Laparoscopic Suture Sacrohysteropexy

If you require the services of an interpreter, contact us on 020 3447 4735. We will do our best to meet your needs.

Contents

1. Introduction 3
2. What does laparoscopic suture sacrohysteropexy mean? 3
3. How can a laparoscopic suture sacrohysteropexy help? 4
4. What are the risks of laparoscopic suture sacrohysteropexy? 5
5. What will happen if I choose not to have a laparoscopic suture sacrohysteropexy? 13
6. What alternatives are available? 13
7. How should I prepare for a laparoscopic suture sacrohysteropexy? 15
8. Asking for consent 18
9. What happens during a laparoscopic suture sacrohysteropexy? 19
10. What should I expect after laparoscopic suture sacrohysteropexy? 20
11. Where can I get more information? 23
12. References 23
13. Contact details 25
14. How to find us 26

1 Introduction

Prolapse is a condition where the womb or vaginal walls drop down from their normal position. You may feel that ‘something is coming down’ in the pelvis or have symptoms of a lump or bulge in the vagina. Prolapse can sometimes affect how your bladder or bowels work.

This leaflet provides information about an operation called laparoscopic suture sacrohysteropexy. It is one of the operations that we offer to treat prolapse of the womb. This leaflet has been made to help you understand why this operation has been recommended and what surgery might involve.

This leaflet contains information from medical research studies and guidance from independent organisations that specialise in this type of surgery. We have tried to simplify this information and make it easy to understand for patients. We hope that this leaflet will help you decide if you want to go ahead with surgery.

We will review this information every two years. This is to make sure that any information from new research studies is  included. We may do this sooner if we think important new information becomes available that you need to be aware of.

2 What does laparoscopic suture sacrohysteropexy mean?

Laparoscopic suture sacrohysteropexy is an operation that lifts the womb up into its normal position. Using keyhole surgery, one end of a strong stitch is inserted through the bottom of the womb. The other end of the stitch is then placed in strong tissue covering the bones at the bottom of the spine. This tissue is called the anterior longitudinal ligament.

The stitch is then pulled tight. This lifts the womb back in its normal position. We use ‘non-absorbable’ stitches that are designed to be permanent.

3 How can a laparoscopic suture sacrohysteropexy help?

If you have symptoms of womb prolapse, this operation is likely to help you. Lifting the womb can also improve prolapse of the vaginal walls in some cases. This is because a womb prolapse can pull the vaginal walls down with it. Lifting the womb can often help with both problems.

No operation will work for everybody. Rarely, the womb will not stay in place or prolapse of the vaginal walls will continue to cause problems after surgery. Sometimes, surgery works well initially but the problems start again some time later.

Two years after surgery, research studies have shown that:

  • 80 out of 100 women will have no further womb prolapse.

The bladder and bowel are very close to the womb. Because of this, laparoscopic suture sacrohysteropexy can affect how the bladder and bowel work. This means that bladder and bowel symptoms may get better after surgery.

The effect of laparoscopic suture sacrohysteropexy on bladder and bowel symptoms has not been studied closely. In one small study, problems emptying the bladder improved after surgery. This is probably because their womb was so low before surgery that it got in the way. Based on this research, around 90 out of 100 women should find bladder emptying easier after surgery.

Some women describe urine leakage on coughing, sneezing, or activity, which is known as ‘stress urinary incontinence’. Others describe having to suddenly rush to the toilet to pass urine and sometimes they can leak before they get there. This is called ‘urinary urgency’. We are not sure how often these bladder symptoms improve after laparoscopic suture sacrohysteropexy.

Another operation we offer for prolapse of the womb uses a plastic mesh to lift the womb up instead of a strong stitch. After5 this operation, around 60 out of 100 women see improvements in stress urinary incontinence and urinary urgency. Although the operations are similar, we cannot be sure that the effects on the bladder are the same. Laparoscopic suture sacrohysteropexy may not be as good at improving bladder symptoms.

Some women who have surgery for prolapse of the womb may find that existing bowel symptoms improve after their operation. This is because lifting the womb back into place makes things work better. There is very little research that has looked at what happens to existing bowel symptoms after laparoscopic suture sacrohysteropexy. One small study found that on average, bowel symptoms did not change after surgery.

