INTRODUCTION:Laparoscopic promontofixation is often considered the preferred approach for the treatment of significant apical pelvic organ prolapse (POP). Obesity is an established risk factor for pelvic organ prolapse (POP), and obese patients may constitute a substantial portion of those seeking care for uterovaginal prolapse. Our aim was to evaluate the impact of body mass index on perioperative complications and long-term outcomes of this procedure. METHODS:This is a single center retrospective cohort study. All patients who underwent laparoscopic sacrohysteropexy/sacrocolpopexy, between July 2011 and December 2021 were evaluated. The study population was divided into three groups, according to Body mass index (BMI) at time of surgery. RESULTS:Altogether 246 patients were included: 145 in group 1 (mean BMI 21.9 ± 2), 88 patients in group 2 (mean BMI 27.1 ± 1), and 13 patients in group 3 (mean BMI 33.0 ± 3). LSH was more frequent than LSC in all groups. The overall perioperative complications rate was 6.3 %. There were no differences in operative details and rates of perioperative complications between the groups. During follow-up period, 30 patients (12.2 %) presented with prolapse recurrence (objective and/or subjective). The rates of prolapse recurrence, as well as long-term complications, were similar between the groups. Similarly, the groups did not differ in postoperative functional results except for postoperative constipation (group 1--14.5 %, group 2--23.8 %, group 3--25 %, p = 0.001). CONCLUSION:Laparoscopic sacrohysteropexy/sacrocolpopexy is associated with low rates of perioperative and long- term complications. We did not find a difference in rates of complications and/ or long-term outcomes, between different weights groups.

The primary objective is to identify determinants of dissatisfaction after surgical treatment of vaginal prolapse ± rectal prolapse, using laparoscopic mesh sacrohysteropexy (LSH) or sacrocolpopexy (LSC) ± ventral mesh rectopexy (VMR). The secondary objective is the evaluation of complications and objective/subjective recurrence rates. The study performed was a single-surgeon retrospective review of prospectively collected data. LSH/LSC ± VMR were performed between July 2005 and September 2022. Primary investigated outcome was patients’ satisfaction, assessed using the Patient Global Impression of Improvement (PGI-I) score and the bother visual analog scale (VAS) obtained postoperatively (at a 1-month interval and on a 6-month/yearly basis thereafter). We looked for a correlation between the level of satisfaction (as reflected by the VAS) and potential determinants. There were 355 patients with a mean age of 62 ±12 years. Nearly all the patients (94.3

Introduction and hypothesisMayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a condition with an underdeveloped or absent vagina and uterus due to embryological growth failure of the Mullerian ducts. Many techniques have been described to construct a neovagina with an acceptable depth that allows penetrative intercourse. This is a step-by-step video tutorial on the Wharton-Sheares-George surgical technique for vaginoplasty in patients with MRKH syndrome.MethodWith Wharton-Sheares-George vaginoplasty, the rudimentary Mullerian ducts are incrementally dilated by pushing Hegar dilators in the direction of the pelvic axis, and the resulting median raphe is then intersected using diathermy. As a result, a neovagina is created and an estriol-coated vaginal mold is inserted for 3 days. The patient receives comprehensive discharge instructions, a self-dilation program three times a day, and a monthly follow-up.Results A 3-month follow-up showed a high subjective degree of satisfaction with surgery and sexual satisfaction in both patients.ConclusionWharton-Sheares-George vaginoplasty is a safe and efficient technique for creating a neovagina for patients with MRKH syndrome.

Long-term durability and functional outcome of laparoscopic sacrohysteropexy (LSH) remains to be confirmed. We set out to assess the development of surgical outcome in women with increasing minimal follow-up. All women after LSH with anterior and posterior mesh extension operated for advanced apical uterine prolapse at Geoffroy Saint-Hilaire clinic from July 2005 to June 2020 were enrolled in this retrospective study. Last known follow-up information was used for the analysis and allocation into groups. The surgical success was defined as no prolapse beyond hymen, no symptomatic recurrence or no retreatment. Functional outcome was evaluated from validated questionnaires and presence of pelvic floor disorders. The outcomes were compared with preoperative state using chi-square and Fisher’s test; p < 0.05 was considered significant. In total, 270 patients after LSH with a follow-up of up to 14.5 years were enrolled and divided into groups according to their last follow-up length: ≥ 1 year 242, ≥ 3 years 112, ≥ 5 years 76, ≥ 7 years 45 and ≥ 10 years 18 women. Increase of minimal follow-up was associated with gradual decrease in surgical success. Rates of stress urinary incontinence were unchanged by the surgery, while anal incontinence and constipation rates decreased significantly; 14.5% of women were operated on for SUI in the follow-up. The PFDI-20, PFIQ-7 and VAS bother scores decreased significantly regardless of minimal follow-up length. LSH with anterior and posterior mesh extension is a safe, effective and durable surgery with a positive long-term effect on quality of life. Although the surgical success gradually decreases, LSH remains a surgical success in most women.

