To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension.
Case report SETTINGS: University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, România.
We present the case of a 41 years old women, G1 P1, with no significant medical or surgical history, with a BMI of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele and a positive cough stress test. The pelvic prolapse was classified as POP-Q stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Due to the patient's obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect and Burch colposuspension for the cure of stress incontinence.
The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45o Trendelenburg position. One umbilical 10 mm optical trocar and three 5 mm trocars were used, two inserted 2 cm above and medial to the anterior superior iliac crests and the third at 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a "V" shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesico-vaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 by 15 cm polypropylene mesh, cut in T shape, was introduced in the abdomen. First, the short arm of the "T" was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack™ - ABSTACK30X Fixation Device, Medtronic, UK). In order to use a type of non-absorbable fixation, we decided to also fix the mesh to the cervix stump with three isolated stitches (Silk suture 2.0, Ethicon, USA). Second, with the purpose of ensuring a permanent fixation the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple non-absorbable tacks on both sides (ProTackTM, Fixation Device, Medtronic, UK). The procedure continued with the complete closure of the peritoneum with vicryl 2.0. Because the patient also had stress urinary incontinence a Burch colposuspension was performed. In order to expose its limits, the urinary bladder was filled with 200 ml of saline. After the incision of the peritoneum the avascular space of Retzius was opened. The dissection continued until the Cooper's ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant's intravaginal finger. Two isolated non-absorbable silk stitches (Silk suture 2.0, Ethicon, USA) were placed through the Cooper's ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction.
The length of the surgery was 95 minutes with minimal blood loss of about 60 ml. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6 months follow up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix, at 6 cm above the hymenal ring and no urinary incontinence.
Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present and the follow up assessment revealed an effective correction of the prolapse. Further studies are needed in order to conclude the efficiency and safety of this new procedure.
Journal of minimally invasive gynecology. 2019 Nov 01 [Epub ahead of print]
L Pirtea, O Balint, C Secoșan, D Grigoraș, R Ilina
Pirtea Laurentiu, Associate Professor, MD, PhD and Senior Consultant, University of Medicine and Pharmacy Timișoara., Balint Oana, Assistant Professor, MD, University of Medicine and Pharmacy Timișoara. Electronic address: ., Secosan Cristina, Assistant Professor, MD, University of Medicine and Pharmacy Timișoara., Grigoras Dorin, Professor, MD, PhD, University of Medicine and Pharmacy Timișoara Senior Consultant and Chief of the Department of Obstetrics and Gynecology Timisoara County Hospital., Ilina Razvan, Assistant Professor, MD, PhD and Senior Consultant, University of Medicine and Pharmacy Timișoara.