus and the puborectalis fibers of the left levator ani muscle. The dissection of the right levator ani muscle is performed in an identical manner.
After exposure of the levator ani muscles, the remaining attachments of the rectum to the vagina are dissected free to allow for optimal positioning of the prosthesis.
A voluminous rectocele can make dissection of the inter-recto-vaginal space difficult, because it causes a considerable portion of the rectum to come into contact with the posterior surface of the vagina. Care must be taken to always perform the dissection against the posterior vaginal wall to avoid rectal injury.

11. Posterior prosthesis

• Inserting the prosthesis

The prosthesis is inserted into the abdominal cavity via the camera trocar.

• Attaching to the levator ani muscles

1. Rectum
2. Levator ani muscles
The prosthetic material is attached with a suture onto the right and left levator ani muscles. On the right, a forehand throw is anchored deep into the right levator ani muscle (pubococcygeus and puborectalis fibers). The muscle is taken cephalad to caudad at a distance from the rectum, while rotating the needle 180°. The suture is then tied, securing the mesh.
The needle is inserted in the same fashion on the left (backhand throw). Throughout this step, the assistant holds the ribbon retractor in an anteverted position in the posterior cul-de-sac.

• Vaginal attachment

1. Posterior wall of the vagina
The prosthesis is attached to the posterior wall of the vagina. When the two ends have been firmly anchored to the levator ani muscles, the midpoint of the curved portion of the mesh is anchored on the vagina deep in the previously dissected space. This is done to prevent the intestinal loops from coming between the curved portion of the mesh and the vagina.

12. Closure

Closure of the rectouterine pouch
1. Uterosacral ligaments
2. Rectum
3. Peritoneum
This is done with a suture to reapproximate the uterosacral ligaments and to re-peritonealize the rectouterine pouch.
A single stitch successively takes hold of the following elements:
- the uterosacral ligaments, laterally to medially;
- the left edge of the prosthesis, cephalad to caudad;
- the peritoneum, posteriorly to anteriorly;
- the peritoneum, anteriorly to posteriorly;
- the right edge of the prosthesis, caudad to cephalad;
- the right uterosacral ligament, medially to laterally.

13. Promontory

• Incision of the peritoneum

1. Posterior peritoneum
Preparation of the promontory requires a 25° to 30° Trendelenburg position.
This step takes advantage of the exposure that was achieved by suspending the uterus from the abdominal wall. The bulge of the promontory is identified tactually with the scissors’ tips. The assistant pushes back the distal ileal loops with a flat grasper. The posterior peritoneum is opened with the tip of monopolar scissors, while a grasper lifts it off from the posterior plane to prevent injury of the median presacral vessels. Once the peritoneum is incised, gas pressure opens the retroperitoneal dissection plane. This incision enables the surgeons to identify the primitive iliac venous axis as well as the ureter, both of which must remain outside and posterior to the dissection plane.

• Exposure of the promontory

1. Anterior longitudinal ligament
The anterior surface of the promontory is carefully dissected free with instrument tips to expose the pearly white surface of the anterior longitudinal ligament and the median sacral vessels. The peritoneal incision is continued down to the anterior rectal region. The exposure is facilitated by manipulating the ribbon retractor. We recommend opening the peritoneum rather than making a tunnel with a dissector, which can injure the vessels that run perpendicular to the axis of dissection.
It is possible to begin this part of the procedure by exposing the promontory and then performing the posterior step.

14. Vesico-vaginal dissection

• Ribbon retractor

1. Bladder
The bladder is identified by the balloon of the catheter. The ribbon retractor is placed in the anterior cul-de-sac or at the fornix of the vagina in the case of a hysterectomy. The ribbon retractor is directed posteriorly after transverse incision of the retrovesical peritoneum. The assistant holds the anterior edge of this peritoneum with an atraumatic grasper.

• Dissection

The dissection begins on the midline. The pearly white anterior surface of the vagina can be used as a landmark. By dividing the adhesional tissue with scissors, the bladder can be separated from the vagina. The dissection is performed over a 25 mm width to the retrotrigonal space.

15. Anterior mesh

• Anterior mesh

1. Uterus
2. Vesico-vaginal space
The tip of the mesh is bevelled and fitted with a preknotted, threaded suture. It is placed underneath the bladder, as far as possible from the vesico-vaginal dissection plane. The prosthesis is then attached laterally along the entire length of the vagina with 2 running sutures. The stitches should not transfix the vagina.

• Anterior prolapse of the uterus

1. Uterus
2. Uterine isthmus
When a decision is made to preserve the uterus, it is essential to remove the ribbon retractor and to retract the uterus posteriorly. This makes it possible to continue the running suture to attach the mesh to the level of the uterine isthmus, thereby preventing the cervix from protruding. The mesh is then slit lengthwise to take on the shape of the letter Y, the limbs passing through the open broad ligament in its avascular portion.
It is possible to pass the mesh on only one side of the uterus, through the right broad ligament.

16. Promontory fixation

• Fixation stitch

1. Mesosigmoid
2. Promontory covered by the anterior longitudinal ligament.
A single fixation stitch with non-absorbable suture is sufficient. A 26 mm long needle is used, directed forehand, grasped in the distal third of the needle holder’s jaws and directed 120° anteriorly. The stitch is performed laterally to medially and very gently, making sure that it does not enter the periosteum.

• Promontory fixation

1. Uterus
2. Anterior prosthesis
3. Posterior prosthesis
4. Promontory
The posterior prosthesis and then the anterior prosthesis are grasped after obtaining an appropriate tension. Although the traction created must not be too strong, it must offset the pressure of the pneumoperitoneum. The fixation is achieved by an extra-corporeal knot that can be used to evaluate the strength of the repair. The extra prosthetic material is cut and removed.

17. Repair of peritoneum

1. Anterior prosthesis
2. Posterior prosthesis
This is done using absorbable braided suture. The running suture first closes the anterior detachment. It passes through the right broad ligament when the uterus is preserved, and closes the peritoneal opening anterior to the prostheses, excluding them completely from the abdominal cavity. The surgeon must watch out for the right ureter, which remains attached to the right part of the posterior parietal peritoneum.

18. Drainage/closure

Because there is no bleeding, drainage is rarely necessary. Nevertheless, a Redon drain may be placed in the subperitoneal detachment. The trocar wounds are closed in the usual manner.

The urinary catheter can be removed when bowel function is restored on POD2, making hospital discharge possible on POD3.

19. Reference

Cosson M, Bogaert E, Narducci F, Querleu D, Crepin G. Promontofixation coelioscopique: resultats a
court terme et complications chez 83 patientes. J Gynecol Obstet Biol Reprod (Paris) 2000;29:746-
750.
Paraiso MF, Falcone T, Walters MD. Laparoscopic surgery for enterocele, vaginal apex prolapse and
rectocele. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:223-9.
Scali P, Blondon J, Bethoux A, Gerard M. Les operations de soutenement-suspension par voie haute
dans le traitement des prolapsus vaginaux. J Gynecol Obstet Biol Reprod (Paris) 1974;3:365-78.
Wattiez A, Canis M, Mage G, Pouly JL, Bruhat MA. Promontofixation for the treatment of prolapse.
Urol Clin North Am 2001;28:151-7.

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