Uterus preserving surgeries for prolapse

In cases of Nulliparous prolapse or even patients deserving child bearing uterus preserving surgeries are done.
Recently even for prolapse if women want to preserve uterus for variety of reasons ,with newer minimally invasive methods it is now gaining popularity.Larger studies and longer followup is required.

1. Uterus sparing techniques for Prolapse for young DR Rajesh Gajbhiye Consultant Gynecologist & Lap Surgeon Mauli Women’s Hospital . Nagpur

2. Introduction Conservative surgeries- young nulliparous women where menstrual and reproductive function in desired. Vaginal hysterctomy with repair. Advent of minimal invasive surgery Resuspend Uterine conserving re-suspension surgery Augmenting weak connective tissue Stronger apical support

3. Laparoscoic assisted vaginal tape

4. Complications Presacral bleeding. Hence a vascular sacral plexus is a relative contraindication for this surgery. Sigmoid colon and sigmoid mesocolon injury hence short sigmoid mesocolon is relative contraindication for this surgery. Geintofemoral nerve irritation, damage to ureter , recto-vaginal fascia, recurrence, osteomyelitis and bowel obstruction.

5. Reproductive performance following Shirodkar's abdominal sling operation. Allahbadia GN 1 , Ambiye VR . Over a period of 4 years from January 1986 to December 1989, 79 cases in whom Shirodkar's abdominal sling operation carried out, were studied. All the patients were admitted either in active labour or as cases of abortions or for the treatment of infertility. The incidence of full term normal vaginal delivery in this study was 69.56% and the incidence of caesarean section was only 2.9%. There was one case of posterior wall rupture following previous Shirodkar's sling operation. The recurrence rate of prolapse was only 8.69%

6. Evaluation of Shirodkar’s Sling Surgery for Conservative Management of Uterovaginal Descent During Child Bearing Age Group Suchitra Narayan Pandit , Vaman Babu Ghodake , Vijay Chandrakant Pawar

7. Observations: One thousand three hundred and eighty patients having uterovaginal descent were admitted at L.T.M. General Hospital, Sion , Mumbai, from Jan ‘03 - Dec ‘04. 139 patients underwent conservative surgery. Sixty four (46.67%) patients were in the child-bearing age group and underwent Shirodkar’s sling surgery. Twenty four patients (41.37%) conceived post surgery. Nineteen patients delivered normally. Only three patients required L.S.C.S. for obstetric indications. Conclusion: Shirodkar’s Sling operation plays an important role in the conservative management of prolapse in the child bearing age group. It does not affect fertility and course of normal labour in fact it improves it by maintaining the pelvic anatomy.

8. Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse , particularly enterocele . Lecel B evidence

9. Khanna sling

10. The present study demonstrates the long-term safety and effectiveness of pectineal ligament suspension for vaginal vault prolapse by the open and the laparoscopic routes.

11. Sacrohysteropexy -Open -Laparoscopic -Robotic Advantages- Effective correction of descent Anteversion No compression on rectum or ureter . Improved quality of life and sexual function

12. LSH

13. LSC Int Urogynecol J. 2014 Jan;25(1):131-8. doi : 10.1007/s00192-013-2209-5. Epub 2013 Nov 6. Laparoscopic hysteropexy : 1- to 4-year follow-up of women postoperatively. Rahmanou P 1 , White B , Price N , Jackson S .

14. Laparoscopic hysteropexy is a safe and effective treatment. High patient satisfaction and low rates of apical prolapse recurrence. Longer term follow-up and randomized controlled studies are required.

15. Younger patients are best treated with procedures with better efficacy like sacral colpopexy to prevent recurrence.

16. Risk of mesh extrusion and other mesh-related complications after laparoscopic sacral colpopexy with or without concurrent laparoscopic-assisted vaginal hysterectomy: experience of 402 patients. Stepanian AA 1 , Miklos JR , Moore RD , Mattox TF J Minim Invasive Gynecol. 2008 Mar-Apr;15(2):188-96. doi : 10.1016/j.jmig.2007.11.006.

17. Risk of mesh extrusion or other mesh-related complications after laparoscopic sacral colpopexy using soft macroporous Y-shaped polypropylene mesh is about 1% . No significant increase in risk of mesh-related complications was observed in patients receiving concurrent hysterectomy when compared with patients who had a previous hysterectomy. The sample size of almost 2000 patients was needed to detect a statistically significant difference in rate of mesh-extrusion in this study.

18. Gutman and Maher reviewed the literature on sacral colpopexy and uterine prolapse in 2012 and in meta-analysis found 339 cases of sacral colpopexy with hysterectomy and 129 cases of sacral hysteropexy . While the success rate was over 90% in each group the rate of mesh exposures was more than five times higher after sacral colpopexy and hysterectomy as compared to hysteropexy (8.5% versus 1.5%).

19. Sacral colpopexy : long-term mesh complications requiring reoperation(s). Arsene E 1 , Giraudet G , Lucot JP , Rubod C , Cosson M . Int Urogynecol J. 2015 Mar;26(3):353-8. doi : 10.1007/s00192-014-2514-7. Epub 2014 Oct 17. excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed.

20. Surgery for complications after SC.-27 vaginal mesh exposures (VME)-19 intravesical mesh -4(including one with VME) ano -rectal dyschezia-1 one for spondylodiscitis-1 mesh infection,-1 vaginal fistula communicating with a collection in the ischio-coccygeal muscle.-1.

21. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years This case series provides a description of surgical interventions for complications related to sacral colpopexy . These complications may be serious and occur years after the initial surgery

22. Cochrane Database Syst Rev. 2013 Apr 30;4:CD004014. doi : 10.1002/14651858.CD004014.pub5. Surgical management of pelvic organ prolapse in women. Maher C 1 , Feiner B , Baessler K , Schmid C Fifty-six randomised controlled trials were identified evaluating 5954 women.

23. Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy , uterosacral colpopexy and transvaginal mesh. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach

24. Shirodkar’s Extended Manchester Repair: A Conservative Vaginal Surgery for Geital Prolapse in Young Women and Reinforcement of Weak Uterosacral Ligaments with Merselene Tape: Retrospective and Prospective Study Roohi Shaikh,Suman Sardesai 1nternational Journal of Recent Trends in Science A nd Technology, ISSN 2277-2812 E-ISSN 2249-8109, Vol ume 10, Issue 2, 2014 pp 263-266

25. Conclusion: Shirodkar’s Extended Manchester Repair has a definite place in the treatment of genital prolapse especially during the reproductive age, where child-bearing function has to be preserved

26. Two randomized trials in women with stage II or higher POP that compared transvaginal sacrospinous hysteropexy with vaginal hysterectomy (with uterosacral or sacrospinous ligament suspension of the vaginal vault) yielded consistent results: the rate of prolapse recurrence after 9 to 12 months was higher in women who underwent hysteropexy in both trials .

27. Conclusions Consensus is growing that the uterus can be preserved at the time of pelvic reconstructive surgery in appropriately selected women who desire it. Surgeons should be ready to respond to the wishes of female patients who want to preserve vaginal function and the uterus.

28. conclusions In nulliparous prolapse , shirodkars sling the operation of choice. If not comfortable then Khanna sling, joshi sling Sacrohysteropexy is indicated in young prolapse . It is better than vaginal SSF in terms of recurrence and patient satisfaction. Mesh erosion compication is less as compared to hysterectomy with SC.

29. Thankyou