Modified Laparoscopic Uterosacral Ligament Suspension in Patients with Gynecologic Tumors and Advanced Uterovaginal Prolapse

Introduction

Cancers of the female reproductive tract are often accompanied by benign gynecologic diseases. ¹ Although the exact incidence of uterovaginal prolapse among patients with gynecologic tumors remains unclear, the concomitance of both conditions is commonly observed in the clinical practice. ² Despite the fact that this association may have important consequences in the surgical treatment, it is scarcely reported in the literature.

It is indeed a subject of debate whether both conditions can or shall be simultaneously repaired. ³ Many gynecologic oncologists neglect the complaints related to the pelvic floor alleging that priority must be given to the cancer treatment. Meanwhile, a delay in the correction of the genital prolapse may significantly affect patient's quality of life.

At present, practically all suspected or confirmed gynecologic malignancies can be properly managed by laparoscopy and it is also of great value in the surgical repair of a number of pelvic floor defects. ⁴ In this particular scenario, the selected technique for prolapse correction must be effective, rapid, and secure to not jeopardize the oncologic treatment. The authors propose an innovative endoscopic approach to concomitantly treat gynecologic tumors according to their types and advanced uterovaginal prolapse by the use of modified uterosacral ligament suspension (USLS) associated to McCall culdoplasty. The present article aims to describe the surgical techniques and also evaluate the feasibility, short-term efficacy, and safety of the combined procedure.

Materials and Methods

We conducted a prospective pilot study with women who were assigned to have operative laparoscopy for the treatment of different gynecologic tumors and also presented symptomatic uterovaginal prolapse. From February 2012 to June 2013, six consecutive patients underwent surgery at the Instituto do Câncer do Estado de São Paulo–Universidade de São Paulo, Brazil. The study was approved by the local ethics committee and the patients provided consent. The following preoperative information was collected: age, parity, body mass index (BMI), previous pelvic operations, oncologic diagnosis and prolapse staging by POP-Q. Intraoperative data parameters were as follows: type of surgery, estimated blood loss, length of USLS/culdoplasty and overall operating time, and complications. Postoperative evaluation included the following: final pathology, hospital stay, complications, oncologic and urogynecologic follow-up, indication for adjuvant therapy, level of satisfaction, and postoperative POP-Q.

We have not performed additional pelvic floor repairs other than USLS/culdoplasty. All women received antibiotic prophylaxis, low-molecular-weight heparin and antiembolism stockings. Urethral catheter was routinely removed 24 hours after the procedure. Residual urine was measured before hospital discharge (considered normal <50 mL). Oncologic and urogynecologic follow-up consisted of pelvic examination (including postoperative POP-Q) and clinical signs for tumor relapse. Patients were asked to complete a satisfaction survey based on a semantic and visual scale: very satisfied, quite satisfied, quite unsatisfied, or very unsatisfied. ⁵

The operative technique

Patients were routinely positioned in the semilithotomy position. After pneumoperitoneum is obtained, five laparoscopic trocars were placed: an 11-mm trocar at the umbilicus level; two 5-mm trocars in each abdominal lower quadrant; a 5-mm trocar in the midline suprapubically; and a 10-mm trocar in the left midclavicular line when paraaortic lymphadenectomy or omentectomy was necessary.

The first part of the procedure consisted of peritoneal inspection and washings, total laparoscopic hysterectomy, and bilateral salpingo-oophorectomy. In cases of ovarian tumor, after completion of hysterectomy and opening of the vaginal vault, the specimens were removed through the vagina following oncologic principles. ⁴ The ovarian tissue was systematically submitted to the frozen section and additional endoscopic omentectomy and transperitoneal pelvic/paraaortic nodal dissections were performed in cases of malignancy.

In the last phase of the surgery, the support of the vaginal vault was implemented. USLS was initiated with exploration of the retroperitoneum (already opened during hysterectomy or pelvic lymphadenectomy) and direct identification of both ureters. These structures were gently moved laterally to permit a proper access to the medial pararectal space and the visualization of the uterosacral ligaments (USLs). At this point, permanent running sutures (Polypropylene 0) were placed along the USLs and the peritoneum of the cul-de-sac. Both lines of sutures were anchored in the posterior vaginal wall and peritoneum. Subsequently, the vaginal vault was closed with interrupted polyglactin 0 stitches. Finally, McCall stitches provide obliteration of the Cul-de-sac (Fig. 1). The above-described maneuvers characterize the modification of the classic laparoscopic USLS. They permit a better identification of the USL and the incorporation of a thicker peritoneal layer in the suture. Consequently, the quality of the fixation and the safety, basically in regard to ureter injury, are possibly improved.

OPEN IN VIEWER

FIG. 1.

Laparoscopic view of the modified McCall culdoplasty. Final aspect shows isolated ureters, partial obliteration of cul-de-sac, and support of the vaginal vault.

Results

A total of six women underwent to one-stage endoscopic treatment of both conditions. Epidemiologic and clinical features of the included patients are summarized in the Tables 1 and 2. Two women had surgery due to ovarian tumor and four for uterine cancer. Women presented uterine prolapse stage 3 (four cases) or 4 (two cases) measured by C point. No intraoperative complication or conversion to laparotomy occurred. Additional operative time related to the USLS/culdoplasty was ∼36 minutes (30–42 minutes). The length of this additional procedure represented nearly 16% of the total intervention. Voiding dysfunction was observed in one patient, which was successfully managed with indwelling Foley catheterization for 7 days.

