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Keywords:

  • abdominal hysteropexy;
  • uterine prolapse;
  • young women

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References

Aim

To demonstrate an alternative surgical approach for the management of uterine prolapse in young women by a technique that was previously defined for post-hysterectomy vaginal vault suspension in published work and also to demonstrate successful operative results.

Methods

The study population consisted of 12 women aged 28–41 years who had stage 4 uterine prolapse and who were surgically treated by abdominal hysteropexy using autogenous rectus fascia strips. Operative results and postoperative follow-up Pelvic Organ Prolapse Quantification and Prolapse Quality of Life results were recorded.

Results

Mean age of patients was 35.5 ± 4.1 years (range, 28–41). Mean parity in the study group was 2.6 ± 1.0 (range, 1–5). Mean operation time was 32.0 ± 5.2 min (range, 25–42). All patients were discharged on the postoperative 3rd day and no complications were observed postoperatively. Mean follow-up period was 20 ± 7.0 months (range, 12–36). All of the patients had complete remission for uterine prolapse and none of the patients had complaints related to the operation.

Conclusion

Abdominal hysteropexy operation using rectus fascia strips provides a safe and alternative approach for the management of uterine prolapse in young women who desire to preserve their uterus. But further analysis is needed to confirm our results.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References

Uterovaginal prolapse is a common gynecological problem affecting up to 50% of parous women.[1] There are several proposed conservative methods for the management of uterine prolapse such as physiotherapy, electrical therapy and pessaries, but none of them had real evidence for efficacy. Although the use of pessary has been advocated, it creates some complaints such as vaginal discharge, ulceration, discomfort and dyspareunia, so vaginal hysterectomy still remains the definitive treatment.[2] However, it is inappropriate for some women who desire further fertility and to preserve their uterus. For those women, Manchester repair, sacrospinous hysteropexy and sacral hysteropexy have been proposed as alternative surgeries in the published work.

In this report, another surgical approach, which was previously defined as post-hysterectomy vaginal vault suspension in the published work,[3] is demonstrated for the management of uterine prolapse, by creating an artificial suspensory ligament using rectus fascia strips to keep the uterus in place for young women.

Materials and Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References

Study design and subject selection

Twelve cases of stage 4 uterine prolapse were included in the study. The study group consisted of patients admitted to Çorum State Hospital (n = 9) and Necmettin Erbakan University Meram Faculty of Medicine Gynecology Department (n = 3) with the complaint of protruding vaginal mass and had stage 4 uterine prolapse on gynecologic examination. The study population consisted of patients with desire for further fertility and/or those who wanted to preserve their uterus. All patients were informed about the surgical procedure and written and signed informed consent was obtained from each patient. All of the patients were aware of the fact that the surgical procedure was new. Abdominal hysteropexy operation using rectus fascia strips was performed in all cases by the same operative technique. All patients were evaluated for pelvic organ prolapse and total vaginal length after surgery. Preoperative and postoperative pelvic organ prolapse were evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system; stage II or more was considered a prolapse. Prolapse Quality of Life (P-QOL) scores were obtained before and after the operations.

Surgical technique

The surgical technique was originally described by Richardson and Williams for suspension of the vaginal vault after hysterectomy in 1969.[4] The authors reported on the attachment of rectus fascia flaps to the apex of the vaginal vault following hysterectomy. Our technique provides a modified version of that operation, and we attach flaps to the anterior cervix while preserving the uterus.

Abdominal hysteropexy operation using rectus fascia strips was planned as a surgical procedure. Approximately 6-cm long at the level of anterior superior iliac spine, the rectus sheath was separated from the underlying subcutaneous adipose tissue along the entire length of transverse skin incision (Pfannenstiel) and approximately 2 cm in breadth (Fig. 1). A longitudinal incision of approximately 1 cm was made in the rectus sheath in the midline, and laterally this incision was extended transversely approximately 3–4 cm on either side superiorly as well as inferiorly beyond the lateral margin of the rectus muscle, with the inferior end of the strip still attached to the sheath. In this way, two strips of the rectus fascia were devised (Fig. 2). Then, a transverse incision at the vesicouterine peritoneal reflection was used to open the uterovesical pouch, followed by downward dislocation of the bladder until exposure of the uterine isthmus and supravaginal cervix. Bilateral strips were protruded through the lateral side of the rectus muscle beyond the peritoneum with the help of a right-angled device and strips were protruded retroperitoneally (can be changed to extraperitoneally) (Figs 3, 4). Then, a rectus fascia strip was attached to the anterior supracervical cervix and fixed with a no. 1 monofilament polypropylene continuous suture (Fig. 5). The same procedure was performed on the opposite side. Both flaps were opposed by a separate Z-suture at the midline. The peritoneum was then closed with stitches (Fig. 6) and the abdomen was closed in layers after securing homeostasis. After the operation, the patients were hospitalized for 3 days, and discharged later on without any complications. All patients were followed up after the operation at 3-month intervals.

