Uterosacral SuspensionUterosacral Suspension

Educational ObjectivesEducational Objectives

• This lecture will enable the participant to list and discuss the indications and complications of uterosacral suspension for apical defects.

• This lecture will enable the physician to describe the surgical technique for uterosacral suspension

TechniquesTechniques

• There are many techniques for reestablishing support of the vaginal apex

• Sacrospinous ligament suspension• Iliococcygeus fascia suspension• Abdominal sacral colpopexy• Uterosacral ligament suspension

Historical PerspectiveHistorical Perspective

• Miller (1927) –bilateral suspension of the vaginal vault to the uterosacral ligaments

• McCall (1957) –combined uterosacral suspension with an extensive culdeplasty

• Jenkins (1997) –vaginal approach

• Miklos (1998) –laparoscopic approach

AnatomyAnatomy

• The uterosacral ligament is a fanlike structure originating at the sacrum and narrowing just proximal to its insertion at the cervix.

Divisions of the Uterosacral Divisions of the Uterosacral Ligament (Campbell 1950)Ligament (Campbell 1950)

• Cervical –made up of smooth muscle with abundant blood vessels and nerve fibers

• Intermediate—predominantly connective tissue, fewer nerves and vessels

• Sacral—almost entirely composed of loose strands of connective tissue intermingled with fat

Vascular structures adjacent to the Vascular structures adjacent to the Uterosacral LigamentUterosacral Ligament

• Sacral portion— the superior gluteal vein lies medial to the superior gluteal artery

(post. branch of Hypogastric)

Inferior gluteal vein and artery (anterior branch of Hypogastric)

• Intermediate portion— the middle rectal artery is near the inferior margin ( hypogastric and Inferior mesenteric)

• Cervical portion— the coccygeal and accessory coccygeal artery (Branch of inferior gluteal)

Proximity of the UreterProximity of the Ureter

• Sacral portion---4.1 +- 0.6 cm

• Intermediate portion—2.3 +- 0.9 cm

• Cervical portion—0.9 +- 0.4 cm

• Ischial spine—4.9 +- 2 cm

Effect of SuturesEffect of Sutures

• Sutures placed at the cervical portion

exerted greater pressure on the ureter

• Sutures placed in the sacral portion pulled out easiest

The Intermediate portionThe Intermediate portion

• Provides strong suture fixation

• Little pressure on the ureter

• Greater distance from vascular structures

LocationLocation is everything is everything!!!!

• Level of the ischial spine

• One centimeter posterior to the anterior most palpable margin of the uterosacral ligament while held on tension

Uterosacral Plication ?Uterosacral Plication ?

• We do not plicate the uterosacral ligaments

• Narrowing of the upper vagina

• Increased risk of ureteral obstruction?

Abdominal and Laparoscopic Abdominal and Laparoscopic ApproachApproach

• Permits uterine preservation

• Better for patients with shortened vagina?

• Those with lifestyles involving heavy work

• Prior prolapse surgery or procedures in the cul de sac

• Suspicion of endometriosis

• Severe uterine prolapse?

Steps for Vaginal Uterosacral Steps for Vaginal Uterosacral SuspensionSuspension

• Dissect cuff-enter peritoneum• Develop anterior and posterior endopelvic fascia• Three permanent double armed sutures on each

side• 1.5 cm posterior to the ischial spine and1-2 cm

apart toward the sacrum• Distal sutures placed laterally and proximal

sutures medially through the fascia of the cuff

(Shull 2000)

ResultsResults

• 82% had good support at two years

• The anterior segment was more likely to fail

• Anterior enterocele (Barber 2000)

ComplicationsComplications

• Ureteral obstruction—11% (Barber, 2000)

• Cystoscopy with indigo carmine is indicated

• Significant vascular involvement ?

• Have a plan to handle it

ConclusionConclusion

• Uterosacral suspension is a safe and effective technique for the treatment of apical prolapse.

• The gynecologic surgeon should be familiar with the vascular structures adjacent to the uterosacral ligaments and their proximity to the ureters at all levels.

Suggested readingSuggested reading

• McCall ML; Posterior culdeplasty, Obstet Gynecol 10;595, 1957

• Shull BL, Capen CV:preoperative analysis of site specific pelvis support defects in 81 women treated with sacrospinous ligament suspension, Am J Obstetric Gynecol 166:1764. 1992

• Shull BL, Bachofen C, Coates KW. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 183:1346, 2000