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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 4  |  Page : 252-253

Laparoscopic sacrohysteropexy: A conservative approach to uterine prolapse


Department of Obstetrics and Gynecology, Apollo Womens Hospital, Chennai, Tamil Nadu, India

Date of Submission23-Oct-2019
Date of Acceptance30-Oct-2019
Date of Web Publication12-Dec-2019

Correspondence Address:
U Nagashree
No. 8, Shafee Mohammed Road, Thousand Lights West, Thousand Lights, Chennai - 600 006, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_65_19

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  Abstract 


Uterovaginal prolapse is a common gynecological problem, mostly seen in 50% of parous women. The surgical management of uterine prolapse in women who wish to retain their uterus remains a challenge. Laparoscopic approach offers both excellent intraoperative visualization of supportive and adjacent structures and quick postoperative recovery. We present a case of third-degree uterine prolapse, who successfully underwent laparoscopic sacrohysteropexy at our center.

Keywords: Laparoscopy, sacrohysteropexy, uterovaginal prolapse


How to cite this article:
Sundaram M, Nagashree U, Swetha P. Laparoscopic sacrohysteropexy: A conservative approach to uterine prolapse. Apollo Med 2019;16:252-3

How to cite this URL:
Sundaram M, Nagashree U, Swetha P. Laparoscopic sacrohysteropexy: A conservative approach to uterine prolapse. Apollo Med [serial online] 2019 [cited 2020 Mar 28];16:252-3. Available from: http://www.apollomedicine.org/text.asp?2019/16/4/252/272830




  Introduction Top


Uterine prolapse is the descent of uterus from its normal position into the vagina or outside. The objective is to restore normal uterine support and to preserve fertility. Uterine suspension using mesh or nonabsorbable suture to repair uterine prolapse involves attaching the uterus or cervix either to the sacrum or iliopectineal ligaments. This procedure can be performed vaginally, abdominally, and laparoscopically. Laparoscopic approach is challenging and has a longer learning curve.


  Case Report Top


A 32-year-old parous female with the complaint of mass descending per vaginum for 8 months presented to the outpatient department. She had third-degree uterine prolapse with a hypertrophied cervix and a decubitus ulcer. It was not associated with incomplete emptying or retention of urine, nor difficulty in passing stools. She is married for 9 years; her periods are irregular, once in 2 months. She had a full-term normal vaginal delivery 7 years ago. There is no undue prolongation of second stage of labor. The weight of the baby was 2.8 kg. The postpartum period was uneventful. She had a spontaneous miscarriage at the 2nd month, for which she underwent dilatation and curettage. There was no significant medical history.

She underwent laparoscopic adhesiolysis with plication of bilateral round ligaments in May 2019 at a private hospital as she wishes to have a second child. No significant family history regarding any collagen disorders was seen. She was taken up for laparoscopic sacrohysteropexy after necessary investigations. ProLite™ mesh was fixed on the sacrum with tackers [Figure 1], and the other end was fixed on the cervix with prolene nonabsorbable suture [Figure 2]. Her postoperative period was uneventful. She was discharged the following day. Her review checkup after a month was remarkable with no complaints. Follow-up would be after 3, 6, and 12 months.
Figure 1: Mesh tacked on to the sacral promontory

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Figure 2: Fixation of mesh onto the cervix with prolene suture

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  Discussion Top


Pelvic organ prolapse is a common condition, with 11% of women opting for surgical management by the age of 80 years.[1] Majority of women request uterine preservation for individual preferences,[2] fertility, and minimizing morbidity. Current treatment options include pelvic floor muscle training, use of pessaries, and surgery.

Uterine suspension is performed abdominally, vaginally, and laparoscopically. The surgical procedures aim to restore normal uterine suspension by the use of mesh, Mersilene ® tape, and nonabsorbable sutures to reinforce uterosacral ligaments and suspend uterus to sacrum.

Open abdominal procedures including sacrohysteropexy with synthetic meshes such as Teflon or Gore-Tex ® are performed.[3],[4] Vaginal surgeries involve procedures such as sacrospinous hysteropexy where a nonabsorbable suture is used. Transvaginal uterosacral plication has also been reported, but increased association with ureteric injury and neurological morbidity has been reported. Use of mesh in vaginal surgeries has been reported with high rate of complications including infection and erosion.[5]

The following three types of procedures have been described laparoscopically:

  • Suspension of uterus to round ligaments
  • Plication of uterosacral ligaments
  • Suspension to sacral promontory


    • Suspension to round ligaments has a very poor success rate
    • Plication of uterosacral ligaments such as high McCall culdoplasty is performed
    • Suspension to sacral promontory involves three steps:


      1. Exposure of anterior longitudinal ligament over sacral promontory and creating a tunnel up to the uterosacral ligaments
      2. Fixation of Mersilene ® tape or mesh onto the sacral promontory and the other end on to the cervix above the uterosacral ligaments
      3. Closure of the incised visceral peritoneum to avoid adhesion.


Complications such as intestinal obstruction, adhesions, and ureteric or bowel injuries are possible.

Laparoscopic dissection and suturing are technically more challenging and demanding. The complication rates with laparoscopic procedures were 3% compared to 7% with vaginal surgeries. The success rate of this procedure laparoscopically is almost 100% with hysterosacropexy.


  Conclusion Top


The demand for uterine-preserving surgery in the management of uterine prolapse is increasing. With continued advances in laparoscopic instrumentation and surgical techniques and laparoscopic benefits to the patients such as early recovery, less adhesions, and good visualization, laparoscopic sacrohysteropexy is a novel procedure. There is a need for further prospective studies assessing the outcome of reported surgical techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-6.  Back to cited text no. 1
    
2.
Diwan A, Rardin CR, Strohsnitter WC, Weld A, Rosenblatt P, Kohli N. Laparoscopic uterosacral ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:79-83.  Back to cited text no. 2
    
3.
Leron E, Stanton SL. Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse. BJOG 2001;108:629-33.  Back to cited text no. 3
    
4.
Costantini E, Lombi R, Micheli C, Parziani S, Porena M. Colposacropexy with Gore-Tex mesh in marked vaginal and uterovaginal prolapse. Eur Urol 1998;34:111-7.  Back to cited text no. 4
    
5.
Baessler K, Hewson AD, Tunn R, Schuessler B, Maher CF. Severe mesh complications following intravaginal slingplasty. Obstet Gynecol 2005;106:713-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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