Symptoms associated with prolapse of the uterus
- A lump inside or outside the vagina.
- A dragging sensation.
- Backache, worse when standing.
- Impression of something being hit at the top during intercourse.
- Deep dyspareunia (pain on intercourse).
- Difficulty emptying the bladder or bowel.
- Movement related urinary urgency.
Indications for uterine suspension
The main indication for uterine suspension is symptomatic prolapse of the uterus into the vagina.
Uterine suspension used to be performed in women known to have a retroverted uterus who were having difficulty conceiving. The belief was that retroversion of the uterus was associated with subfertility. The technique used was suspension of the round ligament to the abdominal wall.
Uterine suspension is appropriate for women who have a symptomatic uterine prolapse who wish to have uterine preservation surgery. The best results are achieved when the prolapse is no greater than Grade 2 descent. Surgery can be performed for women who have Grade 3 and Grade 4 descent, but the rate of recurrence of prolapse in these cases is higher.
The relevant anatomy
The principle ligamentous supports of the uterus are the utero-sacral ligaments. There is additional support from:
- The transverse cervical (also known as the Cardinal or McKenrodt’s) ligaments
and minimal support from:
- The round ligament
A fibrous fascial band on each side of the uterus that passes along the lateral wall of the pelvis from the uterine cervix to the sacrum.
Attaches the cervix to the lateral pelvic wall by its attachment to the obturator fascia of the obturator internus muscle.
Originates at the uterine horns (the points at which the fallopian tubes enter the uterus) and attaches to the labia minor passing through the inguinal canal.
Muscular or active support of the uterus is provided by the:
- Pelvic diaphragm
- Perineal body
- Urogenital diaphragm
The surgery – laparoscopic uterine/pelvic floor suspension
The most effective uterine suspension is a uterine/pelvic floor suspension involving the fixation of the uterosacral and cardinal ligaments to the rectovaginal and pubocervical fascia. Dr Onuma does this as a laparoscopic (keyhole surgery) procedure.
The uterus is pushed up from below using a special manipulator passed through the cervix. This places tension on the weak utero-sacral ligaments so that they become more prominent.
The peritoneum lateral to each utero-sacral ligament is open, thus creating a window. This enables isolation of the true utero-sacral ligaments whilst keeping the ureters away from the operating field and reducing the risk of ureteric injury or kinking.
Permanent sutures are used. The left utero-sacral ligament is sutured first (in this case) and is then attached to the left transverse cervical ligament.
The suture is carried forward to take a bite through the posterior aspect of the left pubocervical fascia, thus completing the suspension of the left utero-sacral ligament.
The same process is carried out on the right to attach the utero-sacral ligament to the transverse cervical ligament and pubocervical fascia.
Suspension is complete and a check is made that the ureters are not kinked and that there is no bleeding before the suture is cut and the needle removed.
Inspection of the pelvis is carried out and at this point the angle created by the utero-sacral ligaments as they attach to the cervix is assessed. Too wide an angle is associated with enterocele formation or recurrence. Too narrow an angle can negatively impact bowel emptying.
The angle is judged as too wide. A modified McCall Culdoplasty is commenced to reduce this angle. This involves plicating both utero-sacral ligaments to the pubocervical fascia.
The modified McCall culdoplasty is complete and this part of the surgery complete. The utero-sacral ligaments are shorter. The uterus is high up within the vagina. The angle of the Pouch of Douglas where utero-sacral ligaments attach to the posterior aspect of the cervix has been narrowed.
Dr Onuma will proceed to correct any other prolapse that you have been consented for. A cystoscopy (inspection of the bladder with a telescope) will be performed before you are woken up.
You will be transferred from the operating theatre to the recovery room where you will spend approximately an hour before being transferred to the ward.
When you first wake up from surgery you will notice a variety of things attached to you. These may (or may not) include a:
- Vaginal pack
- Calf compressor
- Intravenous access
- A fluid bag
- A nasogastric tube or oxygen mask
- A blood pressure cuff
Risks of surgery
- General surgical
- General medical
- Specific to laparoscopic surgery
- Organ injury
- Dissatisfaction with outcome