Int Urogynecol J DOI 10.1007/s00192-015-2766-x
IUJ VIDEO
Laparoscopic sacrocolpopexy in a patient with vault prolapse of the sigmoid stump Alexandr Popov 1 & Dina Gumina 1 & Kseniya Mironenko 1 & Boris Slobodyanyuk 1 & Tatiana Manannikova 1 & Anton Fedorov 1 & Svetlana Tyurina 1 & Alexey Koval 1
Received: 1 February 2015 / Accepted: 7 June 2015 # The International Urogynecological Association 2015
Abstract Surgical creation of a neovagina using the sigmoid was one of the main techniques used in patients with Mayer– Rokinatsky–Küster–Hauser syndrome. Nowadays, this surgery is not common as a result of the high frequency of complications and adverse outcomes, one of which is sigmoid neovagina prolapse. There are no standards of treatment because of the rarity of these clinical events; therefore, any medical case is important. We present a case report of a 72-yearold patient with prolapse of the sigmoid stump. Perscrutation of this example allows us to conclude that laparoscopic sacrocolpopexy is the optimal operation for patients with apical prolapse and a history of sigmoidal colpopoiesis owing to its high level of safety and excellent outcomes.
used because of its high level of traumatization and high rate of intra- and postoperative complications, such as infection (peritonitis, abscesses, etc.), bowel obstruction, and the scarring and stricture of the vaginal orifice, which can lead to total sexual abstinence [3, 4]. The prolapse of the neovaginal vault is also of frequent occurrence in these patients and to our knowledge, there are currently no guidelines available for managing women with this pathological condition. Therefore, we feel that it is very important to collect data relating to such cases and hope that this case report is useful for urologists and gynecologists.
Materials and methods Keywords Sigmoid stump . Sacrocolpopexy . Mayer– Rokitansky–Küster–Hauser syndrome
Introduction Vault prolapse is a common condition; however, cases of prolapse in patients with sigmoid neovagina are relatively rare [1, 2]. This surgical technique of sigmoidal colpoplasty is rarely
Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2766-x) contains supplementary material. This video is available to watch on http://springerlink.com/. Please search for this article by the article title or DOI number, and on the article page click on ‘Supplementary Material’. * Alexandr Popov [email protected] 1
Moscow Regional Research Institute of Obstetrics and Gynecology, Pokrovka str. 22A, 7 101000 Moscow, Russia
A 72-year-old woman was admitted to our clinic with complaints of pelvic pain, vaginal bleeding, and the feeling of a bulge in the vagina over the previous year. She was subsequently diagnosed with C-IV prolapse of a sigmoid stump. She had a history of Müllerian agenesis (Mayer– Rokitansky–Küster–Hauser syndrome [4]) and underwent sigmoidal colpopoiesis at the age of 21. Apical prolapse of the sigmoid stump with moderate cystocele and no signs of posterior vaginal wall dystopia was revealed (CIV prolapse according to the pelvic organ prolapse quantification system of the International Continence Society [POP-Q]): Аа −1, Ва 0, Вр –4, С +4). Operation The optimal surgical approach for this patient should be minimally invasive, safe, and provide the best vision of the pelvic area. It should also allow us to reach the best outcome and to minimize the recurrence risk. According to these specifications, laparoscopic sacrocolpopexy with GyneMesh soft was
Int Urogynecol J
chosen as an optimal surgical technique. The patient had a consultation with an internist and anesthesiologist at the stage of preoperative assessment. Endotracheal anesthesia was chosen as the narcosis. This video aims to provide insight into the technique of sacrocolpopexy in such cases and to illustrate the main steps of the surgery. Intraoperative findings The adhesions involving the bowel were widely spread in the abdominal cavity and the cavity of the lesser pelvis. The uterus was absent. The right adnexa was fixed to the parietal peritoneum by adhesions; the left adnexa to the pelvic peritoneum, colon, and mesosigmoid. The structure of the two ovaries was appropriate for postmenopausal changes. Sigmoidal colpopoiesis usually leads to massive adhesions in the pelvic area and it was expected that dissection of the sigmoidal stump and its preconditioning for further mesh fixation would be the most time-consuming part of the operation. Different types of energy such as bipolar electrocoagulation and ultrasound were used for adhesiolysis to minimize bleeding and tissue destruction. After the neovagina was mobilized, it became clear that it was formed from sigmoid bowel and its length was about 7 sm. As the neovagina wall was represented by the bowel tissue, its structure was thin and tender. The next step was wide dissection of the posterior abdominal layer and preparation of the promontory, which was conducted without any difficulties, in addition to bilateral dissection of the levator ani muscles, which was also performed in the same way as in traditional sacrocolpopexy. Luckily, there were no adhesions in these areas. It is also worth noting that the risk of organ injury (ureter, vessels, bladder, etc.) in this patient was quite high owing to the changes in the topography of the pelvic organs caused by conformational abnormalities and previous operations. After the dissection was finished we moved to mesh fixation. The technique that was used in this case is a modification of a classical sacrocolpopexy method, which is very popular in Europe. The lack of typical fixation points such as the perineal body and sacro-uterine ligaments, is a weak point of the surgery. The thinness of the sigmoid wall is another aspect that should always be considered by surgeons. First, posterior mesh was fixated to the levator ani muscles and to the posterior wall of the sigmoid stump by interrupted extracorporeal sutures. Non-absorbable suture material BEthibond^ was chosen. Anterior mesh was fixed to the anterior wall of the stump in the same way by three interrupted sutures. Then, the length of the anterior mesh was adjusted and both meshes were stitched together. The final stage of the operation was mesh
peritonization with a running vicryl suture. This step is essential to minimize the risk of postoperative complications such as erosions, massive adhesions, and adhesive bowel obstruction. From our point of view it is more convenient to perform the initial part of peritonization before the mesh is finally fixed to a longitudinal presacral ligament. Before the final fixation of the mesh to the promontory we ensured that the mesh was moderately tense and that the sigmoid stump was in the correct anatomical position. Fixation was made using one interrupted Ethibond suture and then the sacral area was peritonized.
