Uterine Preservation Surgery for Prolapse

This condition refers to the bulging or herniation of one or more pelvic organs into or out of the vagina. Prolapse is a common condition in women and can give the sensation of a bulge or fullness in the vagina, a dragging feeling or backache. It can also sometimes cause some difficulty with emptying the bowel or bladder. Approximately 1 out of 9 women (11%) will have surgery for prolapse (see leaflet on pelvic organ prolapse). Many women may wish to keep their uterus, especially if they are young and wish to preserve fertility.

If you do not wish to have a hysterectomy as a part of the surgery for prolapse, there are other operations which may be offered to you. They include sacrohysteropexy (which can be done open abdominal or laparoscopic ‘keyhole’), vaginal sacrospinous hysteropexy, and uterosacral ligament suspension (open abdominal, laparoscopic ‘keyhole’ or vaginal; see leaflet on uterosacral ligament suspension).

A Manchester procedure was previously considered an alternative but is currently only offered to women with elongation of the cervix (neck of the uterus). A colpocleisis or vaginal closure may also be considered in women who do not wish to be sexually active. This involves placing stitches in the vagina, without the need for a hysterectomy (see leaflet on colpocleisis). It is important to mention that there are alternative treatment options to surgery such as pelvic floor muscle training and use of pessaries (see leaflet on pelvic floor exercises and vaginal pessary for POP).

Sacrohysteropexy
A sacrohysteropexy involves lifting the uterus and restoring the vaginal walls back to their original positions. This can be done either through a cut in the abdomen (open abdominal) or by keyhole surgery (either laparoscopically or using a surgical robot). The uterus is lifted and held in place by attaching a mesh (usually a synthetic lightweight mesh made from woven polypropylene) around the cervix and then fixing the other end of the mesh to the bone at the base of the spine using either stitches or titanium clips. The mesh is buried under the lining of the abdomen to stop the bowel from getting stuck to the mesh. Please note that the abdominal mesh is not included in the recent controversies involving vaginal meshes (see our FAQ section on mid-urethral slings). Once this part of the operation is done, an assessment is made of the vaginal walls. Some women will have a vaginal repair for prolapse or continence surgery at the same as a sacrohysteropexy.

Vaginal Sacrospinous Hysteropexy
A vaginal sacrospinous hysteropexy is an operation which is performed through a vaginal route; there are no cuts on the abdomen. A cut is made in the back wall of the vagina and the cervix or ligaments attached to the cervix (uterosacral ligaments) are fixed with stitches to a ligament in the back of the pelvis (the sacrospinous ligament). It is usually fixed to the sacrospinous ligament on the right, but if additional support is needed it may also be fixed to the ligament on the left. This operation is usually done at the same time as a repair to the vaginal wall(s). The vaginal skin is then closed over the stitches. Continence surgery can also be performed at the same time if needed.

Uterosacral Ligament Suspension
The uterosacral ligaments are strong supportive structures that attach the cervix (neck of the uterus) to the sacrum (bottom of the spine). Weakness and stretching of these ligaments can contribute to pelvic organ prolapse. A uterosacral ligament suspension involves stitching the uterosacral ligaments to the apex or top of the vagina, thereby restoring normal support to the top of the vagina. This operation can be done vaginally, abdominally, or laparoscopically (“keyhole”), and your surgeon will discuss these options with you. It can be combined with other procedures for prolapse or continence surgery (see leaflet on uterosacral ligament suspension).

Sacrohysteropexy
Three- to five-year success rates have shown about 90% of women are cured of their prolapse and prolapse symptoms. The longer-term benefit and data are still being looked at. There is a small chance of another part of the vagina (such as the front or back wall), or the uterus prolapsing again, which may necessitate further treatment or surgery in the future.

Vaginal Sacrospinous Hysteropexy
Quoted success rates are between 80-90%. However, there is a chance that the prolapse could return in the future or another part of the vagina may prolapse, requiring further treatment or surgery.

Uterosacral Ligament Suspension
Quoted success rates for uterosacral ligament suspension are between 80-90%. However, as with any prolapse surgery, there is a chance that the prolapse might come back in the future, or another part of the vagina may prolapse which may require further treatment.

There are general risks associated with any operation, including the risks associated with anesthesia (general, spinal or epidural). Other general risks include wound infections, urinary tract infections, bleeding, blood clots in the legs and lungs, and pain or discomfort following the operation – in general and/or specifically with intercourse. Sometimes there can be difficulties in emptying the bladder or a worsening of existing urinary symptoms, such as urgency or stress urinary incontinence. More specific risks for the operations are discussed below.

Sacrohysteropexy
As this is done either through a keyhole operation or a bigger cut, there is the risk of damaging the other organs in your abdomen, such as the bladder, bowel, or ureters. There is also a small risk (2-4% of cases) of the mesh protruding into surrounding organs, such as the bowel, bladder or vagina. This is uncommon but may require a repeat operation to trim or remove the mesh.

Vaginal Sacrospinous Hysteropexy
There is a small risk of damage to the bladder or bowel. There is about a 1 in 10 chance of having buttock pain on the side of the stitch. This usually settles by itself with time. It can be quite common to be constipated following the operation, but this can be managed with laxatives. As mentioned above, there is a chance that another part of the vagina (especially the front wall) may prolapse in future.

Uterosacral Ligament Suspension
Ureteric injury is quoted to occur in 1-10% of women undergoing this procedure (the ureters are the tubes that connect the kidneys to the bladder). At the time of the procedure, your surgeon may look inside the bladder with a telescope (cystoscopy) to check that the ureters are still functioning. Ureteric injury may require further procedures in the future. Buttock pain is a short-term problem that can be managed with pain medication. Constipation is a common short-term problem and your doctor may prescribe laxatives for this. Try to maintain a high-fiber diet and drink plenty of fluids to help as well. Pain with intercourse can occur rarely, although most women find that their sex lives improve once a prolapse is treated.

You will be asked about your general health and any medications you may be taking. You will have any relevant tests such as an ECG (trace of the heart), chest x-ray or blood tests. You will also be given any relevant information about your hospital stay, when to stop eating and drinking before the operation, and what to expect after the operation. You will have the opportunity to discuss the operation and the anesthetic with the team beforehand.

To help prepare yourself for the operation, make sure you have some extra help available for the first couple of weeks after the operation. If you smoke, you are advised to try to stop completely before your operation as this will help make the anesthetic safer and reduce the chance of complications. Even if you can’t stop completely, holding off for just a few days before your operation will help greatly. If you are overweight, losing weight is also beneficial to the safety and success of the operation.

You will need to take it easy for 4-6 weeks after the operation, which means no heavy lifting, heavy housework, or exercise.  A month after surgery, you should be able to start doing gentle exercises, starting off slowly and building it up. Your doctor will advise you about driving depending on the type of surgery you’ve had. For vaginal surgery, you should avoid swimming, use of spas, and intercourse for six weeks to prevent infection. Some women find using additional lubricant during intercourse is helpful and your doctor may suggest a course of vaginal oestrogen cream or pessaries. Your doctor will advise you how long to be off work depending on your job and the type of surgery (usually about 4-6 weeks).

Sacrohysteropexy
How the operation is performed, either keyhole or through a cut in the abdomen, will dictate how long you stay in the hospital. With a keyhole operation, recovery tends to be quicker and you should be able to go home 1-2 days after the operation. You will have a catheter in the bladder to help you pass urine immediately after the operation. This is usually taken out the next day. If any vaginal repair(s) have been done, you may have a pack in the vagina, like a big tampon, which puts gentle pressure on the cuts in the vagina. This is usually removed the morning after the operation.

Vaginal Sacrospinous Hysteropexy
You will usually be in the hospital for 1-2 days after the surgery. You will likely have a pack, like a big tampon, in the vagina to put gentle pressure on the wounds. You will have a catheter in the bladder to help you pass urine immediately after the operation. Both the pack and the catheter are usually removed the morning after the operation.

Uterosacral Ligament Suspension
Your stay in the hospital will depend on how the operation was done, but in general you should be able to go home 1-2 days after the operation. You may have a catheter which is removed within 24 hours.