- Email: [email protected]
Laparoscopic Sacrocervicopexy for the Treatment of Uterine Prolapse: A Retrospective Case Series Report
Original Articles
Laparoscopic Sacrocervicopexy for the Treatment of Uterine Prolapse: A Retrospective Case Series Report Peter L. Rosenblatt, MD, David Chelmow, MD, and Tanaz R. Ferzandi, MD, MA* From the Mount Auburn Hospital, Cambridge, Massachusetts (Drs. Rosenblatt and Ferzandi), and New England Medical Center, Boston, Massachusetts (Dr. Chelmow).
ABSTRACT Study Objective: To evaluate apical support in patients desiring uterine preservation with pelvic organ prolapse who underwent laparoscopic sacrocervicopexy. Design: Retrospective case series report (Canadian Task Force classification III). Setting: Academic community teaching hospital. Patients: Forty consecutive women who underwent laparoscopic sacrocervicopexy. Interventions: Synthetic mesh was used to attach the distal uterosacral ligaments and posterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory. Measurements and Main Results: Pelvic organ prolapse quantification system measurements were used and apical support was evaluated using point C. Mean C was ⫺1.13 (⫹9 to ⫺4) preoperatively, ⫺5.28 (⫺3 to ⫺13) at 6 weeks postoperatively, ⫺5.26 (⫺3 to ⫺8) at 6 months postoperatively, and ⫺4.84 (⫺3 to ⫺7) at 1 year postoperatively. Conclusion: Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation. Journal of Minimally Invasive Gynecology (2008) 15, 268 –272 © 2008 AAGL. All rights reserved. Keywords:
Laparoscopy; Sacrocervicopexy; Pelvic organ prolapse; Uterine preservation
Pelvic reconstructive surgery has traditionally been performed using an abdominal or vaginal approach. A review showed the efficacy and safety of abdominal sacrocolpopexy for the treatment of vaginal vault prolapse [1]. Although abdominal sacrocolpopexy is considered by many authorities to be the gold standard in the treatment of vaginal vault prolapse, vaginal approaches to pelvic floor relaxation were advocated by many gynecologic surgeons because of the potential advantages of this less invasive approach. Vaginal operations for vaginal vault prolapse include sacrospinous ligament fixation and uterosacral ligament suspension. These procedures are often used at the time of vaginal hysterectomy to support the vaginal apex and can be used for the treatment of vaginal vault prolapse, which can occur remote from hysterectomy. Vaginal vault The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Tanaz R. Ferzandi, MD, MA, Mount Auburn Hospital, 725 Concord Avenue, #3300, Cambridge, MA 02138. E-mail: [email protected] Submitted September 14, 2007. Accepted for publication January 9, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ -see front matter © 2008 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.01.001
prolapse was reported to occur in 11.6% of women who undergo hysterectomy for prolapse, but only in 1.8% of women with hysterectomy performed for other indications, such as myomas or dysfunctional uterine bleeding [2]. Vaginal hysterectomy is often recommended for the treatment of uterine prolapse, along with concomitant procedures for coexisting pelvic floor relaxation. Vaginal hysterectomy, however, may be associated with significant morbidity, including intraoperative hemorrhage, cuff cellulitis, and ureteral injury. Almost 2 decades ago, a study pointed out that uterine prolapse is the result of pelvic floor relaxation and the uterus itself is not the cause of prolapse [3]. There was renewed interest among pelvic reconstructive surgeons in uterine preservation at the time of prolapse surgery. Advances in the treatment of benign uterine conditions, such as endometrial ablation for menorrhagia, and uterine artery embolization for symptomatic uterine myomas, has decreased the need for hysterectomy for associated reasons at the time of prolapse surgery. Many procedures were described for uterine suspension, including uterosacral ligament uterine suspension and sacrospinous hysteropexy [4,5]. Uterosacral ligament uterine suspension can be performed using a vaginal, abdominal, or laparoscopic ap-
Rosenblatt et al.
Laparoscopic Sacrocervicopexy
proach, and success rates of 79% to 100% were reported with great variations in length of follow-up and definition of success [5–11]. Sacrospinous hysteropexy was reported in a few case series with success rates of 79% to 97% [12–21]. Sacrocervicopexy is a procedure similar to sacrocolpopexy, in which a graft material is used to suspend the posterior vaginal apex and cervix to the anterior longitudinal ligament of the sacrum [1]. Sacrocervicopexy can either be performed with uterine preservation or after supracervical hysterectomy. We report our results of a series of patients who underwent laparoscopic sacrocervicopexy (LSCx) (with uterine preservation) using synthetic mesh for the treatment of symptomatic uterine prolapse.