Results The total operation time was 120 min, of which sacrocolpopexy itself lasted 90 min. The estimated blood loss was 50 ml. The patient was discharged 4 days after the operation with no complications identified. The results of the 6month follow-up were Ва −3, Вр −4, Аа −3, С −4.
Conclusion This clinical case clearly shows the effectiveness of laparoscopic sacrocolpopexy in the treatment of apical prolapse in patients with a sigmoid neovagina.
Consent Written informed consent was obtained from the patient for publication of this video article and any accompanying images. Conflict of Interest None.
References 1.
2.
3.
4.
Freundt I, Toolenaar TA, Jeekel H, Drogendijk AC, Huikeshoven FJ (1994) Prolapse of the sigmoid neovagina: report of three cases. Obstet Gynecol 83(5 Pt 2):876–879 Zhu L, Chen N, Lang J (2013) Vault prolapse of sigmoid neovagina 26 years after vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome: a case report. Int Urogynecol J 24(1):179–180. doi:10. 1007/s00192-012-1755-6 Freundt I (1994) Colocolpopoiesis. The use of sigmoid colon in the treatment of conditions associated with absence of the vagina. Erasmus Universiteit, Rotterdam, pp 54–56 Sanfilippo JS, Lara-Torre E, Edmonds DK, Templeman C (2008) Clinical pediatric and adolescent gynecology. In: Treatment of anomalies of the reproductive tract. Informa Healthcare, New York, pp 389–392
IUJ VIDEO
Laparoscopic sacrocolpopexy in a patient with vault prolapse of the sigmoid stump Alexandr Popov 1 & Dina Gumina 1 & Kseniya Mironenko 1 & Boris Slobodyanyuk 1 & Tatiana Manannikova 1 & Anton Fedorov 1 & Svetlana Tyurina 1 & Alexey Koval 1
Received: 1 February 2015 / Accepted: 7 June 2015 # The International Urogynecological Association 2015
Abstract Surgical creation of a neovagina using the sigmoid was one of the main techniques used in patients with Mayer– Rokinatsky–Küster–Hauser syndrome. Nowadays, this surgery is not common as a result of the high frequency of complications and adverse outcomes, one of which is sigmoid neovagina prolapse. There are no standards of treatment because of the rarity of these clinical events; therefore, any medical case is important. We present a case report of a 72-yearold patient with prolapse of the sigmoid stump. Perscrutation of this example allows us to conclude that laparoscopic sacrocolpopexy is the optimal operation for patients with apical prolapse and a history of sigmoidal colpopoiesis owing to its high level of safety and excellent outcomes.
used because of its high level of traumatization and high rate of intra- and postoperative complications, such as infection (peritonitis, abscesses, etc.), bowel obstruction, and the scarring and stricture of the vaginal orifice, which can lead to total sexual abstinence [3, 4]. The prolapse of the neovaginal vault is also of frequent occurrence in these patients and to our knowledge, there are currently no guidelines available for managing women with this pathological condition. Therefore, we feel that it is very important to collect data relating to such cases and hope that this case report is useful for urologists and gynecologists.
