Discussion
Abdominal or minimally invasive sacrohysteropexy is regarded as the
standard reference procedure for apical and multicompartment prolapse,
especially in women who want a uterus-sparing procedure. Although it has
a relatively high success rate, these procedures require advanced
suturing and dissection skills and are related to complications such as
mesh exposure, dyspareunia, ileus, de novo bowel dysfunction, and
intraoperative bladder and intestine injury.6 The
technique described here has several advantages over conventional
techniques.
The uterosacral ligament, which is 12–14 cm long, can be subdivided
into cervical (2–3 cm), intermediate (5–6 cm) and sacral (5–6 cm)
sections.7 The cervical section of the ligament is
made up of dense connective tissue containing small blood vessels and
small branches of the hypogastric plexus. The novel intracervical
placement of mesh described here mimics sacrouterine ligament insertion,
providing strong attachment without the need for any anchor or suture,
which may decrease the detachment and mesh exposure risks.
The stiffness and geometry of the uterosacral ligament play important
roles in the biomechanics of apical uterovaginal
prolapse.8 By helping to maintain a symmetrical,
anteflexed and anteverted position of the uterus, this technique can
reconstruct the biomechanics that may cause anterior or posterior
vaginal wall prolapse after other apical prolapse repair
techniques.9 The minimal use of polypropylene mesh and
avoidance of mesh in the vaginal wall can eliminate the risk of mesh
erosion or exposure. The calculated polypropylene mesh load surface area
is 4 × 10-3 m2 (0.3 g) for SUTS and
13 × 10-3 m2 (1 g) for
sacrocolpopexy mesh.
The vaginal approach for mesh insertion is a feasible technique and
provides an opportunity to repair anterior and posterior vaginal wall
defects and to perform a mid-urethral sling and perineoplasty. Fixation
of mesh up to the bladder neck in the anterior vaginal wall and up to
the levator ani muscle level in the posterior vaginal wall can
ameliorate prolapse of the anterior and posterior vaginal walls, but it
can also cause de novo pain or sexual
dysfunction.10 Therefore, conventional colporrhaphy
may result in better anatomic outcomes without mesh-related pain.
De novo bladder dysfunction or bowel dysfunction can be seen
after conventional hysteropexy or sacrocolpopexy operations. This
impaired function can be due to inferior hypogastric plexus injury
during dissection of the sacrum, dissection of the peritoneum medial to
the sacrouterine fold or vaginal dissection.11 The new
tunneling technique described here uses an angled semicircular bended
grasper, thereby avoiding vigorous dissection of the peritoneum and
consequently minimizing ureter, nerve and vessel injuries. The use of a
bended, disposable grasper without a port instead of rigid laparoscopic
instruments is a practical idea that is also easy to perform. The
reasons for bowel dysfunction after conventional hysteropexy can include
the approximation of the uterus to the sacrum and compression of sigmoid
colon between the sacrum and over the displaced uterus. This new
technique permits bowel movements between the two tape arms.