Gamal M. Ghoniem1 and Jane Cho1
(1)
Department of Urology, University of California Irvine, 333 City Boulevard West, Suite 2100, Orange, CA 92868, USA
Gamal M. Ghoniem
Email: gghoniem@uci.edu
Abstract
While transabdominal approaches to the treatment of pelvic dysfunction have had high rates of success and were the gold standard for many years, they were often associated with increased morbidity compared to transvaginal procedures. Over the last 15 years, laparoscopic and robotic-assisted techniques have been described for colposuspension, sacrocolpopexy, and vesical fistula repair. The pendulum is swinging the other way as these minimally invasive techniques reduce the morbidities of transabdominal surgeries. As an increasing number of surgeons gain experience in these techniques, success rates have become comparable (if not, better) to transvaginal and open transabdominal procedures. Laparoscopy and robotic-assisted laparoscopy have become essential tools in the armamentarium of surgeons treatment of pelvis dysfunction.
Urinary incontinence continues to have a significant impact on the quality of life of women and is the chief complaint in more than 1.1 million office visits per year [1]. Pelvic dysfunction leading to incontinence occurs when there is a disruption in either the storage or voiding of urine and the etiology of incontinence can vary from overactive bladder, intrinsic sphincter deficiency, urethral hypermobility, and pelvic organ prolapse to vesical fistulas. The symptoms are often nonspecific and complete evaluation is necessary to completely characterize the incontinence.
Diagnostic Work-up
The standard evaluation of patients with incontinence includes a thorough and detailed history and can be done with the help of various validated questionnaires. Regardless of which questionnaire is utilized, it is important to characterize the incontinence by frequency of incontinence episodes, urgency, precipitating or exacerbating factors, severity, degree of bother, and, eventually, patient expectations of treatment [2]. Specific to pelvic organ prolapse, awareness of a bulge or discomfort should be assessed. Past medical and surgical history including gynecologic and obstetric history and medication list are also vital in the history of present illness. By defining these parameters, the etiology can be ascertained leading to proper treatment planning.
Physical examination includes a focused pelvic examination. Depending on the history of present illness, it may also include a stress test, where the bladder is filled with 250–300 ml of fluid prior to increase in abdominal pressures with either Valsalva or cough. While not pathognomonic for stress urinary incontinence (SUI), urethral hypermobility can also be assessed with a standard Q-tip test. Prolapse should be assessed with patient in both lithotomy and standing positions.
Most patients should undergo urinalysis with culture as well as uroflow and post-void residual measurement. Additional diagnostic studies include voiding diary, urodynamics (with or without fluoroscopy), cystoscopy, and radiographic imaging (especially in the setting of vesical fistula). While not standard, these tests can help elucidate the nature of incontinence when complex.
Indications
The main indication for the treatment of symptomatic incontinence is significant adverse effect on the quality of life of the patient (i.e., incontinence leading to social or hygiene issues). Conservative therapies for incontinence depend on the etiology of the incontinence and may include physical therapy, and pessary use. Surgical intervention includes injection of bulking agents, fulguration of fistulas, neuromodulation, and various transvaginal procedures which are covered in other chapters.
While the first transvaginal procedure for SUI was described in 1913 [3], it was 35 years more until a transabdominal retropubic approach was described [4]. This procedure was later modified by Burch by placing sutures more laterally into Cooper’s ligament [5] and was the gold standard transabdominal approach for the treatment of SUI. More recently, tension-free transvaginal slings (TVT) have become the gold standard secondary to their ease in placement as well as comparable results to colpopexy [6].
Abdominal sacrocolpopexy is often considered in the setting of isolated apical prolapse or enterocele. While open abdominal sacrocolpopexy is slowly going by the wayside to the laparoscopic and robotic approach [7], the principles have not changed.
Unlike SUI or pelvic organ prolapse, incontinence as a result of urinary fistula is often continuous and sudden in onset. In addition, the etiology is often iatrogenic and, as a result, often causes considerable distress. Therefore, surgery is often the primary treatment in these patients. Patient comorbidities, size, number, and location of fistula are important factors in the surgical approach. However, surgeon experience and preference often have the largest influence.
Advantages to an abdominal approach are:
· Familiarity of retropubic anatomy to most urologists.
· Excellent exposure.
· Reduction in dyspareunia risk.
· Opportunity to repair any coexisting abdominal disease through one incision.
· Increased efficiency in the setting of limited vaginal access.
· Less recurrence of prolapse.
· Maintenance of functional vaginal length in sexually active women.
· Avoidance of vaginal mesh complications and their medicolegal implications.