Objective: To compare patients undergoing laparoscopic sacrocolpopexy for pelvic organ prolapse POP, in terms of sexual function and surgical anatomical outcomes more than 5-years follow up period. Design: This is a cohort study of prospectively collected data that includes all women who underwent LSC between July 2005 and December 2021 at a tertiary care center. Setting: Improvement in sexual function is an acknowledged goal for women undergoing pelvic organ prolapse repair. The impact of POP surgeries on sexual activity and function is very controversial, with some studies showing improvement, while others showed no differences or worsening in sexuality after the surgery Population: 228 women were enrolled in this study. Methods: Patients completed the validated quality of life questionnaires and were evaluated using the POP-Q, the PFDI-20, PFIQ-7 and the PISQ-12 scores. Patients were divided preoperatively according to their sexual activity and postoperatively according to the sexual improvement after POP surgery. Main Outcomes: To compare the PISQ-12 score pre and postoperatively and to assess anatomical and sexual improvement after surgery. Results: There was a statistically significant improvement in the PFDI, PFIQ and POPQ-score score. There was no significant improvement in the PISQ-12 score with more than 5 years follow-up. 76.1% of patients who were not sexually active preoperatively resumed their sexual activity after the surgery. Conclusions: The anatomical correction of a pelvic organ prolapses and pelvic floor disorders by laparoscopic sacrocolpopexy may improve sexual function but did not change significantly the sexuality score. Funding: No funding. Keywords: prolapse, sacrocolpopexy, laparoscopy, sexuality.

Objectives: We set out to assess long-term anatomical and functional outcomes in women after laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse.Methods: All women with a history of pelvic organ prolapse surgery operated between 2005 and 2022 were enrolled in this retrospective observational study. The indication for recurrent POP surgery was a symptomatic stage II and above pelvic organ prolapse. The data from objective urogynecologic examination and subjective patient assessment using validated questionnaires were collected. The last follow-up information was evaluated. The outcomes were compared with preoperative state using Student t-test and Wilcoxon test, p<0.05 was considered significant.Results: 39 women were enrolled in the study. The rate of perioperative complications was very low; no significant hemorrhage, ureteral damage or conversion to laparotomy were observed. The mean follow-up was 40 ± 26.8 months. The postoperative course was not complicated by bowel incarceration, pelvic infection or mesh exposure. We observed a statistically significant elevation of all POP-Q points and decrease in all mean scores of PFDI, PFIQ, Wexner and VAS prolapse bother postoperatively. Improvement in stress urinary incontinence, anal incontinence and constipation was found.Conclusions: Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse is a safe and effective surgery regardless of the type of the original repair performed. It provides good subjective and anatomical outcomes with a lasting effect on the quality of life in a long-term follow-up.

Introduction and hypothesis Bulking agents are a minimally invasive treatment option for women with stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI). Recurrent SUI is a major challenge for most clinicians because there is little evidence in the literature on the best option after midurethral sling (MUS) failure. Methods Bulkamid® (Contura International A/S), a urethral bulking agent, is a homogenous gel without particles, consisting of a polyacrylamide hydrogel that is nonbiodegradable. Results In this video case report, we demonstrate the Bulkamid® injection procedure. This procedure can be carried out as an office-based procedure under local anesthesia, with no down time and only minor possible complications. Conclusions We consider it a valid option for patients with recurrent or persistent SUI after failed MUS surgery.

