BMC Women's Health Volume 21, Article Number: 244 (2021) Cite this article

Laparoscopic lateral sling (LLS) is a laparoscopic technique used to treat pelvic organ prolapse (POP) in apical and anterior compartment defects using synthetic T-shaped mesh grafts. The posterior compartment is repaired using a second mesh or a procedure with LLS, such as posterior vaginoplasty. The purpose of this study is to evaluate the clinical results of LLS on POP, using five-arm mesh instead of T-shaped mesh graft to repair the posterior ventricular defect except for the apical and anterior ventricle.

We retrospectively analyzed the data of 37 patients diagnosed with advanced (≥ 3) POP and receiving LLS and using five-arm mesh. Determine the preoperative and postoperative examinations and the results of the operation. Analyze measurement and examination results, reoperation rate, erosion rate, lower urinary tract symptoms and complications. The prolapsed quality of life questionnaire (P-QOL) was also used.

The median follow-up time after surgery was 20 (13-34) months. The POP-Q scores of all treated compartments were significantly improved. The overall objective cure rate of the apical compartment was 94.5%, the anterior compartment was 86.4%, and the posterior compartment was 91.8%. The median operation time is 96 (76-112) minutes. The median length of hospital stay is 2 (1-3) days. Significant improvement in vaginal bulging, urgency, incomplete urination, frequent urination, and constipation were observed after surgery. The sexual behavior of patients increased from 13 cases (35.1%) before surgery to 22 cases (59.4%) after surgery. Seven (18.9%) patients developed new stress urinary incontinence. The P-QOL score improved significantly after surgery.

For patients with advanced POP, a single five-arm mesh can also be used in LLS to repair posterior ventricular injury without additional surgery, which can reduce the recurrence rate.

Pelvic organ prolapse (POP) is when one or more of the uterus or vaginal parts (anterior or posterior vaginal wall, uterus [cervix] or vaginal apex [vaginal vault or cuff scar after hysterectomy]) protrude downward[ 1]. When defined and graded according to symptoms or examinations, the prevalence of POP in postmenopausal women is 3-6% or 41-50% [2]. The lifetime risk of surgery for POP women is 12-19%, of which 10-30% of women need another operation [3].

Various vaginal and abdominal surgery methods using natural tissue or mesh have been used to treat POP. Following the US Food and Drug Administration's announcement of vaginal patches for POP repair in 2009 and 2011, transabdominal patch surgery has become more and more popular [4, 5]. Sacral fixation (SCP) is the first and most preferred laparoscopic technique for the treatment of POP. However, it has a long operating time and a steep learning curve. These techniques require dissections in the cape or sacrum area, which can be challenging, especially in obese women. Injury to the sacrum area can cause severe nerve, ureter or blood vessel damage [6, 7].

Laparoscopic lateral suspension (LLS) surgery described by Dubuisson et al. No need for anatomy in the cape or sacrum area. Therefore, the risk of serious complications is low. LLS uses a synthetic T-shaped mesh graft, which can be performed with or without hysterectomy or in women undergoing hysterectomy [8]. Data from the LLS of the anterior and apical compartments show that the objective success rate after 1 year is> 90% [9, 10]. LLS can replace SCP to repair the apical compartment [11, 12]. Use a second mesh or long-term use of LLS procedures to repair the posterior compartment, such as posterior vaginoplasty [13]. To help determine the best method for POP surgical treatment, we modified the LLS with a five-arm mesh instead of a synthetic T-shaped mesh graft to repair the defects of the posterior ventricle and the apical and anterior ventricles. Advanced patients who have not removed the uterus (≥ 3). In the current study, we have proposed an improved LLS to analyze the clinical results of this improved procedure.

This retrospective study was conducted at the Department of Obstetrics and Gynecology, School of Medicine, Sitkokoman University, Mulamura, Turkey. Obtained ethical approval from the college ethics committee (No. 2/II; January 20, 2021). The study was conducted in accordance with the recommendations of the Declaration of Helsinki. All patients obtained written informed consent before undergoing surgery.

Between March 2016 and January 2020, we performed LLS on 49 patients diagnosed with advanced (≥ 3) POP using the five-arm network. Patients who had previously undergone POP surgery (4) and used vaginal mesh and lacked medical records (8) were excluded. A total of 37 patients with ≥3 stage uterine vagina prolapse were included in the study.

Retrieve demographic and clinical characteristics from electronic medical records, imaging results, and preoperative, intraoperative, and postoperative records.​​​ The data includes simplified quantification of pelvic organ prolapse (POP-Q) stages and degree of prolapse (points Ba, Bp, and C) [1] and symptoms related to prolapse.

