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Abstract: Objective: The aim of our study is to describe the course of the autonomic nerves in the presacral space and to find the best nerve-preserving approach for sacrocolpopexy. Study design: The autonomic nerves of the presacral space were dissected on six specially preserved female cadavers. Results: The superior hypogastric plexus is located in front of the abdominal aorta and its bifurcation and deviates to the left of the midsagittal plane. At the level of the promontory, or just below, the superior hypogastric plexus branches into two hypogastric nerves that run in front of the sacrum. In the presacral space the parasympathetic pelvic splanchnic nerves from the ventral rami of the sacral spinal nerves (S2–S3) join the hypogastric nerves, forming the inferior hypogastric plexus on both sides. From the inferior hypogastric plexus, nerve fibres spread out bilaterally to the pelvic organs. In two of the six cadavers sacral splanchnic nerves could be identified leading from the sacral sympathetic ganglion S1 of the sympathetic trunk to the inferior hypogastric plexus. Conclusion: Longitudinal incision of the peritoneum along the right common iliac artery and above the promontory allows for a safe approach for sacrocolpopexy. After exposing the vascular structure (e.g. medial sacral vessels) above the promontory, the anterior longitudinal ligament becomes visible and can be prepared for the fixation of the mesh for vaginal suspension. By protecting the superior hypogastric plexus and the part of the presacral area below the promontory we can preserve the hypogastric nerves, the sacral and pelvic splanchnic nerves and thus the autonomic innervation of the pelvic organs. Awareness of the course of the autonomic nerves in the presacral space will significantly improve the functional outcome of sacrocolpopexy and reduce bowel, urinary and sexual dysfunctions. [ABSTRACT FROM AUTHOR]

Abstract: Pelvic organ prolapse results from the failure of muscular and fascial supports of the pelvis. Symptoms of prolapse overlap with the dysfunction of other pelvic organs such as the bowel and the bladder. Some degree of prolapse is common in most parous women, but treatment is required only for the symptomatic patients. The past decade has seen several innovations in the treatment of prolapse due to greater understanding of pelvic anatomy and pathophysiology. This review focuses on the clinical assessment of prolapse and the current available evidence on treatment of various compartments. [Copyright &y& Elsevier]

Objectives: To evaluate results of laparoscopic sacropexy with introital and vaginal ultrasonography, that is to observe dynamic behavior of the mesh, to measure precisely its position and to conclude on the feasibility of this exam. Patients and methods: The surgery was a laparoscopic subtotal hysterectomy and a suspension of the cervix with an anterior vesicovaginal mesh and a posterior rectovaginal mesh. These meshes are joined together and fixed on the sacrum. Ultrasound was performed in fifteen patients to see in the sagital plane the position of the mesh. The distance anterior mesh–bladder neck and the distance posterior mesh–anal sphincter were measured at rest, during straining and during retaining. The spreading out and the dynamic behavior of the mesh were studied. Results: The distance anterior mesh–bladder neck is 12mm at rest, 15mm during straining and 13mm during retaining. The distance posterior mesh–anal sphincter is 30mm at rest, 26mm during straining and 31mm during retaining. The mesh is always seen as spread out, or folded, but never strained. Video recording shows that sacropexy does not block pelvic dynamics. Discussion and conclusion: Ultrasound imaging appears in this study as a simple and efficient exam to study and measure prosthesis. It could be a good help for clinical examination to explain failure or complication of surgery. [Copyright &y& Elsevier]

Abstract: Objectives: This prospective, randomised study investigated whether a prophylactic procedure, performed during colposacropexy for prolapse repair, prevents ex novo postoperative incontinence. Sixty-six consecutive continent patients with advanced prolapse were randomised into two groups: group A underwent sacropexy combined with a Burch colposuspension; no anti-incontinence procedure was performed in group B patients. Methods: Work-up included clinical assessment (Halfway System and International Continence Society [ICS] classification for prolapse and Ingelman Sunderberg scale for incontinence), the Urogenital Distress Inventory and Impact Incontinence Quality of Life questionnaires, urogynaecologic ultrasound scans, and complete urodynamic testing that included the urethral pressure profile and Valsalva leak point pressure with reduced prolapse. Check-ups were done at 3, 6, 12 mo postoperatively and then yearly. Mean follow-up time was 39.5 mo. Results: The mean age (± standard deviation) was 62±9 yr. All patients presented with grade (G) 3–4 prolapse. Postoperative incontinence was present in 12 of the 34 patients in group A: 7 G1; 4 G2, and 1 G3. Postoperative incontinence was present in 3 of the 32 patients in group B: 2 G1, 1 G3. The frequency of postoperative incontinence was significantly greater in patients who had undergone colposuspension (p <0.05). Conclusions: These preliminary data cast doubt on whether colposuspension should be performed during sacropexy for severe urogenital prolapse as prophylaxis for postoperative incontinence because it seems to emerge as overtreatment. Incontinence developed ex novo in 35% of continent patients treated with colposuspension combined with sacropexy. [Copyright &y& Elsevier]

Abstract: Purpose:: The aim of this study was to determine whether or not abdominal or vaginal access is the best choice for treating genital prolapse in term of anatomical postoperative results, using an MRI pre and postoperative assessment. Materials and methods:: Prospective study was conducted on 43 consecutive patients planned for surgery for genital prolapse from October 2001 to February 2002. The patients were studied with dynamic and static MRI sequence 4 months after surgery to indicate surgical effects on organ position. The position was evaluated with respect to the pubo coccygeal line in a dynamic sequence. Results:: Fifteen patients had their prolapse corrected by laparotomy always associated with sub-total hysterectomy, anterior and posterior prosthetic mesh with promontory fixation to the prevertebral ligament. Sixteen others were subjected to vaginal route with vaginal hysterectomy, paravaginal suspension followed in all cases by suspension of the vaginal cuff using Richter''s technique and myorraphy of the levators. Finally, 12 patients benefited from a suspension of a sacrospinous suspension and myorraphy of the levators, without paravaginal suspension. Measure of the MRI organ location showed no significant difference except for bladder position in vaginally operated women (P =0.02). Vaginal length and axis were comparable in all groups. Conclusion:: Our study confirmed the objective effectiveness of the anatomical prolapse corrections conducted by abdominal route using sacropexy or by vaginal route using sacrospinous fixation. The correction provided by vaginal route always results in a return of the bladder and the vaginal fundus to their normal positions, which clearly demonstrates the short-term effectiveness of these surgical suspensions. Prolapse corrections by vaginal route did not result in any shortening of the vagina or postoperative change in vaginal orientation. Further evaluations will be needed to assess the long-term results. [Copyright &y& Elsevier]