Arch Gynecol Obstet (2007) 276:225–229 DOI 10.1007/s00404-006-0285-1

O RI G I NAL ART I C LE

Laparoscopic uterosacral ligaments plication for the treatment of uterine prolapse Stefano Uccella · Fabio Ghezzi · Valentino Bergamini · Maurizio Serati · Antonella Cromi · Massimo Franchi · Pierfrancesco Bolis

Received: 1 September 2006 / Accepted: 2 November 2006 / Published online: 10 December 2006 © Springer-Verlag 2006

Abstract Objective To present preliminary results of a simple, minimally interventional, uterus-sparing procedure for uterine prolapse repair. Methods This prospective study was undertaken on women with symptomatic uterine prolapse ¸2nd stage, who declined hysterectomy at the time of prolapse surgery. A 10 mm laparoscope and three 5 mm ancillary trocars were used to perform the procedure. The uterosacral ligament was invested with a nonabsorbable suture. A total of three helical type sutures were placed full-thickness in the uterosacral ligament, beginning in the distal third of the ligament. The ends of the suture were tied with an extra-corporeal knot-tying technique on each side, thus shortening the ligaments. Finally, the round ligaments were plicated to restore the uterus to its correct anatomic position. No additional surgical procedure was performed concomitantly. Results Ten patients underwent laparoscopic uterosacral ligaments plication for the treatment of symptomatic uterine prolapse. The median (range) patients age was 45.5 years (36–66). Five (50%) patients were premenopausal and 3 (60%) had not completed their family. The median operating time was 22.5 min (20–45). No intraoperative complications occurred. The median follow-up time was 21 months (range 15–33). The S. Uccella (&) · F. Ghezzi · M. Serati · A. Cromi · P. Bolis Department of Obstetrics and Gynecology, University of Insubria, Piazza Biroldi 1, 21100 Varese, Italy e-mail: [email protected] V. Bergamini · M. Franchi Department of Obstetrics and Gynecology, University of Verona, Verona, Italy

median postoperative diVerence in POP-Q point C was ¡3 cm (range 0 to ¡5). Eight (80%) patients were objectively cured at the last follow-up evaluation and all of them reported a complete resolution of their symptoms. Two women had prolapse recurrence and underwent vaginal hysterectomy 7 and 24 months after primary surgery, respectively. Conclusion Laparoscopic uterosacral ligaments plication is a minimally invasive and straightforward simple procedure that appears to be a safe and eVective treatment option for women with uterovaginal prolapse who desire uterine preservation. Keywords Hysteropexy · Laparoscopy · Uterine prolapse · Uterine suspension · Utero-sacral ligaments plication

Introduction Uterine prolapse is a major health issue aVecting a large segment of the female population. Although surgically managed cases represent only a small fraction of symptomatic patients, it is estimated that 11% of all women undergoes some type of surgical procedure to correct prolapsed pelvic organs during their lifetime [1]. The rate of pelvic organ prolapse surgery increases with advancing age, peaking in the sixth decade. However, a national survey in the United States showed that 18% of prolapse procedures were performed in women aged 20–40 years and hysterectomies for prolapse were most commonly performed in the younger women (<50 years old) [2]. Hysterectomy, alone or in combination with other procedures, is very frequently implemented in the