Methods This study is a retrospective case series of 40 women with uterine prolapse who underwent LSCx from August 2002 through December 2005 by the same surgeon (P. L. R.). Patients with symptomatic uterine prolapse who desired surgical correction were counseled regarding hysterectomy or uterine preservation. All patients had normal cervical cytology performed within 12 months of the procedure. Preoperative evaluation included pelvic organ prolapse quantitative (POP-Q) assessment [22], cotton-swab determination of urethral mobility, postvoid residual by ultrasound or catheterization, and multichannel urodynamic testing with prolapse reduction (which included uroflowmetry, complex cystometry, leak point pressure determination, and urethral pressure profilometry). Patients who indicated stress incontinence during urodynamic testing underwent a concomitant continence procedure at the time of surgery. All patients were required to take an oral bowel preparation the day before surgery. Preoperative antibiotics (1 g of cefazolin intravenously; if penicillin allergic, the patient was given clindamycin [600 mg] intravenously) were administered to all patients, and patients received 2 more doses of intravenous antibiotics postoperatively. Our technique for LSCx underwent only a few minor modifications during the course of the study period (as described below), but the basic steps remain unchanged. The patient is positioned in a low-lithotomy position with sequential compression devices and a Foley catheter is placed in the bladder. A plastic uterine manipulator (ZUMI; Cooper Surgical, Trumbull, CT) is placed into the cervix. After pneumoperitoneum is established, a 5-mm trocar is inserted in the umbilicus and 2 10-mm trocars are placed just below the level of the umbilicus, lateral to the inferior epigastric vessels. A 5-mm trocar is also inserted suprapubically. With the patient in the Trendelenburg position, the procedure begins with identification of the structures of the presacral space, including the common iliac arteries and the middle sacral vessels, which can often be seen through the intact peritoneum over the sacral promontory. Special at-
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tention is paid to identifying the location of the left common iliac vein, which is medial to the left common iliac artery and can be more difficult to visualize during laparoscopy, because of the effects of pneumoperitoneum. In addition, the course of the right ureter is positively identified by its peristalsis. The peritoneum is elevated over the sacral promontory and incised using monopolar scissors. This dissection is carried down to the anterior longitudinal ligament of the sacrum, with care taken to avoid injury to the middle sacral vessels. The peritoneal incision is then carried caudad into the pelvis, lateral to the rectosigmoid and medial to the right uterosacral ligament to avoid injury to the right ureter. A plastic probe is then placed in the rectum (Apple Medical, Bolton, MA) to assist with dissection in the rectovaginal space. An incision is made in the peritoneum posterior to the cervix and the rectovaginal space is developed, exposing the posterior rectovaginal fascia. A 10- ⫻ 3-cm piece of synthetic mesh (PelviTex; Bard Urological Division, Covington, GA or Mersilene; Ethicon, Somerville, NJ) is introduced through one of the lateral ports and then sutured to the distal uterosacral ligaments (at their insertion into the cervix) and to the posterior rectovaginal fascia. In all, 22 patients received Mersilene polyester mesh and 18 patients received PelviTex polypropylene mesh. Approximately 8 to 10 CV-0 GoreTex sutures (W.L. Gore, Flagstaff, AZ) on a THX-26 needle are used to secure the mesh to the vagina and cervix, using an extracorporeal knot-tying technique. The mesh is then sutured to the anterior longitudinal ligament of the sacral promontory with 2 to 3 of the same sutures, without undue tension on the mesh. After the suspension, the mesh is completely covered by reapproximating the peritoneum over the mesh. This was initially accomplished with interrupted figure-of-eight sutures (GoreTex). More recently, a running stitch of 2-0 polydioxanone with absorbable clips (Lapra-Ty; Ethicon EndoSurgery, Cincinnati, OH) was used for reperitonealization. Concomitant procedures were performed as indicated by the POP-Q examination, urodynamic testing, or both. Cystoscopy was performed at the conclusion of each case and ureteral function was confirmed by the observation of brisk efflux of indigo carmine dye from each ureteral orifice. Patients were admitted to the hospital overnight and had sequential compression devices on their lower extremities until ambulating. Voiding trials were performed on the first postoperative day, and patients who failed their voiding trials were seen on an outpatient basis within 1 to 3 days to repeat the trial. Patients were asked to refrain from heavy lifting (⬎10 lb) and take stool softeners for 8 to 10 weeks. Postoperatively, patients were seen at 2 weeks, 6 weeks, 6 months, 12 months, and then annually. Pelvic organ prolapse quantitative examinations with maximal straining were performed at each visit (with the exception of the 2-week postoperative visit). Postoperative POP-Q compar-
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Table 1
Table 2
Patient demographics
Concomitant surgery
Variable
Mean (⫾SD) or count (%)
Procedure
n
Age (yr) Weight (lb) Height (in.) Body mass index Median parity Menopausal (n) Hormone replacement therapy (n) Sexually active (n) Pessary use before surgery (n)
48.41 ⫾ 8.49 147.9 ⫾ 26.4 64.6 ⫾ 2.6 24.8 ⫾ 4.4 2 12 2
Laparoscopic paravaginal repair Midurethral sling Posterior colporrhaphy Laparoscopic supracervical hysterectomy Laparoscopic Burch Anterior colporrhaphy Cervical amputation
27 24 11 3 4 2 2
(95% CI 45.7–51.13) (95% CI 139.37–156.47) (95% CI 63.77–65.50) (95% CI 23.37–26.24) (range 0–4) (30%) (5%)
28 (70%) 19 (47.5%)