All operations are performed by a surgeon (EA). The operation was performed under general anesthesia in the Trendelenburg position. Polypropylene macroporous mesh (Parietene™, Sofradim-Covidien, Trévoux, France) cut 30 × 30 cm with scissors, five-arm mesh, the front rectangular part is about 4 × 6 cm, two long arms 2 × 18 cm, prepare two A short arm of 2 × 6 cm (Figure 1). We use a central 10 mm umbilical cord trocar for zero-degree optics and three 5 mm trocars (lower right, lower left and upper left quadrants of the abdomen). Insert the RUMI® II retractor (CooperSurgical, Trumbull, CT, USA) into the uterine cavity for uterine operation. By guiding the uterus, cervix and part of the vagina with a retractor, the vesico-vaginal space is dissected to the boundary of the lower third of the vagina. The rectovaginal space is dissected. Then, a 1.5 cm diameter bilateral window was opened in the avascular area of ​​the broad ligament lobe.

Place the front part of the mesh in the space between the bladder and vagina and suture the front wall of the vagina, the cervix and the isthmus of the uterus respectively. 2-0 Prolene® (polypropylene monofilament suture; Ethicon, Somerville, NJ, USA) to prevent mesh shrinkage. At this stage, absorbable tucker fixtures (AbsorbaTack™ [ABSTACK30X]; Covidien) were also used to secure the net. The two side arms of the net pass through the opening windows on the bilateral uterine ligament lobes and the back of the uterus, and are sutured to the rectovaginal fascia, the sacral ligament, and the posterior wall of the vagina, respectively. 2-0 Prolene suture. Make a 3 mm skin incision on both sides 2 cm above the iliac crest and 4 cm behind the anterior superior iliac spine. Advance the laparoscopic grasping forceps to the avascular area by examining the large blood vessels (external iliac arteries and veins) in the retroperitoneal area and passing under the round ligament. Then, pull the tip of one of the long arms (2×18 cm) of the mesh from the skin. Repeat the same procedure on the other side. Carry out symmetrical lateral suspension. Following the "tension-free" repair principle, the side arms of the mesh are not sutured to the fascia. The mesh is then cut at the level of the skin before the incision is closed. The mesh part placed in the vesicovaginal and rectovaginal spaces can absorb Vicryl Rapide™ (polyglactin 910; Ethicon) sutures using no. 0 (Figures 2 and 3).

Urogynecological examinations are performed in the lithotomy position, and Valsalva maneuvers are performed in the standing position. The exam includes grading and POP-Q staging. The results of the operation were determined according to the recommendations of the International Association of Urology and Gynecology [14]. Record measurement and examination results, reoperation rate, erosion rate, lower urinary tract symptoms (LUTS) and complications.

Anatomical objective cure satisfaction is defined as POP-Q score ≤ − 1. Complications were assessed according to the Clavien-Dindo classification, and according to the combined complication classification of the International Urological Association/International Incontinence Association (IUGA/ICS) [15, 16]. The validated Turkish version of the prolapsed quality of life questionnaire (P-QOL) is used to assess the quality of life of patients [17]. The questionnaire includes general health concepts, prolapse effects, role restrictions, physical/social restrictions, personal relationships, emotions, sleep/energy, and severity measurement issues. The lower the score, the better the quality of life (range 0-100).

Use IBM SPSS Statistics version 20.0 (IBM, Armonk, NY, USA) for Windows to analyze the data. The Shapiro-Wilk test is used to assess the normality of the data. Continuous data are reported as mean ± standard deviation, median and range, median and 25th/75th percentile. Classification data is reported as numbers and percentages. For comparison between groups, Wilcoxon signed rank test was used. The post-effect analysis is 98%, indicating that our research has enough power to prove that our technology is significantly different. A p-value of <0.05 is considered statistically significant.

Table 1 summarizes the patient's demographic data, preoperative examination results, and previous POP-related surgical history.

Table 2 summarizes the preoperative and postoperative anatomical results. The median follow-up time after surgery was 20 (13-34) months. The POP-Q scores of all treated compartments were significantly improved. The overall objective cure rate of the apical compartment was 94.5%, the anterior compartment was 86.4%, and the posterior compartment was 91.8%. The median operation time is 96 (76-112) minutes. The median length of hospital stay was 2 days.

