https://doi.org/10.1177/2051415816686791
Journal of Clinical Urology
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DOI: 10.1177/2051415816686791
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Introduction
Uterine prolapse is a common problem for which several
treatment options have been developed, which are the subject
of ceaseless refinement.1–7 Salem et al. described the
original anterior abdominal wall cervicopexy (AWC) as an
effective uterine conservation approach for stages III and
IV uterovaginal prolapse.1
Laparoscopic cervicopexy: a novel
minimally invasive fertility conservative
procedure for stages III and IV uterine
prolapse – case series
Ali M El-saman1, Ahmed M Abbas1, Ahmed F Amin1,
Ahmed N Fetih1, Mustafa Bahloul1, Mohammed N Salem2
and Hossam T Salem1
Abstract
Objective: To evaluate the safety and efficacy of laparoscopic anterior abdominal wall cervicopexy (LAWC), a novel
minimally invasive procedure for management of stages III and IV uterine prolapse.
Subjects and methods: The procedure was performed on 39 cases with symptomatic uterine prolapse during the
period from June 2012 to January 2015. The procedure was started with obliteration of the pouch of Douglas through
the approximation of the uterosacral ligaments with non-absorbable suture. Then, the procedure completed through
anchoring the supravaginal cervix to the anterior abdominal wall by two non-absorbable sutures taken in good bites in
the dense stroma of the supravaginal cervix.
Results: Uterine prolapse was diagnosed as stage III in 36 (92.3%) women and stage IV in three cases. The procedure
was conducted safely without any intraoperative complications. At 3 month follow-up, there was a statistically significant
reduction in the extent of prolapse at all pelvic organ prolapse quantification (POP-Q) points as compared with
preoperative assessment (p = 0.000). Only five cases (12.8%) were found to have stage I uterine prolapse on evaluation
by the POP-Q system after one year.
Conclusion: LAWC is a minimally invasive, simple, and highly effective procedure to treat marked uterine prolapse and
seems not to compromise fertility.
Keywords
Anterior abdominal wall cervicopexy, uterine prolapse, laparoscopy, uterine descent
Date received: 22 July 2016; accepted: 14 November 2016
1Department of Obstetrics and Gynecology, Assiut University, Egypt
2Department of Obstetrics and Gynecology, Sohag University, Egypt
Corresponding author:
Ahmed M Abbas, Department of Obstetrics and Gynecology, Assiut
University, Women’s Health Hospital, 71511, Assiut, Egypt.
Email: bmr90@hotmail.com
686791URO0010.1177/2051415816686791Journal of Clinical UrologyEl-saman et al.
research-article2016
Original Article
2 Journal of Clinical Urology
The AWC technique was very simple and could be performed
by residents and young gynecologists with success
rates of 90%.1 The original AWC procedure was performed
via conventional laparotomy and required direct manipulations
nearby the tubes and ovaries during obliteration of
the pouch of Douglas. Pelvic adhesions were reported in
those young women who chose AWC to keep their reproductive
potential.1 The costs, operative time, technical
requirements, and complications of AWC are incomparably
lower than other procedures.7–13
Consequently, El-saman et al. reintroduced the AWC
procedure in a less invasive way for low-resources areas
through maximum vaginal repair and a 3–4 cm minilaparotomy.
14 This avoids the direct manipulation of the
pelvic organs and subsequent formation of adhesions. The
present report represents the latest refinement for the reintroduction
of AWC in a less invasive and safer way.
The aims of the present study were to evaluate the
safety and efficacy regarding the anatomical and functional
outcomes of laparoscopic anterior abdominal wall
cervicopexy (LAWC), a novel minimally invasive procedure
for women with stage III and IV uterine prolapse.
Materials and methods
During the period from June 2012 to January 2015, after
obtaining ethical and institutional review board approvals,
39 cases with symptomatic uterine prolapse were
recruited and considered eligible for the present study.
The study was conducted in Assiut Women’s Health
Hospital, Egypt.
We only included cases with stage III or IV uterine prolapse
according to the pelvic organ prolapse quantification
(POP-Q) evaluation system with a desire to retain their fertility
potential after signing a written consent. Women who
had associated tubal or ovarian pathology, previous failed
surgery for prolapse, or had completed their families were
excluded. Those who refused to participate in the study
were also excluded.