isons were performed with the Wilcoxon test as these measurements are not normally distributed. Results From August 2002 through December 2005, 40 women underwent LSCx for symptomatic uterine prolapse. The setting was an academic, community teaching hospital and all the procedures were performed by the same attending surgeon (P. L. R.) and assisted by a urogynecology fellow. All women either requested uterine preservation initially, or were offered hysterectomy versus uterine preservation and they chose the latter after extensive counseling. The mean age of the women was 48.4 years old (95% CI 45.7–51.13) and the median parity was 2.0. Of the women in the group, 30% (12 of 40) were postmenopausal. The mean body mass index for the group was 24.80 (range: 19 –39), and 70% (28 of 40) of the patients were sexually active (Table 1). Of the women, 67% had coexisting cystocele, 27.5% had rectocele, and 60% had subjective symptoms of stress urinary incontinence. Preoperative urodynamic testing with prolapse reduction revealed genuine urinary stress incontinence in 22 (55%) of 40 patients. Eighteen (45%) patients had subjective symptoms of stress urinary incontinence in their intake evaluation. Of these patients, 5 had no stress incontinence on urodynamic testing, whereas 9 patients, who had no symptoms subjectively, tested positive for potential stress incontinence when their prolapse was reduced. In all, 85% (34 of 40) of the patients in the study group underwent concomitant reconstructive procedures. Of the 40 patients, 67.5% underwent laparoscopic paravaginal repair, 5% underwent anterior colporrhaphy, 27.5% underwent posterior repair, and 60% underwent midurethral sling. Two patients with a clinically elongated cervix had partial amputation of the cervix at the time of the sacrocervicopexy (Table 2). The mean intraoperative blood loss was 86.7 mL (95% CI 65.09 –108.36). One patient who had an estimated blood loss of 300 mL (predominantly during the concomitant paravaginal repair portion of the case) was transfused post-
operatively as she was mildly symptomatic. The mean operative time was 248 minutes, which included concomitant procedures (Table 3). Although not officially recorded in the medical record, the time required to perform the LSCx portion was consistently 90 to 100 minutes. No intraoperative complications related to the sacrocervicopexy portion of the procedure occurred and no conversions to laparotomy or vaginal surgery existed at the time of the original procedure. One patient had a left-sided bladder perforation during the tension-free vaginal tape suburethral sling portion of the procedure. Postoperatively, complications included the following. One patient was followed for a minor mesh/suture erosion from the sacrocervicopexy that was managed conservatively without surgery. One patient was noted to have a small umbilical hernia at her 1-year postoperative visit. She had discussed surgical correction of this, however, in the interim underwent a laparoscopic sigmoid colectomy for newly diagnosed adenocarcinoma of the sigmoid colon. One patient was taken to the operating department 23 days after her initial surgery with a previously unrecognized rectal injury. The patient underwent an exploratory laparotomy with drainage of pelvic abscesses, proximal proctectomy, removal of the mesh, small bowel segment resection, left colectomy, and Hartman colostomy. The injury to the rectum was isolated and it appeared to have occurred secondary to the running suture used to reperitonealize over the mesh. The patient’s colostomy was reversed 5 months later. In all, 23 patients were evaluated at 12 months, and 28 patients were seen at 6 months postoperatively. To date, all are symptomatically cured of their prolapse (mean follow-up 8.4 months). Success was defined in this study as an improvement in point C from the preoperative position and that point C was above the hymen postoperatively. Preop-
Table 3
Intraoperative data Mean (⫾SD) EBL (including concomitant procedures) (mL) Operating department time (min) EBL ⫽ estimated blood loss.
86.7 ⫾ 67.6 (95% CI 65.09–108.36) 248.0 ⫾ 54.8 (95% CI 226.86–268.08)
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Fig. 1. Average point C (in cm) with pelvic organ prolapse quantitative exams preoperatively and postoperatively.
erative POP-Q evaluation revealed a mean point C of –1.13 (median –2; range: ⫹9 to – 4), and mean point Aa of – 0.69 (median –1; range: ⫹2 to –3) (Fig. 1). No patient failed using our definition of success for apical suspension. Table 4 shows the median POP-Q measurements for the 40 patients. Discussion There are several factors that may be associated with the decision to consider uterine preservation during prolapse surgery, including but not limited to the risk of intraoperative and postoperative complications, availability of global endometrial ablation techniques for abnormal uterine bleeding, and the potential role of the cervix in sexual response. A recent systematic review comparing total with supracervical hysterectomy, however, did not indicate any signifi-
cant difference in measures of postoperative sexual function, nor were there any differences in constipation or in incontinence [23]. Patients, however, increasingly want to have justification for having their uterus removed when no pathology or disease other than pelvic floor relaxation exists. The concept of uterine preservation at the time of prolapse surgery is certainly not novel. In 2001, authors reported on their use of Teflon mesh (Bard Europe, London, UK) to attach the uterine isthmus to the anterior longitudinal ligament of the first or second sacral vertebra in 13 women with symptomatic uterovaginal prolapse. No complications occurred, and at a mean follow-up of 16 months, only 1 patient had first-degree uterine prolapse [24]. A small series of 3 patients who underwent abdominal sacrocervicopexy for preservation of fertility was published [25]. No complications or recurrences were reported during the follow-up period. One study described a series of 81 patients who underwent laparoscopic sacral suture hysteropexy for uterine prolapse and noted a 94% success rate with objective examinations. It also stated that 82% of patients were satisfied with surgery [26]. Absolute and relative contraindications to LSCx are similar to those for any laparoscopic surgery. Patients who are obese present a special challenge for this procedure in that retraction of the bowel and dissection over the sacral promontory, in addition to entry into the rectovaginal space, is more difficult. Sacrocolpopexy was associated with the risk of mesh erosion [1], and the vaginal apex seems to be particularly vulnerable to this complication. Retention of the cervix may lower the risk of mesh erosion compared with sacrocolpopexy for several reasons. After hysterectomy, the vaginal cuff may have a reduced vascular supply secondary to scar tissue, which can compromise the healing process and lead to erosion. On the other hand, a comprehensive review of sacrocolpexy found a variable risk of erosion with concomitant hysterectomy [1]. In addition, because this procedure does not require an anterior extension, less mesh is used compared with sacrocolpopexy. Reduction of mesh load is thought to be a factor in reducing the risk of mesh erosion in pelvic reconstructive surgery.
