This document describes a randomized controlled trial that compared the anatomical and functional outcomes of laparoscopic sacrocolpohysteropexy (LSC) versus vaginal mesh repair (VRM) for cystocele repair. 376 patients undergoing surgery for cystocele were randomly assigned to LSC (n=127) or VRM (n=127). At 12 months, there was no significant difference between the groups in symptoms, quality of life, or anatomical outcomes. However, the rate of dyspareunia was lower and obstructive defecation scores were better in the LSC group compared to the VRM group. The study aimed to properly evaluate the risk-benefit ratio of surgery including mesh procedures for cyst

1. eloy.moral.santamarina@sergas.es
COMPLEXO HOSPITALARIO DE PONTEVEDRA
Tratamiento Laparoscópico
de la patología del
COMPARTIMENTO MEDIO y ANTERIOR
( PROMONTOPEXIA Y REPARACIÓN PARAVAGINAL)

2. PROLAPSO DE ÓRGANOS PÉLVICOSPROLAPSO DE ÓRGANOS PÉLVICOS
VÍA ABDOMINALVÍA VAGINAL
ÚTERO / CÉRVIX / CÚPULA
PARED ANTERIOR Y POSTERIOR
DEFECTOS PARAVAGINALES
HIPERMOVILIDAD URETRAL
REPARACIÓN CLÁSICA
MATERIALES PROTÉSICOS
QUÉ OPERAMOS
CÓMO
CARACTERÍSTICAS
PRIMERA ELECCIÓN
MUY EFICAZ Y POCO INVASIVA
BUENA RECUPERACIÓN
PERMITE TRATAR MÚLTIPLES DEFECTOS
NO SIEMPRE MANTIENE BUENA FUNCIÓN COITAL
Prolapso ÚTERO/ CÚPULA
HIPERMOVILIDAD URETRAL
DEFECTOS PARAVAGINALES
ENTEROCELES
PREVENCIÓN ENTEROCELE
REPARACIÓN CLÁSICA
MATERIALES PROTÉSICOS
QUÉ OPERAMOS
CÓMO
CARACTERÍSTICAS
SOBRE TODO PARA DEFECTOS APICALES
MANTIENE LONGITUD DE VAGINA
MENOS DISPAREUNIA
SIMILAR EFICACIA
pero…
+ COMPLICACIONES y PEOR RECUPERACIÓN

3. REPRODUCE LA CIRUGÍA Y REDUCE LA MORBILIDAD DE LA VÍA ABIERTA
- NO SE ABRE VAGINA
- PROCEDIMIENTO ABDOMINAL CERRADO
IGUALA O MEJORA LA EFICACIA DE LA VIA ABDOMINAL.
MEJOR RECUPERACIÓN DE TODAS LAS VÍAS (↓ estancia, menos sangrado, < dolor y recuperación )
NO ACORTA VAGINA ELECCIÓN SI DESEA MANTENER FUNCIÓN COITAL
< TASA DE INFECCIÓN
PROLAPSO DE ÓRGANOS PÉLVICOS
VÍA ABDOMINALVÍA VAGINAL
VÍA LAPAROSCÓPICA
HT Laparoscópica 1989 Reich
Burch Laparoscópico1991
Colposacropéxia 1994 Nezhat
Colposacropexia 1957 Savage
Colposuspensión 1962 Burch

4. HISTEROSACROPÉXIAS / CERVICOSACROPÉXIA
COLPOSACROPÉXIA (1957 Savage )
PECTOPEXIA / POPS
REPARACIÓN PARAVAGINAL
COLPOSUSPENSIÓN ( 1962 Burch)
SUSPENSIÓN A ÚTERO-SACROS
REPARACIÓN ENTEROCELE
¿ QUÉ OPERAMOS ACTUALMENTE ?
PROLAPSO DE ÓRGANOS PÉLVICOS
VÍA LAPAROSCÓPICA

5. ENCUESTA SECCIÓN DE SUELO PÉLVICO DE LA SEGO 2012
TRATAMIENTO DEL PROLAPSO DE CÚPULA VAGINAL
43,5 %
Mallas
Mallas
Vaginales 25,2 %
Colpectomía-Cleisis
PROMONTOPÉXIA
Laparoscópica
7,8 %
Colpoespinofijación
(Richter)
8,5 %
43,5 %
SACROPÉXIA
Abierta

6. LIMITACIONES de la LAPAROSCOPIA
( cada vez menos…)
- Historia de múltiples cirugías abdominales o EIP.
- Patología que contraindique anestesia general e
insuflación abdominal.
- Abordajes previos para cirugia del prolapso.
- IMC muy altos
- Limitaciones del cirujano (sutura, nudos).

