Vaginally-Assisted Laparoscopic Sacrohysteropexy - Indications, Surgical Techniques, and Complications

Introduction

Pelvic organ prolapse is when the pelvic organs (area below the abdomen, between hip bones) plunge into or outside the vaginal canal or anus due to pelvic muscle or ligament weakness. The pelvic organs include the urethra, cervix, uterus, vagina, rectum, and bladder. Uterine prolapse occurs when the uterus drops from its usual position into the vagina, affecting urinary, bowel, and sexual functions and the quality of life. Uterovaginal prolapse is commonly seen in older women. Uterovaginal prolapse can be corrected through different approaches, such as abdominal, vaginal, and laparoscopic procedures.

What Is Laparoscopic Sacrohysteropexy?

It is a procedure that involves lifting the prolapsed uterus with the help of an artificial mesh material attached to the uterus and sacrum bone. Therefore sparing the uterus in case of prolapse. The operation is performed using laparoscopy, a minimally invasive procedure.

What Are the Causes of Uterine Prolapse?

Some of the common reasons for uterine prolapse are:

• One or more vaginal delivery.

• Old age.

• Obesity.

• Previous pelvic organ surgeries.

• Respiratory problems with a chronic, long-term cough.

• Chronic constipation.

• Pelvic tumor.

• Pelvic organ cancers.

• Family history of pelvic organ prolapse or hernia.

• Increased intra-abdominal pressure due to heavy lifting.

• Chronic cough.

• Menopause.

• Hypoestrogenism (low level of estrogen).

What Are the Symptoms of Uterine Prolapse?

Some of the common symptoms of uterine prolapse are:

• Fullness or pressure in the pelvic area.

• Feeling bulging in the vagina.

• Leaking of urine and a chronic urge to urinate.

• Bladder infections.

• Constipation.

• Loss of bowel control.

• Spotting or bleeding from the vagina.

• Increased vaginal discharge.

• Pain in the lower back.

• Painful intercourse.

How Is Uterine Prolapse Diagnosed?

Uterine prolapse can be diagnosed in the following ways:

• In the visual examination, part or all of the uterus may protrude into the vagina.

• Pelvic Organ Prolapse Quantification (POP-Q) system is used to diagnose the degree and location of pelvic floor dysfunction.

• Bladder function tests (detects the structures around the bladder).

• Intravenous pyelography (X-ray of the urinary tract that detects kidneys, bladder, and ureters).

• Doctors can perform computed tomography (CT) scans, ultrasound, and magnetic resonance imaging (MRI) scans of the pelvis.

What Are the Stages of Uterine Prolapse?

It is divided into four stages:

Stage I - The lower part of the uterus descends into the upper half of the vagina.

Stage II - The lower part of the uterus descends near the opening of the vagina.

Stage III - A part of the uterus protrudes out of the vagina.

Stage IV - The entire uterus descends out of the vagina.

What Is the Treatment of Uterine Prolapse?

It depends on the severity of the condition. No medical treatment is required if a mild prolapsed uterus is not causing any symptoms. To prevent the uterus from further descending, kegel exercises can be performed to strengthen the pelvic floor muscles. In addition, a vaginal pessary (a small rubber or plastic device) can be inserted into the vagina to support the uterus. Although, a more severe condition may require surgery or a hysterectomy (removal of the uterus).

What Is the Procedure for Vaginally-Assisted Laparoscopic Sacrohysteropexy?

Vaginally-assisted laparoscopic sacrohysteropexy is done under general anesthesia and in a lithotomy position (patient placed in a supine position with legs separated) and has three stages.

• Laparoscopic Stage 1: Laparoscopic incisions are made about 10 millimeters near the umbilical, and 2 to 3 incisions of about 5 millimeters are made in the lateral or suprapubic area (region below the umbilical) to achieve proper surgical site exposure. The peritoneum (a membrane that lines the abdominal and pelvic region) over the superior aspect of the sacrum is incised. A small tunnel of 5 centimeters is made beneath the peritoneum to the cervix (lower end of the uterus). Then, a mesh is placed over the superior aspect of the sacrum.

• Vaginal Stage: A semicircular incision is made at the posterior cervicovaginal junction. A curved ring forceps is placed into the retroperitoneal (behind the peritoneum) area through the tunnel, which is made in the vagina towards the superior aspect of the sacrum. The direction is monitored by laparoscopy. When the forceps tip is seen near the peritoneum, the mesh is grasped and pulled within the tunnel and fixed onto the posterior surface of the uterine cervix using non-absorbable sutures, and the vaginal incision is closed.

• Laparoscopic Stage 2: Using laparoscopy, the uterus is pushed up to the required level using Rubin’s cannula, and the mesh is sutured to the anterior longitudinal ligament of the superior aspect of the sacrum bone. The peritoneal membrane over that is sutured. A trans-obturator tape insertion procedure is done in patients with stress urinary incontinence.

What Are the Advantages of Vaginally-Assisted Laparoscopic Sacrohysteropexy?

The advantages of vaginally-assisted laparoscopic sacrohysteropexy are:

• Shorter hospital stays and fast recovery.

• Less pain.

• Minimal blood loss.

• Minimal scarring.

• Fewer complications.

• Due to better visibility and access, surgery is done better.

• The recurrence rate is low.

• It is safe and easy to perform.

• It preserves the uterus.

• Total and adequate vaginal length is preserved.

• Proper physiological vaginal axis is maintained.

• Absence of mesh erosion.

• Better anatomic cure rates.

What Are the Complications of Vaginally-Assisted Laparoscopic Sacrohysteropexy?

The complications of vaginally-assisted laparoscopic sacrohysteropexy are;

• Laparoscopic sacrohysteropexy is associated with a higher cystocele (bladder plunges into the vagina), tissues around the sacrum that can cause nerve and vessel injuries, and defecation disorders.

• It can cause rare injury to the bladder, bowel, blood vessels, and pelvis nerves.

• After the surgery, there may be slight pain in the shoulder because of the carbon dioxide gas used to inflate the abdomen during laparoscopic surgery.

• Bladder spasm, which will diminish over time.

• Blood-stained urine for several days may occur after surgery.

• Damage to the bladder or intestine during surgery.

• Excessive bleeding.

• Deep venous thrombosis (a blood clot in a leg vein).

• Implant complications (damage to pelvic structures caused by vaginal mesh material).

• Infection.

• Recurrence of the prolapse.

Conclusion

Vaginally-assisted laparoscopic sacrohysteropexy is a safe, easy-to-perform, and minimally-invasive procedure for uterine prolapse, preserving the uterus and enabling future normal vaginal delivery and low recurrence rates. This technique had positive anatomical and functional outcomes a year after surgery.