Jennifer T. Anger and Karyn S. Eilber (eds.)The Use of Robotic Technology in Female Pelvic Floor Reconstruction https://doi.org/10.1007/978-3-319-59611-2_9

9. Sacrohysteropexy

Bilal Chughtai¹ and Dominique Thomas¹

(1)

Department of Urology, Weill Cornell Medicine/New-York Presbyterian, 425 East 61st Street, 12th Floor, New York, NY 10065, USA

Bilal Chughtai

Email: bic9008@med.cornell.edu

Keywords

Pelvic Organ Prolapse (POP)Uterine-preservationSacrohysteropexyAbdominalLaparoscopicRobot-assistedSexual functionPelvic floorMeshSuture

Introduction

Pelvic organ prolapse (POP) affects an increasing number of women over the age of 50 as the aging population grows in size [1, 2]. An estimated 300,000 procedures to correct this condition are performed annually in the US alone [3]. Over the last several years, interest in uterine-preservation has been on the rise due to a woman’s desire to maintain her sense of self, prolong her childbearing potential, and preserve sexual function [4, 5].

The appropriate surgical approach for patients with POP depends on a number of different factors including the degree of prolapse , the patient’s general health status, her current physical activity level, desire for sexual function, and the surgeon’s experience and skill with the procedure. Vaginal hysterectomy with apical suspension has been the most common approach of correcting POP [6]; however, a hysterectomy does have significant long-term sequelae that some women with POP are not willing to accept.

Reasons to Utilize a Uterine-Sparing Approach

An increasing number of women are opting for uterine-sparing surgery at the time of POP surgery for a multitude of reasons, including their desire to prolong their childbearing years and maintain a sense of self [6, 7]. In a study of 213 women in which surgical outcomes were similar across different procedure types, 36% preferred uterine-preservation, 20% chose hysterectomy, and 44% had no preference. If uterine-preservation was perceived as being superior, then 46% preferred this method compared to 11% for hysterectomy. Interestingly, even when hysterectomy had a higher success profile, uterine-preservation still remained a popular choice at 21%. Importantly, women who believed the uterus was important to their sense of self had increased odds for preserving their uterus (OR = 28.2; 95% CI, 5.00–158.7) [4].

Hysterectomy has been perceived to also have significant effects on a woman’s personality and femininity, as well as her postoperative sexual function [8]. Different factors such as nerve damage and shortening of the vagina following a hysterectomy can all lead to a negative impact on a woman’s self-esteem and sexual function. Thus, the utilization of uterine-preserving procedures can help to boost a women’s body image, her overall self-esteem, and her sexual femininity [9]. It is important to counsel women that a supracervical hysterectomy should not impact either sexual function or hormonal status , as this is a common misconception among women. One disadvantage of preserving the uterus is that women who opt for these procedures are at continued risk for cervical and endometrial cancer [10].

However, because a woman’s pelvic anatomy is not altered during uterine-sparing surgery, there are fewer complications such as shorter length of hospital stay, less intraoperative bleeding, and decreased operating times. Studies demonstrating the benefits of uterine-preservation have given momentum to the healthcare field to develop better procedures for POP surgery. The known benefits are faster healing times, less invasive surgery, and a reduction in postoperative risks. In a study by Dietz et al., women were randomized to either undergo a vaginal hysterectomy or sacrospinous hysteropexy [11]. They evaluated recovery time, anatomical outcomes, functional outcomes, and quality of life [11]. Women who did not have their uterus removed took less time to return to work (43 days vs. 66 days, p = 0.02) [11]. Both the vaginal hysterectomy and sacrohysteropexy were comparable in terms of functional outcomes and quality of life. However, women who underwent vaginal hysterectomy had a lower incidence of stage 2 uterine descent (3%) when compared to sacrohysteropexy (27%).

Sacrohysteropexy , a uterine-preserving surgical technique, can be achieved via many different surgical approaches including open abdominal, traditional laparoscopy, and robotic-assisted laparoscopy. Despite this, there is no real data explicitly stating which method is superior [9, 10, 12]. When choosing an appropriate technique for a surgical candidate, many factors bear importance such as the surgeon’s experience and the patient’s general health status.

Abdominal Sacrohysteropexy

The abdominal sacrohysteropexy (ASH ) may require both transvaginal and transabdominal access [13, 14]. Patients are placed in a low lithotomy position, and a midline infraumbilical or Pfannenstiel incision is made to enter the peritoneal cavity [15]. As described by Barranger et al., “… a transverse incision was made through the peritoneum between the uterus and the bladder…Polyester fiber mes h, roughly 3–4 cm wide, was then attached to the anterior [vaginal] wall, with four or five stitches of interrupted nonabsorbable suture, which were then passed through the right and left broad ligaments and then attached to the posterior cervix” [15]. Another mesh is attached to the posterior vaginal wall in similar fashion. In the posterior peritoneum, an incision is made over the sacral promontory, and the anterior and posterior meshes are then attached to the ligament overlying the sacral promontory with two nonabsorbable sutures to elevate the vagina and uterus. The original peritoneal incision can then be closed to cover the mesh using a continuous suture. Care should be taken to avoid the mesocolon and the right ureter [15].