4 What are the risks of laparoscopic suture sacrohysteropexy?

All treatments and procedures have risks and we will talk to you about the risks of laparoscopic suture sacrohysteropexy. Problems that occur during or after surgery are called complications. These are undesirable or unwanted effects that happen as a result of surgery. If a complication affects you, it does not mean that something must have gone wrong during the surgery. If you have a complication, you can expect us to explain what has happened, and whether any further treatment is required. We always provide additional care and support for patients who experience problems after an operation.

We will use numbers to explain how often we might expect problems to happen after laparoscopic suture sacrohysteropexy. For example, a ‘10 in 100’ chance of a problem means that if we performed 100 operations, the problem would happen 10 times. This is the same as a 10 per cent chance.

Problems that may happen straight away

Bleeding during surgery

  • Bleeding that might need a blood transfusion: 1 in 100.

Infections after surgery

  • Urine infection immediately after surgery: 10 in 100.
  • An infection of the small ‘keyhole surgery’ wounds: 1 in 100.
  • Infection inside the pelvis: We are not sure how often this happens, as it has not been reported in research studies. It is probably very uncommon.


Damage to other organs during surgery

  • Damage to bladder, bowel or ureters: We are not sure how often this happens. The risk is probably around 1 in 100 based on information from similar operations.

The ureters are the tiny tubes that carry urine from the kidneys to the bladder.

If you are affected, the damaged organs will be repaired during the operation. Sometimes a cut on your abdomen called a laparotomy is needed in order to fix things. If you have had previous abdominal or pelvic surgery the risk of damage may be higher.

Rarely, damage might occur that is not recognised during the operation. If this happened, you might experience no symptoms, or you could become ill after your surgery. You would need extra tests to find out if this was the case. You might need another operation to repair the damage.


Bladder symptoms after surgery

Some women have bladder symptoms as well as prolapse. Although these symptoms might improve after surgery, sometimes they can get worse. In addition, there is a small risk that you could be troubled by new symptoms after surgery that were not there before.

If you already have bladder symptoms, we do not know how likely they are to worsen after surgery. There is not enough research information to be sure how often this happens. We also do not know how many women develop new bladder symptoms after laparoscopic suture sacrohysteropexy.

We have some information about what happens to bladder symptoms after a similar operation to lift up the womb. This procedure is called a laparoscopic mesh sacrohysteropexy. This operation uses a mesh, rather than stitches, to lift things up. After laparoscopic mesh sacrohysteropexy, new bladder symptoms are uncommon. New stress urinary incontinence or urinary urgency only affect around 5-10 in 100 women. Only 1 in 100 women report new problems with bladder emptying.

We have included this information to give you an idea of how often problems might arise after surgery to lift up the womb. You should remember that although the procedures are similar, the two operations could have different effects on the bladder.

Bowel symptoms after surgery

If you already have bowel symptoms they are unlikely to change after your operation. Although symptoms can improve after surgery, it is possible that things can get worse. There is also a small risk that you might develop new bowel symptoms after laparoscopic suture sacrohysteropexy.

If you already have bowel symptoms, we do not know how likely they are to worsen after surgery. It is possible that your symptoms could be made worse by surgery. Unfortunately, there is not enough research information to be sure how often this happens. We also do not know how many women develop new bowel symptoms after surgery.

After a similar operation, called laparoscopic mesh sacrohysteropexy, new bowel symptoms are uncommon. After this operation, around 15 in 100 women have trouble with constipation. Difficulty emptying the bowels, having to rush to the toilet without warning, or leakage affects 1-5 in 100 women.

Although the procedures are similar, the risk of new bowel symptoms might not be the same for both operations. This information is just to give you an idea of how often problems happen after surgery to lift the womb up.

Pelvic pain or problems with painful sexual intercourse

We cannot be certain how often pain symptoms are a problem after laparoscopic suture sacrohysteropexy. The available research does not provide enough information to be sure.

Laparoscopic mesh sacrohysteropexy is a similar operation that uses mesh to lift the womb up, rather than stitches. After this
operation, problems with pain are uncommon:

  • New or worsening pelvic pain: 1-5 in 100.
  • New or worsening painful sexual intercourse: 1-5 in 100.

