Laparoscopic Utero-Sacral Plication Addressing Apical Vaginal Prolapse: Nothing New!

Abstract

Study Objective: To describe and lend further support to a simple, effective, safe and minimally invasive surgical technique (laparoscopic uterosacral ligament plication), used to address apical vaginal prolapse. To report objective clinical data that demonstrate successful outcome. Design: Describe technique, report data on a case series from retrospective chart review and clinical interview. Setting: Antrim Area Hospital, Department of Gynaecology, Northern Ireland. Patients: 10 patients with apical vaginal prolapse underwent laparoscopic uterosacral ligament plication either as a primary procedure or as an adjunct to laparoscopic paravaginal repair or total laparoscopic hysterectomy. Intervention: The ureters are first identified and releasing incisions made medially on the uterosacral ligaments. Non-absorbable, monofilament, sutures 0 (Monosof™) are then run continuously from a posterior position, anteriorly onto the pubo-cervical fascia. Extra-corporeal sutures are then tied and tightened to shorten the uterosacral ligament, elevating the vaginal apex. Cystoscopy is performed using intravenous indigo carmine to ensure there is no ureteric injury, occlusion or kinking. Measurements and Main Results: Pelvic organ prolapse quantification (POP-Q) assessments were made pre and post operatively and at 3 months post surgery, providing an objective measurement of the surgical result. POP-Q demonstrated immediate improvement in prolapse staging of all patients. Three months to 1 year after initial operation 2 patients required further surgery to address middle compartment prolapse. These women had chosen to retain their uteri and went on to have a hysterectomy. Subjectively 8/10 (80%) patients reported a “satisfactory to excellent” result from the procedure. There were no major complications or ureteric injuries. Conclusion: This small case series demonstrates the safety and effectiveness of a laparoscopic equivalent to the vaginal apical support technique originally described by McCall in 1957.