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Introduction and hypothesis Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament. Methods We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures. Results We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture. Conclusions Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

Introduction and Hypothesis In the setting of recurrent female urethral stricture, urethroplasty offer the best chance of cure. However, which approach (dorsal or ventral) and which tissue (buccal mucosa, vaginal graft, vaginal flap) remain areas of controversy. In this article and accompanying video, we describe female urethroplasty with a supraurethral approach using a buccal mucosa graft. Methods A stricture of 3 cm in length was observed in the mid urethra. A supraurethral semi-lunar incision was made and dissection was performed up to the stricture. A dorsal urethrotomy was performed and a 3 × 2 cm oral mucosal graft was harvested from the left cheek. The mucosal graft was anastomosed to both urethral edges with running sutures. The graft was fixed to the supraurethral tissue with quilting sutures. A urethral catheter and a suprapubic catheter were left in place for 3 weeks. Results Following removal of the catheters, the patient was able to void satisfactorily with no incontinence. No complications were observed in the urethral area or at the graft harvest site. Conclusions Buccal mucosa graft urethroplasty with a supraurethral approach is a reliable method in the treatment of female urethral stricture.

Introduction and hypothesis The objective is to develop a low-risk, cost-effective method to teach procedures that require learning by feel and high-volume pattern recognition, starting with the midurethral sling. Methods This video describes the creation of a virtual reality model utilizing de-identified patient data, artificial intelligence algorithms and haptics; and demonstrates the use of the training system for trocar passage of the retropubic midurethral sling procedure. Results This innovative system overcomes the lack of visualization and “blind” nature of sling surgery. Novel artificial intelligence provides high accuracy of anatomical landmarks and a realistic 3D environment. The trainee benefits from haptic and visual alerts for real-time feedback on the trocar insertion pathway and scoring to develop competency. Conclusion This is one of the first noncadaveric, nonstatic models available in the field. It allows for multiple low-risk exercises and provides more surgeons with training outside the operating room, at their own institution, and avoids the need for patient subjects. Training can be disseminated at a significantly lower cost and greater convenience than remote cadaver laboratories or intraoperative observation and has a higher fidelity than available static models, particularly after multiple passes. This has implications not only for retropubic midurethral slings but also for urogynecological and “blind” surgery as a whole.

Obliterative surgical procedures have been classically used as a method to reduce pelvic organ prolapse in elderly women who do not wish to preserve the vagina for sexual intercourse. The aim of this video is to demonstrate a surgical technique of repairing complete labia majora fusion in a woman who had previously undergone one of these procedures. We present the case of an 80 year-old woman with a history of progressive difficulty on voiding onset and sensation of incomplete bladder emptying. She reported an obliterative procedure to correct her pelvic organ prolapse (POP) 10 years earlier. On physical examination, complete fusion of labia majora was observed, causing abnormal urinary drainage. Perineal reconstructive surgery was performed without complications and the application of topical Promestriene was prescribed. Optimal genital re-epithelization was observed during follow-up. As observed, patients undergoing obliterative surgery who present with genital atrophy are at increased risk of developing vulvar adherences. Applying vaginal moisturizers or local topical estrogens can prevent this condition. In severe vulvar fusions, early surgical treatment is recommended to prevent potentially serious complications.

Introduction and Hypothesis Concurrent pelvic organ and rectal prolapse have an incidence of 38%. Dynamic pelvic magnetic resonance imaging (MRI) is the modality of choice for workup. We discuss dynamic pelvic MRI indications, interpretation, and clinical application to pelvic floor disorders. Methods The pubococcygeal line (PCL) extends from the pubic symphysis to the last coccygeal joint. The “H line” demonstrates the levator hiatus size, drawn from the inferior pubic symphysis to the posterior rectal wall at the anorectal junction. The “M line” represents vertical descent of the levator hiatus and extends perpendicularly from the PCL to the posterior aspect of the H line. With rectovaginal fascial defects, the small bowel, the peritoneum, and the sigmoid colon can prolapse. Posterior compartment abnormalities include rectocele, rectal prolapse, and descending perineal syndrome. Pelvic MRI can evaluate functional disorders such as anismus, where the anorectal angle is narrowed and associated with lack of pelvic floor descent and incomplete evacuation. Conclusions Particularly for patients with concurrent urogynecological and colorectal complaints, previous pelvic reconstructive surgery, or when clinical symptomatology does not correlate with physical examination, dynamic pelvic MRI can impact management. It is critical for pelvic reconstructive surgeons to be familiar with this imaging modality to counsel patients and interpret radiographic findings.

Introduction and hypothesis Rectovaginal fistula is an epithelium-lined direct communication route between the vagina and the rectum. The gold standard of fistula management is surgical treatment. Rectovaginal fistula after stapled transanal rectal resection (STARR) may be challenging to treat, due to the extensive scarring, the local ischemia, and the risk of rectal stenosis. We aimed to present a case of iatrogenic rectovaginal fistula after STARR that was successfully treated with a transvaginal primary layered repair and bowel diversion. Methods A 38-year-old woman was referred to our division for continuous fecal discharge through her vagina that developed a few days after she had a STARR for prolapsed hemorrhoids. Clinical examination revealed a 2.5 cm-wide direct communication between the vagina and rectum. After proper counseling, the patient was admitted to transvaginal layered repair and temporary laparoscopic bowel diversion Results No surgical complications were observed. The patient was successfully discharged home on postoperative day 3. Bowel diversion was reversed after 2 months. At the current follow-up (6 months), the patient is asymptomatic and without recurrence. Conclusions The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this severe condition.