Table 4
Median pelvic organ prolapse quantitative measurements preoperatively and postoperatively Measurement
Preoperatively
6 wks postoperatively
6 mos postoperatively
1 yr postoperatively
Aa Ba C GH PB TVL Ap Bp D C-D discrepancy Stage
–1 0 –2 4 4 10 –2 –2 –7 6 2
–3 –3 –5 3 4 10 –3 –3 –9 4 0
–2 –2 –5 3 4 10 –3 –3 –10 4 1
–2 –2 –5 3 4 10 –3 –3 –9 4 1
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One scenario that should be considered when one is contemplating LSCx is the route of hysterectomy, should this be required in the future. In all likelihood, vaginal hysterectomy would not be possible, because of both the lack of descent of the cervix and the obliteration of the posterior cul-de-sac with the mesh segment. Either an abdominal or laparoscopic approach could be used as the mesh would not need to be removed for the hysterectomy; vaginal support should not be compromised. If a total hysterectomy is performed, the surgeon would need to dissect posteriorly between the cervix and the synthetic mesh to gain access to the posterior vaginal fornix. One of the limitations of this study is the use of 2 types of mesh during the study period: a type I polypropylene mesh and a type III polyester mesh. Published data suggest that different types of mesh, based on their pore size and filamentous nature, may lead to different erosion rates [27]. We initially used polyester mesh because of its favorable handling characteristics laparoscopically, but changed to the porcine collagen-coated polypropylene mesh to reduce the likelihood of mesh erosion. Fortunately, there was only 1 mesh erosion (Mersilene) in our series to date, which was managed conservatively. We recognize that larger studies will be necessary to address whether patients fare as well with laparoscopic correction of their prolapse as they do with the traditional abdominal approaches. In addition, a learning curve is associated with complicated laparoscopic surgery, as is increased operating department time, which is offset by shorter length of hospital stay and faster return to normal activity. In an era in which patients are more often requesting both minimally invasive surgery and uterine preservation, we believe that this approach provides a viable surgical alternative for uterovaginal prolapse. References 1. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104:805– 823. 2. Marchionni M. True incidence of vaginal vault prolapse: thirteen years of experience. J Reprod Med. 1999;44:679 – 684. 3. Nichols D, Randall C. Vaginal Surgery. 3rd ed. Baltimore, MD: Williams and Wilkins; 1989. 4. Donald A. A short history of the operation of colporrhaphy, with remarks on the technique. J Obstet Gynecol Br Emp. 1921;28:356 – 359. 5. Lin L, Ho M, Haessler A, et al. A review of laparoscopic uterine suspension procedures for uterine preservation. Curr Opin Obstet Gynecol. 2005;17:541–546. 6. Medina C, Takacs P. Laparoscopic uterosacral uterine suspension: a minimally invasive technique for treating pelvic organ prolapse. J Minim Invasive Gynecol. 2006;13:472– 475. 7. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-
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specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol. 2000;183:1402–1410. Karram M, Goldwasser S, Kleeman S, Steele A, Vassallo B, Walsh P. High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse. Am J Obstet Gynecol. 2001;185:1339 –1342. Lin LL, Phelps JY, Liu CY. Laparoscopic vaginal vault suspension using uterosacral ligaments: a review of 133 cases. J Minim Invasive Gynecol. 2005;12:216 –220. Silva WA, Pauls RN, Segal JL, Rooney CM, Kleeman SD, Karram MM. Uterosacral ligament vault suspension: five-year outcomes. Obstet Gynecol. 2006;108:225–263. Maher CF, Carey MP, Murray CJ. Laparoscopic suture hysteropexy for uterine prolapse. Obstet Gynecol. 2001;97:1010 –1014. Nieminem K, Huhtala H, Heinonen PK. Anatomic and functional assessment and risk factors of recurrent prolapse after vaginal sacrospinous fixation. Acta Obstet Gynecol Scand. 2003;82:471– 478. Allahdin S, Herd D, Reid BA. Twenty-five sacrospinous ligament fixation procedures in a district general hospital: our experience. J Obstet Gynaecol. 2005;4:361–363. Elghorori MR, Ahmed AA, Sadhukhan M, Al-Taher H. Vaginal sacrospinous fixation: experience in a district general hospital. J Obstet Gynaecol. 2002;22:658 – 662. Maher CF, Carey MP, Slack MC, Murray CJ, Milligan M, Schluter P. Uterine preservation or hysterectomy at sacrospinous colpopexy for uterovaginal prolapse? Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12:381–384. Guner H, Noyan V, Tiras MB, Yildiz A, Yildirim M. Transvaginal sacrospinous colpopexy for marked uterovaginal and vault prolapse. Int J Gynaecol Obstet. 2001;74:165–170. Maher CF, Murray CJ, Carey MP, Dwyer PL, Ugoni AM. Iliococcygeus or sacrospinous fixation for vaginal vault prolapse. Obstet Gynecol. 2001;98:40 – 44. Lantzsch T, Goepel C, Wolters M, Koelbl H, Methfessel HD. Sacrospinous ligament fixation for vaginal vault prolapse. Arch Gynecol Obstet. 2001;265:21–25. Ozcan U, Gungor T, Ekin M, Eken S. Sacrospinous fixation for the prolapsed vaginal vault. Gynecol Obstet Invest. 1999;47:65– 68. Meschia M, Bruschi F, Amicarelli F, Pifarotti P, Marchimi M, Crosignani PG. The sacrospinous vaginal vault suspension: critical analysis of outcomes. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10: 155–159. Sze EGM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997;89:466 – 475. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10 –17. Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev. 2006:CD004993. Leron E, Stantin SL. Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse. Br J Obstet Gynecol. 2001; 108:629 – 633. Karateke A, Gurbuz A, Kabaca C, Mengulluoglu M. Sacrocervicopexy and combined operations involving cases of total uterine prolapse: case reports. Med Princ Pract. 2004;13:164 –168. Krause HG, Goh JT, Sloane K, Higgs P, Carey MP. Laparoscopic sacral suture hysteropexy for uterine prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:378 –381. Chen, CCG, Ridgeway B, Paraiso MFR. Biologic grafts and synthetic meshes in pelvic reconstructive surgery. Clin Obstet Gynecol. 2007; 50:383– 411.