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approach to symptomatic uterine prolapse, making this condition the third cause of hysterectomy in the USA [3]. In the last decade a trend toward hysterectomy alternatives for benign gynaecologic disorders has been observed in women health care. A growing number of women are declining hysterectomy for the delay in childbearing to a later age, the belief that the uterus plays a role in the perceived sexual satisfaction or the desire to avoid major surgery. Moreover, hysterectomy fails to address the underlying deWciency of the pelvic supportive system and concerns have been raised about the long-term eVects of this procedure on urinary continence and pelvic Xoor support [4–7]. Despite well-designed prospective comparative studies of uterovaginal prolapse surgery with and without hysterectomy are lacking, the current body of medical literature supports the concept that pelvic Xoor reconstruction with uterine preservation is a viable and safe option [8, 9]. With advances in minimally invasive surgery and laparoroscopic surgical skills, several authors have proposed uterus-sparing laparoscopic procedures for the management of uterine prolapse, often including the use of meshes [10–13]. The ideal treatment option would be easy to perform, it would provide a deWnite cure and relieve symptoms while minimizing surgical morbidity (also related to the use of foreign body materials), it would preserve childbearing potential and satisfactory sexual function, and it would not compromise other procedures to follow. To date, the paucity of data in the literature does not allow to determine the most appropriate approach to prolapse surgery in candidates for uterine preservation. We present our experience with a simple, minimally interventional procedure for uterine prolapse repair involving laparoscopic uterosacral ligaments plication.

Arch Gynecol Obstet (2007) 276:225–229

those of the International Continence Society [14]. Pelvic organ prolapse was evaluated with the patients in lytotomic position and using a Sims speculum during a Valsalva maneuver. We deWned the uterine prolapse according to the pelvic organ prolapse quantiWcation (POP-Q) system (according to the standardization of the terminology of lower urinary tract function made by the ICS and published in 2003) [15]. Clinical examination was performed in order to identify which of the three fascial levels of the pelvic Xoor (according to DeLancey anatomical theory [16]) was deWcient and women with deWcit of the Wrst level (i.e., utero-sacral and cardinal ligaments) were included. Inclusion criteria were symptomatic uterine prolapse ¸2nd stage; desire to preserve the uterus, negative cervical cytology and no abnormal uterine bleeding. The concomitant presence of anterior or posterior vaginal prolapse ·2nd stage and/or urinary incontinence were not considered as exclusion criteria. All patients were extensively counselled on the possible alternative surgical treatments and gave their written consent to the procedure. No concomitant surgical procedure was performed. Follow-up evaluations were scheduled 1 and 3 months post-operatively, and every 3 months. At every follow-up visit, patients were examined using physical and ultrasonographic examination, urinary voiding diary, urine analysis, complete urodynamic testing and we asked about prolapse symptoms as it was done pre-operatively. We deWned as objectively cured all women with a POP-Q stage ·1. Postoperative evaluations were performed in all cases by a non-surgical co-author. Subjective cure was deWned as absence of prolapse symptoms. Surgical technique

Materials and methods All women referred to the Urogynecologic Units of two academic hospitals from September 2003 to April 2005 for symptomatic uterine prolapse, who declined hysterectomy at the time of prolapse surgery, were oVered laparoscopic hysteropexy. Preoperative evaluation included medical history, physical and ultrasonographic examination, cervical citology, urinary voiding diary, urine analysis and complete urodynamic testing. Patients were interviewed about symptoms of prolapse, urinary symptoms (in terms of recurrent UTIs, dysuria, esitation, intermittence, voiding dysfunction), bowel symptoms (in terms stipsis, diarrhea, anal incontinence) and sexual function. All procedures and all deWnitions correspond to

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After pneumoperitoneum has been created, a 10 mm 0° laparoscope is introduced at the umbilical site. Under direct visualization three 5 mm ancillary trocars are inserted, one suprapubically and two laterally to the epigastric arteries, in the left and right lower abdominal quadrants, respectively. The pelvis is inspected and the speciWc site of ligamentous laxity is identiWed. The uterus is lifted into an anteverted position with an intrauterine manipulator (RUMI System®, CooperSurgical, Trumbull, CT) for easier exposure of the uterosacral ligaments. The course of the pelvic ureters is identiWed and if necessary, mobilized from the pelvic peritoneum to avoid ureteral kinking or obstruction. The uterosacral ligament is grasped from the controlateral side to ease the passage of the suture. A nonabsorbable suture (No. 1 Gore-

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tex) is placed full-thickness through the uterosacral ligament, beginning in the distal third of the ligament at the level of the ischial spine. A total of three helical type sutures are placed in the uterosacral ligament, with the last one approximately 1 cm beneath the cervix (Fig. 1). The ends of the suture are tied down with an extra-corporeal knot-tying technique on each side, thus shortening the ligament. In a similar fashion, the contralateral ligament is plicated. Finally, the round ligaments are plicated using endo-loops to restore the uterus to its correct anatomic position.