Study Objective To compare the risk of intraoperative and perioperative complications and prolapse recurrence among normal-weight, overweight, and obese women after minimally invasive sacrocolpopexy and sacrohysteropexy for pelvic organ prolapse (POP). Design A retrospective study. Setting A pelvic reconstructive surgery unit. Patients or Participants Patients who had laparoscopic sacrocolpopexies and hysteropexies performed at a single center from July 2005 and December 2019. Interventions Laparoscopic sacrocolpopexies and hysteropexies. Measurements and Main Results The cohort was divided to three groups, according to body mass index (BMI). Patient demographics and clinical and surgical data were compared between the groups, using χ2 test, analysis of variance (ANOVA), and logistic regression. Group 1- Normal (BMI 18- 25 kg/m2); Group 2- Overweight (BMI 25-30 kg/m2); Group 3- Obese (BMI >30 kg/m2).A total of 347women were included: group 1: mean BMI 22.1±2.0 kg/m2 (n=217); group 2: mean BMI 27.2±2.4 kg/m2 (n=106); group 3: mean BMI 33.0±3.1 kg/m2 (n=24), (p<0.001). Patients with higher BMI had higher rates of comorbidities (group 1- 16.1%, group 2- 30.2%, group 3- 45.8%; p<0.001). Anatomical results (post-operative stage of prolapse) were comparable between the groups. Surgical outcome, including operative time, rate of complications, and rate of reoperation due to complications were similar between the groups. Conclusion Laparoscopic sacrocolpopexy and/ or sacrohysteropexy is associated with low rates of perioperative and long- term complications. In our experience, the rate of complications and/ or long-term results are not affected by patients BMI.

Study Objective To compare perioperative and long-term outcomes of laparoscopic sacrocolpopexy/ sacrohysteropexy in different groups of age. Design This was a prospective study. Setting All surgeries were made by single surgeon, in a referral unit for pelvic reconstructive surgeries. Patients or Participants All the patients who underwent laparoscopic sacrocolpopexy/ sacrohysteropexy, between July 2005 and December 2019 were prospectively evaluated preoperatively and postoperatively (starting from 1 month after surgery, and then annually). Interventions Laparoscopic sacrocolpopexy/ sacrohysteropexy. Measurements and Main Results The study population was divided to three groups, according their age at time of surgery: group 1- younger than 65 years, group 2- between 65-75 years, and group 3- older than 75 years. We compared patients' demographics, surgical characteristics, perioperative complications, and immediate and long-term outcomes, between the groups. A total of 347 women were included: group 1: (n=192, 55.3%), mean age 53.4±8.2; group 2- (n=98, 28.2%), mean age 69.2±2.9; group 3 (n=57, 16.4%), mean age 79.3±3.5 (p<0.001). The older patients were less married (group 1- 82.3%, group 2- 72.5%, group 3- 54.4%; p<0.001), sexually active (group 1- 35.4%, group 2- 27.5%, group 3- 19.3%; p=0.05), and had lower rate of past obstetric trauma (group 1- 27.6%, group 2- 23.5%, group 3- 3.5%; p<0.001), however they had higher rates of previous hysterectomy (group 1- 11.4%, group 2- 17.3%, group 3- 31.5%; p=0.005), as compared to the younger patients. The rates of perioperative complications, as well as long term complications or recurrence were similar between the groups. Conclusion Laparoscopic sacrocolpopexy and/ or sacrohysteropexy is associated with low rates of perioperative and long- term complications. The rates of complications and/ or long-term results are not affected by patients' age.

Laparoscopic sacrocolpopexy (LSC) provides excellent long-term anatomic and functional results [1], with a 3.7% cumulative prolapse recurrence after LSC over 10 years' follow-up [2]. Surgery for recurrent pelvic organ prolapse (POP) after LSC is debated. A reoperation, when the sacral promontory has been dissected anteriorly, can be associated with bowel, ureteral, and vascular injuries due to distorted anatomy [3]. A new procedure was described in 2007 to treat female POP: laparoscopic pectopexy (LP) [4].

