Laparoscopy in urogynecology: advances, challenges and future directions

Introduction

Pelvic organ prolapse (POP) is a prevalent condition that significantly impacts the quality of life of women, particularly those above 50 years of age. The prevalence of POP increases with age, with estimates suggesting that up to 50% of women over 50 years old are affected by some degree of prolapse⁽¹⁾. Furthermore, the lifetime risk of requiring surgical intervention for prolapse is estimated at 11%, a figure that is expected to rise as life expectancy increases and as lifestyle changes influence health outcomes⁽²⁾. The primary objective of prolapse surgery is to restore normal pelvic anatomy and support, thus returning pelvic organs to their normal function. Traditionally, pelvic floor reconstruction surgeries have been performed through abdominal or vaginal routes; however, the advent of laparoscopic techniques has revolutionized the surgical management of POP⁽³⁾.

Laparoscopic surgery, which operates on the same principles as related open procedures, has been successfully applied to several urogynecological surgeries. The advantages of laparoscopy include superior intraoperative visibility of pelvic anatomy and the retroperitoneal area, reduced blood loss, decreased postoperative pain, and shorter hospital stays, leading to faster recovery times⁽⁴⁾. Despite these benefits, laparoscopic surgery requires a high level of skill, particularly in suturing and retroperitoneal dissection, which can pose a steep learning curve. Additionally, insufficient training opportunities during residency and fellowship programs have limited the widespread adoption of laparoscopic techniques for prolapse and urinary incontinence surgeries⁽⁵⁾.

This paper explores the various laparoscopic surgical methods currently available for continence procedures and reconstructive pelvic surgery, with a focus on their efficacy, safety and role in modern urogynecology.

Laparoscopic sacrocolpopexy for vaginal vault prolapse

Vaginal vault prolapse is a condition that can occur in up to 43% of women following a hysterectomy⁽⁶⁾. Abdominal sacrocolpopexy is widely regarded as the gold standard treatment for vaginal vault prolapse due to its high success rate, ranging from 78% to 100%, and lower recurrence, postoperative dyspareunia, and resurgery rates compared to other vaginal procedures such as sacrospinous fixation and high uterosacral suspension⁽⁷⁾. Laparoscopic sacrocolpopexy has evolved from the traditional abdominal approach, offering similar efficacy without the need for a large abdominal incision, packing, or extensive bowel manipulation, which can result in less postoperative pain, reduced immobility, and a lower risk of ileus⁽⁸⁾. The laparoscopic approach allows surgeons to apply mesh lower over the posterior vaginal wall, extending down to the pelvic floor (levator ani muscle) and perineal body, which has been shown to enhance the efficacy of the procedure⁽⁹⁾. Visualization through laparoscopy magnifies anatomical structures, facilitating precise mesh placement and minimizing the risk of complications, as shown in Figure 1. A 2-0 polyglactin suture is commonly used to reapproximate the peritoneum after mesh placement and hemostasis inspection in the presacral cavity⁽¹⁰⁾. Laparoscopic sacrocolpopexy demonstrates a high success rate of 90-96%, with mesh erosion rates reported between 1% and 8%⁽¹¹⁾.
 

One of the key benefits of laparoscopic sacrocolpopexy is the enhanced intraoperative visibility, which allows for meticulous dissection and suturing, leading to improved surgical outcomes. However, a significant drawback is the technical difficulty associated with retroperitoneal dissection and suturing, necessitating advanced laparoscopic skills that may not be readily acquired during standard surgical training⁽¹²⁾.

Laparoscopic uterine preservation surgeries for uterine prolapse

The concept of uterine preservation in uterovaginal prolapse repair has gained traction, particularly among women who wish to maintain their fertility. The notion that the uterus plays only a passive role in uterovaginal prolapse dates back to Bonney in 1900, and since then, numerous procedures utilizing vaginal and abdominal techniques have been proposed for prolapse repair with uterine preservation⁽¹³⁾. Laparoscopic approaches for uterine prolapse repair include ventrosuspension and sacrohysteropexy. Ventrosuspension involves suspending the uterus to the round ligaments, uterosacral ligaments, and sacral promontory, while sacrohysteropexy suspends the uterus from the sacral promontory using a polypropylene mesh placed medially to the uterine arteries⁽¹⁴⁾.

Sacrohysteropexy is currently considered the preferred method among laparoscopic uterine-preserving surgeries due to its ability to provide robust support while preserving the uterus. However, evidence supporting the long-term effectiveness and safety of these procedures is still limited, with a lack of extensive longitudinal studies assessing the impact on subsequent conception and childbirth⁽¹⁵⁾. Although uterine pre­servation offers advantages such as reduced adhesion formation and faster recovery, more research is needed to validate these benefits and establish standardized protocols⁽¹⁶⁾.

