Laparoscopic Sacrocolpopexy Versus Transvaginal Mesh Pelvic Floor Reconstruction Surgery For Treatment Of Pelvic Organ Prolapse

Background:The pelvic organ prolapse is an atypical dropping of the organs of the pelvis from their normal position into the vaginal or beyond due to connective tissue fragility,which aggravates while getting older.In view of the fact that this disease can deteriorate patient life quality,made it a veritable public health issue.Historically,the surgery was performed on a native tissue.Then,recurrences were reported.Thus,to counterweight this issue;the surgeons began to perform the transvaginal mesh(TVM)technique,which tends to provide longevity of the repaired structure with the replacement of the native weakened tissue by a graft to treat apical,paravaginal and midline vaginal defect.TVM repair has shown a great success rate in the anatomic outcome than native tissue repair.Nevertheless,the transvaginal technique is debated due to mesh-related complications;leading the warnings initiated by the American Food and Drug Administration(US FDA)in 2008 and 2011.The earlier complications include the vaginal hematoma and bladder injury.The meshrelated complications were recorded in Some studies such as dyspareunia,mesh exposure,and mesh infection.Others authors emphasis on the surgeon's technique and the kind of mesh.The matter of concern is that these complications can occur irrespective of surgeon's expertise,neither of the mesh itself,but the consequence of some conditions such as patient's immune hypersensitivity,smoking,and diabetes.Many other authors reported a better success rate with fewer recurrences rate by adjusting the technique such as a saline infiltration of the vaginal mucosa prior a colpotomy and recommend the use of vaginal estrogen cream,avoidance of mesh looseness and overlapping.The vaginal mesh advantage is the possibility to perform a regional anesthesia,especially in women with additional diseases.The Sacrocolpopexy has a reputation of conservation of the general structure of the vagina,its mobility,and avoid its shortening as well.The use of the Laparoscopic Sacrocolpopexy(LSC)technique has increased giving a satisfactory success rate.Recently the robotic-assisted laparoscopic sacrocolpopexy reveals his importance in performing sutures.The LSC advantages are more significant than the Abdominal Sacrocolpopexy(ASC)in offering a better view by magnification,using a minimal abdominal incision,a minimal intestinal manipulation and shorter inpatient time.However,the LSC requires skills and experience.Therefore,it is difficult for beginners' laparoscopic surgeons.The LSC also holds a risk of injury to abdominopelvic organs,such as bowel,ureter injury and hemorrhage of the sacrum vessels.The LSC is the cornerstone approach addressing the multiple organs prolapsed especially in repairing the vault prolapse and prolapse recurrence.The previous study reported that supracervical hysterectomy concomitantly performed during Sacrocolpopexy prevents vaginal bacterial infection.However,these treatment strategies require a continuous assessment to ameliorate the patients' wellbeing of the affected population.According to a randomized study,LSC had a higher surgery outcome than TVM for the correction of vault prolapse.However,a study from Taiwan by Chih Ku Liu reported that the use of lightweight mesh had shown comparable treatment outcomes between LSC and TVM.Another study compared ASC,Transvaginal procedure,and Uterosacral ligament suspension found similar apical success rate.Objective: The study aims to compare the objective and subjective outcomes of Laparoscopic Sacrocolposcopy(LSC)and Transvaginal Mesh(TVM)surgery.Materials and Methods: A retrospective study of 62 women with pelvic organ prolapse stage III and IV among patients who underwent LSC(n=30)and TVM(n=32).The pelvic floor quality of life questionnaires(PFDI-20,PFIQ-7,PISQ-12)and the pelvic organ prolapse quantification(POP-Q)were used to assess the subjective and objective outcomes,respectively.The intraoperative details and long-term surgery complications were assessed as well.The patients were reviewed after operation for a gynecological examination,the treatment,and functional outcomes evaluation.Result: LSC group had younger patients than TVM,54± 8.52 versus(Vs)59.93 ±7.14 respectively,(P= 0.001).The preoperative objective POP-Q points Aa,Ba,Ap,Bp were not different between LSC and TVM groups,except for point C,which was greater in LSC group as linked to TVM group(2.83± 2.58 Vs 0.53±3.88(P= 0.01)).Compared to preoperative POP-Q measurement,except for PB and TVL,the postoperative objective outcomes improved significantly for the two groups,(P<0.05).The postoperative mean for PB increased significantly in TVM group than in LSC group,2.75 ± 0.49 Vs 2.45 ± 0.68,(P= 0.04),and the postoperative mean for the point C was more improved in LSC than in TVM group,(-5.68±2.76 Vs-5.59± 2.07),respectively.The success rate was defined at POPQ points Aa,Ba,C,Ap,Bp less than-1(POP-Q stage 0 or stage I).After adjustment,the objective success rate for LSC and TVM were 86.7 %(26/30)and 90.6%(29/32),respectively(P=0,624;OR =1.487;95%CI= 0.304-7.277).The PFDI-20 questionnaire shows that the post-operative subjective outcomes were significantly improved compared to preoperative status in LSC and TVM(P< 0.05),except CRADI-8 questionnaire for LSC(P= 0.4).The PFIQ-7improved significantly in TVM(p<0.05),except CRAIQ-7(P= 0.5).However,there were not statistically significant in LSC group(P> 0.05).There was no significant difference in the quality of life between LSC and TVM pre and postoperatively as indicated by PFDI-20,PFIQ-7 and FISQ-12 questionnaire,(P>0.05).Patients who went for LSC procedure had a longer operation time and greater blood loss than TVM.The occurrences of concomitant hysterectomy were higher in LSC group than in TVM(93.3% Vs 62.3%(P= 0.009)).The percentage of dyspareunia was higher in TVM group than in LSC(15%(4/32)Vs 7 %(2/30)).Conclusion: In 20 ±12 months mean follow up,LSC and TVM had a similar objective success rate.LSC was more suitable for apical compartment repair,while TVM was more suitable for perineal body reconstruction.The TVM surgery offered a high patient satisfaction for colorectal-anal symptoms than LSC.The patients who underwent LSC had a more extended operating time and a greater blood loss,while those who underwent TVM had a higher rate of dyspareunia.