figure

Figure 1. Separation of rectus sheath from the underlying subcutaneous adipose tissue.

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figure

Figure 2. Formation of rectus fascia strip.

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Figure 3. Rectus fascia strip protruded retroperitoneally.

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Figure 4. Rectus fascia strip protruded retroperitoneally and attached to anterior cervix.

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Figure 5. Rectus fascia strip is attached to anterior supracervical cervix.

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Figure 6. Peritoneum is closed with stitches.

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The study was approved by a local ethics committee in Turkey (Meram Medical Faculty's Ethics Committee, ref. 2012/151).

Statistical analysis

Values are expressed as mean ± standard deviation for continuous variables and number. SPSS ver. 18 was used for descriptive statistics. Preoperative and postoperative P-QOL scores were analyzed by paired sample Student's t-test. P < 0.05 was accepted as statistically significant.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References

The study group consisted of 12 patients and their operative and follow-up records were calculated. The mean age of patients was 35.5 ± 4.1 years (range, 28–41). Mean gravidity and parity in the study group was 2.6 ± 1.0[1-5] and 3.2 ± 1.2[1-5], respectively. None of the patients had any systemic disease or prior abdominal surgery. Three patients (25%) had stress urinary incontinence concomitant with uterine prolapse, and only one patient had (8.3%) urinary intermittence. All of the patients had difficulty during sexual intercourse and complained of dyspareunia. The mean operation time was 32.0 ± 5.2 min (range, 25–42). Mean blood loss was 76 ± 18 cc (range, 50–100). At the same time, Burch operation was carried out in three patients with stress urinary incontinence. None of the patients had any complications postoperatively. The mean follow-up period was 20 ± 7.0 months (range, 12–36). All of the patients had complete remission (stage 0) for uterine prolapse during the postoperative control (Table 1) and none of the patients had complaints related to the operation. During the postoperative control, two patients had stage 2 anterior prolapse (%16.7) and only one patient had stage II posterior prolapse (8.3%). (The preoperative POP-Q results of these patients are summarized at Table 1; all had stage 4 anterior, posterior and uterine prolapse preoperatively.) Urinary complaints of four patients regressed postoperatively (%100). All of the patients reported sexual improvement after the operation. P-QOL results are reported at Table 2.

Table 1. Distribution of patients according to preoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stages
 POP-Q stagePreoperativePostoperative
(no. of patients)%(no. of patients)%
Anterior prolapseStage 000866.6
Stage 100216.7
Stage 200216.7
Stage 30000
Stage 41210000
Posterior prolapseStage 000975
Stage 100216.7
Stage 20018.3
Stage 30000
Stage 41210000
Uterine prolapseStage 00012100
Stage 10000
Stage 20000
Stage 30000
Stage 41210000
Table 2. Preoperative and postoperative Prolapse Quality of Life results
 Preoperative (mean ± SD)Postoperative (mean ± SD)P-values
  1. EM, emotions; GHP, general health perceptions; GS, general score; PI, prolapse impact; PL, physical limitations; PR, personal relationships; RL, role limitations; SD, standard deviation; SE, sleep/energy; SL, social limitations; SM, severity measures.

GHP4.16 ± 0.931.75 ± 0.750.000
PI32.16 ± 5.215.91 ± 1.880.000
RL5.41 ± 1.312.0 ± 0.00.000
PL5.16 ± 0.932.0 ± 0.00.000
SL2.91 ± 0.792.08 ± 0.280.010
PR6.41 ± 0.990.50 ± 0.670.000
EM6.83 ± 1.023.0 ± 0.00.000
SE3.08 ± 1.162.0 ± 0.00.008
SM8.41 ± 1.164.08 ± 0.280.000
GS74.58 ± 6.5423.25 ± 2.220.000

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References

Pelvic organ prolapse is usually caused by weakness of the pelvic diaphragm. In most cases, labor and childbirth are thought to be the primary initiating factors for prolapse. Certain connective tissue defects, congenital defects and operative procedures also contribute to pelvic support defects.[5] In our study, none of the patients had any systemic disease, congenital defect or any abdominal operation.

Vaginal hysterectomy is the most common surgical treatment for women with uterovaginal prolapse.[2] However, some women desire childbearing or to preserve their uterus because they believe that they may have difficulty in sexual intercourse. This study included women with the desire to preserve their uterus.

Conservative treatment include modalities such as intravaginal pessaries, physiotherapy, electrical therapy and pelvic floor muscle training, but none of them have proven treatment efficacy. On the surgical aspect, Manchester repair, sacrospinous hysteropexy and sacral hysteropexy have been proposed as alternative surgical procedures in those women who desire uterine preservation.

Manchester repair has been demonstrated to be associated with high failure rate, reduction in fertility, and difficulty in sampling of the cervix and uterus due to the cervical stenosis.[6] On the other hand, sacrospinous hysteropexy and sacral hysteropexy are reported to be usually complicated by high incidences of postoperative anterior vaginal wall prolapse.[7]

Vaginal hysterectomy has traditionally been considered as an initial step in the repair of uterine prolapse[8-10] because it is thought to facilitate pelvic floor repair and improve results.[11] Recent studies on the dynamics of pelvic organ support discuss the role of vaginal hysterectomy in uterovaginal prolapse repair.[2, 12, 13] The current trend is delayed childbearing, and there is a widespread belief that the uterus is necessary for sexual satisfaction, and there is a common desire to avoid major surgery.[14] Following vaginal hysterectomy, the vaginal vault may descend on follow-up and the shortened vagina may lead to dyspareunia.

Several techniques are defined for cervical and uterine suspension: vaginal sacrospinous cervicocolpopexy, vaginal posterior intravaginal slingplasty, abdominal or laparoscopic sacrocolpopexy and posterior mesh repair. The sacrospinous ligament suspension of the uterus is called sacrospinous cervicocolpopexy or sacrospinous hysteropexy, and this is a popular surgical technique. There are also reports about laparoscopic approaches for sacrospinous hysteropexy.

Recently, we have reported a case of pregnancy complicated with uterine prolapse and treated by abdominal hysteropexy using rectus fascia strips at the same time as cesarean section.[15]

Our study offers an alternative approach for hysteropexy operations in young women. However, because our group is small and the study is single-armed, results should be confirmed by larger and controlled studies.

In our series, although we have no recurrent cases of uterine prolapse, we have two cases of stage II anterior and one case of stage II posterior prolapse during the postoperative control. These patients may be considered as recurrent cases in the untreated site. However, these recurrences did not have a negative impact on overall postoperative P-QOL scores of these patients, and these recurrent cases had significant improvement in quality of life.

Uterine preservation has many advantages. Operative morbidity and hospital stay are reduced compared with hysterectomy.[11, 12, 16-18] There is evidence that uterine preservation is associated with a reduced risk of urinary dysfunction.[19-24] This could be explained by avoiding bladder dissection or division of the pericervical ring of connective tissue, both of which are inevitable during hysterectomy.[25] In our study group, urinary complaints of four patients regressed postoperatively.

In conclusion, conservative surgery for uterovaginal prolapse in young women of reproductive age is feasible and yields favorable outcome, especially in women with desire for further fertility.

In our limited experience, abdominal hysteropexy using rectus fascia strips seems to be a successful and safe procedure to restore pelvic anatomical relationships and sexual function in young women with uterovaginal prolapse. However, because our study group is small, these results are preliminary and we need further cases to evaluate, so we are continuing to perform operations and taking follow-up records.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and Methods
  5. Results
  6. Discussion
  7. References
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    van Brummen HJ, van de Pol G, Aalders CI et al. Sacrospinous hysteropexy compared to vaginal hysterectomy as primary surgical treatment for a descensus uteri: Effects on urinary symptoms. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 350355.
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    Roovers JP, van der Bom JG, Huub van der Vaart C et al. Does mode of hysterectomy influence micturition and defecation? Acta Obstet Gynecol Scand 2001; 80: 945951.
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