Laparoscopic and minimally invasive techniques for stress urinary incontinence

Stress urinary incontinence (SUI) is another common condition addressed through minimally invasive surgical techniques. Historically, open Burch colposuspension was regarded as the gold standard for SUI treatment, providing long-term continence results⁽¹⁷⁾. Laparoscopic Burch colposuspension, first described in the early 1990s, offers several advantages over the open approach, including better visualization of pelvic anatomy, reduced blood loss, less postoperative pain, shorter hospital stays, and quicker recovery times⁽¹⁸⁾.

The laparoscopic Burch colposuspension involves placing four permanent helix sutures at the levels of the bladder neck and midurethra, with two sutures placed at each level and passed through the Cooper’s ligament⁽¹⁹⁾, as shown in Figure 2. Studies have revealed that using four sutures rather than two results in higher cure rates⁽²⁰⁾. A recent Cochrane review that included nine studies on laparoscopic versus open Burch colposuspension found that the laparoscopic approach was consistently associated with less blood loss, decreased postoperative discomfort, shorter catheterization time, and reduced hospital stays⁽²¹⁾.

Despite the advantages of laparoscopic Burch colposuspension, the procedure requires advanced laparoscopic skills, particularly in suturing and tissue manipulation, which can be a barrier to its widespread adoption. The learning curve for this procedure is steep, and adequate training and experience are crucial for achieving outcomes comparable to the open technique⁽²²⁾.

Laparoscopic anterior wall prolapse repair

Anterior vaginal wall prolapses, or cystocele, is the most common type of vaginal prolapse, often exacerbated by vaginal childbirth⁽²³⁾. The traditional treatment for cystocele is anterior colporrhaphy, a vaginal repair technique with success rates ranging widely from 36% to 100%, depending on various factors such as patient characteristics and surgical technique⁽²⁴⁾. Laparoscopic approaches for anterior wall prolapse repair include paravaginal repair, which addresses lateral defects by reattaching the lateral side of the anterior vaginal wall to its original attachment site at the arcus tendineus fascia pelvis (ATFP)⁽²⁵⁾.

The laparoscopic paravaginal repair involves reapproximating the vaginal wall and fascia overlying the obturator internus muscle to the ATFP, thereby restoring the normal anatomical position of the bladder and urethra⁽²⁶⁾. The success rates for paravaginal repair, whether performed using a vaginal or an abdominal approach, have been reported to range from 76% to 100%⁽²⁷⁾. However, there is limited evidence from randomized controlled trials to definitively establish the superiority of laparoscopic paravaginal repair over traditional methods⁽²⁸⁾.

Laparoscopic posterior wall prolapse repair

Posterior compartment prolapses, including rectocele and enterocele, are typically managed through vaginal repair, which is favored for its simplicity, accessibility, and generally high success rates⁽²⁹⁾. However, for women undergoing surgery for uterine or vault prolapse, concurrent laparoscopic repair of posterior compartment defects can prevent the need for subsequent vaginal procedures⁽³⁰⁾. Laparoscopic posterior compartment repair during sacrocolpopexy involves extending the mesh placement across the posterior vaginal wall to the level of the levator ani muscle and perineal body, which has been shown to provide good anatomic and functional outcomes for prolapse⁽³¹⁾.

The laparoscopic approach to posterior compartment repair offers the advantage of superior visualization and access to the deep pelvic structures, allowing for precise dissection and mesh placement. However, the procedure’s efficacy and safety require further evaluation through well-designed studies to compare it with traditional vaginal repair techniques⁽³²⁾.

Discussion

The advent of laparoscopic techniques has revolutionized the field of urogynecology, offering numerous benefits over traditional open surgery. Laparoscopic surgery, characterized by smaller incisions, reduced blood loss and shorter hospital stays, has become increasingly favored in the management of pelvic organ prolapse and stress urinary incontinence. Despite these advantages, the transition to minimally invasive surgery in urogynecology is not without challenges. This discussion expands on the advancements, challenges and potential future directions of laparoscopic surgery in urogynecology.

Advancements in laparoscopic techniques

Laparoscopy has evolved significantly with the integration of advanced technologies such as high-definition imaging, robotic assistance, and enhanced suturing devices, which have improved surgical precision and outcomes. The introduction of 3D visualization and robotics has provided surgeons with enhanced depth perception and dexterity, which are crucial in the confined spaces of the pelvic anatomy. Robotic-assisted laparoscopic sacrocolpopexy, for instance, has shown promising results in terms of durability and lower recurrence rates of prolapse, making it a preferred option for many surgeons⁽³³⁾.

Moreover, the application of energy-based devices, such as bipolar and ultrasonic energy systems, has reduced intraoperative bleeding and minimized tissue trauma, contributing to faster recovery and less postoperative pain. Laparoscopic procedures, including colposuspension, sacrocolpopexy and midurethral sling placements, have become standard practices in many institutions, offering effective alternatives to open and vaginal surgeries for POP and SUI⁽³⁴⁾.

Challenges and limitations

Despite the clear advantages, the widespread adoption of laparoscopic surgery in urogynecology faces several barriers. A significant challenge is the steep learning curve associated with advanced laparoscopic techniques. Mastering the required skills demands extensive training, which is often time-consuming and resource-intensive. Many residency and fellowship programs may not provide sufficient hands-on experience with complex laparoscopic procedures, resulting in a slower adoption rate among newly trained urogynecologists⁽³⁵⁾.

Another challenge is the cost associated with laparoscopic and robotic surgeries. Robotic systems, while offering enhanced precision and reduced surgeon fatigue, are expensive and may not be readily available in all healthcare settings, particularly in low-resource environments. This financial barrier can limit access to the most advanced surgical care for patients, perpetuating disparities in treatment options based on geographic and socioeconomic factors⁽³⁶⁾.

In addition, the potential for complications such as organ injury, mesh erosion, and chronic pain remains a concern. Mesh-related complications, in particular, have garnered significant attention and have led to increased scrutiny and regulation of mesh use in prolapse surgeries. Although the incidence of these complications is relatively low, the severity and impact on quality of life can be substantial, necessitating careful patient selection and thorough preoperative counseling⁽³⁵⁾.

Patients’ outcomes and quality of life

The primary goal of laparoscopic surgery in urogynecology is to improve patients’ outcomes, including symptom relief, anatomical correction, and enhancement of quality of life. Studies have demonstrated that laparoscopic procedures can achieve these outcomes with high success rates and patient satisfaction. For example, laparoscopic sacrocolpopexy has shown favorable long-term results in terms of prolapse recurrence and maintenance of vaginal length, which is critical for sexual function and overall pelvic floor health⁽³⁰⁾.

Quality of life metrics, such as reduced postoperative pain, faster return to normal activities and improved sexual function, are consistently reported advantages of laparoscopic over open surgery. These benefits are particularly relevant for younger, sexually active women who may prioritize these aspects when choosing a surgical option. However, it is essential to balance these benefits with a thorough discussion of the risks and potential for complications, ensuring that patients are fully informed and involved in the decision-making process⁽³⁴⁾.

Future directions

The future of laparoscopic surgery in urogynecology is likely to be shaped by ongoing technological innovations, including the development of even less invasive techniques such as single-incision laparoscopy and natural orifice transluminal endoscopic surgery (NOTES). These approaches aim to further reduce the invasiveness of surgical interventions, minimize scarring, and enhance recovery times. Additionally, advancements in simulation training and virtual reality are expected to play a pivotal role in overcoming the learning curve associated with these procedures, allowing for safer and more efficient training of new surgeons⁽³⁷⁾.

Research into the long-term outcomes and cost-effectiveness of laparoscopic and robotic-assisted surgeries will also be critical. Large-scale, multicenter randomized controlled trials are needed to establish standardized protocols and guidelines, which can help streamline practices and ensure consistent, high-quality care across different healthcare settings. Furthermore, patient-reported outcome measures (PROMs) should be incorporated into clinical trials and routine practice to capture the full impact of surgical interventions on patients’ lives, beyond just anatomical success⁽³⁵⁾.

Another promising area is the use of artificial intelligence (AI) and machine learning to enhance surgical planning and intraoperative decision-making. AI algorithms can analyze large datasets from past surgeries to predict outcomes and assist surgeons in identifying optimal approaches tailored to individual patient characteristics. This precision medicine approach has the potential to further refine laparoscopic techniques, reduce complication rates, and improve overall patient satisfaction⁽¹⁸⁾.

Training and education

To address the skills gap in laparoscopic surgery, there is a growing need for comprehensive training programs and workshops specifically tailored to urogynecological procedures. Simulation-based training, using virtual reality platforms and robotic simulators, offers a safe and effective way for surgeons to practice and refine their skills before operating on patients. These training modalities can help reduce the initial learning curve, improve surgical confidence, and ultimately lead to better patient outcomes⁽³⁶⁾.

Additionally, the integration of laparoscopic skills training into residency and fellowship programs is essential. This includes not only technical skills but also a thorough understanding of the indications, contraindications, and patient selection criteria for various laparoscopic procedures. Enhanced training efforts will be crucial in expanding the pool of skilled laparoscopic surgeons and promoting the broader adoption of minimally invasive techniques in urogynecology⁽³⁶⁾.

Conclusions

Laparoscopic surgery has established itself as a cornerstone of modern urogynecology, offering a minimally invasive alternative with substantial benefits for patients undergoing treatment for pelvic organ prolapse and stress urinary incontinence. Despite the challenges associated with its adoption, continued advancements in technology, training and research are poised to enhance the role of laparoscopy in urogynecology. By addressing the current limitations and embracing innovative approaches, the field can move towards a future where laparoscopic surgery is accessible, effective, and tailored to meet the needs of every patient.

Autori pentru corespondenţă: Smit Bharat Solanki E-mail: drsmitbharat@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.