Disadvantages traditionally included a larger incision resulting in prolonged hospital stay, recovery, and increased pain. However, with the advent of minimal invasive technology, this disadvantage has been largely eliminated. There is also the added benefit of increased magnification. Disadvantages to laparoscopic approach include greater technical difficulty with a steeper learning curve and higher operating costs.
Laparoscopic Colposuspension
Laparoscopic colposuspension can be performed via an extraperitoneal or transperitoneal approach [8]. For all transabdominal procedures, patients perform bowel prep the day before surgery, and receive antibiotics 30 min prior to surgery. Five thousand units of subcutaneous heparin are also administered at the time of surgery. In transperitoneal approach patient is placed in low lithotomy position in slight Trendelenburg and the vagina and abdomen are prepped and draped in the usual sterile fashion. A 16 Fr Foley catheter is initially placed which decompresses the bladder and helps prevent trauma during initial port placement. The peritoneum is entered through a small infraumbilical incision using either the standard Veress needle or Hasson trocar. Once pneumoperitoneum is established up to 15 mmHg, a trocar is inserted infraumbilically. Two more working trocars are placed at the left lateral border of rectus muscle under direct vision. Care is taken to avoid any superficial inferior epigastric vessels by transilluminating the abdominal wall. The left-sided placement would allow the surgeons to not only operate with the laparoscopic instrument using their dominant hand but also be able to place the nondominant index finger in the vagina during the procedure, if necessary.
The space of Retzius is dissected by identifying the umbilical ligaments laterally and then incising the anterior parietal peritoneum over the bladder directly under the pubic symphysis. Once the pubic bone is identified, it can be followed into the space of Retzius. The bladder neck can be identified by the Foley balloon and the endopelvic fascia at the bladder neck and Cooper’s ligament along the superior surface of the pelvic bone are then identified. With the surgeon’s finger elevating the vagina toward the ligament, the endopelvic fascia is sutured to the ligament on both sides. This elevation of the bladder neck behind the pubic symphysis addresses the urethral hypermobility causing stress incontinence. However, it should be noted that the vaginal tissue should not be completely tacked up to the ligaments as this may result in overcorrection as well as kinking of the ureter. Instead, approximately 2 cm of space between the suture and Cooper’s ligament is usually left. Once the fascia is sutured, intravenous indigo carmine is routinely given and cystoscopy is carried out to assure no bladder or urethral perforation as well as the patency of bilateral ureters.
Other complications that may occur include hemorrhage, bladder or urethral injury, and infection as in almost any other major surgical procedures. Specific to colposuspension, patients should be counseled on potential for postoperative voiding difficulty necessitating intermittent catheterization. Reported rates range from 3.5 % to as high as 32 %; however, most incidences were temporary and the risk for permanent urinary retention was estimated to be <5 % [9]. The presence of overactive bladder symptoms with stress incontinence (mixed with incontinence) preoperatively may resolve in most patients after suspension. Those with persistent overactivity may be treated with anticholinergic therapy, or even botulinum toxin therapy, neuromodulation, or augmentation cystoplasty. Another potential complication is the development or exacerbation of vaginal prolapse, especially apical and posterior. In one recent prospective study, 38 % of women who underwent colposuspension developed symptomatic prolapse by 7 years [10]. Regarding laparoscopic surgery, there have been some studies reporting higher incidences of complications with bladder injury being the most common with laparoscopic procedures. It should be noted, however, that the same study reported a decline in injury with experience [11].
Laparoscopic colposuspension procedures were first described in 1991 and since then multiple studies have been published comparing outcomes between open and laparoscopic colposuspension. These studies vary in follow-up data and methodology in assessing outcomes. One of the largest studies was a randomized trial carried out by Carey et al. [12]. They found no significant difference in urodynamic cure rate or patient satisfaction at 6 months, 24 months, and at a mean follow-up of 3.7 years. The COLPO trial found similar results with no difference in objective or subjective cure rates [13]. Of note, this trial found that while complication rates were low, more bladder and bowel injuries occurred in the laparoscopic arm and more wound infections occurred in the open approach [13].
Laparoscopic Sacrocolpopexy
Unlike colposuspension surgery, the principles of the abdominal sacrocolpopexy have not changed since its initial description. The laparoscopic approach is described as follows. Again, patients undergo a bowel prep and are administered intravenous antibiotics and subcutaneous heparin prior to the procedure. Patients are placed in low lithotomy and both the abdomen and vagina are prepped and draped in the usual sterile fashion. A 16 Fr Foley catheter is inserted to decompress the bladder. Pneumoperitoneum is achieved in the same manner described above with either the Veress needle or the Hasson trocar. Once 15 mmHg of pressure is achieved, the camera port is inserted infraumbilically. At this point, the port placement varies slightly depending on whether the procedure will proceed with pure laparoscopy or with robotic assistance. When utilizing the robot, either docking may occur between the patient’s legs or side-docking to the left of the patient, allowing an assistant access to the vagina.