Although the procedures are not identical, the risks of the two procedures are probably similar. We think that the risk of pain after laparoscopic suture hysteropexy might be smaller, although we cannot be sure.

If you already experience chronic pain in other areas of the body, the risk of pain after surgery is higher.

Problems that may happen later

Your prolapse might come back

Whilst it is unlikely that the womb can prolapse again, this is a possibility. Two years after surgery, around 20 in 100 women would be expected to have a recurrent prolapse of the womb.

We are not sure what happens after two years. Even if the womb does not prolapse again, there is a small risk that new prolapse of the vaginal walls can develop. If these problems occur you may need further treatment.

Problems that are rare, but serious

  • Damage to major blood vessels and life-threatening bleeding:
    1 in 1000.
  • Blood clots in the legs that can travel to the lungs: 5 in 1000.


Problems with the anaesthetic

You will be given a general anaesthetic for your operation. This means that you will be unconscious and will not feel anything during your surgery. Anaesthetists are doctors who specialise in anaesthetics. Your anaesthetist will give you your anaesthetic medication and gently place a tube through your mouth into your throat. This is to keep your windpipe open so oxygen can get to your lungs.

Some problems are very common after an anaesthetic. They normally settle down very quickly after surgery or are easy to treat. Sore throat or throat pain, feeling sick and vomiting, or shivering after surgery, can affect up to half of patients.

Some problems are more likely to affect certain groups of patients. If you are older, overweight, a smoker, or have other medical problems, you are more likely to be affected:

  • Chest infection after surgery: 1-10 in 100.
  • Permanent nerve damage: 1 in 1000.
  • Permanent loss of sight: 1 in 100,000.
  • Death as a result of anaesthesia: 1 in 100,000.

Older patients, especially those with dementia, poor eyesight or hearing, can become confused after an operation. It is not known how often this happens.

Damage to the lips and tongue may occur but this is usually minor. Tooth damage is more likely to happen if you have diseased teeth and gums, or have had extensive dental work:

  • Damage to the lips and tongue: 5 in 100.
  • Damage to teeth: 5 in 10,000.13

Some problems can happen to anyone as a result of an anaesthetic:

  • The eyeball getting grazed or damaged: 4 in 10,000.
  • Being aware of what is happening during surgery despite the anaesthetic: 5 in 100,000.
  • Life-threatening allergic reaction: 1 in 10,000.

5 What will happen if I choose not to have laparoscopic suture sacrohysteropexy?

If you decide not to have this operation you could simply carry on as you are. You will continue to have symptoms of prolapse.
Whilst these symptoms can be distressing, you are unlikely to come to any harm.

6 What alternatives are available?

After reading this leaflet, you may decide that you want to look at other options. We provide a separate leaflet on the available treatments for prolapse and we should have given you this to read. Please ask for this leaflet if you do not already have it.

The alternatives to laparoscopic suture sacrohysteropexy are:

  • Pelvic floor physiotherapy.
  • A vaginal pessary.
  • Laparoscopic mesh sacrohysteropexy.
  • Sacrospinous hysteropexy.
  • Hysterectomy, which is an operation that removes the womb.

Sometimes your doctor may suggest that one treatment might be better than another in your particular case. They will obviously provide you with the reasons why this is so.


7 How should I prepare for laparoscopic suture sacrohysteropexy?

The Preoperative Assessment Clinic (PAC)

Before your operation, you will be seen in the PAC to make sure that you are fit for your surgery. Specialist nurses and anaesthetists run the clinic. This normally happens a few weeks before your operation. When you come to your appointment,
you should bring the following:

  • A list of your medical conditions and previous operations.
  • A list of your current medications and allergies.

Sometimes, certain types of medication need to be stopped before your operation. The team in PAC will tell you if any of your medication needs to be stopped and which ones you16 should take on the day of your operation. Please do not stop any medication before your operation unless you are asked to do so. Stopping important medication before your surgery may mean that your operation is cancelled or you come to harm.