Laparoscopic Sacrocervicopexy for the Treatment of Uterine Prolapse: A Retrospective Case Series Report Peter L. Rosenblatt, MD, David Chelmow, MD, and Tanaz R. Ferzandi, MD, MA* From the Mount Auburn Hospital, Cambridge, Massachusetts (Drs. Rosenblatt and Ferzandi), and New England Medical Center, Boston, Massachusetts (Dr. Chelmow).
ABSTRACT Study Objective: To evaluate apical support in patients desiring uterine preservation with pelvic organ prolapse who underwent laparoscopic sacrocervicopexy. Design: Retrospective case series report (Canadian Task Force classification III). Setting: Academic community teaching hospital. Patients: Forty consecutive women who underwent laparoscopic sacrocervicopexy. Interventions: Synthetic mesh was used to attach the distal uterosacral ligaments and posterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory. Measurements and Main Results: Pelvic organ prolapse quantification system measurements were used and apical support was evaluated using point C. Mean C was ⫺1.13 (⫹9 to ⫺4) preoperatively, ⫺5.28 (⫺3 to ⫺13) at 6 weeks postoperatively, ⫺5.26 (⫺3 to ⫺8) at 6 months postoperatively, and ⫺4.84 (⫺3 to ⫺7) at 1 year postoperatively. Conclusion: Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation. Journal of Minimally Invasive Gynecology (2008) 15, 268 –272 © 2008 AAGL. All rights reserved. Keywords:
Laparoscopy; Sacrocervicopexy; Pelvic organ prolapse; Uterine preservation
Pelvic reconstructive surgery has traditionally been performed using an abdominal or vaginal approach. A review showed the efficacy and safety of abdominal sacrocolpopexy for the treatment of vaginal vault prolapse [1]. Although abdominal sacrocolpopexy is considered by many authorities to be the gold standard in the treatment of vaginal vault prolapse, vaginal approaches to pelvic floor relaxation were advocated by many gynecologic surgeons because of the potential advantages of this less invasive approach. Vaginal operations for vaginal vault prolapse include sacrospinous ligament fixation and uterosacral ligament suspension. These procedures are often used at the time of vaginal hysterectomy to support the vaginal apex and can be used for the treatment of vaginal vault prolapse, which can occur remote from hysterectomy. Vaginal vault The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Tanaz R. Ferzandi, MD, MA, Mount Auburn Hospital, 725 Concord Avenue, #3300, Cambridge, MA 02138. E-mail: [email protected] Submitted September 14, 2007. Accepted for publication January 9, 2008. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ -see front matter © 2008 AAGL. All rights reserved. doi:10.1016/j.jmig.2008.01.001
prolapse was reported to occur in 11.6% of women who undergo hysterectomy for prolapse, but only in 1.8% of women with hysterectomy performed for other indications, such as myomas or dysfunctional uterine bleeding [2]. Vaginal hysterectomy is often recommended for the treatment of uterine prolapse, along with concomitant procedures for coexisting pelvic floor relaxation. Vaginal hysterectomy, however, may be associated with significant morbidity, including intraoperative hemorrhage, cuff cellulitis, and ureteral injury. Almost 2 decades ago, a study pointed out that uterine prolapse is the result of pelvic floor relaxation and the uterus itself is not the cause of prolapse [3]. There was renewed interest among pelvic reconstructive surgeons in uterine preservation at the time of prolapse surgery. Advances in the treatment of benign uterine conditions, such as endometrial ablation for menorrhagia, and uterine artery embolization for symptomatic uterine myomas, has decreased the need for hysterectomy for associated reasons at the time of prolapse surgery. Many procedures were described for uterine suspension, including uterosacral ligament uterine suspension and sacrospinous hysteropexy [4,5]. Uterosacral ligament uterine suspension can be performed using a vaginal, abdominal, or laparoscopic ap-
Rosenblatt et al.
