Pelvic organ prolapse is a common condition that affects many women, especially those who have given birth or are post-menopausal.
There are different types of pelvic organ prolapse, depending on which organs are affected and how severe the condition is.
Symptoms of pelvic organ prolapse can include discomfort or pressure in the pelvic region, urinary incontinence, and difficulty with bowel movements.
Treatment for pelvic organ prolapse depends on the severity of the condition and can range from conservative measures such as pelvic floor exercises and pessaries to surgical options like laparoscopic uterine suspension or hysterectomy.
Introduction and Objectives of Uterine Suspension Technique
This video describes a laparoscopic uterine suspension technique for the treatment of pelvic organ prolapse. We have no conflicts of interest to disclose. The objectives of this video are to discuss the advantages, disadvantages and contraindications of uterine preserving surgeries for prolapse and to demonstrate a technique for native tissue apical suspension of the uterus by a laparoscopic approach.
Advantages of Uterine Preserving Surgeries
Uterine preserving surgeries for prolapse have gained increased attention in recent years due to mounting evidence of equivalence to hysterectomy based procedures. Suspension of the uterus is less invasive, associated with decreased surgical time and decreased blood loss and may have other advantages, depending on patient perspectives and preferences.
Potential Risks of Uterine Conservation
However, fewer long-term studies exist that examine this approach, and conservation of the uterus results in a small but ongoing risk for cervical or endometrial cancer. Therefore, patients at high risk for cervical or endometrial cancer should be considered for hysterectomy based procedures.
Techniques of Uterine Preserving Surgeries
Many approaches to uterine preserving surgeries exist. There are native tissue and mesh-augmented techniques via vaginal, abdominal and laparoscopic approaches. Laparoscopic uterosacral ligament uterine suspension is one native tissue technique which is particularly useful. Advantages include maintenance of a normal vaginal axis and calibre, improved visualization of the relationship between the uterosacral ligaments and the course of the ureters and the ability to perform a higher apical suspension.
Equipment for Laparoscopic Uterine Suspension
The equipment required is similar to that of a laparoscopic hysterectomy. A uterine mobilizer second assistant and 30-degree laparoscope are required to visualize the anatomy in the posterior cul-de-sac. An 8 mm or 10 mm port is required to facilitate suture placement and extracorporeal knot tying. We prefer use of a non-observable monofilament suture. Very limited data exists for use of observable sutures, but may be used depending on surgeon or patient preferences.
Procedure for Uterine Suspension
To perform the suspension, the patient is placed in dorsal lithotomy position with their arms tucked. We prefer to perform vaginal repairs first, as they are often more difficult to perform once the uterus is suspended. A uterine mobilizer is then inserted, and once abdominal access has been obtained, the pelvic anatomy is surveyed.
Completing the Uterine Suspension
Opportunistic salpingectomy or salpingo-oophorectomy can then be performed, depending on the patient’s age and personal preferences. The uterine suspension is then completed and cystoscopy is used to confirm bilateral ureteric patency at the end of the procedure.
In-depth Anatomy Survey and Techniques for Advanced Prolapse
Here, we demonstrate a survey of the anatomy and the posterior cul-de-sac and the course of the ureters in relationship to the uterosacral ligaments. The patient has been placed in steep Trendelenburg position. The 30-degree laparoscope is pointing up, and the uterus has been steeply anteverted by the second assistant.
If the relationship between the ureters and the uterosacral ligaments cannot be visualized or is quite close, ureterolysis may be performed. If the uterosacral ligaments are not particularly visible, the uterus can be deeply anteverted by a second assistant. This is particularly useful in cases of advanced prolapse.
Placement of Uterosacral Suspension Suture
We start with placement of the right uterosacral suspension suture. The suture is front loaded and passed through the base of the right uterosacral ligament in a lateral to medial direction. Alternatively, it may be easier to back load the suture. The suture is then back loaded and passed in a lateral to medial direction through the cervical isthmus. This is to avoid inadvertent injury to the uterine artery. The sutures should be placed deep into the cervical stroma but not within the endocervical canal.
The needle is then cut off, the ends of the suture are left untied and passed to the assistant to remove out of the right lower quadrant port. This allows improved visualization for placement of the left suspension suture while keeping the right suture out of the way. The left suspension suture is then placed in an identical manner as on the right.
Securing the Suspension Sutures
This is the first suture that will be tied down and is done extracorporeally. The uterus is angled towards the left, and the anteversion is relaxed while the assistant lifts the cornua to ensure the knot is completely pushed down. Tension must be maintained on both ends of the suture to ensure an air knot doesn’t develop. We generally place five to six knots on the monofilament polypropylene suture, and the ends are then trimmed long.
Tying the Second Suspension Suture
The assistant then grasps the ends of the right suspension suture and passes them back to the surgeon. This suture is also tied extracorporeally and is typically more difficult to tie. It’s important for the assistant to lift the cornua to ensure the knot is completely pushed down once again. The assistant can also ensure that the bowel and adnexa are not inadvertently tagged within the suture.
Potential Addition of a Third Suspension Suture
If desired to strengthen the suspension or to close any remaining enterocele sac, a third suspension suture can be placed by placing a purse string suture between the uterosacral ligaments, where they were previously tagged, up towards the cervical isthmus.
Closing the Enterocele Sac and Suture Bridging
In this patient, you can see how placement of a third suspension suture effectively suspends the uterus and closes any potential enterocele sac. A third suspension suture can also be used to reduce any suture bridge that may have formed from an air knot rather than having to cut and replace another right suspension suture.
Confirming Bilateral Ureteric Patency
Cystoscopy is then performed to confirm bilateral ureteric patency. We have yet to identify a case of ureteric injury performing this procedure. However, if ureteric jets were not visualized, we would err on the side of performing a peritoneal releasing incision over cutting a suspension suture if at all possible.
Alternative Approach in the Event of Inaccessible Uterosacral Ligaments
It is important to have an alternative approach to uterine suspension in the event the posterior cul-de-sac and the uterosacral ligaments are inaccessible. In this patient, the posterior cul-de-sac was completely obliterated by bowel adhesions, almost up to the level of the uterine fundus. Therefore, the suspension was completed by a vaginal sacrospinous approach.
In conclusion, apical suspension can be achieved by uterine suspension for women who wish to conserve their uterus and who do not have contraindications. A laparoscopic approach ensures clear visualization of anatomy and effective suspension. Native tissue suspension can be achieved in this manner by uterosacral ligament suspension, as described by the technique in this video.