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LAPAROSCOPIC
SACROCOLPOPEXY FOR GRADE IV PELVIC ORGANS PROLAPSE WITH ASSOCIATED BILATERAL
PYELOCALICEAL DILATATION: THE FIRST CASE REPORTED
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LESSANDRO
CURCIO, ROMOLO GUIDA, ANTONIO C. CUNHA, JUAN RENTERIA, RICARDO FREIRE,
GERALDO DI BIASE
Ipanema Federal Hospital
(LC, ACC, JR, RF, GDB) and State Civil Servant Hospital (RG), Rio de Janeiro,
Brazil
ABSTRACT
Introduction:
The main structures involved in maintaining the integrity of the pelvis
include the ureterosacral ligament, pubocervical fascia, and the paracervical
tissues. A compromise to any of these areas can promote a weakness leading
to herniation or prolapse of the urethra, bladder, and/or rectum. Hydronephrosis
can range from 5% in first-degree to 40% in patients with third-degree
prolapse. A variety of laparoscopic techniques has been described and
some have used meshes as an integral part for the repair. This approach
aims to restore normal voiding function while preserving female sexual
function. Here, we provide a video of a pelvic organ prolapse (POP) female
patient with bilateral pyelocaliceal dilation, that was corrected through
a laparascopic sacrocolpopexy with mesh technique.
Methods: A 56 year-old female, complained
of a ball in your vagina and just evacuated fezzes with aid of the fingers
introduced inside the vagina. Her physic exam evidenced a grade 4 pelvic
prolapse, bringing down rectum, bladder and urethra and probably kinking
bilaterally the ureters, since IVP exam showed a dilated right kidney,
almost without function, and the left with a delayed excretion. A laparoscopic
correction of the POP was proposed. A 4 ports pneumoperitoneum was utilized.
We dissected the retovaginal and bladder vaginal spaces. The mesh was
sutured posterolaterally to the distal levator ani muscles, and centrally
to central perineum tendon. Anteriorly, the mesh was sutured to the anterior
vaginal wall and then passed through the broad ligaments. Both meshes
were trimmed and sutured to the anterior longitudinal ligaments of the
sacral promontory. The Douglas pouch and peritoneal incision were closed
and a transobturator sub-urethral sling was positioned.
Results: The surgery lasted 240 minutes,
with a minimum blood loss and just paracetamol was used for postoperative
pain. She was discharged in 3 days and her 2 months contrast exam showed
pelvic organs in a correct location and better contrast elimination of
both kidneys. After a follow up of 12 months, she is continent, with no
prolapse recurrence.
Conclusion: Despite some authors contesting
the type of access required to correct the pelvic prolapse, undoubtedly
the laparoscopic approach provides more anatomic detail, a clear surgical
field, better cosmesis, and an early return to physical activity. Moreover,
we showed that laparoscopic mesh approach for sacrocolpopexy is feasible,
with a minimum morbidity, even in the context of bilateral hydronephrosis
secondary to POP. To our knowledge, this is the first published case approached
in such a manner in the scientific literature.
Int Braz J
Urol. 2010; 36 (Video #6): 375_6
Available at: www.brazjurol.com.br/videos/may_june_2010/Curcio_375_376video.htm
_______________________
Correspondence
address:
Correspondence address:
Dr. Lessandro Curcio
Ipanema Federal Hospital
Av. Ayton Senna, 1850 / 223
22790-700, Rio de Janeiro, RJ, Brazil
E-mail: lessandrocg@ig.com.br
EDITORIAL
COMMENT
Curcio et al. have
described and shown nice detail pertaining to the Laparoscopic Sacrocolpopexy
for Grade IV pelvic organ prolapse. The authors also delineate the relationship
between the presence of preoperative bilateral pyelocaliceal dilation
and the subsequent resolution postoperatively. This observation is somewhat
novel.
A nice review of the pertinent anatomy and technique is explained both
in the written abstract as well as in the video. Finally, technical points
of the actual repair are clear, concise and the satisfactory postoperative
information is reported.
Dr.
Rafael E. Carrion
Associate Professor of Urology
Department of Urology
USF Health College of Medicine
Tampa, Florida, USA
E-mail: rcarrion@health.usf.edu |