Laparoscopic Sacrocervicopexy
proach, and success rates of 79% to 100% were reported with great variations in length of follow-up and definition of success [5–11]. Sacrospinous hysteropexy was reported in a few case series with success rates of 79% to 97% [12–21]. Sacrocervicopexy is a procedure similar to sacrocolpopexy, in which a graft material is used to suspend the posterior vaginal apex and cervix to the anterior longitudinal ligament of the sacrum [1]. Sacrocervicopexy can either be performed with uterine preservation or after supracervical hysterectomy. We report our results of a series of patients who underwent laparoscopic sacrocervicopexy (LSCx) (with uterine preservation) using synthetic mesh for the treatment of symptomatic uterine prolapse.
Methods This study is a retrospective case series of 40 women with uterine prolapse who underwent LSCx from August 2002 through December 2005 by the same surgeon (P. L. R.). Patients with symptomatic uterine prolapse who desired surgical correction were counseled regarding hysterectomy or uterine preservation. All patients had normal cervical cytology performed within 12 months of the procedure. Preoperative evaluation included pelvic organ prolapse quantitative (POP-Q) assessment [22], cotton-swab determination of urethral mobility, postvoid residual by ultrasound or catheterization, and multichannel urodynamic testing with prolapse reduction (which included uroflowmetry, complex cystometry, leak point pressure determination, and urethral pressure profilometry). Patients who indicated stress incontinence during urodynamic testing underwent a concomitant continence procedure at the time of surgery. All patients were required to take an oral bowel preparation the day before surgery. Preoperative antibiotics (1 g of cefazolin intravenously; if penicillin allergic, the patient was given clindamycin [600 mg] intravenously) were administered to all patients, and patients received 2 more doses of intravenous antibiotics postoperatively. Our technique for LSCx underwent only a few minor modifications during the course of the study period (as described below), but the basic steps remain unchanged. The patient is positioned in a low-lithotomy position with sequential compression devices and a Foley catheter is placed in the bladder. A plastic uterine manipulator (ZUMI; Cooper Surgical, Trumbull, CT) is placed into the cervix. After pneumoperitoneum is established, a 5-mm trocar is inserted in the umbilicus and 2 10-mm trocars are placed just below the level of the umbilicus, lateral to the inferior epigastric vessels. A 5-mm trocar is also inserted suprapubically. With the patient in the Trendelenburg position, the procedure begins with identification of the structures of the presacral space, including the common iliac arteries and the middle sacral vessels, which can often be seen through the intact peritoneum over the sacral promontory. Special at-
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tention is paid to identifying the location of the left common iliac vein, which is medial to the left common iliac artery and can be more difficult to visualize during laparoscopy, because of the effects of pneumoperitoneum. In addition, the course of the right ureter is positively identified by its peristalsis. The peritoneum is elevated over the sacral promontory and incised using monopolar scissors. This dissection is carried down to the anterior longitudinal ligament of the sacrum, with care taken to avoid injury to the middle sacral vessels. The peritoneal incision is then carried caudad into the pelvis, lateral to the rectosigmoid and medial to the right uterosacral ligament to avoid injury to the right ureter. A plastic probe is then placed in the rectum (Apple Medical, Bolton, MA) to assist with dissection in the rectovaginal space. An incision is made in the peritoneum posterior to the cervix and the rectovaginal space is developed, exposing the posterior rectovaginal fascia. A 10- ⫻ 3-cm piece of synthetic mesh (PelviTex; Bard Urological Division, Covington, GA or Mersilene; Ethicon, Somerville, NJ) is introduced through one of the lateral ports and then sutured to the distal uterosacral ligaments (at their insertion into the cervix) and to the posterior rectovaginal fascia. In all, 22 patients received Mersilene polyester mesh and 18 patients received PelviTex polypropylene mesh. Approximately 8 to 10 CV-0 GoreTex sutures (W.L. Gore, Flagstaff, AZ) on a THX-26 needle are used to secure the mesh to the vagina and cervix, using an extracorporeal knot-tying technique. The mesh is then sutured to the anterior longitudinal ligament of the sacral promontory with 2 to 3 of the same sutures, without undue tension on the mesh. After the suspension, the mesh is completely covered by reapproximating the peritoneum over the mesh. This was initially accomplished with interrupted figure-of-eight sutures (GoreTex). More recently, a running stitch of 2-0 polydioxanone with absorbable clips (Lapra-Ty; Ethicon EndoSurgery, Cincinnati, OH) was used for reperitonealization. Concomitant procedures were performed as indicated by the POP-Q examination, urodynamic testing, or both. Cystoscopy was performed at the conclusion of each case and ureteral function was confirmed by the observation of brisk efflux of indigo carmine dye from each ureteral orifice. Patients were admitted to the hospital overnight and had sequential compression devices on their lower extremities until ambulating. Voiding trials were performed on the first postoperative day, and patients who failed their voiding trials were seen on an outpatient basis within 1 to 3 days to repeat the trial. Patients were asked to refrain from heavy lifting (⬎10 lb) and take stool softeners for 8 to 10 weeks. Postoperatively, patients were seen at 2 weeks, 6 weeks, 6 months, 12 months, and then annually. Pelvic organ prolapse quantitative examinations with maximal straining were performed at each visit (with the exception of the 2-week postoperative visit). Postoperative POP-Q compar-
