Pelvic Organ Prolapse
Laparoscopic uterine-sparing suspension procedures have become a popular alternative to classical treatment of pelvic organ prolapse, as they have the advantage of smaller intraoperative blood loss and faster postoperative recovery. Moreover, patient’s wishes regarding uterus conservation can be considered. Our aim is to present our variation of uterine-preserving laparoscopic sacrohisteropexy: laparoscopic loop sacrohysteropexy (LLSH).
For LLSH, the peritoneum covering the sacral promontory is dissected and opened towards the right sacrouterine ligament (SUL), over the posterior side of the cervix and towards the left SUL. Broad ligaments (BL) are opened through the avascular area. Vesico-uterine fold peritoneum is opened and the bladder is reflected distally. One short arm of the bifurcated mesh is cut off and the remaining mesh band is introduced through the window in the right BL, over the anterior part of the uterus and through the left BL. The leading part of the mesh is sutured just above the level of the right SUL and joined with the adjacent middle part of the mesh that is going through the right BL, thus creating a loop that surrounds the uterus. Additionally, mesh is fixated just above the left SUL. Mesh is then attached to the sacral promontory and peritoneum is closed.
Patients were invited for a short-term follow-up at least six months after procedure. For each patient, POP-Q status was obtained at the follow-up. Additionally, patients evaluated their satisfaction with the procedure and filled out the PFIQ-7, PFDI-20 and PISQ-12 questionnaires.
Since September 2017, we performed 30 LLSH. Twelve patients fulfilled the criteria for a short-term follow-up and nine responded to our invitation (75% response rate). Their average age at the procedure was 53±11 years (range 34-68) and mean time from the procedure was 0.8±0.2 year (range 0.5-1.1). All patients had at least one concomitant procedure such as salpingectomy, fibroma enucleation, adhesiolysis, etc. Average time to perform LLSH only was 87.8±31 minutes (range 55-140), the longest procedure being performed by a resident and the others by a consultant. Average blood loss was 6.7±9 mL (range 0-20). All patients were discharged within 2-3 days. There was one case of an early postoperative complication – a minor hematoma after enucleation of an intraligamentary fibroma, but none after LLSH as such.
At the follow-up, the average differences in pre- and postoperative points Aa, Ba and C were -2.7±1 cm (range -4 to -1), -3.6±1.8 cm (range -7 to -1), and -7.1±1.9 (range -10 to -4), respectively. Average PFIQ-7, PFDI-20 and PISQ-12 scores were 65±87.3 (range 0-190), 68.4±57.9 (range 0-100), and 14.9±8.4 (range 4-33), respectively. All patients but one noticed a partial or significant improvement in their symptoms and seven were very or extremely satisfied with the procedure. All but one would recommend the procedure to their friends. The patient that was unsatisfied with the procedure had a concomitant urge urinary incontinence even before the procedure, which was the main reason for her dissatisfaction despite an optimal restoration of pelvic organs statics.
The aim of LLSH is to provide an efficient level I support of the uterus, while minimizing the operating time and reducing the amount of the material needed to perform the procedure. By creating a loop that joins at the level of the SUL, we avoid suturing of the mesh to the anterior part of the uterus, which is usually more time-consuming. Fixation above SUL also reduces the pressure of the mesh on the anterior segment of the uterus and when rise in abdominal pressure occurs, there is lower risk of cervical erosion. Our initial short-term results show excellent anatomical results and high patients’ satisfaction rate.