Laparoscopic hysterosacropexy with subsequent pregnancy and delivery by cesarean section: case report with short term follow-up

Summary

Objective: To report a case of laparoscopic hysterosacropexy with subsequent pregnancy complicated by car accident, and terminated by cesarean section due to gestational hypertension.

Design: Case report and literature review.

Setting: Department of Obstetrics and Gynecology, University Hospital and Faculty of Medicine Olomouc, Palacký University.

Case report: The patient is a 38 years old woman diagnosed with prolapse of the uterus POP-Q III. She had history of three spontaneous vaginal deliveries. In 2016 she underwent laparoscopic hysterosacropexy using Alyte mesh. There were no intraoperative complications, operating time was 80 min and blood loss 60 ml. Three moths after surgery patient became pregnant spontaneously. In 30th week of gestation patient had a car accident with intact pregnancy. During the third trimester patient has developed gestational hypertension which lead in 2017 to termination of pregnancy by cesarean section at 37 weeks. Mesh was found to be intact in the lower uterine segment. Follow up at 30 months after hysterosacropexy and 18 months after cesarean section revealed well supported cervix and no vaginal prolapse.

Conclusion: Laparoscopic hysterosacropexy is feasible and safe method for treatment of the uterine prolapse. In young women it can be used to spare reproductive function.

Keywords:

laparoscopy – hysterosacropexy – prolaps – cesarean section – delivery

INTRODUCTION

Pelvic organ prolapse (POP), i.e., the descent of one or more of the pelvic organs (uterus, vagina, bladder, and bowel), is estimated to affect nearly half the female population over 50 years of age and has a negative impact on the patient’s quality of life (QoL) [20]. In young women, uterine prolapse is uncommon, and a Swedish study found a preva­lence of uterine prolapse of 5% in women aged 20 to 59 years [19].

Women have an 11% lifetime risk of undergoing pelvic reconstructive surgery for POP and/or urinary incontinence [16]. Vaginal techniques include hysterectomy, anterior and posterior vaginal wall repair, and several vault suspension procedures. Abdominal approaches are performed through an open incision or by laparoscopy often with mesh [10]. In young women, the successful surgical treatment of uterine prolapse with retention of the uterus is a surgical challenge. The aims of the surgical procedure are to correct prolapse with the most efficient long-lasting results, to allow normal sexual function, and to preserve childbearing function. However, most believe that definitive surgical management should be deferred until childbearing is completed because of the potential impact of future pregnancy and delivery on pelvic support and surgical repair. Long-term results after surgical treatment in young women with symptomatic uterovaginal prolapse are not well established. Abdominal hysteropexy studies revealed 9 pregnancies with mostly vaginal deliveries and no recurrences [5, 15]. Data on reproductive results in patients after laparoscopic hysterosacropexy are very sparse. Here, we report a case of 38 years old women with delivery by cesarean section after laparoscopic hysterosacropexy.

CASE REPORT

The patient is a 38 years old woman with history of three spontaneous vaginal deliveries (in 2012 female newborn weight 3250 g, at 35 weeks; in 2013 female newborn weight 2500 g, at 36 weeks and in 2015 female newborn weight 2250 g, at 36 weeks). In november 2016 she was diagnosed with prolapse of the uterus P-Q III (Picture 1). Laparoscopic hysterosacropexy was performed the 16th of December 2016 using nonabsorbable Y-mesh (Alyte; Bard Medical, Covington, GA, USA). The procedure was done under general anesthesia with the patient placed in the dorsal lithotomy position. A Foley catheter was placed into the bladder. Veress needle was introduced and CO₂ was insufflated in order to achieve pneumoperitoneum. Subsequently, a 10-mm camera port (port 1) was placed infraumbilically and two 5-mm trocars (port 2 and 3) were placed bilaterally under vision and symmetrically at the midclavicular line 4–5 cm under the umbilicus. Another 10-mm trocar was placed medially suprasymphyseally (Picture 2). The camera used a 30° lens. Serosal layer of the uterus and presacral peritoneum were opened. The peritoneum overlying the sacral promontory was adequately dissecteduntil the periosteum was exposed, once the longitudinal ligament of the sacrum was found. The posterior layer of broad ligament was carefully dissected in the avascular zones of the parametrium, to obtain two eyelets. In order to do that, the broad ligament was prepared by preforming two little windows inside it using a monopolar scissors in order to allow the mesh passage. The distal end of the graft was sutured to the anterior and posterior cervix. On the right side of the pelvic wall a retroperitoneal tunnel was developed between the distal end of the mesh and peritoneal opening above the promontory. The proximal end of the Y mesh was anchored to the sacrum with absorbable Monoplus suture gently positioned on the sacral ligament, taking care to avoid penetrating the periosteum. A suitable length of the mesh was established and the redundant portion of the mesh was excised. The peritoneum was then closed using Stratafix (Ethicon, Johnson and Johnson, USA). The residual end Stratafix was 1 cm in length. The procedure went smoothly without complication during surgery, operating time was 80 min and blood loss 60 ml. Three moths after surgery patient became pregnant spontaneously. In 30th week of gestation patient suffered a car accident with intact pregnancy at the follow up. During the third trimester patient has developed gestational hypertension which lead to termination of pregnancy at 37 weeks. Cesarean section was done the 7th of December 2017 with mesh intact and localized in the lower uterine segment (Picture 3). Follow up at 30 months after hysterosacropexy and 18 months after cesarean section revealed well supported cervix and no vaginal prolapse (Picture 4).