Barranger et al. evaluated the long-term efficacy of ASH in women with prolapse. A total of 30 women with an average age of 35.7 years who underwent the uterine-preserving technique were included in the study between 1987 and 1999 [15]. All women simultaneously underwent a Burch procedure and posterior colporrhaphy. Intraoperative and postoperative complications were relatively low in this cohort, at 6.6% and 13.3%, respectively. Mean follow-up was 94.6 months. Two cases (6.6%) presented with recurrent prolapse at the last physical examination, and one of these patients required surgical retreatment because of symptomatic prolapse, specifically the anterior compartment. No other patients presented with recurrent prolapse, nor did they need surgical re-intervention. In conclusion, ASH was demonstrated to be a safe and effective treatment for women with uterine-prolapse who are of childbearing age.

Costantini et al. evaluated the use of sacrohysteropexy for POP, aiming to report on extended follow-up in 55 patients who underwent the uterine-preserving method [14]. All the participants in the study were followed on an annual basis. Voiding and storage symptoms resolved postoperatively in 42 (93.4%) and 30 (83.3%) patients, respectively. All patients retained sexual activity [14]. De novo stress urinary incontinence was exhibited in four patients. In summary, this procedure was effective in treating not only POP, but it was also effective in preserving postoperative sexual function.

In another series, Leron and colleagues reported on sacrohysteropexy in 13 women [16]. The mean age of the cohort was 38 years. In total, 12 women had second-degree prolapse and one patient presented with third-degree prolapse. There were no reported intraoperative or postoperative complications. Mean follow-up was 16 months, and at this time period, only one woman had first-degree prolapse [16]. Preoperatively, four women (30.8%) reported constipation, and this number increased to seven (53.8%) women postoperatively [16].

An additional study evaluatin g abdominal sacrohysteropexy reported on the results of 20 women with uterine-prolapse [17]. The mean age of the participants was not mentioned, but mean follow-up was 25 months. Postoperatively, 19 patients expressed that their sexual function had improved, while three of these patients reported dyspareunia [17]. Postoperative quality of life (QOL) and symptom inventory scores were significantly lower (improved) compared to those taken at baseline, indicating that this cohort had a high rate of satisfaction and no symptoms related to prolapse following the procedure.

Although ASH has acceptable reported outcomes, potential complication s of abdominal sacrohysteropexy include bowel injury, small bowel obstruction, wound-site infection, and recurrent prolapse [15, 17]. Dietz et al. reported recurrent prolapse in 22% of women [18].

Laparoscopic Sacrohysteropexy

The two main laparoscopic sacrohysteropexy techniques include laparoscopic suture sacrohysteropexy (LSH ) and laparoscopic mesh sacrohysteropexy (LMH) [12]. Either laparoscopic technique is very difficult compared to the open abdominal approach. The surgeon has to not only be well-versed in laparoscopy, but also needs to be very sound with their knowledge of the pelvic as well as the retroperitoneal anatomy.

The advantages of laparoscopic sacrohysteropexy over an open approach are shorter recovery, significantly less blood loss, and more readily visible anatomy. Postoperatively, women experience less pain, length of stay (LOS) in the hospital is much shorter, aesthetically the incision is much smaller and less visible, while maintaining sexual function and vaginal anatomy . Furthermore, the number of intraoperative adhesions is relatively low, which can prevent infertility in the future. This procedure is performed similarly to the open sacrohysteropexy described above [15].

Suture Sacrohysteropexy

Suture sacrohysteropexy is a safe and reliable method for women who need an effective treatment for the management of uterine POP, but wish to avoid the use of mesh. This procedure is unique in that the uterosacral ligaments are attached to the cervix following the closure of the pouch of Douglas. Krause et al. describes the procedure by first introducing a 10-mm laparoscope using the Hasson technique. A total of three ports are inserted: one at each iliac fossa and one suprapubically at the midline. The supravaginal portion of the posterior cervix is suspended from the sacral promontory using suture material that is monofilamentous and nonabsorbable. Exact suture type was not described. Another set of sutures are placed at the posterior end of the cervix and at the insertions of the uterosacral ligaments attached to the promontory, where a stitch is employed back towards the cervix [19].

A study by Maher et al. evaluated laparoscopic suture hysteropexy in 43 women [20]. Mean follow-up was 12 ± 7 months and mean operative time was 42 ± 15 min. The mean blood loss was less than 50 mL. During the follow-up period, it was found that 35 (81%) patients had no symptoms of prolapse. Furthermore, 34 (79%) had no evidence of prolapse on exam. Interestingly, two women subsequently sustained pregnancies without prolapse. Both women underwent elective Cesarean delivery. This procedure is very effective in correcting the prolapse without rendering the cervix incompetent for successful pregnancy.

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