Laparoscopic Uterine Suspension Using Three-Stitch Technique

Objective

To assess the efficacy of a new laparoscopic hysteropexy technique in alleviating pelvic pain.

Subjects

Fifty women (average age 27.8 years, range 23-39 years) with chronic pelvic pain or dyspareunia in whom the only clinical finding was uterine retroversion. Most were multiparous.

The principal symptom was chronic pelvic pain (38 women). Ten patients (20%) had associated unexplained infertility, 28 (56%) had deep dyspareunia, and 12 (24%) had deep dyspareunia with infertility.

Patients with only minimal endometriosis were included in the study. Those with low back symptoms were referred for orthopedic assessment, while women who expressed or appeared to have anxiety and those in whom marital problems were suspected were referred for psychologic assessment.

Methods

Patients had a general physical exam and were asked to rate their pain on a scale from zero (no pain) to 10 (unbearable pain). A detailed pelvic exam was conducted to assess the position of the uterus and whether it was mobile and no lesions were found to explain the symptoms. The degree of pain induced by the exam was also assessed.

The women underwent a pessary test and transvaginal ultrasonography. Hysterosalpinography was performed in infertile women at least 6 months before surgery.

The procedure was performed laparoscopically through one 10 mm and two 5 mm ports. Hysteropexy was performed by grasping each round ligament 3 to 4 cm from its uterine insertion; a needle was passed through the round ligament at this level and inserted into an appropriate site on the anterior wall of the uterus at the level of the uterine horns. The suture was tied intracorporeally. Once both round ligaments had been sutured to the anterior aspect of the uterine fundus, a third suture was placed to approximate the uterosacral ligaments directly behind the cervix with the same nonabsorbable suture.

Results

At six weeks follow-up, the uterus was anteverted in 48 women. Pain was markedly improved in 44 (88%) of the women, with absence of dyspareunia. In 39 women pain was totally eliminated. An examination confirmed persistence of uterine retroversion in the two women whose symptoms remained unchanged.

At one year, 10 patient (20%) were lost to follow-up. In 33 of the 40 remaining women, the restored uterine axis was maintained with complete remission of chronic pelvic pain. The patients reported markedly improved sex life. Of the 22 women who had associated infertility for longer than 3 years, 10 became pregnant with 1 year after the surgery.

The mean operating time was 39 ± 18 minutes (range 35-64 minutes). There were no intraoperative complications. The only postoperative complication was abdominal pain in one woman.

The average length of hospitalization was 3.1 ± 1.1 days (range 2-4 days). Patients returned to normal activity within 7 to 10 days (mean 8.5 days).

Conclusion

The three-stitch technique is simple, performed quickly by laparoscopy, requires no dissection, and thus is less likely to cause bleeding.