Laparoscopic Uterine Suspension with the UPLIFT Procedure for the Treatment of Deep Dyspareunia

Introduction

Dyspareunia is relatively common among reproductive age women, affecting approximately 21% of women between the ages of 18-29 years, and 15% of women between the ages 29-39 years.¹ Deep dyspareunia is often diagnosed as a secondary symptom of endometriosis or other pelvic pathology and results from retrodisplacement of the uterus consequential to entrapment by endometrial implants in the cul-de-sac and/or the presence of pelvic adhesions.

Although uterine retroversion affects about 20 to 30% of women, it is often not considered a primary etiology of deep dyspareunia. However, uterine retroversion without pelvic pathology is associated with chronic pelvic pain, dysmenorrhea, and deep dyspareunia.² Uterine retroversion should be considered a primary etiology of deep dyspareunia, if a woman with a retroverted uterus reports moderate to severe deep dyspareunia that is causing her distress. These cases of deep dyspareunia are surgically treatable by repositioning the uterus. We routinely question patients presenting with chronic pelvic pain and dysmenorrhea about painful intercourse since they are often reluctant to discuss their sexual concerns unless asked directly.

In our experience, laparoscopic uterine suspension with the UPLIFT procedure is a highly effective treatment for women presenting with deep dyspareunia and a retroverted uterus diagnosed on bimanual exam.

Objective

The purpose of this study was to assess the effectiveness of the UPLIFT laparoscopic uterine suspension procedure with the Metra PSŪ kit (Inlet Medical Inc., Eden Prairie, MN) for the treatment of deep dyspareunia.

Materials and Methods

A retrospective study was conducted on 18 women (mean age 25 years, range 21-43 years) who had a retroverted uterus and moderate to severe dyspareunia and who underwent laparoscopic uterine suspension with the UPLIFT procedure. The women were seen at a private gynecological clinic between April 2001 and October 2002. All of the women had uterine retroversion and failed to respond to conservative treatments such as positional changes with intercourse, birth control pills and nonsteroidal anti-inflammatory agents. A total of 8 (44%) patients had endometriosis including one who had slight retroversion and endometriosis in the cul-de-sac, 3 (17%) had adhesions, 4 (22%) had menorrhagia, 2 (11%) had ovarian cysts, and 1 (5.5%) had fibroids. Six patients (33%) had no pelvic pathology other than uterine retroversion.

The patients were surveyed by telephone in November 2002 and asked whether they had no improvement, mild improvement, moderate improvement, dramatic improvement, or resolution of their deep dyspareunia since undergoing the UPLIFT procedure. They were also asked if they would recommend the UPLIFT uterine suspension procedure. The surveys were conducted over a 2-day period by the nurse clinical coordinator for the practice.

All of the patients underwent a preoperative clinical assessment that included a medical and sexual history, bimanual pelvic examination, and lab work. Informed consent for the UPLIFT uterine suspension procedure was obtained from each patient, and all patients underwent diagnostic laparoscopy. All of the surgeries were conducted at two community hospitals.

Surgical Procedure

Videolaparoscopy was performed under general anesthesia with the patient placed in the dorsal lithotomy position. In some cases operative hysteroscopy was completed prior to performing laparoscopy. All pathologies were treated prior to performing the uterine suspension.

The patients were then placed in the supine position to facilitate access to the round ligaments. A 22-gauge spinal needle was placed through the skin and fascia crossing the round ligaments. The site was injected with 5-10 ml of 0.5% Marcaine prior to the procedure to minimize postoperative incisional pain. The UPLIFT procedure was performed according to the technique described by Carter.³ A 3-mm incision was made just inferior to the iliac crest. The suture passer included in the Metra PS kit was loaded with suture material and then advanced through the round ligament. The suture material included in the kit (0 INVESTA, monofilament polybutester) is permanent and has some elasticity. Passage was aided by the use of a grasper to stabilize the ligament just proximal (1 cm) to the uterus where the suture passer exits on the first pass. The suture was dropped, and the suture passer withdrawn. A second pass was performed without suture, exiting 1 cm proximal to the first exit point. The suture was retrieved in the jaws of the suture passer, and pulled through the fascia truncating the ligament and creating a facial bridge to support the suspension. The contralateral ligament was invested in the similar manner. The uterus was lifted out of the cul-de-sac to a moderately anteverted position on the midline. The suture material was then tied above the fascia to create a strong lateral wall fixation point that is anatomically aligned within the inguinal canal. In our practice, the operating time for the UPLIFT suspension procedure is between 10-20 minutes.

Results

There were no intraoperative or postoperative procedural complications. All surgery was performed on an outpatient basis, and patients were discharged with oral analgesics. Most patients experienced mild to moderate postoperative incisional and abdominal pain within the first week. Three (17%) of the patients required postoperative injections for pain, usually during the 1-week follow-up visit.

The average follow-up from the time of surgery to the last office exam was 5 months (range 0-14 months). All patients presented during their office follow-up visits with uterine anteversion. The mean follow-up from the time of surgery to the telephone survey was 10 months (range 2-17 months). At the time of the survey, 16 of the 18 patients (89%) reported that their dyspareunia had improved since undergoing the UPLIFT procedure. Two patients (11%) reported moderate improvement, 6 (33%) had dramatic improvement, and 8 (44%) said that their dyspareunia had resolved. Two (11%) had no improvement. Sixteen of the 18 patients (89%) said they would recommend the UPLIFT procedure.

Conclusion

Repositioning a retroverted uterus should be considered in patients with moderate to severe deep dyspareunia with or without other pathology or symptomatology. In our experience, 77% of the patients in this series reported that their dyspareunia had significantly improved since undergoing the UPLIFT procedure. Therefore, we recommend obtaining consent for uterine suspension at the time that consent is taken for diagnostic laparoscopy.

References

1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States. JAMA 1999;281:537-544.
   
   
2. Yen CF, Wang CJ, Lin SL, Lee CL, Soong YK. Combined laparoscopic uterosacral and round ligament procedures for treatment of symptomatic uterine retroversion and mild uterine decensus. J Am Assoc Gynecol Laparosc 2002:9;359-366.
   
   
3. Carter JE. Carter-Thomason uterine suspension and positioning by ligament investment, fixation and truncation. J Reprod Med 1999:44;417-422.

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