Table 3 shows the comparison of symptoms before and after surgery. The most common symptoms are palpable swelling of the genital area and the consequent difficulty in walking. Significant improvement in vaginal bulge, urinary urgency, incomplete urination, and frequent urination were observed after the operation. Also noticed the improvement of constipation symptoms. In addition, the number of sexually active patients increased from 13 before surgery to 22 after surgery. Three of these 22 patients (13.6%) had dyspareunia. Before surgery, 2 patients developed occult stress urinary incontinence (SUI), and 7 patients developed new SUI after surgery. The P-QOL score improved significantly after surgery (Table 3).

Postoperative complications are shown in Table 4. No serious complications were found (Clavien-Dindo grade 1).

3 patients (Ba 1, 2 and 2) developed cystocele, and 2 patients (Bp 1, 3) developed rectocele. Two symptomatic patients with recurrent cystocele underwent anterior colposcopy. Patients with recurrence of rectal protrusion (≥3 stage) did not undergo surgery because they were asymptomatic. Level 2 (> 1 cm) exposure of the anterior vaginal wall mesh was observed in one patient. In the 5th month after the operation, the part of the vaginal wall exposed by the mesh was determined and classified as 3BT3S according to the IUGA/ICS prosthesis/transplant complications classification system. Excise the exposed part and initially repair the vaginal mucosa. Four of the seven new-onset SUI patients underwent retropubic tension-free vaginal tape surgery, while the other three chose conservative treatment.

POP is accompanied by anatomical symptoms such as palpable swelling and bruising in the genital area, and causes incontinence, dysfunction such as bowel and urination difficulties, and sexual dysfunction. Due to their nature, these dysfunctions and symptoms can have a serious negative impact on the mental health and social life of patients [18]. Restoring compartment defects in POPs that are close to normal anatomy can help alleviate these effects [19].

A study reported that the 1-year anatomical success rate of the posterior anterior compartment of LLS was 88.2%, the apical part was 86.1%, and the posterior compartment was 80.8% [20]. In this study, we used a five-arm grid in 37 LLS surgeries for patients with stage ≥3 POP. Analysis of POP-Q staging showed a statistically significant improvement in anatomical defects. The best results appear in the apical ventricle, with a success rate of 94.5%. The success rate of the anterior atrial septum was 86.4%. All patients had posterior atrioventricular defect before operation, and the postoperative improvement rate was 91.8%. Although the apical and anterior compartment results obtained with the five-arm mesh are similar to those obtained with SCP and LLS, the results of posterior vaginal repair using the five-arm mesh are better than those obtained with LLS [7, 9].

LLS is not suitable for patients with obvious apical and posterior defects (such as enterocele or high rectocele) [21]. A previous study reported that when the anterior and posterior ventricular repairs are performed at the same time, the risk of reoperation is reduced in patients undergoing apical ventricular defect repair [22]. The side arms of the synthetic T-shaped mesh graft used in LLS cannot ensure the closure of the Douglas capsule. This may lead to the progression of the posterior defect [9].

In order to repair apical and posterior compartment defects or prevent new posterior defects, use natural tissue for posterior staining, or add posterior compartment repair procedures using mesh to SCP or LLS [11]. In POP patients undergoing hysterectomy with SCP or LLS, the four-arm mesh is placed in the apical compartment and sutured to the deep posterior wall of the vagina to enter the rectovaginal space without additional posterior repair procedures [23, 24].

The risk of grid-related complications increases with the size of the grid [25]. In their first attempt with non-hysterectomy patients, Dubuisson et al. To perform LLS, place two independent 14 × 3 cm meshes in the front and rear compartments [8]. Later, Dubison et al. A T-shaped patch with a middle part of 5-8 cm long, 4-6 cm wide, and 3 cm arm width was used to repair the apical and anterior ventricular defects, and a rectangular polyester patch with a length of 6-8 cm and a width of 4-6 cm was used. The film was fixed to the rectovaginal fascia to repair the posterior ventricular defect, but was not suspended [11]. We repaired the posterior compartment defect by suturing the two short arms of the five-arm net with a length of 6 cm and a width of 2 cm to the sacral nerve ligament, posterior cervical wall and vaginal posterior wall. When we raise the long arm, symmetrical suspension is achieved not only in the anterior and apical chambers, but also in the posterior chamber. During the follow-up period of at least 1 year, the distance of the Bp point is-5 cm. Posterior ventricular prolapse occurred in only 3 (8.1%) patients. Dubison et al. The apical and anterior ventricular repairs were performed on 73 POP patients. They cut from a 25 x 25 cm polypropylene net and got two long arms 15-20 mm wide and a rectangular piece of 4-7 cm wide. They also used the same size grid in the back compartment. Their analysis showed that the postoperative posterior wall recurrence rate was 11% [26].