Once ports are placed in appropriate position, patient is placed in steep Trendelenburg, thereby keeping the small bowel out of the pelvis. The rectum is slightly retracted to the left, exposing the right paracolic gutter and sacral promontory. An incision is made in the posterior peritoneum over the sacral promontory, taking care to avoid any presacral and the middle sacral vein. Dissection is carried out until the anterior surface of the promontory is identified by the anterior longitudinal ligament. Attention is then turned to the vaginal cuff. An obturator (either a sponge stick or Deaver or anastomosis sizer) is placed in the vagina to identify the vaginal cuff. The peritoneum over the cuff is incised and carefully dissected off of the vaginal cuff. Care must be taken to avoid complete perforation resulting in loss of pneumoperitoneum.
A Y-shaped graft made of polypropylene macroporous monofilament must be utilized. The two short arms of the Y-shaped grafts are sutured to the exposed vaginal cuff using several permanent interrupted stitches, taking care to avoid the bladder. The long end of the graft is then secured to the promontory. Excessive tension must be avoided and any excess length is carefully trimmed. The peritoneum is then closed over the graft over the sacrum and vaginal cuff with running stitch.
Potential complications from this procedure include hemorrhage (especially secondary to sacral vessel injury), bladder or bowel injury, ureteral injury, mesh infection and vaginal erosion, and ileus, and rates vary from 6 to 16 % [14]. There has been a concern of mesh erosion especially in the setting of combined hysterectomy and abdominal sacrocolpopexy. However, this has not been reported in the laparoscopic approach.
Success rates for laparoscopic sacrocolpopexy are reported to be as high as 100 % in some series [15]. Very few studies compare laparoscopic sacrocolpopexy to the open abdominal approach but similar complication and success rates are reported [16]. There are multiple studies comparing transvaginal sacrospinous fixation with abdominal sacrocolpopexy with most reporting higher success rates with the abdominal approach [17]. In these studies, postoperative morbidity was higher in the transabdominal approach but one can argue that morbidity would decrease significantly given the minimally invasive nature of laparoscopy.
Laparoscopic Vesicovaginal Fistula Repair
The initial step in fistula repair is cystoscopy. During cystoscopy, bilateral ureteral orifices are identified and stented. If possible, the fistulous opening is identified and also stented in order to facilitate dissection later. A Foley catheter is placed and kept accessible. The patient is then placed in supine position. Pneumoperitoneum is established as previously described. Camera port placement is usually umbilical with one working port in each midclavicular line. An assistant port is often placed in the left lower abdomen for retraction as well as suction and irrigation. Once the bladder is dissected off of the anterior vaginal wall, the bladder is filled with fluid and the wall is incised in the midline up to the edge of the fistula. A sponge stick should be placed in the vagina, not only for assistance in traction but also to maintain pneumoperitoneum. The vaginal wall is further dissected and separated from the bladder approximately 2 cm beyond the fistula. The vaginal defect is closed in two layers using absorbable suture. At this time, if omentum can be mobilized, it is sutured over the vaginal repair. The bladder defect is then closed in multiple layers. The bladder is then refilled to confirm a watertight closure. A suprapubic catheter is placed extraperitoneally and an abdominal drain is also placed in the pelvis.
Potential complications from transabdominal and transvesical repair of vesicovaginal fistula include vascular injury and bowel perforation. Another complication unique to fistula repair is ureteral injury especially if the fistula is located in close proximity to the ureteral orifice. Therefore, initial cystoscopy with catheterization of bilateral ureteral orifices is essential. The most important complication of vesicovaginal fistula repair is recurrence of the fistula. However, it should be noted that regardless of approach, vesicovaginal fistula repair success rates are often reported to be greater than 90 % [18]. Radiation-induced fistula has the lowest reported success rates (only 67 %). Laparoscopic repair was first described in 1994 [15] and robotic-assisted repair was described in 2005 [19]. To date, very little is published on the outcomes of these procedures with most being small case series. The largest series was by Sotelo et al. [20] who described 15 patients who underwent laparoscopic repair. In that particular study, one patient did develop recurrence.
Conclusion
Since its advent in 1901, laparoscopy has advanced in leaps and bounds and has become a viable option in the treatment of pelvic dysfunction. As increased concerns are raised over FDA warnings of vaginal mesh complications, there has been a rise in interest in alternative options such as transabdominal procedures. While transabdominal procedures have traditionally been attributed with increased patient pain and hospital stays, the application of laparoscopy has decreased these issues. The future role of laparoscopy and robotic-assisted laparoscopy in the treatment of pelvis dysfunction will continue to rise.
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