OBJECTIVE:No recommendation regarding the number of meshes to be implanted in laparoscopic genital prolapse surgery exists. Is it necessary to implant a mesh into a compartment that is not affected to prevent its prolapse in the follow-up? Our objective was to compare the long-term outcomes of laparoscopic sacrocolpopexy according to compartments where mesh was implanted. STUDY DESIGN:This is a retrospective cohort study of 328 patients after laparoscopic sacrocolpopexy at our centre in 7/2005 - 3/2021. 294 patients with perioperative data and POP-Q and/or prolapse symptoms in mean follow-up of 42.8 months was available for the outcome analysis. Surgical failure was defined as prolapse beyond hymen, subjective recurrence or retreatment. The women were divided into four groups depending on compartments, where the mesh was implanted. Group A - anterior, group P - posterior, Group AP - compound of patients with anterior or posterior single arm mesh placement and (B), with anterior and posterior arm placement. Groups AP and B were compared for feasibility of single compartment mesh implantation. Comparison of groups A and P allowed assessment of non-inferiority of single anterior vs. posterior compartment placement. The data were compared using Wilcoxon Two Sample test, Chi-square test or Fisheŕs Exact test, p-value < 0.05 was considered statistically significant. RESULTS:A single compartment mesh implantation was associated with shorter operating time and hospital stay and comparable incidence of complications. A statistically significant difference in all POP-Q points in favour of group B was observed, however, with comparable rate of prolapse beyond hymen(6.3%AP vs. 7.8%B). Similar frequency of surgical failure (17.5%AP vs. 13.8%B) and incidence of de novo pelvic floor disorders or pain was observed. Comparison of groups A and P showed higher suspension of point C in group P(-2.6 vs. -4.0, p < 0.05) with no difference in points Ba, Bp, surgical failure rate and de novo pelvic floor disorders. CONCLUSION:Implantation of a single sheet of mesh was not associated with inferior outcome to implantation of mesh to both compartments. Laparoscopic sacrocolpopexy with a single mesh arm placed into the affected compartment along with apical suspension does not induce a de novo prolapse in unoperated compartment.

INTRODUCTION:In this video, we present a case of rectal and bladder injury, which occurred during laparoscopic mesh removal following sacrohysteropexy treated 6 months later with a laparoscopic pectopexy.METHODS:We present the case of a 66-year-old woman with a prolapse recurrence after sacrohysteropexy. During the laparoscopic explantation of the mesh, we detected a fixation of the mesh to the bladder and the rectum rather than a fixation to the vaginal walls. Consequently, bladder and rectal injuries occurred during the dissection and were diagnosed and repaired immediately. Due to bowel injury, the treatment of the prolapse was postponed. Six months later, a laparoscopic pectopexy was performed to avoid complications during the repeated dissection of the promontory. The postoperative recovery after the pectopexy was uncomplicated with no short-term prolapse recurrence or postoperative complications.CONCLUSION:Laparoscopy appears to be an efficient approach to mesh explantation. Futhermore, laparoscopic pectopexy seems to be a good approach to secondary prolapse reconstruction after sacrohysteropexy mesh explantation avoiding complications during repeated dissection of the promontory.

Laparoscopic sacrohysteropexy (LSH), sacrocolpopexy (LSC) and ventral rectopexy (LVR) with mesh are advocated for surgical treatment of pelvic and rectal prolapse. Our study aims at showing the feasibility of concomitant laparoscopic prolapse repair by comparing perioperative and long-term outcomes of LSH or LSC with and without LVR. This is a retrospective study carried out on 348 women operated on between July 2009 and July 2019. Patients were divided into four groups: (1) LSH only, (2) LSC only, (3) LSH + LVR and (4) LSC + LVR. POP-Q scores and satisfaction questionnaires were recorded at baseline and then annually. Outcomes were defined as subjective failure (vaginal/rectal prolapse symptoms), objective failure (prolapse to/beyond the hymen, full thickness rectal prolapse) or retreatment for prolapse. Complications were collected and graded according to the Clavien-Dindo classification. Three hundred forty-eight women underwent laparoscopic repair for pelvic and rectal prolapse (219, 44, 66 and 19 in group 1, 2, 3 and 4, respectively). Median follow-up was 24 (4–174) months. Success rate for both rectal and pelvic prolapse was 90.2%. Recurrence rates were not significantly different between the groups (12.3%, 6.8%, 9.1% and 10.5% for groups 1, 2, 3 and 4, respectively). Significant improvement was noticed in satisfaction questionnaires in all groups. There was no difference in perioperative and late complications. The combined laparoscopic procedure appears to be safe and efficient in treating pelvic and rectal prolapse. Appropriate patient selection and available surgical expertise should determine whether to perform these procedures combined or separately.