All cases were interviewed by a gynecologist in the
urogynecology clinic. A full history had been taken from
each participant and body mass index (BMI) was estimated.
Gynecological examination and evaluation of the
prolapse stage with the POP-Q system were performed.
The distance of each point was measured and recorded
preoperatively. Hemoglobin level was estimated for all
cases in the preoperative day.
Surgical procedure
All cases were performed under general anesthesia in the
dorsal lithotomy position to facilitate access to both perineum
and anterior abdominal wall. Operative time was
defined from the beginning of skin incision to completion
of skin closure.
Three ports were used to perform the LAWC procedure.
One 10 mm reusable trocar was inserted through the
umbilicus to hold the optic camera, and the other two 5
mm ports were inserted suprapubic in the abdominal
crease 2–3 cm above the pubic bone, 5–7cm apart from
each other. All ancillary instruments including atraumatic
graspers and scissors (Karl Storz Endoskope, Tuttlingen,
Germany) were reusable.
The first step in the LAWC procedure was the obliteration
of the pouch of Douglas through an approximation of
the uterosacral ligaments with non-absorbable No. 1
monofilament polypropylene blue suture (Prodek; Sutures
Ltd, Ruabon, Wales, UK). This step was done while the
uterus was in the anteversion position by uterine manipulator,
as shown in the diagram in Figure 1.
The second step was to expose the supravaginal cervix
through downward dissection of the bladder. A set of two
non-absorbable No. 1 monofilament polypropylene blue
sutures was taken in good bites in the dense stroma of the
supravaginal cervix. The first and second sutures were 1
cm apart. Then extraction of the supporting sutures was
done (Figure 2).
A conventional atraumatic laparoscopic grasper was
introduced through a right suprapubic ancillary port to
grasp and extract the right ends of the sutures. The same
was done for the left ends but through the left suprapubic
port. By the end of this step, the two supporting sutures
were extracted through two ancillary ports and were ready
for crossing and tying. Each of the two sutures is like the
letter U with one of its arms being extracted out of one of
the suprapubic ports and its bottom is passing through the
supravaginal cervix.
To fasten these U-shaped sutures it is necessary to cross
one of its arms from its suprapubic port to the other
suprapubic port. This was done by tunneling the right arm
of the first suture under the skin from the right port to be
extracted from the left port (Figures 2 and 3). Tunneling
was done via a conventional long curved needle after
attenuation of its curve. It could also be done via a straight
Figure 1. (a) Diagram showing obliteration of the Douglas
pouch. (b) Diagram showing placement of cervical sutures.
El-saman et al. 3
needle or an artery forceps (Figure 3). This was followed
by tunneling the left arm of the second suture under the
skin from the left port to be extracted from the right port.
After crossing the sutures’ arms, the first suture is now
ready for fastening at the left port and the second suture is
ready for fastening at the right port.
The third step was to fasten the right arm of the upper
suture (first suture) with its corresponding left arm (Figure
3). The same was done with the lower suture (second
suture). Adjusted tying was accomplished by the surgeon
and an assistant. The surgeon elevates the sutures from the
abdominal side and the assistant monitors the uterus while
it is being pulled up until the cervix is at or just above the
level of the ischial spines (Figure 4). It is important to tie
the sutures with care to avoid overcorrection because of
the slippery and sliding nature of the monofilament suture
knots. The knots were pushed medially by an artery forceps
to be buried under the intact skin and subcutaneous
tissue within the tunnel between the two suprapubic ports
(Figure 5).
After recovery from the anesthesia, patients were transferred
to the postoperative ward for follow-up. Hemoglobin
assessment was performed 12 hours after the operation.
The length of hospital stay was counted from the first postoperative
day. Any postoperative complications were
recorded and managed accordingly. The patients were discharged
after asking them to abstain sexual intercourse for
at least 8 weeks after surgery.
Follow-up
Patients were invited to the follow-up visits every 3 months
at the urogynecology clinic. At the first follow-up visit, 3
months postoperatively, gynecological examination and
POP-Q evaluation with measurement of the distance of
each point and evaluation of persistence, recurrence or
development of new urinary symptoms.
At each subsequent visit, gynecological examination
was done with prolapse staging using the POP-Q system.
Figure 2. (a) One of each arms of the first suture is extracted
from a suprapubic port. (b) The left arm is tunneled to the
right port.
Figure 3. (a) Both arms of the first suture are ready for
traction and adjusted fastening at the right suprapubic port. (b)
Adjusted fastening of the first suture was completed.
Figure 4. (a) Excess arms of the first suture were cut short
and the knot was grasped by small artery forceps. (b) The knot
was pushed under the intact skin (away from the port opening).
Figure 5. The same steps were done for the second suture.
4 Journal of Clinical Urology
The procedure was considered to have been successful if
there were no recurrence of complaints confirmed by
gynecological examination with the POP-Q system. Any
case got pregnant during follow-up was recorded and followed
up till delivery. A trial of vaginal delivery was
allowed unless there was an obstetric indication for cesarean
section (CS). Any case of post-delivery recurrence was
documented.
The data were collected and analyzed using SPSS software,
version 20 (SPSS Inc, Chicago, IL). Qualitative variables
are expressed as frequency and percentage.
Chi-square test was used to examine the relation between
qualitative variables. Quantitative variables are presented
in terms of mean and standard deviation or median and
range. Wilcoxon test was used to compare the pre- and
postoperative data. For analysis, p < 0.05 was considered
to be significant.
Results
The mean age of the study participants was 25.17±3 years
and the mean BMI was 28.1±3.19 kg/m2. All women were
married; nine of them were nulliparas and 30 multiparas.
Uterine prolapse was diagnosed as stage III in 36 (92.3%)
women and stage IV in three cases. The mean duration of
prolapse was 9.75±3.28 months. Table 1 shows the demographic
characteristics of the patients.
The mean time of the procedure was 50.42±6.27 min
(range 42–65 min). The procedure was conducted safely
without any intraoperative complications. The postoperative
course was complicated by febrile morbidity in only
one woman. There were two women suffered from urinary
retention relieved by fixing a Foley’s catheter for 4 days.
No statistically significant difference was observed in the
hemoglobin level postoperatively (p = 0.075), as shown in
Table 1.
At 3 month follow-up, all women were normal when
evaluated by the POP-Q system. There was a statistically
significant reduction in the extent of prolapse at all POP-Q
points as compared with preoperative assessment (p =
0.000), as shown in Table 2.
Table 3 shows the postoperative quantification of urinary
symptoms at 3-month follow-up visit. There was a
significant improvement of all urinary symptoms. Only
three cases (7.7%) continued to suffer from the symptoms
of overactive bladder (OAB) without urge incontinence
and frequency of micturition.
Table 4 shows the results of long-term follow-up of the
women. All cases had no prolapse related complaints during
the first year. Women with persistent postoperative urinary
symptoms were also improved. Only five cases
(12.8%) were found to have stage I uterine prolapse on
evaluation by the POP-Q system after one year. During the
period of follow-up, 16 women (41%) became pregnant;
eight of them were delivered by CS, five of them were
delivered vaginally, and the last three currently have ongoing
pregnancy.
In the eight cases where CS was carried out in our hospital,
the abdominal incision was carefully planned to
avoid cutting the supporting sutures. On opening the peritoneal
cavity, 1–2 cm of the supporting sutures were seen
passing beneath the visceral peritoneal crossing to the
anterior abdominal wall. Follow-up assessment of these
cases at 6–12 weeks postpartum confirmed maintained
success.
Discussion
The management of uterine prolapse in young women who
need fertility conservation is a great challenge for reconstructive
pelvic surgeons. No ideal procedure has been
described in the literature so far. In the present case series,
we introduced a novel procedure via a minimally invasive
route for the management of stage III and IV uterine prolapse
with fertility conservation. LAWC is a more advantageous
procedure if compared with previously reported
AWC procedures.
Originally, the traditional AWC was introduced via a
standard laparotomy that made the procedure a form of
Table 1. Demographic and operative data of the study
participants (n = 39).