A meta-analysis found that SCP with hysterectomy was associated with a four-fold increase in the risk of mesh exposure compared with SCP without hysterectomy [27]. In another study, POP patients who underwent hysterectomy and LLS had lower success rates, higher recurrence rates and mesh erosion rates than patients who did not undergo hysterectomy [28]. We did not perform any hysterectomy with indications of prolapse. The five-arm net can be easily used for LLS without the need for hysterectomy.

In this study, we observed improvement in symptoms and anatomy. Significant improvements in vaginal bulge, urgency, incomplete urination, frequent urination, constipation, and fecal incontinence were noted. Previous studies have reported that the rate of new-onset constipation in patients receiving abdominal SCP is 1.9-11.4%, and that of patients receiving LLS is 5.5-8.4% [12, 29]. In our study, 8.1% of patients experienced postoperative constipation. The incidence of SUI is estimated to be 20% in patients diagnosed with POP, and is even higher in patients with advanced POP [30]. Veit-Rubin et al. According to reports, the incidence of SUI in patients with grade 2-4 POP after LLS is 5.2% [12]. In our study, the incidence of de novo SUI was 18.9%. The reason why our SUI ratio is higher than that in the literature may be that all our cases are advanced POP (stage 3-4).

LLS seems to preserve or restore normal sexual function. Failure to perform simultaneous hysterectomy is associated with a more favorable outcome [20]. In our study, although the quality of sexual function was assessed based on patients' self-reports, the number of postoperatively sexually active patients seemed to increase, and the incidence of intercourse pain appeared to decrease.

Although the use of patches in POP surgery reduces the recurrence rate, the patch-related complications such as vaginal erosion, granulomas, dyspareunia, vesicovaginal fistula, and increased overactive bladder cannot be ignored.​​​​ In order to reduce the risk of mesh erosion, it is important to choose the appropriate mesh type (macroporous and monofilament polypropylene). In addition, aggressive anatomy that may worsen perfusion should be avoided, and care should be taken not to damage surrounding organs, such as the bladder and rectum [31]. Vaginal erosion is the most common grid-related complication [32]. Although it can be treated with conservative methods, it may also require complex and repetitive surgical interventions [33]. In patients undergoing POP or urinary incontinence surgery, the risk of mesh erosion is 5 times higher. Compared with the front net, the rear net has a higher risk of erosion [34]. A systematic review of more than 7,000 women undergoing abdominal POP surgery found that during an average of 2 years of follow-up, the median mesh erosion was 4% [35]. In our study, one patient (2.7%) experienced mesh erosion in the anterior compartment (1.5 cm).

The main limitations of our study are the retrospective design, relatively small sample size, and subjective assessment of sexual activity. The advantage of our research is that all operations are standardized and performed by a surgeon. As far as we know, the current study is the first to study the efficacy of five-arm mesh modified LLS in pelvic organ prolapse surgery.

In patients with advanced POP who use five-arm mesh for LLS, damaged compartments, including the posterior compartment, can be repaired without additional surgery, and the recurrence rate can be reduced. Randomized controlled trials are needed to determine the best surgical method for POP treatment.

The data set used and/or analyzed during the current research period can be obtained from the corresponding author upon reasonable request.

Prolapse quality of life questionnaire

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The author would like to thank the many individuals who participated in this research. In addition, the authors thank all peer reviewers for their comments and suggestions.

Department of Obstetrics and Gynecology, Mura Sit Kokman University School of Medicine, Mura City, Turkey

Alan Akbaba and Brak Sezkin

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EA conceptualized and designed the research, drafted the initial manuscript, performed operations, and reviewed and revised the manuscript. BS designed data collection tools, collected data, conducted preliminary analysis, and reviewed and revised the manuscript. Both authors read and approved the final manuscript.

The study was approved by the Ethics Committee of the Medical School of Mulasit Cokoman University, dated and numbered January 20, 2021, numbered: 2/II. The study was conducted in accordance with the recommendations of the Declaration of Helsinki. All patients obtained written informed consent before undergoing surgery.

E.Akbaba and B.Sezgin stated that they have no interest competition.

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Akbaba, E., Sezgin, B. Use of five-arm mesh to improve laparoscopic side suspension in pelvic organ prolapse surgery. BMC Women's Health 21, 244 (2021). https://doi.org/10.1186/s12905-021-01388-0

DOI: https://doi.org/10.1186/s12905-021-01388-0

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