7. INTERVENCIONES
LAPAROSCÓPICAS
• COMPARTIMENTO ANTERIOR
Reparación de defecto paravaginal
Colposuspensión Burch para IUE
Colposacropexia
POPS (cinta de malla subperitoneal parietal)
Pectopexia ( fijación con malla a lig.ileopectíneo)
• COMPARTIMENTO APICAL
Mc Call Laparoscopico (fijación a Lig.US)
Colposacropexia
Histeropromontopexia
POPS
Pectopexia

8. DEFECTOS DEL COMPARTIMENTO
ANTERIOR

9. Desinserción LATERAL de la fascia pubocervical +++
DeLancey, AJOG 187:93;2002

10. Defecto paravaginal

11. Defecto paravaginal
Es posible corregir el cistocele por LPS (reparación paravaginal).
Curación (POP-Q: Ba ≤0): 96% (12 m); 76% (5 a) .
O´Shea, Behnia-Willison, et al. Laparoscopic paravaginal repair. Objective outcomes. J Minim Invasive
Gynecol 2012;19: S61.
PERO …
No existe evidencia que apoye la superioridad de los resultados
anatómicos con respecto a cirugía vaginal clásica o mallas
Karram. Int Urogynecol J 2004; 15:1-2.
Frick, Paraiso. Clin Obstet Gynecol 2009; 52:390-400.
Shippey. Int Urogynecol J 2010; 21:279-83.