Variables Results
Age (years), mean ± SD
(range)
25.17 ± 3 (20–30)
BMI (kg/m2), mean ± SD
(range)
28.1 ± 3.19 (22.5–33.2)
Parity, median (range) 1 (0–2)
Previous vaginal delivery,
n (%)
8 (76.9)
Nullipara, n (%) 3 (23.1)
Duration of prolapse
(months), mean ± SD (range)
9.75 ± 3.28 (5–14)
Operative time (minutes),
mean ± SD (range)
50.42 ± 6.27 (42–65)
Postoperative hospital stay
(days), mean ± SD (range)
2.5 ± 0.8 (2–4)
Hemoglobin level, mean ± SD
Preoperative 11.28 ± 0.43
Postoperative 11.05 ± 0.4
p-valuea 0.075
BMI, body mass index; SD, standard deviation.
ap-value was measured by Wilcoxon test.
El-saman et al. 5
major open surgery. Pelvic adhesions were reported in
some cases during follow-up in spite of adherence to the
principles of microsurgical techniques.1 We initially
refined the AWC procedure by shifting from a standard
laparotomy to a mini-laparotomy without uterine manipulations
or intestinal packing during abdominal obliteration
of the Douglas pouch. Instead, the Douglas pouch was
obliterated via vaginal approximation of the uterosacral
ligaments. In addition, the supravaginal cervix was
exposed vaginally and the supporting sutures were placed
vaginally and extracted through a mini-laparotomy.14
The present modification entailed laparoscopic obliteration
of the Douglas pouch via approximation of the uterosacral
ligaments, a step that augments the obliteration of
the posterior compartment, supports the vaginal apex posteriorly,
and prevents the development of iatrogenic
enterocele.
Despite the fact that there are several uterine conservation
techniques for treatment of uterovaginal prolapse,7–13,15,16 the
AWC procedure has many advantages. The uterus in AWC is
supported from a favorably appropriate site. The supporting
sutures are taken in the strong stroma of the supravaginal
cervix. This makes an important contrast to cases treated by
anchoring the uterus to the anterior abdominal wall from the
weak site at the round ligaments. Furthermore, the cervix’s
normal anatomical site is intra-pelvic (low seated) and the
target site to which the cervix is going to be anchored is the
suprapubic area of the lower abdominal wall.
In the present cases series, LAWC continues to hold the
whole advantages presented before for the original AWC
and modified AWC. Besides that, the novel procedure has
its own merits.
Firstly, the entire procedure is performed via laparoscopy,
a form of minimal invasive surgery, without any
direct intra peritoneal manipulations. This avoids the risk
of pelvic adhesions reported before. Secondly, there are
neither big abdominal nor vaginal incisions in the LAWC
procedure; this is definitely associated with less blood loss
and early postoperative recovery with a short hospital stay.
No significant difference was found in the hemoglobin
Table 2. Pre- and postoperative quantification of the prolapse by POP-Q measurements (n = 39).
Points Preoperativea Postoperativea p-valueb Mean differencea
Aa 2.1 (1–3) −2 (−1 to −3) 0.000* 4.1 (2–6)
Ba 2.7 (1.5–4) −2.4 (−1 to −3) 0.000* 5.1 (2.5–7)
C 5.6 (4 to 7.5) −5.4 (−4 to −7) 0.000* 11.7 (8–14.5)
D 5.1 (4.5 to 8) −7.1 (−6 to −8.5) 0.000* 13.2 (10.5–16.5)
Ap 0.9 (0 to 2) −2.2 (−1.5 to −3) 0.000* 3.1 (1.5–5)
Bp 0.7 (0 to 1.5) −2.5 (−1.5 to −3) 0.000* 3.2 (1.5–4.5)
POP-Q, pelvic organ prolapse quantification points measured in cm in relation to the position of the genital hiatus; Aa, a point located in the midline
of the anterior vaginal wall, 3 cm proximal to the external urethral meatus; Ba, the most distal/dependent point on the anterior vaginal wall from
point Aa to the anterior vaginal fornix; C, the most distal/dependent edge of the cervix or vaginal cuff (a measure of uterine descent); D, the position
of the posterior fornix; Ap, a point located in the midline of the posterior vaginal wall, 3 cm proximal to the hymen; Bp, the most distal/dependent
point on the posterior vaginal wall above point Ap.
aData are presented as mean (range).
bp-value was measured by Wilcoxon test,
*Statistical significant difference.
Table 3. Pre- and postoperative quantification of urinary symptoms (n = 39).
