Uterine Suspension Surgery: Comprehensive Guide for Surgeons

Introduction

Uterine suspension, also known as uterine prolapse surgery or uterine repositioning, is a surgical procedure designed to correct uterine prolapse. Uterine prolapse occurs when the uterus descends from its normal position into the vaginal canal due to weakened pelvic floor muscles and ligaments. This condition can cause discomfort, urinary and bowel dysfunction, and a significant impact on a woman’s quality of life. Uterine suspension aims to restore the uterus to its original anatomical position, relieving symptoms and preventing further complications.

Indications

Uterine suspension is primarily indicated for women with symptomatic uterine prolapse. The severity of the prolapse is often classified into four stages, ranging from mild (stage I) to complete prolapse (stage IV), where the uterus protrudes outside the vaginal canal. Indications for uterine suspension include:

1. Symptomatic Prolapse: Women experiencing significant discomfort, pressure, or pain due to uterine prolapse.
2. Urinary Symptoms: Prolapse causing urinary incontinence, urgency, or difficulty in voiding.
3. Bowel Symptoms: Prolapse leading to bowel dysfunction, such as constipation or fecal incontinence.
4. Sexual Dysfunction: Prolapse affecting sexual activity or causing dyspareunia (pain during intercourse).
5. Failed Conservative Management: When non-surgical treatments such as pelvic floor exercises, pessary use, or lifestyle modifications fail to alleviate symptoms.
6. Desire to Preserve the Uterus: Women who wish to retain their uterus and avoid hysterectomy for personal or reproductive reasons.

Preoperative Evaluation

A thorough preoperative evaluation is essential to ensure the patient is an appropriate candidate for uterine suspension and to plan the most effective surgical approach. The evaluation should include:

1. Medical History: Detailed history of symptoms, duration, and impact on daily life. Previous surgeries, obstetric history, and any other medical conditions should be noted.
2. Physical Examination: A pelvic examination is crucial to assess the degree of prolapse and evaluate the integrity of the pelvic floor muscles. The presence of associated conditions such as cystocele or rectocele should be identified.
3. Imaging Studies: Pelvic ultrasound or MRI may be used to assess the anatomy and rule out other pelvic pathologies.
4. Urodynamic Testing: If urinary symptoms are present, urodynamic studies can help determine the nature of bladder dysfunction and guide the surgical approach.
5. Anesthetic Evaluation: Assess the patient’s fitness for surgery, particularly in elderly patients or those with comorbidities.

Contraindications

While uterine suspension can be beneficial for many women, there are certain contraindications that may preclude surgery or necessitate an alternative approach:

1. Severe Comorbidities: Patients with significant cardiovascular, respiratory, or other systemic conditions may not tolerate surgery well.
2. Active Pelvic Infections: The presence of an untreated infection in the pelvic area is a contraindication until the infection is resolved.
3. Advanced Uterine Cancer: In cases of malignancy involving the uterus, a hysterectomy may be more appropriate.
4. Patient Preference: Some patients may prefer non-surgical management or opt for a hysterectomy instead.

Surgical Techniques and Steps

There are several techniques for uterine suspension, each with specific indications based on the patient's condition and the surgeon's expertise. The most common methods include:

1. Sacrospinous Ligament Fixation (SSLF)

Overview: SSLF involves anchoring the uterus to the sacrospinous ligament, located near the sacrum. This method is often used in cases of mild to moderate prolapse.

Steps:

• Preparation: The patient is placed in the lithotomy position, and a vaginal approach is typically used.
• Incision: A posterior vaginal incision is made to access the sacrospinous ligament.
• Suturing: Non-absorbable sutures are placed through the sacrospinous ligament and then attached to the cervix or vaginal cuff.
• Closure: The vaginal incision is closed, and the uterus is repositioned.

2. Uterosacral Ligament Suspension (USLS)

Overview: USLS involves attaching the uterus to the uterosacral ligaments, which provide strong support. This technique is suitable for patients with more severe prolapse.

Steps:

• Preparation: The procedure can be performed vaginally or abdominally.
• Incision: A vaginal or laparoscopic incision is made to access the uterosacral ligaments.
• Suturing: Sutures are placed through the uterosacral ligaments and then attached to the cervix or vaginal cuff.
• Closure: The incision is closed, and the uterus is elevated to its normal position.

3. Sacrocolpopexy

Overview: Sacrocolpopexy is a more complex procedure that involves attaching the uterus to the sacrum using a synthetic mesh. It is often used in cases of severe prolapse or recurrent prolapse after previous surgeries.