12. REPARACIÓN PARAVAGINAL LAPAROSCÓPICA
DEFECTOS DEL COMPARTIMENTO ANTERIOR

13. DEFECTOS DEL COMPARTIMENTO
ANTERIOR

14. We found no difference concerning symptoms, quality of life, improvement (PFDI-20, PFIQ-7, ICIQ-SF, EQ5D
Barber score [3]. There was no difference in the rate of patients still sexually active at one year (LSC = 87.2% v
but the rate of dyspareunia was lower after LSC (14.1%) than after VRM (29.5%, p = 0.031), as was the r
worsening of dyspareunia (8.5% vs. 19.7%, p = 0.061). At 12 months, there was a significant difference in favour
the Obstructed Defecation Score (ODS) at 12 months (see Table), however the difference was no longer signific
for posterior mesh placement (p=0.167).
Outcome Measure LSC group
n/N (%)
VRM group
n/N (%)
OR [95% CI]
No. with Point Ba < -10 mm 73/127 (57.5) 75/127 (59.1) 0.94 [0.57-1.54]
No. with Point C < -10 mm 125/127 (98.4) 114/126 (90.5) 6.58 [1.44 - 30.03]
No. with Point Bp < -10 mm 106/127 (83.5) 102/127 (80.3) 1.24 [0.65-2.35]
No. Prolapse stage 0 or 1 59/127 (53.5) 59/127 (53.5) 1.00 (0.61 - 1.64)
Barber score 109/127 (85.8) 112/127 (88.2) 0.81 (0.39 – 1.69)
No. with Symptom of vaginal
bulge
118/128 (92.2) 122/127 (96.1) 0.48 (0.16 - 1.46)
No. of patients still sexually
active
67/78 (87.2) 59/67 (88.1) 0.92 (0.34 - 2.49)
No. with Dyspareunia 7/68(10.3) 16/59 (27.1) 0.308 (0.12 – 0.81)
No. with Improvement (PGI-I) 117/128 (91.4) 111/127 (87.4) 1.53 (0.68 – 3.45)
Mean (95% CI) mean (95% CI) mean difference [95%
CI]*
PFDI score 25.0 (20.0-29.9) 26.1 (21.2 -31.1) -1.14 (-8.16 - 5.88)
POPDI subscale 5.7 (3.9- 7.6) 6.5 (4.7- 8.4) -0.80 (-3.41 - 1.81)
DDI-8 subscale 11.1 (9.2 - 13.1) 9.2 (7.3 - 11.2) 1.92 (-0.82 - 4.67)
UDI subscale 8.3 (5.9 - 10.6) 10.4 (8.1 - 12.8) -2.15 (-5.49 - 1.19)
PFIQ-7 score 6.1 (2.9- 9.3) 9.8 (6.6 – 13.1) -3.74 (-8.29 – 0.82)
EuroQoL5D scale 82.4 (76.7 - 85.1) 81.9 (79.2 -
84.7)
0.48 (-3.37 - 4.34)
FSFI score for sexually active
patients
27.4 (26.1 - 28.8) 26.8 (25.4 -
28.2)
0.63 (-1.36 - 2.61)
ICIQ-UI SF score (0-21) 1.7 (1.1- 2.3) 2.2 (1.6 - 2.8) -0.48 (-1.33 - 0.36)
ODS score 4.8 (4.2 to 5.5) 3.9 (3.2 to 4.6) 0.94 (0.01 to 1.89)
Tratamiento del CISTOCELE
Histeropéxia Laparoscópica vs. Mallas vaginales
376
Fauconnier A1, Cosson M2, Debodinance P3, Bader G4, Youssef Azer Akladios C5, Salet-Lizee D6, Campagne-
Loiseau S7, Deffieux X8, Ferry P9, de Tayrac R10, Fritel X11, Lucot J12
1. CHI Poissy-Saint-Germain, Poissy, EA 7285 RISCQ, Université Versailles Saint-Quentin, France, 2. Univ. Hosp.
Jeanne de Flandre, Lille, France,, 3. Centre Hosp. de Dunkerque, Dunkerque, France, 4. CHI Poissy-Saint-Germain,
Poissy, France, 5. Ho^pital de Hautepierre, Strasbourg, France, 6. Groupe Hosp. Diaconesses Croix St-Simon, Paris,
France, 7. CHU Estaing, Clermont-Ferrand, France, 8. Hôpital Antoine Béclère, Clamart, France, 9. La Rochelle
Hosp., La Rochelle, France, 10. Caremeau Univ. Hosp., Nîmes, France, 11. CHU de Poitiers, Poitiers, France, 12.
Univ. Hosp. Jeanne de Flandre, Lille, France
ANATOMICAL AND FUNCTIONAL OUTCOMES OF VAGINAL MESH SURGERY VERSUS
LAPAROSCOPIC SACROCOLPOHYSTEROPEXY FOR CYSTOCELE REPAIR: 12-MONTH
RESULTS OF THE PROSPERE (PROSTHETIC PELVIC FLOOR REPAIR) RANDOMISED
CONTROLLED TRIAL.
Hypothesis / aims of study
Cystocele is a frequent and sometimes disabling type of pelvic organ prolapse (POP) in women. Sacrocolpohysteropexy using
synthetic mesh is considered as the surgical gold standard, and the laparoscopic approach (LSC) has supplanted the open
abdominal route because it offers the same anatomical results with lower morbidity. The use of mesh during vaginal repair (VRM)
may have many advantages: easiness to perform, shorter operative time and recovery [1]. At the present time only one RCT has
compared LSC and VRM: the results were in favour of LSC in terms of anatomical results, but it was a single-site study with only
2 surgeons (consultant and fellow urogynaecologist) that may limit the generalisability of the findings [2]. Both the French HAS
(Haute Autorité de Santé) and the UK Department of Health have highlighted the need for a comparative study to properly evaluate
the risk and benefit ratio of surgery including mesh procedures. A French national multicentre randomised study, including centres
with experience of both the vaginal and laparoscopic approach, was designed for comparison of the safety, functional and
anatomical results of these approaches. We present here the results of functional and anatomical outcomes at one year.
Study design, materials and methods
376
Fauconnier A1, Cosson M2, Debodinance P3, Bader G4, Youssef Azer Akladios C5, Salet-Lizee D6, Campagne-
Loiseau S7, Deffieux X8, Ferry P9, de Tayrac R10, Fritel X11, Lucot J12
1. CHI Poissy-Saint-Germain, Poissy, EA 7285 RISCQ, Université Versailles Saint-Quentin, France, 2. Univ. Hosp.
Jeanne de Flandre, Lille, France,, 3. Centre Hosp. de Dunkerque, Dunkerque, France, 4. CHI Poissy-Saint-Germain,
Poissy, France, 5. Ho^pital de Hautepierre, Strasbourg, France, 6. Groupe Hosp. Diaconesses Croix St-Simon, Paris,
France, 7. CHU Estaing, Clermont-Ferrand, France, 8. Hôpital Antoine Béclère, Clamart, France, 9. La Rochelle
Hosp., La Rochelle, France, 10. Caremeau Univ. Hosp., Nîmes, France, 11. CHU de Poitiers, Poitiers, France, 12.
Univ. Hosp. Jeanne de Flandre, Lille, France
ANATOMICAL AND FUNCTIONAL OUTCOMES OF VAGINAL MESH SURGERY VERSUS
LAPAROSCOPIC SACROCOLPOHYSTEROPEXY FOR CYSTOCELE REPAIR: 12-MONTH
RESULTS OF THE PROSPERE (PROSTHETIC PELVIC FLOOR REPAIR) RANDOMISED
CONTROLLED TRIAL.
Hypothesis / aims of study
Cystocele is a frequent and sometimes disabling type of pelvic organ prolapse (POP) in women. Sacrocolpohysteropexy using
synthetic mesh is considered as the surgical gold standard, and the laparoscopic approach (LSC) has supplanted the open
abdominal route because it offers the same anatomical results with lower morbidity. The use of mesh during vaginal repair (VRM)
may have many advantages: easiness to perform, shorter operative time and recovery [1]. At the present time only one RCT has
compared LSC and VRM: the results were in favour of LSC in terms of anatomical results, but it was a single-site study with only
2 surgeons (consultant and fellow urogynaecologist) that may limit the generalisability of the findings [2]. Both the French HAS
(Haute Autorité de Santé) and the UK Department of Health have highlighted the need for a comparative study to properly evaluate
the risk and benefit ratio of surgery including mesh procedures. A French national multicentre randomised study, including centres
with experience of both the vaginal and laparoscopic approach, was designed for comparison of the safety, functional and
anatomical results of these approaches. We present here the results of functional and anatomical outcomes at one year.
Study design, materials and methods
PROSPERE RCT is a randomised multicentre controlled trial conducted in 12 participating French hospital referral centres for
pelvic reconstructive surgery. Inclusion criteria were: patients aged 45 to 75 years old, with cystocele ≥ stage 2 of the POP-Q
classification. Exclusion criteria were a previous surgical POP repair, and inability or contra-indication for one or the other
technique.
Both LSC and VRM surgery were standardised using a consensus Delphi method. For LSC, the mesh had to be fixed to the
promontory by stitches; peritonisation of the mesh was mandatory. For vaginal repair, the mesh had to be suspended by four

15. Tratamiento del CISTOCELE
Histeropéxia Laparoscópica vs. Mallas vaginales
Mejoría funcional y de CdV significativa tras cirugía
sin diferencias entre mallas vaginales/laparoscopia
(excepto menos dispareunia en laparoscopia)
la laparoscopia debería favorecerse en pacientes sexualmente activas
376
Fauconnier A1, Cosson M2, Debodinance P3, Bader G4, Youssef Azer Akladios C5, Salet-Lizee D6, Campagne-
Loiseau S7, Deffieux X8, Ferry P9, de Tayrac R10, Fritel X11, Lucot J12
1. CHI Poissy-Saint-Germain, Poissy, EA 7285 RISCQ, Université Versailles Saint-Quentin, France, 2. Univ. Hosp.
Jeanne de Flandre, Lille, France,, 3. Centre Hosp. de Dunkerque, Dunkerque, France, 4. CHI Poissy-Saint-Germain,
Poissy, France, 5. Ho^pital de Hautepierre, Strasbourg, France, 6. Groupe Hosp. Diaconesses Croix St-Simon, Paris,
France, 7. CHU Estaing, Clermont-Ferrand, France, 8. Hôpital Antoine Béclère, Clamart, France, 9. La Rochelle
Hosp., La Rochelle, France, 10. Caremeau Univ. Hosp., Nîmes, France, 11. CHU de Poitiers, Poitiers, France, 12.
Univ. Hosp. Jeanne de Flandre, Lille, France
ANATOMICAL AND FUNCTIONAL OUTCOMES OF VAGINAL MESH SURGERY VERSUS
LAPAROSCOPIC SACROCOLPOHYSTEROPEXY FOR CYSTOCELE REPAIR: 12-MONTH
RESULTS OF THE PROSPERE (PROSTHETIC PELVIC FLOOR REPAIR) RANDOMISED
CONTROLLED TRIAL.
Hypothesis / aims of study
Cystocele is a frequent and sometimes disabling type of pelvic organ prolapse (POP) in women. Sacrocolpohysteropexy using
synthetic mesh is considered as the surgical gold standard, and the laparoscopic approach (LSC) has supplanted the open
abdominal route because it offers the same anatomical results with lower morbidity. The use of mesh during vaginal repair (VRM)
may have many advantages: easiness to perform, shorter operative time and recovery [1]. At the present time only one RCT has
compared LSC and VRM: the results were in favour of LSC in terms of anatomical results, but it was a single-site study with only
2 surgeons (consultant and fellow urogynaecologist) that may limit the generalisability of the findings [2]. Both the French HAS
(Haute Autorité de Santé) and the UK Department of Health have highlighted the need for a comparative study to properly evaluate
the risk and benefit ratio of surgery including mesh procedures. A French national multicentre randomised study, including centres
with experience of both the vaginal and laparoscopic approach, was designed for comparison of the safety, functional and
anatomical results of these approaches. We present here the results of functional and anatomical outcomes at one year.
Study design, materials and methods
376
Fauconnier A1, Cosson M2, Debodinance P3, Bader G4, Youssef Azer Akladios C5, Salet-Lizee D6, Campagne-
Loiseau S7, Deffieux X8, Ferry P9, de Tayrac R10, Fritel X11, Lucot J12
1. CHI Poissy-Saint-Germain, Poissy, EA 7285 RISCQ, Université Versailles Saint-Quentin, France, 2. Univ. Hosp.
Jeanne de Flandre, Lille, France,, 3. Centre Hosp. de Dunkerque, Dunkerque, France, 4. CHI Poissy-Saint-Germain,
Poissy, France, 5. Ho^pital de Hautepierre, Strasbourg, France, 6. Groupe Hosp. Diaconesses Croix St-Simon, Paris,
France, 7. CHU Estaing, Clermont-Ferrand, France, 8. Hôpital Antoine Béclère, Clamart, France, 9. La Rochelle
Hosp., La Rochelle, France, 10. Caremeau Univ. Hosp., Nîmes, France, 11. CHU de Poitiers, Poitiers, France, 12.
Univ. Hosp. Jeanne de Flandre, Lille, France
ANATOMICAL AND FUNCTIONAL OUTCOMES OF VAGINAL MESH SURGERY VERSUS
LAPAROSCOPIC SACROCOLPOHYSTEROPEXY FOR CYSTOCELE REPAIR: 12-MONTH
RESULTS OF THE PROSPERE (PROSTHETIC PELVIC FLOOR REPAIR) RANDOMISED
CONTROLLED TRIAL.
Hypothesis / aims of study
Cystocele is a frequent and sometimes disabling type of pelvic organ prolapse (POP) in women. Sacrocolpohysteropexy using
synthetic mesh is considered as the surgical gold standard, and the laparoscopic approach (LSC) has supplanted the open
abdominal route because it offers the same anatomical results with lower morbidity. The use of mesh during vaginal repair (VRM)
may have many advantages: easiness to perform, shorter operative time and recovery [1]. At the present time only one RCT has
compared LSC and VRM: the results were in favour of LSC in terms of anatomical results, but it was a single-site study with only
2 surgeons (consultant and fellow urogynaecologist) that may limit the generalisability of the findings [2]. Both the French HAS
(Haute Autorité de Santé) and the UK Department of Health have highlighted the need for a comparative study to properly evaluate
the risk and benefit ratio of surgery including mesh procedures. A French national multicentre randomised study, including centres
with experience of both the vaginal and laparoscopic approach, was designed for comparison of the safety, functional and
anatomical results of these approaches. We present here the results of functional and anatomical outcomes at one year.
Study design, materials and methods
PROSPERE RCT is a randomised multicentre controlled trial conducted in 12 participating French hospital referral centres for
pelvic reconstructive surgery. Inclusion criteria were: patients aged 45 to 75 years old, with cystocele ≥ stage 2 of the POP-Q
classification. Exclusion criteria were a previous surgical POP repair, and inability or contra-indication for one or the other
technique.
Both LSC and VRM surgery were standardised using a consensus Delphi method. For LSC, the mesh had to be fixed to the
promontory by stitches; peritonisation of the mesh was mandatory. For vaginal repair, the mesh had to be suspended by four

16. 2017
DEFECTO DE COMPARTIMENTO MEDIO . ÚTERO
similar mejoría en síntomas de POP
similares tasas de recurrencia de POP
similares tasas de IUE de novo

17. Cochrane Databaseof SystematicReviews
Surgery for women with apical vaginal prolapse (Review)
Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J
Sacral colpopexy has superior outcomes to a variety of vaginal
procedures including sacrospinous colpopexy, uterosacral colpopexy and
transvaginal mesh “
DEFECTO DE COMPARTIMENTO MEDIO . CÚPULA
Lower risk of awareness of prolapse, recurrent prolapse on examination,
repeat surgery for prolapse, postoperative SUI and dyspareunia
2016
Cochrane Databaseof SystematicReviews
Surgery for women with apical vaginal prolapse (Rev
Maher C, Feiner B, Baessler K, Christmann-Schmid C, Haya N, Brown J

18. Comparativos con mallas vaginales
LPS > tasa de curación subjetiva y objetiva
LPS < morbilidad perioperatoria y tasa de reintervenciones
LSC TVM
Tiempo operatorio 191 +/- 48 101 +/- 31 P=0.001
Complicaciones intra 1.6% 6.5% ND
Hospitalización 4.02 +/- 1.37 5.27 +/- 2.2 ND
Dispareunia de novo 1.6% 13.1% P=0.015
Estreñimiento post 27.8% 6.5% P=0.02
ReIQ complicaciones 8.2% 14.75% ND
ReIQ prolapso 3.3% 4.9% ND
DEFECTO DE COMPARTIMENTO MEDIO . CÚPULA
Maher. Am J Obstet Gynecol 2011

19. RESULTADOS CSP LAPAROSCOPICA.
EUROPEAN UROLOGY 2014

20. REVIEW ARTICLE
The treatment of post-hysterectomy vaginal vault prolapse:
a systematic review and meta-analysis
Anne-LotteW. M. Coolen1
&Bich Ngoc Bui1
&VivianeDietz2
&Rui Wang3
&
Aafke P. A. van Montfoort4
&Ben Willem J. Mol3
&Jan-Paul W. R. Roovers5
&
MarliesY. Bongers1 ,4
Received: 13 May 2017 /Accepted: 13 September 2017
# TheAuthor(s) 2017. This articleisan open accesspublication
Abstract
Introduction and hypothesis The treatment of post-
hysterectomy vaginal vault prolapse (VVP) has been investi-
gated in several randomized clinical trials (RCTs), but a sys-
tematic review of the topic is still lacking. The aim of this
study is to comparetheeffectivenessof treatmentsfor VVP.
Methods We performed a systematic review and meta-
analysis of the literature on the treatment of VVP found in
PubMed and Embase. Reference lists of identified relevant
articles were checked for additional articles. A network plot
was constructed to illustrate the geometry of the network of
thetreatmentsincluded. Only RCTsreportingonthetreatment
of VVP were eligible, conditional on a minimum of 30 par-
ticipantswith VVP and afollow-up of at least 6 months.
Results NineRCTsreporting 846 women (rangingfrom95to
168women) met theinclusion criteria. All surgical techniques
wereassociated with good subjectiveresults, and without dif-
ferencesbetween thecompared technique, with theexception
of the comparison of vaginal mesh (VM) vs laparoscopic
sacrocolpopexy (LSC). LSC isassociated with ahigher satis-
faction rate. The anatomical results of the sacrocolpopexy
(laparoscopic, robotic [RSC]. and abdominal [ASC]) are the
best (62–91%), followed by the VM. However, the ranges of
the anatomical outcome of VM were wide (43–97%). The
poorest results are described for the sacrospinal fixation
(SSF; 35–81%), which also correlateswith thehigher reoper-
ation ratefor pelvicorgan prolapse(POP; 5–9%). Thehighest
percentage of complications were reported after ASC (2–
19%), VM (6–29%), and RSC (54%). Mesh exposure was
seen most often after VM (8–21%). The rate of reoperations
carriedout becauseof complications, recurrenceprolapse, and
incontinence of VM was 13–22%. Overall, sacrocolpopexy
reported the best results at follow-up, with an outlier of one
trial reporting thehighest reoperation ratefor POP(11%). The
results of the RSC are too small to makeany conclusion, but
LSC seemsto bepreferable to ASC.
Conclusions A comparison of techniques was difficult be-
cause of heterogeneity; therefore, a network meta-analysis
was not possible. All techniques have proved to beeffective.
The reported differences between the techniques were negli-
gible. Therefore, a standard treatment for VVP could not be
given according to thisreview.
Resultswerepresented at apreviousconference: Poster EUGA,
Amsterdam, theNetherlands
Electronic supplementary material Theonlineversion of thisarticle
(https://doi.org/10.1007/s00192-017-3493-2) containssupplementary
material, which isavailableto authorized users
* Anne-LotteW. M. Coolen
anne_lotte_coolen@hotmail.com
1
Department of Obstetricsand Gynecology, MáximaMedical Centre,
DeRun 4600, 5500 MB Veldhoven, The Netherlands
2
Department of Obstetrics and Gynecology, Catharina Hospital,
Michelangelolaan 2, 5623 EJEindhoven, TheNetherlands
3
RobinsonResearch Institute, AdelaideMedical School,University of
Adelaide, Adelaide, SA, Australia
4
Department of Obstetrics and Gynaecology, Maastricht University,
Grow School for Oncology and Developmental Biology,
Minderbroedersberg 4, 6211 LK Maastricht, TheNetherlands
Int Urogynecol J
https://doi.org/10.1007/s00192-017-3493-2
Int Urogyn J 2017
Revisión Sistemática y Metaanálisis
n: 846 mujeres
Seguimiento > 6 meses
Todas las técnicas dan buenos resultados
( CSP abierta y Lap // Mallas Vaginales // RICHTER)
CSP Lap. mejores resultados
> Satisfacción // < Tasa Reoperaciones
Restauración Anatómica ( 62-91%)
(Mejor CSP  malla vaginal  Richter el peor 35-81%)
Complicaciones 1º CSP abd  Mallas vaginales
RESULTADOS CSP LAPAROSCOPICA.
COMPARACIÓN DIFICIL POR HETEROGENEIDAD

21. 2018

22. 2018

23. 2018

24. CURVA DE APRENDIZAJE
Hsiao, 2007 220 min reducción Tpo. del 30% tras 10 cx
Claerhout, 2009 206 min reducción Tpo significativa tras 30 cx
Akladios, 2010 237 min reducción Tpo del 25% tras 20 cx
Mustafá, 2012 176 min reducción Tpo del 20% tras 15 cx
Tiempo operatorio (97-276 min)
•( entrenamiento y habilidad con
las suturas ) Akladios, 2010
CURVAS DE APRENDIZAJE

25. Técnica clásica Clermond-Ferrand
• - Corrección integral de todos los defectos existentes a nivel
de los diferentes compartimentos
• - Previene defectos secundarios a la misma cirugía.
• - Mallas por laparoscopia < complicaciones en comparación
a la vía vaginal.
Mejor visión anatómica
Mejor resolución quirúrgica
Menor sangrado
Wattiez et al. Promontofixation for the treatment of prolapse. Urol Clin North Am 2001
DEFECTO DE COMPARTIMENTO MEDIO . CÚPULA

26. Preparación del campo pélvico
Suspensión de sigma a pared pélvica

27. incisión peritoneo cara posterior cúpula

28. Preparación de accesos laterales pararectales hasta MEA (fasciculo puborectal)

29. Incisión / disección/ Preparación pared anterior

30. Incisión / disección/ Preparación pared anterior

31. Incisión / disección/ Preparación promontorio sacro

32. Incisión / disección/ Preparación promontorio

33. Incisión / disección/ Preparación promontorio sacro

34. Incisión / disección/ Preparación promontorio sacro

35. Anclaje de sutura irreabsorbible en MEA

36. Puntos de fijación de “patas” posteriores de la malla en MEA

37. Puntos de fijación de malla posterior a muscularis vaginal posterior

38. Puntos de fijación de malla anterior a muscularis vaginal anterior

39. Punto sobre ligamento sacro anterior en promontorio

40. Fijación extremo craneal de la malla sobre promontorio ( sutura irreabsorbible)

41. Peritonización sobre la malla con sutura continua reabsorbible

42. INTERVENCIONES
LAPAROSCÓPICAS
• COMPARTIMENTO ANTERIOR
Reparación de defecto paravaginal
Colposuspensión Burch para IUE
Colposacropexia
POPS (cinta de malla subperitoneal parietal)
Pectopexia ( fijación con malla a lig.ileopectíneo)
• COMPARTIMENTO MEDIO
Mc Call Laparoscopico (fijación a Lig.US)
Colposacropexia
Histeropromontopexia
POPS
Pectopexia

43. Fijación a lig. úterosacros útero

44. Laparoscopic vaginal vault suspension using uterosacral ligaments: a review of 133 cases.
Lin, Phelps, Liu. J Minim Invasive Gynecol, 2005
Colpopexia a lig úterosacros:
133 pacientes con prolapso severo de cúpula.
Tpo seguimiento: 2-7,3 a.
87.2% no recurrencia del prolapso.
Uterosacral colpopexy at the time of vaginal hysterectomy: comparison of laparoscopic and vaginal
approaches. Rardin, Erekson. J Reprod Med 2009.
HT + colpopexia a lig úterosacros:
•N=96. V.VAGINAL (seguimiento medio: 8.8m)
•N=22. V.LAPAROSCÓPICA (seguimiento medio: 10.8m)
< Compromiso ureteral 4.2% vs 0%
< Recurrencia del prolapso sintomático de cúpula 10% vs 0%
Fijación a lig. úterosacros cúpula

45. Fijación de cúpula vaginal a lig.úterosacros
post Histerectomía total laparoscópica

46. Laparoscopia vs. Robótica
Paraiso. Laparoscopic compared with Robotic Sacrocolpopexy for Vaginal Prolapse. Obstet Gynecol 2011
Anger. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol 2014
Barber. Apical prolapse. Int Urogynecol J 2013
> tiempos operatorios
> dolor postoperatorio
> coste económico
NO superioridad en ningún parámetro clínico.

47. Conclusiones
• El objetivo de la cirugía laparoscópica es reproducir los
resultados de las técnicas abiertas mediante técnicas
mínimamente invasivas
• Adecuada valoración preoperatoria para la elección
de la técnica quirúrgica.
• El tratamiento completo del prolapso genital por vía
laparoscópica es una técnica efectiva y reproducible.
• Curva de aprendizaje y habilidades quirúrgicas (sutura)

48. LA LAPAROSCOPIA EN PATOLOGÍAS DE SUELO PÉLVICO
….NO ES SENCILLA … PERO TAMPOCO UNANO ES SENCILLA … PERO TAMPOCO UNA “MISIÓN IMPOSIBLE”“MISIÓN IMPOSIBLE”