Some patients may need to take additional medication the day before their surgery to clear their bowels. This is called ‘bowel preparation’. Not all patients require bowel preparation and if is needed, we will discuss it with you before your operation.

The day of your surgery

On the day of surgery, you will come to the Surgical Reception on the First Floor of University College Hospital at 07:00 in the
morning. You will receive a letter confirming these details. Your operating surgeons will see you for final checks. Please note that your operating surgeon may not be the same specialist as you saw in clinic. The nurses will then prepare you for your surgery. You may be given an enema to clear out the lower bowel before your operation. You will not need this if you took bowel preparation.

On the day of surgery, you should follow the instructions given to you at the PAC appointment about the following:

  • Which medications to take on the morning of surgery.
  • When to stop eating and drinking before your surgery.

If you are confused about any of the instructions, you must contact them before your surgery. Their details are at the end of this leaflet.

  • Bring your regular medications along with you.
  • Pack a bag with clothes and toiletries for your stay.
  • Bring the copy of your consent form that we gave you.

Please be aware that your surgeons will be operating through the day until 19:00. They are often unable to leave the operating theatre between patients. For this reason, they see all patients in the morning, even if surgery is planned for later in the day.

If your surgery is in the afternoon, you may be allowed to drink some water. You might also be able to leave the Surgical Reception for a little while until you are due for surgery. Please do not drink, or leave the Surgical Reception, until instructed to do so. Drinking at the wrong time may mean that your operation is cancelled.

There is a very small chance that your surgery may be cancelled on the day you come in to hospital. This might happen because the hospital is full and there is no bed for you. This is uncommon but obviously very distressing if it occurs.

Whilst beds often become available as the day passes, this is not always the case. If it looks like your surgery will have to be cancelled, we will let you know as early as we can. We will then work with our management team to rearrange your surgery as soon as possible.

Making plans for after your surgery

Please make plans well in advance:

  • You will be in hospital for one or two nights. Up to two people can visit you in hospital between 09:00 and 20:00 every day.
  • Please ensure that your travel plans are flexible. Remember that your stay might also be extended on medical grounds.
  • You will need an escort to help you get home and you will not be able to use public transport to get home alone.
  • You will need four weeks off work. If you have a very strenuous job you may need slightly longer to recover.
  • You should avoid carrying anything heavier than 5kg during this time.
  • You will need friends and family to help with groceries and household chores, particularly in the first week or two.

Unfortunately, we will be unable to extend your hospital stay if you have not made transport arrangements. If you already use hospital transport because of a medical illness, we will be able to help arrange this. Unfortunately, hospital transport is not available for other patients.

8 Asking for your consent

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please ask to speak with a senior member of staff again. Our contact details are at the end of this leaflet.

9 What happens during a laparoscopic suture sacrohysteropexy?

The operation takes around two hours and is performed using ‘keyhole surgery’.

  • Four or five small cuts are made on the abdomen and special tubes, known as ‘ports’, are placed through these cuts.
  • A tiny camera and special operating instruments are inserted through the ports.
  • Pictures of the inside of the abdomen are sent from the camera to television screens that the surgeons watch.
  • A strong stitch, which does not dissolve, is placed through the bottom of the womb.
  • The other end is pulled up, lifting the womb to its normal position. It is then attached to a ligament covering the bones at the bottom end of the spine.
  • Finally, the stitch used to lift up the womb is covered using peritoneum. This is the thin, stretchy tissue that lines the inside of your abdomen.
  • You will have a drip in your hand and a catheter tube in the bladder. These will normally be removed within 24 hours.

Some women have prolapse of the vaginal walls as well as prolapse of the womb. Lifting the womb often lifts up the vaginal walls. If your vaginal wall prolapse is not fixed by lifting the womb, you may need a small operation on the vagina. Only around 10 in 100 women need a vaginal operation. If we think you might also need a vaginal operation, we will give you extra information about vaginal surgery. Sometimes we cannot make the final decision about this until during your operation.