DISCUSSION

Currently, most women who have surgery for uterine prolapse will undergo concomitant hysterectomy [8]. Several reasons were advocated against uterus sparing surgery, i.e., potential neoplastic pathologies and/or concern about complications that are associated with mesh use [3]. However, hysterectomy at the time of surgery has not been proven to improve functional or anatomic outcomes or to prevent prolapse recurrence, and may cause an increase in morbidity, blood loss, operative and postoperative hospital stay, pelvic neuropathy, and disruption of the natural support [9]. Moreover, uterus sparing showed fewer disadvantages, a shorter operative time, preserved women’s future childbearing ability, and maintained sexual satisfaction [1]. For uterine preservation during prolapse surgery three surgical options are available: Manchester repair [23], sacrospinous hysteropexy [12, 13, 24] and sacral hysteropexy [6]. Early studies on abdominal hysterosacropexy performed in the 1950s either directly sutured the uterus to the anterior longitudinal ligament or used a thin strip of external abdominal oblique fascia tunnelled retroperitoneally from the sacral promontory to the posterior cervix for support [4, 21]. Addison and van Lindert published a series of abdominal sacral colpopexy in 1993 containing subsets of women undergoing successful abdominal sacral hysteropexy with synthetic mesh [2, 25]. In 2005 Rozet et al. introduced laparoscopic sacral colpopexy approach with uterus sparing in 228 patients from a large series of 363 cases [18]. Price at al. confirmed that laparoscopic hysteropexy was both feasible and effective procedures for correcting uterine prolapse without recourse to hysterectomy [17]. Hysterosacropexy, performed through a laparotomy incision or laparoscopically, showed favorable cure rates, ranging from 91 to 100% with improvements in both quality of life and sexual function [11]. In 2007, Daneshgari et al. reported the short-term outcomes of 12 women who underwent robot assisted laparoscopic sacropexy with or without anti-incontinence surgery in the presence (sacrouteropexy) or absence of uterus (sacrocolpopexy), without a clear discrimination between the results from the two surgical groups [7].

Deciding on which abdominal, vaginal, combined, laparoscopic, or robotic approach depends on the surgeon’s experience, his/her level of confidence with the specific technique, the patient’s general conditions and comorbidities (i.e., obesity), and respect for right indications.

Despite relatively good anatomic outcomes, limited information exists to aid in counselling patients who desire hysteropexy and plan to become pregnant in the future. Barranger et al. reported pregnancy after abdominal open uterus-sparing surgery for prolapse in 3 out of 30 young patients, which led to 3 early legal abortions [5]. The mean age of patients was 35 years at the time of surgery, and they did not want to take the risk of recurrent prolapse. Lewis and Culligan reported a case report of a 35-year-old gravida 2 para 2, undergoing laparoscopic sacrohysteropexy and suburethral sling for stage III prolapse and stress urinary incontinence, who conceived 6 months after the procedure via cesarean section at term and with no signs of prolapse at follow-up [14]. Recently, Szymanowski et al. published a case report of 32 year old woman who underwent in 2016 a laparoscopic hysterosacropexy with lateral repair and Burch operation. Pregnancy in 2018 was delivered by cesarean section. The effect of the prolapse operation was not affected and the quality of life maintained. A follow-up examination 6 weeks postpartum was normal and the follow-up in February 2019 also revealed no problems [22].

Our case report demonstrates in concordance with published data the feasibility and safety of laparoscopic hysterosacropexy, as well as the possibility of successfully achieving pregnancy and delivery by cesarean section.

CONCLUSION

Laparoscopic hysterosacropexy seems to be a safe and effective procedure, offering a low complication rate, low estimated blood loss, rapid recovery, and preserving fertility in young patients. Yet, we do not know the true impact of a future pregnancy on long-term success rates and whether a caesarean delivery prevents recurrent prolapse compared with vaginal delivery.

Podpořeno MZ ČR – RVO (FNOl, 00098892).

Prof. MUDr. Radovan Pilka, Ph.D.

Porodnicko-gynekologická klinika LF UP a FN

I. P. Pavlova 6

750 00 Olomouc

e-mail: radovan.pilka@fnol.cz