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Journal of Minimally Invasive Gynecology, Vol 15, No 3, May/June 2008
Table 1
Table 2
Patient demographics
Concomitant surgery
Variable
Mean (⫾SD) or count (%)
Procedure
n
Age (yr) Weight (lb) Height (in.) Body mass index Median parity Menopausal (n) Hormone replacement therapy (n) Sexually active (n) Pessary use before surgery (n)
48.41 ⫾ 8.49 147.9 ⫾ 26.4 64.6 ⫾ 2.6 24.8 ⫾ 4.4 2 12 2
Laparoscopic paravaginal repair Midurethral sling Posterior colporrhaphy Laparoscopic supracervical hysterectomy Laparoscopic Burch Anterior colporrhaphy Cervical amputation
27 24 11 3 4 2 2
(95% CI 45.7–51.13) (95% CI 139.37–156.47) (95% CI 63.77–65.50) (95% CI 23.37–26.24) (range 0–4) (30%) (5%)
28 (70%) 19 (47.5%)
isons were performed with the Wilcoxon test as these measurements are not normally distributed. Results From August 2002 through December 2005, 40 women underwent LSCx for symptomatic uterine prolapse. The setting was an academic, community teaching hospital and all the procedures were performed by the same attending surgeon (P. L. R.) and assisted by a urogynecology fellow. All women either requested uterine preservation initially, or were offered hysterectomy versus uterine preservation and they chose the latter after extensive counseling. The mean age of the women was 48.4 years old (95% CI 45.7–51.13) and the median parity was 2.0. Of the women in the group, 30% (12 of 40) were postmenopausal. The mean body mass index for the group was 24.80 (range: 19 –39), and 70% (28 of 40) of the patients were sexually active (Table 1). Of the women, 67% had coexisting cystocele, 27.5% had rectocele, and 60% had subjective symptoms of stress urinary incontinence. Preoperative urodynamic testing with prolapse reduction revealed genuine urinary stress incontinence in 22 (55%) of 40 patients. Eighteen (45%) patients had subjective symptoms of stress urinary incontinence in their intake evaluation. Of these patients, 5 had no stress incontinence on urodynamic testing, whereas 9 patients, who had no symptoms subjectively, tested positive for potential stress incontinence when their prolapse was reduced. In all, 85% (34 of 40) of the patients in the study group underwent concomitant reconstructive procedures. Of the 40 patients, 67.5% underwent laparoscopic paravaginal repair, 5% underwent anterior colporrhaphy, 27.5% underwent posterior repair, and 60% underwent midurethral sling. Two patients with a clinically elongated cervix had partial amputation of the cervix at the time of the sacrocervicopexy (Table 2). The mean intraoperative blood loss was 86.7 mL (95% CI 65.09 –108.36). One patient who had an estimated blood loss of 300 mL (predominantly during the concomitant paravaginal repair portion of the case) was transfused post-
operatively as she was mildly symptomatic. The mean operative time was 248 minutes, which included concomitant procedures (Table 3). Although not officially recorded in the medical record, the time required to perform the LSCx portion was consistently 90 to 100 minutes. No intraoperative complications related to the sacrocervicopexy portion of the procedure occurred and no conversions to laparotomy or vaginal surgery existed at the time of the original procedure. One patient had a left-sided bladder perforation during the tension-free vaginal tape suburethral sling portion of the procedure. Postoperatively, complications included the following. One patient was followed for a minor mesh/suture erosion from the sacrocervicopexy that was managed conservatively without surgery. One patient was noted to have a small umbilical hernia at her 1-year postoperative visit. She had discussed surgical correction of this, however, in the interim underwent a laparoscopic sigmoid colectomy for newly diagnosed adenocarcinoma of the sigmoid colon. One patient was taken to the operating department 23 days after her initial surgery with a previously unrecognized rectal injury. The patient underwent an exploratory laparotomy with drainage of pelvic abscesses, proximal proctectomy, removal of the mesh, small bowel segment resection, left colectomy, and Hartman colostomy. The injury to the rectum was isolated and it appeared to have occurred secondary to the running suture used to reperitonealize over the mesh. The patient’s colostomy was reversed 5 months later. In all, 23 patients were evaluated at 12 months, and 28 patients were seen at 6 months postoperatively. To date, all are symptomatically cured of their prolapse (mean follow-up 8.4 months). Success was defined in this study as an improvement in point C from the preoperative position and that point C was above the hymen postoperatively. Preop-
Table 3
Intraoperative data Mean (⫾SD) EBL (including concomitant procedures) (mL) Operating department time (min) EBL ⫽ estimated blood loss.
86.7 ⫾ 67.6 (95% CI 65.09–108.36) 248.0 ⫾ 54.8 (95% CI 226.86–268.08)
Rosenblatt et al.