Results During the study period, ten patients underwent laparoscopic uterosacral ligaments plication for the treatment of symptomatic uterine prolapse. The median (range) patients age and BMI of the study population were 45.5 years (36–66) and 23 kg/m2 (21–27), respectively. The median parity was two (2–4). Five (50%) patients were premenopausal and three (60%) had not completed their family. Before surgery all patients complained of prolapse symptoms and Wve (50%) women experienced dyspareunia related to the uterine prolapse. Pre-operatively no patient had signiWcative

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post-voiding residual, two patients had a history of recurrent UTIs and three patients complained of stipsis. Intraoperative details are summarized in Table 1. The median follow-up time was 21 months (range 15– 33). The median postoperative diVerence in POP-Q point C was ¡3 cm (range 0 to ¡5). Postoperative changes in prolapse stage and total vaginal length are displayed in Table 2. Eight (80%) patients were objectively and subjectively cured at the last follow-up evaluation and all of them reported a complete resolution of their prolapse symptoms after surgery. All women experiencing painful sexual intercourse before surgery had no sexual complaint postoperatively. One woman had a recurrence of her preoperative third stage prolapse at the 3 months follow-up examination. Another patient with no objective evidence of uterine prolapse at the 21 months evaluation had a recurrence three months later after an acute exacerbation of chronic bronchitis. Both women underwent vaginal hysterectomy 7 and 24 months after primary surgery, respectively. Among patients desiring future childbearing, no pregnancy has been achieved so far. The follow-up period of these three patients ranged from 15 to 18 months. None of the cured patients had occurrence of anterior or posterior compartment defects, neither de novo urinary or bowel dysfunction. No patient had occurrence of de novo urodynamic stress incontinence or Table 1 Intraoperative and post-operative details N = 10 Operating time (min) Estimeted blood loss (ml) Intra-operative complications Post-operative complications Hospital stay

22.5 (20–45) 0 (0–20) 0 0 1 (1–2)

Data are expressed as median (range) or number (%)

Table 2 Follow-up data

Fig. 1 Three helical type sutures are placed full-thickness in the uterosacral ligament. A good bite of the ligament should be obtained, with the Wrst suture placed in the distal third of the ligament and the last one approximately 1 cm from the cervix

Prolapse degree No prolapse First stage Second stage Third stage Total vaginal length (cm)

Preoperative (N = 10)

Postoperativea (N = 10)

0 0 5 (50%) 5 (50%) 9.5 (8.5–11)

5 (50%) 3 (30%) 0 2 (20%) 11 (8.5–12.5)

Data are expressed as median (range) or number (%) a Findings of the last follow-up evaluation

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detrusorial overactivity. No woman had signiWcant residual volume at ultrasonographic examination after surgery; one of the two women with pre-operative history of recurrent UTI had a positive urine culture 3 months after surgery, associated with symptoms of UTI; she was successfully treated with antibiotical therapy (amoxicillin/clavulanate twice a day for 6 days) on the basis of antibiogram. Two of the three women complaining stipsis before surgery reported an improvement in their bowel function.