Pathology revealed endometrioid endometrial carcinoma in four patients; one woman had serous ovarian adenocarcinoma and one with benign ovarian Brenner tumor. All patients except for #2 underwent nodal staging, including pelvic and paraaortic lymphadenectomy according to preoperative staging. Particularly regarding patient #6, indication for nodal dissection was based on histologic grading (G3). Histopathologic analysis and final staging were performed according to the revised 2009-FIGO and 2010-TNM staging system for ovarian and uterine cancers. In two cases (33%), nodal metastasis was diagnosed. Consequently, these women received adjuvant therapy, either isolated chemotherapy (carboplatin and paclitaxel) or in association with radiotherapy. Another woman with intermediate-risk uterine cancer underwent exclusively to high-dose-rate brachytherapy. Initiation of the complementary therapies was not postponed due to the intervention. Despite the limited follow-up (mean 20.3 months), no relevant complication was observed. All patients have no evidence of local or distant recurrence and they are free of complaints related to the pelvic floor. Data concerning the operative outcomes, oncologic follow-up, urologic complaints, and satisfaction survey are shown in Tables 2 and 3, respectively. All women reported to be very satisfied with the procedure. As summarized in Table 4, an improvement of the C points and anterior compartment measurements (Aa and Ba points) were observed. Moreover, the total vaginal length was slightly reduced (from 8.75 to 7.75 cm) after the procedures.

Discussion

Surgery for gynecologic tumors has been historically performed by means of laparotomy. Taking into consideration that these patients often have relevant medical comorbidities such as obesity, diabetes, hypertension, and older age, minimally invasive surgery has been shown to be a proper, if not preferred, alternative to the traditional approach.^6,7 Image magnification, improved dissection in critical areas, possibility to perform concomitant procedures, shorter hospital stay, lower blood loss and earlier initiation of adjuvant therapies are additional advantages of the endoscopic techniques. ⁷ On the other hand, several important oncologic concerns have limited the widespread use of laparoscopy; possible inadequate staging, portsite metastasis, iatrogenic tumor rupture, and potential cancer cell dissemination, but a number of publications have demonstrated no difference in survival among patients laparoscopically or conventionally operated, since some standard surgical principles are respected.^6,7

According to a recent survey, one in every five women will undergo surgery for pelvic organ prolapse in her lifetime and up 2.6% will have concomitant uterine, benign, premalignant, or malignant pathology. ² Despite the potential magnitude of this problem, the issue of which is, the best surgical approach to patients with uterovaginal prolapse and a known or suspected gynecologic malignancy remains to be determined ⁸ The technical limitation and difficulty to manage both conditions at the same intervention has motivated us to investigate an alternative operative option intending to overcome the problem and allowing that many cancer patients would benefit from a less invasive approach.

Different operations have been described to support apical prolapse. Despite the fact that sacrocolpopexy is currently considered the most durable technique for restoring the prolapsed vaginal apex to normal position, literature is poor concerning the use of this procedure in women with genital cancer.^8–10 Potential negative effects of chemotherapy or radiotherapy on mesh complications or success rates are seldom discussed. ⁸ Moreover, it is well defined that the risk for mesh erosion is significantly higher when colpopexy is performed in conjunction with total hysterectomy. ⁹ From the oncologic point of view, one can speculate if initiation of adjuvant therapies must be postponed due to the presence of an implant. Besides, the duration and extension of a combined operative procedure in this context are of extreme importance. Therefore, sacrocolpopexy should not be liberally employed in this particular situation.

The here-described approach is feasible, effective, and not time-consuming; representing approximately 16% of the overall operating time. A significant change in the point C was achieved, revealing a considerable anatomical and functional improvement in the apical prolapse. The POP-Q points in the anterior compartment were also positively affected, probably as an indirect consequence of the repositioning of the vaginal vault.

In sexually active women, vaginal shortening after the surgical correction for uterovaginal prolapse is an important issue. Although sexual function was not directly addressed, our series showed no significant change in the total vaginal length. In the light of this finding and the positive satisfaction survey, we suppose that the presented approach may lead to fewer sexual dysfunctions in comparison to other surgical techniques.

The epidemiologic characteristics (mean age and BMI) of the included patients reflect a realistic scenario. In our small series, we achieved successful completion in all cases without conversion to laparotomy. We did not observe any significant intra- or postoperative complication. Average operative time, blood loss, and length of hospital stay were favorable. Mean urogynecologic and oncologic follow-up had reached 20.3 months and neither local, distant tumor relapse, nor vaginal vault prolapse was observed. Initiation of the adjuvant therapies was not to be postponed in any of the cases due to the intervention. More importantly, no tumor relapse was detected during the surveillance.

One isolated patient with endometrial cancer developed urinary retention following the surgery that was successfully managed by means of a prolonged bladder catheterization (7 days). In this particular case, the pelvic nodal dissection was quite extensive and the authors attributed the bladder dysfunction to a transient bladder decentralization. In our opinion, this approach also has economic advantages. There is no requirement for expensive surgical material or allogenic tissues, grafts, or meshes. ¹⁰ The method permits that a number of patients remain eligible for laparoscopy. Consequently, shorter hospital stay, a reduction in the need for postoperative analgesics, and less morbidity would have a positive influence on costs.

Indeed, the main objective of the intervention is not to correct pelvic floor defects in different compartments, as we thought that these could excessively prolong the duration of the procedure and elevate morbidity. Although our experience is limited, we strongly believe that these two conditions can be safely addressed by laparoscopy in the one-stage procedure. Further studies are needed to confirm the apparent oncologic safety and the favorable urogynecologic outcomes.