Materials and methods Keywords Sigmoid stump . Sacrocolpopexy . Mayer– Rokitansky–Küster–Hauser syndrome
Introduction Vault prolapse is a common condition; however, cases of prolapse in patients with sigmoid neovagina are relatively rare [1, 2]. This surgical technique of sigmoidal colpoplasty is rarely
Electronic supplementary material The online version of this article (doi:10.1007/s00192-015-2766-x) contains supplementary material. This video is available to watch on http://springerlink.com/. Please search for this article by the article title or DOI number, and on the article page click on ‘Supplementary Material’. * Alexandr Popov [email protected] 1
Moscow Regional Research Institute of Obstetrics and Gynecology, Pokrovka str. 22A, 7 101000 Moscow, Russia
A 72-year-old woman was admitted to our clinic with complaints of pelvic pain, vaginal bleeding, and the feeling of a bulge in the vagina over the previous year. She was subsequently diagnosed with C-IV prolapse of a sigmoid stump. She had a history of Müllerian agenesis (Mayer– Rokitansky–Küster–Hauser syndrome [4]) and underwent sigmoidal colpopoiesis at the age of 21. Apical prolapse of the sigmoid stump with moderate cystocele and no signs of posterior vaginal wall dystopia was revealed (CIV prolapse according to the pelvic organ prolapse quantification system of the International Continence Society [POP-Q]): Аа −1, Ва 0, Вр –4, С +4). Operation The optimal surgical approach for this patient should be minimally invasive, safe, and provide the best vision of the pelvic area. It should also allow us to reach the best outcome and to minimize the recurrence risk. According to these specifications, laparoscopic sacrocolpopexy with GyneMesh soft was
Int Urogynecol J
chosen as an optimal surgical technique. The patient had a consultation with an internist and anesthesiologist at the stage of preoperative assessment. Endotracheal anesthesia was chosen as the narcosis. This video aims to provide insight into the technique of sacrocolpopexy in such cases and to illustrate the main steps of the surgery. Intraoperative findings The adhesions involving the bowel were widely spread in the abdominal cavity and the cavity of the lesser pelvis. The uterus was absent. The right adnexa was fixed to the parietal peritoneum by adhesions; the left adnexa to the pelvic peritoneum, colon, and mesosigmoid. The structure of the two ovaries was appropriate for postmenopausal changes. Sigmoidal colpopoiesis usually leads to massive adhesions in the pelvic area and it was expected that dissection of the sigmoidal stump and its preconditioning for further mesh fixation would be the most time-consuming part of the operation. Different types of energy such as bipolar electrocoagulation and ultrasound were used for adhesiolysis to minimize bleeding and tissue destruction. After the neovagina was mobilized, it became clear that it was formed from sigmoid bowel and its length was about 7 sm. As the neovagina wall was represented by the bowel tissue, its structure was thin and tender. The next step was wide dissection of the posterior abdominal layer and preparation of the promontory, which was conducted without any difficulties, in addition to bilateral dissection of the levator ani muscles, which was also performed in the same way as in traditional sacrocolpopexy. Luckily, there were no adhesions in these areas. It is also worth noting that the risk of organ injury (ureter, vessels, bladder, etc.) in this patient was quite high owing to the changes in the topography of the pelvic organs caused by conformational abnormalities and previous operations. After the dissection was finished we moved to mesh fixation. The technique that was used in this case is a modification of a classical sacrocolpopexy method, which is very popular in Europe. The lack of typical fixation points such as the perineal body and sacro-uterine ligaments, is a weak point of the surgery. The thinness of the sigmoid wall is another aspect that should always be considered by surgeons. First, posterior mesh was fixated to the levator ani muscles and to the posterior wall of the sigmoid stump by interrupted extracorporeal sutures. Non-absorbable suture material BEthibond^ was chosen. Anterior mesh was fixed to the anterior wall of the stump in the same way by three interrupted sutures. Then, the length of the anterior mesh was adjusted and both meshes were stitched together. The final stage of the operation was mesh
peritonization with a running vicryl suture. This step is essential to minimize the risk of postoperative complications such as erosions, massive adhesions, and adhesive bowel obstruction. From our point of view it is more convenient to perform the initial part of peritonization before the mesh is finally fixed to a longitudinal presacral ligament. Before the final fixation of the mesh to the promontory we ensured that the mesh was moderately tense and that the sigmoid stump was in the correct anatomical position. Fixation was made using one interrupted Ethibond suture and then the sacral area was peritonized.
Results The total operation time was 120 min, of which sacrocolpopexy itself lasted 90 min. The estimated blood loss was 50 ml. The patient was discharged 4 days after the operation with no complications identified. The results of the 6month follow-up were Ва −3, Вр −4, Аа −3, С −4.
Conclusion This clinical case clearly shows the effectiveness of laparoscopic sacrocolpopexy in the treatment of apical prolapse in patients with a sigmoid neovagina.
Consent Written informed consent was obtained from the patient for publication of this video article and any accompanying images. Conflict of Interest None.
References 1.
2.
3.
4.
Freundt I, Toolenaar TA, Jeekel H, Drogendijk AC, Huikeshoven FJ (1994) Prolapse of the sigmoid neovagina: report of three cases. Obstet Gynecol 83(5 Pt 2):876–879 Zhu L, Chen N, Lang J (2013) Vault prolapse of sigmoid neovagina 26 years after vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome: a case report. Int Urogynecol J 24(1):179–180. doi:10. 1007/s00192-012-1755-6 Freundt I (1994) Colocolpopoiesis. The use of sigmoid colon in the treatment of conditions associated with absence of the vagina. Erasmus Universiteit, Rotterdam, pp 54–56 Sanfilippo JS, Lara-Torre E, Edmonds DK, Templeman C (2008) Clinical pediatric and adolescent gynecology. In: Treatment of anomalies of the reproductive tract. Informa Healthcare, New York, pp 389–392