Variables Preoperative Postoperative p-valuea
OAB-dry, n (%) 9 (23.1) 3 (7.7) 0.002*
OAB-wet, n (%) 8 (20.5) 0 -------
SUI, n (%) 4 (10.3) 0 -------
Frequency of micturition, n (%) 14 (35.9) 2 (5.1) 0.002*
Nocturia, n (%) 3 (7.7) 0 -------
OAB, overactive bladder; SUI, stress urinary incontinence.
ap-value was measured by Wilcoxon test,
*Statistical significant difference.
6 Journal of Clinical Urology
level when compared pre- and postoperatively (p = 0.075).
The mean duration of postoperative hospital stay was 2.5
days versus 3 days that previously reported with original
AWC.1
Thirdly; the procedure is technically easier with short
operative time if compared with the original AWC and the
modified AWC (60±12.4 and 55.9±9.5 min, respectively
versus 50.42±6.27 min in LAWC). Lastly, the previous
observation that early postoperative urinary retention and
frequency of micturition were the most frequently reported
consequences of AWC. These early urinary symptoms
cloud be attributed to variable degrees of minor overcorrection.
Only two women suffered from intermittent urinary
retention and discharged on the fourth day with
complete cure.
Compared with other laparoscopic procedures for uterine
conservation and prolapse correction, LAWC is much
simpler, less costly, and not associated with the reported
complications of the other procedures, especially those
related to the mesh insertion.17–19
In sacrohysteropexy, the uterus with the vaginal axis is
moved to a backward position consequently making the
development of iatrogenic stress urinary incontinence
(SUI) more likely.20 Suspension of the uterus to the anterior
abdominal wall is not static as the uterus is anchored
to the dynamic anterior abdominal wall but anchoring the
uterus to the sacral promontory or ischial spines represents
a fixed nondynamic suspension. Our experience with 95
pregnancies after original AWC and modified AWC provided
some proof for this, since the course of pregnancy
and that of labor were not compromised with the procedure.
In this case series, pregnancy was also achieved in
16/39 (41%) cases within the first year postoperatively; 13
of them have delivered with no postpartum recurrence of
prolapse.
Laparoscopic ventrosuspension entails suturing both
round ligaments of the uterus to the rectus sheath. The procedure
was reported to be associated with a poor success
rate in a case series of nine women; eight of them suffered
from recurrence within 3 months postoperatively.21
Although no conclusive evidence could be obtained
from our current observational study, we are most encouraged
by its findings that LAWC is a feasible procedure in
treatment of stage III and IV uterine prolapse. These initial
findings need to be confirmed in a well-designed randomized
controlled trial with a longer period of follow-up.
The present refinement represents a continuation of the
authors’ efforts to reintroduce the AWC procedure in a
minimally invasive way.
Conclusions
In conclusion, LAWC is a safe, effective, and feasible procedure
in the management of stage III and IV uterine prolapse
in women who wish for fertility conservation. The
preliminary results are encouraging, showing favorable
anatomical and functional outcomes.
Conflicting interests
The authors declare that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency
in the public, commercial, or not-for-profit sectors.
Ethical approval
The Assiut Faculty of Medicine ethics committee approved this
study (REC number: IRB00006161).
Informed consent
Written informed consent was obtained from the patients for
their anonymized information to be published in this article.
Guarantor
AME.
Contributorship
AME: Protocol development, performing surgery, manuscript
writing. AMA: Data management, assist in surgery and follow-up,
manuscript writing. AFA: Performing surgery, manuscript editing.
ANF: Data management, assist in surgery and follow-up, manuscript
writing. MB: Assist in surgery and follow-up, manuscript
editing. MNS: Assist in surgery and follow-up, manuscript editing.
HTS: Protocol development, performing surgery, manuscript
Table 4. Results of long-term follow-up of the study
participants (n = 39).
Variables Results
Duration of follow-up (months),
median (range)
18 (12–24)
Loss of follow-up after 1 year, n (%) 0
POP-Q stage of prolapse
(stage 0/stage 1), n
After 6 months 36/3
After 1 year 34/5
Pregnancy, n (%) 16/39 (41)
Mode of delivery, n (%)
Vaginal 5/16 (31.25)
Cesarean section 8/16 (50)
Post-delivery recurrence 0
Repeat surgery, n (%) 0
POP-Q, pelvic organ prolapse quantification.
El-saman et al. 7
editing. All authors reviewed and edited the manuscript and
approved the final version of the manuscript.
Acknowledgements
None.
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