Pelvic organ prolapse can include the anterior, posterior, or apical compartments, individually or in combination. When apical suspension is planned for pelvic organ prolapse repair, the surgeon and patient must decide if hysterectomy should be performed simultaneously. Recent literature suggests that 36-60% of women would choose uterine preservation with prolapse repair, if the option was of equivalent efficacy. Interestingly, 21% of women would still choose uterine preservation even if the prolapse repair had lower success rates. There are a variety of techniques for apical suspension with uterine preservation, one of which includes uterosacral ligament suspension, either transvaginal or transabdominal. The risk of ureteral injury during high uterosacral ligament suspension is 1-11%. The main advantage of the laparoscopic approach is appropriate visualization of the ureters in a minimally invasive fashion. In this video, we demonstrate a robotic-assisted laparoscopic approach to high uterosacral ligament suspension with uterine preservation, and Burch urethropexy.

The patient presented is a 51-year-old woman, G2P2, who presented to the clinic for evaluation of a vaginal bulge and stress urinary incontinence. She reported frequent urination, nocturia, and stress urinary incontinence for the past 20 years. She reported use of 10 pads per day which were soaked at time of change. More recently she noticed a progressive vaginal heaviness. Pelvic examination demonstrated a 7cm total vaginal length, 3cm apical descent with Valsalva, stage 1 anterior wall prolapse and urethral hypermobility. Urodynamic testing showed a no detrusor overactivity, a VLPP 106cmH20 and CLPP of 128cmH20 at a volume of 250mL. After discussion of various treatment options, she stated the importance of uterine preservation. Therefore, she was counseled on proceeding with robotic-assisted laparoscopic high uterosacral ligament suspension and Burch urethropexy. An informed consent for the procedure and video recording was obtained.

The patient was given pre-operative broad-spectrum antibiotics and placed in the dorsal lithotomy position, after induction of general anesthesia. Pneumoperitoneum was created via Veress needle and 5 ports were placed in a straight line (RIGHT: 12mm Air seal port, 5mm assistant port, 8mm robotic port; LEFT: 8mm camera port, 8mm robotic ports x 2). Da Vinci Xi robot was docked after patient was placed in steep Trendelenburg position. Monopolar scissors were placed in the right arm, bipolar forceps in the left arm, and prograsp for the assistant “fourth arm”. The procedure is detailed in the video in two parts, (1) Uterosacral ligament suspension (2) Burch urethropexy. Relevant anatomy is elucidated throughout.

The patient was kept overnight for observation, and she was discharged on post-operative day 1 after a successful voiding trial. She was seen at 2 week and 3 month follow-up visit during which she was completely dry with an undetectable PVR, and had no descent of her uterus on examination. Robotic-assisted laparoscopic uterosacral ligament suspension offers a minimally invasive approach to uterine preserving prolapse surgery, and allows for clear visibility of the ureters as well as ease of performing concomitant procedures such as the Burch urethropexy.

Music: Motivate Me by Mixaund | https://mixaund.bandcamp.com Music promoted by https://www.free-stock-music.com