Since 2019, all vaginal mesh implants were removed from the market. Since, surgeons have only the autologous technique left to treat prolapse by vaginal route. The anterior sacrospinofixation is an alternative technique to treat vaginally apical prolapses. We have divided the anterior sacrospinous ligament fixation technique into 10 surgical steps: exposure, infiltration, vaginal incision, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture (two passage in the SSL on each side, using a suture-capturing device), vaginal fixation, vaginal closure, sacrospinous ligament fixation and final closure. We have performed more than 50 ASSF. This technique is not very well known, and the surgeons are more used to approach the SSL by posterior way. We have included a video of the procedure and an anatomical drawing exhibiting the dissection of the SSL without eyes control. We also added tips and tricks to easily apprehend this new technique. The anterior approach seems to has several advantages compared to the traditional posterior technique. We want to share such a video on showing how to approach the paravesical fossa anteriorly without eyes control.

Introduction and Hypothesis This video demonstrates a robotic-assisted sacrocervicopexy using the semitendinosus tendon. Methods Between June 2022 and February 2023, we performed the worldwide first Da Vinci robotic-assisted sacrocervicopexies (SCP) for apical organ prolapse using the semitendinosus tendon of the left knee. Analysis of safety, feasibility, and clinical outcome of the first ten patients operated on using this new surgical technique included the German pelvic floor questionnaire (GPFQ) as well as a clinical examination. Results Ten patients with a follow-up of 12 months were included. There was a significant reduction of the patient’s symptoms according to the GPFQ regarding the domain bladder (preoperatively versus 3 months postoperatively, mean 3.85 vs 1.61, p  = 0.034), total score (preoperatively versus 3 months postoperatively, mean 12.79 vs 3.28, p  = 0.034), and descensus symptoms (preoperatively versus 12 months postoperatively, mean 4.74 vs 0.67, p  = 0.022). POP-Q stage (point C) was significantly reduced between the preoperative period and at the time of discharge (mean 2.2 vs 0, p  = 0.004). No serious intra- and postoperative complications occurred. Conclusions This pilot study showed satisfying clinical outcomes after a follow-up of 12 months, with a low mid-term complication rate.

Introduction and Hypothesis Autologous fascia lata has been increasingly utilised in pelvic floor reconstructive surgeries such as sacrocolpopexy and sacrohysteropexy. This case highlights sacrohysteropexy with autologous fascia lata as a promising option for women with advanced uterovaginal prolapse who wish to preserve their uterus and avoid synthetic mesh. Methods We report the case of a 65-year-old woman with stage 3 pelvic organ prolapse following one forceps and one spontaneous vaginal delivery. She presented with cervical-dominant prolapse (6 cm beyond the hymen) and a widened genital hiatus. She was initially managed with a Gellhorn pessary for 7 months, which was removed before surgery. Preoperative findings included prolapse of the cervix, anterior, and posterior vaginal walls (+ 1 cm distal to the hymen). A robot-assisted laparoscopic sacrohysteropexy with autologous fascia lata was performed. Results The 120-min procedure, conducted by a certified urogynaecologist, began with harvesting a 12 × 4 cm autologous fascia lata graft from the left thigh. The graft site was closed with 2–0 absorbable sutures and supported with a compression bandage for 4 weeks. The graft was secured to the cervix and anterior longitudinal ligament through laparoscopic dissection and robot-assisted suturing. No perioperative complications occurred, and the patient was discharged on postoperative day 2. At 1-year follow-up, there was no recurrence of prolapse. Conclusions Sacrohysteropexy using autologous fascia lata is a feasible and effective alternative to synthetic mesh, providing an additional surgical treatment option for women in settings where synthetic polypropylene meshes are not approved, contraindicated, or an unacceptable option.

Introduction and Hypothesis Sacrocolpopexy (SCP) is a recognized treatment for apical pelvic organ prolapse (POP). However, mesh erosion remains a concern, particularly when performed with concomitant hysterectomy. This video presents data on one case of a modified technique aimed at potentially minimizing mesh erosion in robotic SCP. Methods This technique focuses on reinforcing the vaginal cuff and using a pedicled peritoneal graft to create a tissue barrier between the mesh and the vaginal vault. Procedural steps include intrafascial colpotomy, edge-to-edge cuff closure using barbed sutures, and joining anterior and posterior meshes away from the vaginal cuff. Results The surgical technique was successfully implemented in this single patient presented in the video and was performed in ten more patients with no intraoperative or postoperative complications. During the follow-up period, there were no signs of mesh erosion or exposure. Conclusions This approach emphasizing vaginal cuff strengthening and mesh separation using a pedicled peritoneal graft can be an option for reducing mesh erosion risk. This report does not provide definitive evidence that this approach reduces mesh erosion risk and further research and long-term follow-up are required to validate these findings and integrate this technique into standard management practices.