Discussion Our technique of laparoscopic uterosacral and round ligament plication appears to be a safe and eVective treatment option for women with uterovaginal prolapse who desire uterine preservation at the time of prolapse surgery. The procedure is aimed at shortening and strengthening the uterosacral ligaments to reestablish maximal uterine support and restore the uterus back to its most anatomically correct position. It is clear that successful uterine suspension procedures must address weakened support mechanisms. The uterosacral ligaments, the sacrospinous ligaments, and the anterior ligaments of the presacral space can all be used to anchor the uterus in uterus-sparing procedures for the treatment of uterovaginal prolapse. Many procedures have been proposed to restore support and anatomy by addressing these diVerent structures: sacrospinous hysteropexy, sacral hysteropexy, Manchester repair and laparoscopic uterine suspension. Sacrospinous hysteropexy and sacral colpohysteropexy rely on non-physiologic support to the cervix and upper vagina, resulting in both lateral and antero-posterior deviation of the uterus and vaginal axis with increased risk of anterior compartment or posterior wall defect [17, 18]. Moreover, these procedures require synthetic meshes placement with the potential risks of infection, erosions, and adhesions formation associated with non-absorbable prosthetic reinforcements. Subsequent hysterectomy after these procedures might be highly demanding due to the diYcult dissection required to remove the cervix. The procedure performed in the current series addresses the uterosacral–cardinal ligament complex, that appears from anatomical studies to be the most supportive structure of the uterus and upper third of the vagina [19]. Since a thorough understanding of pelvic support anatomy shows that the round ligaments play no role in uterine suspension, the aim of round ligament plication was mainly to restore the uterus to its correct anatomic position.

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Few authors have previously described laparoscopic uterosacral ligament plication for the management of symptomatic uterovaginal prolapse. Wu Wrst reported this technique in a series of seven women undergoing successful laparascopic correction of uterine prolapse with a high McCall colpopexy [10]. Maher et al. [11] have also described a laparoscopic uterus-sparing procedure for the management of 43 patients with symptomatic uterine prolapse involving a Moschowitz culdoplasty, plication of the uterosacral ligament in the midline and re-attachment to the posterior aspect of the cervix. Of note, all but two women underwent concomitant surgery for pelvic Xoor relaxation. After a mean follow-up time of 12 months the recurrence rate was 16%. Uterosacral ligaments plication provides multiple advantages over other proposed techniques for laparoscopic uterine suspension. First, this is a minimally invasive and straightforward simple procedure, that can enhance the beneWts of laparoscopic approach in terms of minimal tissue trauma, reduced postoperative pain, faster recovery and shorter hospitalization. Second, uterosacral ligament plication preserves pelvic gross and functional anatomy and maintains proper relationship between pelvic viscera and supportive structures. Using our technique, the uterosacral ligament is pulled closer to the midline by tying the suture without constriction or obliteration of the pouch of Douglas. Although we did not perform Moschowitz culdoplasty, neither posterior compartment descensus, nor bowel disorders were reported. Moreover, unlike previously proposed procedures, the sutures are not passed through the cervix, vaginal wall, rectal fascia or sacral wall. Investing only the uterosacral ligaments with suture carries a lower risk of intraoperative complications since it helps to minimize the possibility of vascular and visceral injury. In Maher’s series [11] one woman had an inadvertent lesion of the uterine artery as the suture was passed through the cervix, requiring repair via laparotomy and blood transfusion. Obviously, avoiding Wxity of the cervix and obliteration of the pouch of Douglas and maintaining a normal pelvic anatomy are of utmost importance in patients who decline hysterectomy to preserve their fertility. Finally, uterosacral ligaments plication does not require the placement of prosthetic material since the woman’s own support structures are used to repair the prolapse and the technique does not compromise other surgical procedures to follow. Our results showing a 80% cure rate during a median follow-up time of 21 months appear promising. Diwan et al. [20] have recently published the Wrst comparative study of laparoscopic uterosacral ligaments

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plication versus vaginal hysterectomy, the current gold standard for the management of symptomatic uterine proplapse. Although limited by its retrospective nature, diVerent methods used for vaginal vault suspension in the hysterectomy group, and the small sample size, the study showed a better postoperative support on short-term follow-up in women undergoing laparoscopic uterine suspension. One recurrence occurred in patients managed by laparoscopy versus Wve (20%) recurrences in the hysterectomy group. The major limitations of the current study are the small sample size, the lack of a control group, and the relatively short follow-up time. However, the prospective design, the absence of concomitant surgical procedures, the standardized objective evaluation of postopearative outcome confer reliability to our preliminary results.

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