Laparoscopic Sacrocervicopexy
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Fig. 1. Average point C (in cm) with pelvic organ prolapse quantitative exams preoperatively and postoperatively.
erative POP-Q evaluation revealed a mean point C of –1.13 (median –2; range: ⫹9 to – 4), and mean point Aa of – 0.69 (median –1; range: ⫹2 to –3) (Fig. 1). No patient failed using our definition of success for apical suspension. Table 4 shows the median POP-Q measurements for the 40 patients. Discussion There are several factors that may be associated with the decision to consider uterine preservation during prolapse surgery, including but not limited to the risk of intraoperative and postoperative complications, availability of global endometrial ablation techniques for abnormal uterine bleeding, and the potential role of the cervix in sexual response. A recent systematic review comparing total with supracervical hysterectomy, however, did not indicate any signifi-
cant difference in measures of postoperative sexual function, nor were there any differences in constipation or in incontinence [23]. Patients, however, increasingly want to have justification for having their uterus removed when no pathology or disease other than pelvic floor relaxation exists. The concept of uterine preservation at the time of prolapse surgery is certainly not novel. In 2001, authors reported on their use of Teflon mesh (Bard Europe, London, UK) to attach the uterine isthmus to the anterior longitudinal ligament of the first or second sacral vertebra in 13 women with symptomatic uterovaginal prolapse. No complications occurred, and at a mean follow-up of 16 months, only 1 patient had first-degree uterine prolapse [24]. A small series of 3 patients who underwent abdominal sacrocervicopexy for preservation of fertility was published [25]. No complications or recurrences were reported during the follow-up period. One study described a series of 81 patients who underwent laparoscopic sacral suture hysteropexy for uterine prolapse and noted a 94% success rate with objective examinations. It also stated that 82% of patients were satisfied with surgery [26]. Absolute and relative contraindications to LSCx are similar to those for any laparoscopic surgery. Patients who are obese present a special challenge for this procedure in that retraction of the bowel and dissection over the sacral promontory, in addition to entry into the rectovaginal space, is more difficult. Sacrocolpopexy was associated with the risk of mesh erosion [1], and the vaginal apex seems to be particularly vulnerable to this complication. Retention of the cervix may lower the risk of mesh erosion compared with sacrocolpopexy for several reasons. After hysterectomy, the vaginal cuff may have a reduced vascular supply secondary to scar tissue, which can compromise the healing process and lead to erosion. On the other hand, a comprehensive review of sacrocolpexy found a variable risk of erosion with concomitant hysterectomy [1]. In addition, because this procedure does not require an anterior extension, less mesh is used compared with sacrocolpopexy. Reduction of mesh load is thought to be a factor in reducing the risk of mesh erosion in pelvic reconstructive surgery.
Table 4
Median pelvic organ prolapse quantitative measurements preoperatively and postoperatively Measurement
Preoperatively
6 wks postoperatively
6 mos postoperatively
1 yr postoperatively
Aa Ba C GH PB TVL Ap Bp D C-D discrepancy Stage
–1 0 –2 4 4 10 –2 –2 –7 6 2
–3 –3 –5 3 4 10 –3 –3 –9 4 0
–2 –2 –5 3 4 10 –3 –3 –10 4 1
–2 –2 –5 3 4 10 –3 –3 –9 4 1
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One scenario that should be considered when one is contemplating LSCx is the route of hysterectomy, should this be required in the future. In all likelihood, vaginal hysterectomy would not be possible, because of both the lack of descent of the cervix and the obliteration of the posterior cul-de-sac with the mesh segment. Either an abdominal or laparoscopic approach could be used as the mesh would not need to be removed for the hysterectomy; vaginal support should not be compromised. If a total hysterectomy is performed, the surgeon would need to dissect posteriorly between the cervix and the synthetic mesh to gain access to the posterior vaginal fornix. One of the limitations of this study is the use of 2 types of mesh during the study period: a type I polypropylene mesh and a type III polyester mesh. Published data suggest that different types of mesh, based on their pore size and filamentous nature, may lead to different erosion rates [27]. We initially used polyester mesh because of its favorable handling characteristics laparoscopically, but changed to the porcine collagen-coated polypropylene mesh to reduce the likelihood of mesh erosion. Fortunately, there was only 1 mesh erosion (Mersilene) in our series to date, which was managed conservatively. We recognize that larger studies will be necessary to address whether patients fare as well with laparoscopic correction of their prolapse as they do with the traditional abdominal approaches. In addition, a learning curve is associated with complicated laparoscopic surgery, as is increased operating department time, which is offset by shorter length of hospital stay and faster return to normal activity. In an era in which patients are more often requesting both minimally invasive surgery and uterine preservation, we believe that this approach provides a viable surgical alternative for uterovaginal prolapse. References 1. Nygaard IE, McCreery R, Brubaker L, Connolly A, Cundiff G, Weber AM, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104:805– 823. 2. Marchionni M. True incidence of vaginal vault prolapse: thirteen years of experience. J Reprod Med. 1999;44:679 – 684. 3. Nichols D, Randall C. Vaginal Surgery. 3rd ed. Baltimore, MD: Williams and Wilkins; 1989. 4. Donald A. A short history of the operation of colporrhaphy, with remarks on the technique. J Obstet Gynecol Br Emp. 1921;28:356 – 359. 5. Lin L, Ho M, Haessler A, et al. A review of laparoscopic uterine suspension procedures for uterine preservation. Curr Opin Obstet Gynecol. 2005;17:541–546. 6. Medina C, Takacs P. Laparoscopic uterosacral uterine suspension: a minimally invasive technique for treating pelvic organ prolapse. J Minim Invasive Gynecol. 2006;13:472– 475. 7. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Bilateral uterosacral ligament vaginal vault suspension with site-
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