Robert T. O'Shea

Two-Year Experience with Laparoscopic Pelvic Floor Repair

STUDY OBJECTIVE To evaluate the cumulative experience at our institution of laparoscopic pelvic floor repair to treat genital prolapse and associated symptoms. DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Seventy-three consecutive women treated surgically for symptomatic genital prolapse. INTERVENTION Surgical treatment was site specific depending on findings on physical examination. Anterior compartment defects were treated by laparoscopic paravaginal repair, laparoscopic Burch colposuspension, or transvaginal anterior vaginal repair. Defects in the posterior compartment were treated by a combination of laparoscopic supralevator repair, laparoscopic vaginal vault suspension, enterocele sac invagination or excision, and transvaginal posterior vaginal repair. Anatomic defects in the apical compartment were primarily treated by laparoscopic vaginal vault suspension and enterocele sac excision. Patients whose anatomic anomalies contained elements of anterior, posterior, and apical compartments were classified in a global group. MEASUREMENTS AND MAIN RESULTS Preoperatively, prolapse was considered as an attachment or fascial defect at DeLancey level I, II, or III. Each was then quantified by the pelvic organ prolapse quantification (POPQ) system and compartmentalized according to site of the major defect. Women were assessed by physical examination and repeat POPQ staging 6 weeks postoperatively and every 6 months thereafter. A standard interview was administered to assess functional status. Major complications occurred in 4.1% of women. Objective and subjective cure rates were 90% at 2 years. CONCLUSIONS Laparoscopic pelvic floor repair is an effective procedure with low morbidity. It should play a primary role in surgical management of DeLancey levels I and II attachment defects. For fascial defects, in particular DeLancey level II anteriorly and posteriorly, it should be complemented with vaginal repair.

Laparovaginal hysterectomy: A decade of evolution

Objective:  To compare surgical outcomes for laparoscopically‐assisted vaginal hysterectomy (LAVH) to total laparoscopic hysterectomy (TLH) and to document the modifications to the technique of laparovaginal hysterectomy which have occurred over the last decade at Flinders Endogynaecology, South Australia, Australia. The method of choice at the start of the decade was LAVH and by the end of the study period it had been superceded by TLH.

Laparoscopic treatment of enterocele: A 3-year evaluation

Objective:  To report the morbidity associated with the laparoscopic treatment of enteroceles and assess the durability of the repair.

Beta HCG Levels after Conservative Treatment of Ectopic Pregnancy: is a Plateau Normal?

Summary: In 32 women with unruptured tubal ectopic pregnancies we undertook conservative laparoscopic treatment [local injection of 20 mg methotrexate (n = 18), laser salpingotomy (n = 14)]. The results of serial quantitative beta HCG measurement were followed until either a negative level was reached or until rising levels necessitated alternative/additional therapy. Plateaued values of beta HCG were observed in both the successful (n = 16) and the unsuccessful cases (n = 5).

Long-term outcomes of laparoscopic repair of cystocoele.

There is little information on the effectiveness of laparoscopic techniques for native tissue repair of cystocoele.

Recent trends in the management of pelvic organ prolapse in Australia and New Zealand

To compare current practice in the management of female pelvic organ prolapse in Australia and New Zealand with that in 2007, and assess the impact on practice of the withdrawal of Prolift® and Prosima® mesh kits in 2015.

Reply to Drs McMaster‐Fay and Jones

In the recently reported series of laparovaginal hysterectomies from Flinders Medical Centre, Cook et al. conclude that the evolution of the technique of laparovaginal hysterectomy over the past 13 years has resulted in improved patient outcomes. This confirms the trend previously reported by one of us (RAJ). Cook et al. report that their ureteric injury rate has more than doubled (from 0.3 to 0.7%) since abandoning staples for securing uterine vessels in favour of bipolar diathermy. A recent review of ureteric injuries in pelvic laparoscopic surgery found that electrocautery was the most common cause of such injuries and caused 50% more such injuries than did staples, although only numbers are reported, not rates. In using staples to secure uterine vessels, we have both experienced a lowering of the ureteric injury rates with increasing experience: RAJ having two injuries in his first 100 cases (2.0%) and none in the subsequent 400 cases (0%) and RAM having two ureteric injuries in the first 175 cases (1.1%) and one injury in the last 365 cases (0.27%). The latter case was an injury to an ectopic ureter in a case with a bilateral duplex urinary collecting system in a patient with multiple uterine fibroids. This gives a combined ureteric injury rate for our last 765 cases of 0.13%. This compares favourably with the reported rates for abdominal hysterectomy of 0.24% from western Sydney and 0.4% from Finland. Cook et al. state that abandoning staples to ligate the uterine vessels enhances ureteric protection, yet their data indicate the opposite. From our experience and the above reports, we propose that the securing of uterine vessels at laparoscopic hysterectomy with staples offers better protection of ureters than does bipolar diathermy. In addition, we propose that, in experienced hands and with the right technique, the ureteric injury rate is no higher for laparoscopic hysterectomy than for abdominal hysterectomy, even with high rates for laparoscopic hysterectomy and low conversion rates to abdominal hysterectomy. We would like to take this opportunity to state our opinion that it is now timely that more young gynaecological surgeons in Australia and New Zealand are properly trained in the technique of laparoscopic hysterectomy.