Sacrohysteropexy - A Surgery for Uterine Prolapse

What Is Sacrohysteropexy (SHP)?

It is a surgery performed to repair a prolapsed uterus. Uterine prolapse is a bulge or lump in the vagina caused by the sagging of the uterus (womb). If the uterine prolapse is accompanied by the urinary bladder, rectum, vaginal vault, and intestine, then the resulting condition is known as pelvic organ prolapse (POP). POP or uterine prolapse happens when the muscles or the connective tissue suspending the uterus and pelvic organs in place gets weakened. Common causes of uterine prolapse include vaginal childbirth, obesity, severe coughing, straining on the toilet, and hormonal changes after menopause which can damage the pelvic organ support structures.

The condition can affect the quality of life by causing symptoms of pressure and discomfort and by its effect on urinary, bowel, and sexual functions. Treatment depends on the stage of the uterine prolapse; the four categories of uterine prolapse are:

1. Stage 1 - The uterus is in the upper half of the vagina.

2. Stage 2 - The uterus has descended nearly to the opening of the vagina.

3. Stage 3 - The uterus protrudes out of the vagina.

4. Stage 4 - The uterus is completely out of the vagina.

Depending on the stage of the prolapse, the treatment options include pelvic floor muscle training, the use of pessaries, and surgery (sacrohysteropexy). The surgery can be done either by the abdominal or the laparoscopic approach (laparoscopic sacrohysteropexy), the latter being more popular.

What Is Laparoscopic SHP?

It is an operation that involves supporting the uterus using an artificial mesh. One end of the mesh is sewn into the neck of the womb (cervix), and the other is attached to the sacrum bone using titanium staples. The operation is performed using keyhole surgery (laparoscopy), the procedure uses two or three small incisions instead of one large incision (as seen in the conventional abdominal approach).

How Is Laparoscopic SHP Performed?

The procedure is done under general anesthesia; during the operation, the surgeon will insert a camera into the patient's abdomen through a small cut in, or near the umbilicus. The surgeon will also place a couple of more small incisions around the first incisions to insert the instruments and perform the procedure. Once the uterus is sufficiently exposed, a strip of artificial mesh is stitched onto the cervix with dissolvable sutures, and the other end of the mesh is stapled to the sacrum bone. The mesh is then covered over with the lining of the abdomen, known as the peritoneum and the incisions will be sutured with the help of dissolvable sutures. The procedure takes between one to two hours, and after the procedure, the patient will be prescribed antibiotics and nonsteroidal anti-inflammatory drugs to prevent infection and manage pain.

What Are the Complications of Laparoscopic SHP?

Although SHP is a relatively safe procedure, it is still a major surgery. The healthcare provider must discuss the pros and cons and alternate treatment options before finalizing the procedure. Some of the frequently observed complications of laparoscopic SHP are-

1. Damage to the bladder or one of the tubes (uterus) which drain the kidneys.

2. Damage to the bowel.

3. Damage to the blood vessels and excessive bleeding; if this happens, the patient will need an emergency hysterectomy (complete removal of the uterus). On rare occasions, the patient will need a blood transfusion, either during or after the surgery.

4. Deep vein thrombosis is observed in a few patients; it is the formation of blood clots in the leg vein and can be prevented with the help of medication and stockings.

5. Recurring prolapse is one of the frequently observed complications of laparoscopic SHP. This may happen due to the wearing of the artificial mesh or due to weak vaginal tissues.

6. Pregnancy can damage the repair and cause the prolapse to happen again. This can be prevented by opting for a cesarean instead of vaginal birth.

7. Infections involving the uterus, bladder, lung, and incision site can occur post-surgery. Most infections can be prevented or treated with antibiotics before and after the procedure, but a few might be severe, leading to complications.

8. Sometimes, the laparoscopic approach will have to be changed to a conventional approach or hysterectomy mid-surgery due to unforeseen circumstances like anatomical anomalies or adhesions.

What Are the Alternative Treatment Options for SHP?

There are different alternative treatments for uterine prolapses, such as pelvic exercises, vaginal pessaries, and doing nothing. The choice of treatment depends on the type of prolapse, the extent of discomfort experienced by the individual, and personal factors like future pregnancies.

1. Pelvic Floor Exercises - These can be used to treat stage 1 and 2 uterine prolapses, but they should be done correctly and practiced long enough to strengthen the muscles. Performing pelvic floor exercises involves two steps-

• Identifying the Pelvic Floor Muscles: This can be done by inserting two fingers into the vagina and trying to squeeze them. Other options include trying to stop imaginary urination midstream and squeezing the muscles inside the anus as one does to prevent breaking wind.

• Performing the Exercise: This includes squeezing the vaginal muscles slowly and holding them as strongly as one can for five to ten seconds while maintaining normal breathing. This is followed by releasing the muscles and relaxing for five to ten seconds. The entire process should be continued for up to ten minutes. The next step involves performing quick, short, and strong squeezes for a period of ten minutes. Over time, the individual must squeeze and lift the muscles whenever they cough, sneeze, laugh, or lift anything.

2. Vaginal Pessaries - A pessary is a flexible device that can be fitted into the vagina to support the uterus. There are different shapes and sizes of pessary that can be prescribed and fitted by a trained healthcare professional. The affected women can be taught to remove and re-insert their pessary similar to a tampon. Together with pelvic floor exercises, they provide a non-surgical solution to manage uterine prolapse. Women who are at a higher risk of uterine prolapse can prevent it by addressing the underlying causes, some of them include performing pelvic floor exercises after vaginal childbirth, dietary modifications to remove the excess abdominal fat, estrogen cream to boost flagging hormonal levels, etc.

Conclusion

Sacrohysteropexy is a surgical procedure performed to treat uterine prolapse. Recovery varies in each individual, but overall it is surgery with limited complications. The individual will be able to resume intercourse around six weeks post-surgery, and the patients are advised to continue pelvic floor exercises to prevent relapse.