Sacrohysteropexy for Management of Apical Prolapse

Objectives: In this video we describe the steps of laparoscopic sacrohysteropexy, a uterine-conserving technique to manage apical prolapse. We demonstrate application of this technique in a patient with stage 2 apical prolapse.

Methods: The entirety of above surgical case was recorded. The video footage was then edited to highlight the relevant portions of the procedure. Before and after photographs were also taken to show resolution of the patient’s prolapse following completion of the procedure.

Clinical Relevance: Pelvic organ prolapse is a common condition that can adversely affect quality of life. Uterine prolapse is often treated with a combination of hysterectomy and vaginal vault suspension, though uterine-preserving procedures are becoming more common. Laparoscopic sacrohysteropexy is one such option, and can be offered for definitive management of primarily apical pelvic organ prolapse. Compared to hysterectomy plus mesh sacrocolpopexy, sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without difference in rate of prolapse recurrence (1). In addition to the aforementioned benefits, sacrohysteropexy can be considered for patients who strongly desire uterine preservation and/or future fertility. While data regarding pregnancy outcomes following sacrohysteropexy is currently limited, case series do not suggest adverse effects on subsequent pregnancy (2). In this video demonstration, suture placement at the level of the cervix passes medial to the uterine vessels mimicking that of an abdominal cerclage and thus is not expected to affect uterine blood flow during pregnancy. This is unique compared to previously published descriptions of the procedure, where suture is placed lateral to the uterine vessels (3). It should be noted that if a patient becomes pregnant following sacrohysteropexy, delivery via cesarean section is indicated (2). Furthermore, based on limited case series, pregnancy does not appear to compromise the long-term support provided by sacrohysteropexy (2).
 
In conclusion, laparoscopic sacrohysteropexy provides an effective management option for patients with primarily apical prolapse and is equivalent to hysterectomy plus sacrocolpopexy in terms of prolapse recurrence. In addition, it may considered in patients who desire uterine preservation with the goal of future fertility, though further research is indicated on subsequent pregnancy outcomes.
 

References:
1. Meriwether K V., Antosh DD, Olivera CK, et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol. 2018;219(2):129-146.e2. doi:10.1016/J.AJOG.2018.01.018
2. Jefferis H, Price N, Jackson S. Pregnancy following laparoscopic hysteropexy—a case series. Gynecol Surg. 2017;14(1):1-4. doi:10.1186/S10397-017-1017-1/TABLES/1
3. Rahmanou P, Price N, Jackson S. Laparoscopic hysteropexy: a novel technique for uterine preservation surgery. Int Urogynecol J. 2014;25(1):139-140. doi:10.1007/S00192-013-2129-4