Steps:

• Preparation: The patient is placed in a supine position, and a laparoscopic or open abdominal approach is used.
• Incision: An abdominal incision is made to access the pelvic cavity.
• Mesh Placement: A synthetic mesh is attached to the anterior and posterior walls of the vagina and then anchored to the sacrum.
• Closure: The mesh is secured, and the abdominal incision is closed.

4. Manchester Procedure

Overview: The Manchester procedure involves shortening the cervix and reattaching the cardinal ligaments to support the uterus. This technique is less commonly used but may be appropriate for select patients.

Steps:

• Preparation: The patient is placed in the lithotomy position, and a vaginal approach is used.
• Incision: A vaginal incision is made to access the cervix and cardinal ligaments.
• Cervical Amputation: The cervix is partially amputated, and the cardinal ligaments are reattached to the remaining cervical stump.
• Closure: The vaginal incision is closed, and the uterus is repositioned.

Postoperative Care

Postoperative care is crucial to ensure a successful outcome and minimize complications. Key aspects of postoperative care include:

1. Pain Management: Pain control is achieved using a combination of analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids if necessary.
2. Infection Prevention: Prophylactic antibiotics are often administered to prevent surgical site infections.
3. Bladder Management: A Foley catheter may be placed for 24-48 hours postoperatively to ensure bladder drainage and prevent urinary retention.
4. Mobility and Activity: Early mobilization is encouraged to reduce the risk of thromboembolism, but heavy lifting and strenuous activities should be avoided for 6-8 weeks.
5. Follow-Up: Regular follow-up visits are essential to monitor healing, assess the success of the procedure, and address any complications.

Possible Complications

Like any surgical procedure, uterine suspension carries potential risks and complications. These may include:

1. Infection: Postoperative infections, including urinary tract infections and pelvic infections, are possible.
2. Bleeding: Intraoperative or postoperative bleeding may occur, requiring intervention.
3. Injury to Surrounding Organs: The bladder, rectum, or ureters may be inadvertently injured during surgery.
4. Recurrence of Prolapse: Although uterine suspension is generally effective, there is a risk of recurrent prolapse, especially in patients with weak pelvic floor muscles.
5. Dyspareunia: Pain during intercourse may occur due to scarring or changes in vaginal anatomy.
6. Mesh Complications: In sacrocolpopexy, complications related to mesh, such as erosion or infection, may arise.

Prognosis and Outcome

The prognosis following uterine suspension is generally favorable, with most women experiencing significant relief from prolapse symptoms. The success rate varies depending on the technique used, the severity of the prolapse, and the patient’s overall health. Studies suggest that sacrocolpopexy has the highest long-term success rates, with over 90% of patients remaining prolapse-free after five years. However, recurrence rates can be higher with less invasive techniques, such as sacrospinous ligament fixation.

Alternative Options

For patients who are not candidates for uterine suspension or who prefer non-surgical options, several alternatives are available:

1. Pessary Use: Vaginal pessaries can provide temporary relief by supporting the uterus and alleviating symptoms. They are particularly useful for women who are not surgical candidates.
2. Pelvic Floor Therapy: Physical therapy focusing on strengthening the pelvic floor muscles can help manage mild prolapse symptoms and may prevent progression.
3. Hysterectomy: In some cases, a hysterectomy may be recommended, especially if the patient does not wish to preserve the uterus or if uterine pathology is present.
4. Uterine Artery Embolization (UAE): Although primarily used for fibroids, UAE may be considered in select cases of prolapse, particularly when heavy bleeding is a concern.

Average Cost

The cost of uterine suspension varies depending on the technique used, the surgeon’s expertise, the facility, and the geographic location. In the United States, the cost can range from $10,000 to $20,000, including hospital fees, surgeon fees, and anesthesia. Sacrocolpopexy, being a more complex procedure, tends to be on the higher end of this range.

Recent Advances

Recent advances in uterine suspension focus on minimally invasive techniques, improved mesh materials, and robotic-assisted surgery. Laparoscopic and robotic approaches have become increasingly popular due to their reduced recovery times, less postoperative pain, and smaller incisions. Research is also ongoing into the development of biocompatible mesh materials that reduce the risk of erosion and other complications.

Conclusion

Uterine suspension is a vital surgical option for women suffering from uterine prolapse, offering relief from symptoms and improving quality of life. The choice of technique depends on the severity of the prolapse, the patient’s overall health, and their desire to preserve the uterus. While the procedure is generally successful, careful patient selection, thorough preoperative evaluation, and meticulous surgical technique are essential to achieving the best outcomes.