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.