10 What should I expect after laparoscopic suture sacrohysteropexy?

The first two weeks after surgery

  • You will need to rest and take regular painkillers.
  • You should take regular medicine, known as a laxative, to keep your bowels opening every day.
  • You will spend much of your time at home but you may take short walks. You should avoid anything strenuous and lifting anything heavier than 5kg.
  • You should try to shower, rather than have a bath, to allow the keyhole stitches to heal. If you do take a bath, do so in shallow water for a maximum of ten minutes.
  • You can remove the plasters from the keyhole scars after three days and then keep the areas clean and dry.
  • You will receive a telephone clinic appointment through the post. This is normally scheduled for two to three weeks after surgery. The urogynaecology nurses will call you by phone on this day to check on your progress.

We will give you a two-week supply of painkillers, laxative medication, and any other drugs you will need at home. If you need further supplies after you have gone home, you will need to contact your GP.

Weeks two to four after surgery

You will be able to reduce your regular painkillers, start taking them only if needed, and eventually stop using them.

  • You will continue to use your laxatives to keep your bowels opening daily. If you can do this by eating plenty of fruit and
    fibre, and drinking enough water, you can stop the laxatives.
  • You can increase your activity, go out for longer walks, and visit friends and family, provided you take things easy.
  • You will continue to avoid lifting anything heavier than 5kg.
  • You can start driving again but you should inform your insurance company that you have had surgery. They must be happy for you to drive again. You should only start driving again if you feel safe to do so. You must be able to perform an emergency stop if needed.
  • If you have a period, please use pads rather than tampons.

Four weeks onwards

  • You can get back into your normal routine and return to work. If you have a strenuous job, you may need slightly longer to recover. Please let us know if this is the case.
  • If you exercised regularly before your surgery, please discuss this with us before you go home. We might suggest some changes to your usual exercise programme.
  • You can start having sexual intercourse after six weeks.
  • We will send you a clinic appointment through the post for three months after your surgery. At the appointment, we will ask you how things are and examine you. This is to make sure that the operation has worked and that you do not have any problems.
  • You will need to keep having your smears. Please attend your GP surgery when they send you an invitation letter.

11 Where can I get more information?

The British Society of Urogynaecology
Website: www.bsug.org.uk/patient-information.php
Email: bsug@rcog.org.uk
Telephone: 020 7772 6211
Fax: 020 7772 6410

The International Urogynecological Association
Website:
http://www.iuga.org/general/custom.asp?page=patientinfo
Email at: www.iuga.org/general/?type=CONTACT
UCLH cannot accept responsibility for information provided by
other organisations.

12 References

Aarts, J. W., T. E. Nieboer, N. Johnson, E. Tavender, R. Garry,
B. W. Mol and K. B. Kluivers (2015). “Surgical approach to
hysterectomy for benign gynaecological disease.” Cochrane
Database Syst Rev(8): CD003677.

Desciak, M. C. and D. E. Martin (2011). “Perioperative
pulmonary embolism: diagnosis and anesthetic management.” J
Clin Anesth 23(2): 153-165.

Diwan, A., C. R. Rardin, W. C. Strohsnitter, A. Weld, P.
Rosenblatt and N. Kohli (2006). “Laparoscopic uterosacral
ligament uterine suspension compared with vaginal
hysterectomy with vaginal vault suspension for uterovaginal
prolapse.” Int Urogynecol J Pelvic Floor Dysfunct 17(1): 79-83.

Harkki-Siren, P., J. Sjoberg and T. Kurki (1999). “Major
complications of laparoscopy: a follow-up Finnish study.” Obstet
Gynecol 94(1): 94-98.24

Jimenez, D., J. de Miguel-Diez, R. Guijarro, J. Trujillo-Santos,
R. Otero, R. Barba, A. Muriel, G. Meyer, R. D. Yusen, M.
Monreal and R. Investigators (2016). “Trends in the
Management and Outcomes of Acute Pulmonary Embolism:
Analysis From the RIETE Registry.” J Am Coll Cardiol 67(2):
162-170.

Karthik, S., A. J. Augustine, M. M. Shibumon and M. V. Pai
(2013). “Analysis of laparoscopic port site complications: A
descriptive study.” J Minim Access Surg 9(2): 59-64.
Krause, H. G., J. T. Goh, K. Sloane, P. Higgs and M. P. Carey
(2006). “Laparoscopic sacral suture hysteropexy for uterine
prolapse.” