Laparoscopic suture sacrohysteropexy: A meshless uterine- sparing technique for surgical management of uterine prolapse.

Background: Laparoscopic mesh sacrohysteropexy has been established as an effective, safe, and popular technique to treat uterine prolapse. Nevertheless, recent controversies regarding the role of synthetic mesh in pelvic reconstructive surgery have triggered a trend towards meshless procedures. Other laparoscopic native tissue prolapses techniques such as uterosacral ligament plication and sacral suture hysteropexy have been previously described in literature. Objectives: To describe a meshless minimally invasive technique with uterine preservation, which incorporates steps from the above-mentioned procedures. Materials and Methods: We present a case of a 41-year-old patient with stage II apical prolapse and stage III cystocele and rectocele, who was keen to proceed to surgical management preserving her uterus and avoiding the use of a mesh implant. The narrated video demonstrates the surgical steps of our technique of laparoscopic suture sacrohysteropexy. Main outcome measures: Objective (i.e., anatomic) and subjective (i.e., functional) surgical success on follow-up assessment at least 3 months post-surgery, similarly to every prolapse procedure. Results: Excellent anatomical result and resolution of prolapse symptoms at follow-up appointments. Conclusions: Our technique of laparoscopic suture sacrohysteropexy seems a logical progression in prolapse surgery, responding to patients' wishes for minimally invasive meshless procedures with uterine preservation while at the same time achieving excellent apical support. Its long-term efficacy and safety need to be carefully assessed before it becomes established in clinical practice. Learning objective: To demonstrate a laparoscopic uterine-sparing technique to treat uterine prolapse without the use of a permanent mesh.

'What research was carried out on this vaginal mesh?' Health-related concerns in women following mesh-augmented prolapse surgery: a thematic analysis.

OBJECTIVE: To understand health-related issues in women following mesh-augmented prolapse surgery. DESIGN: Inductive thematic analysis of free-text comments from participants in a cross-sectional study of laparoscopic mesh sacrohysteropexy. SETTING: Tertiary urogynaecology centres, United Kingdom. POPULATION: Women who underwent laparoscopic mesh sacrohysteropexy by surgeons based at two tertiary urogynaecology centres between 2010 and 2018. METHODS: A total of 1766 potential participants were contacted by post and invited to complete paper, online or telephone questionnaires containing a free-text comments section. Of 1121 participants (response proportion 63.5%), 752 (67.1%) provided such comments. These were analysed with a six-stage inductive thematic analysis, using NVivo 11® software. MAIN OUTCOME MEASURES: Themes developed from free-text comments. RESULTS: Following familiarisation, 29 codes and 189 sub-codes were identified. These defined six themes: pelvic floor symptoms, health status, treatment success, mesh, pain and care received. The majority of comments centred on the first of these six themes. There were concerns about mesh use and a desire for more information. A range of pain symptoms were mentioned, often associated with pelvic floor symptoms, prolapse surgery or mesh. CONCLUSIONS: Despite the mesh controversy, pelvic floor symptoms and their impact on quality of life remain the principle concern of women following mesh-augmented prolapse surgery. There is a need for quality, accessible and evidence-based information sources for those women with concerns, and for those considering such surgery in the future, particularly regarding mesh safety and postoperative recovery. The relationships between pain, prolapse, mesh and pelvic floor surgery require further study. TWEETABLE ABSTRACT: Following mesh-augmented prolapse surgery, pelvic floor symptoms remain women's main focus; pain deserves further research.

Pregnancy, thrombophlebitis and thromboembolism: what every obstetrician should know.

Thrombophlebitis is caused by superficial venous thrombosis and vascular inflammatory changes affecting the lower limbs. The condition is often encountered in pregnancy and symptomatic treatment including compression and analgesia are commonly employed. The obstetrician may become involved in the management of thrombophlebitis; however the potential for embolic complications, and need for adequate assessment remain widely unrecognised. This case report highlights pitfalls in the management of thrombophlebitis, in particular the dangers of clinical assessment without the use of Doppler ultrasound and the potential for deep venous extension and embolic complications. The case also documents the use of low molecular-weight heparin in pregnancy to prevent such complications and promote thrombus resolution; a review of the available treatment options, including surgery, is included. Whilst thromboembolism remains a leading cause of maternal death, the potential dangers of symptomatic thrombophlebitis should not be overlooked.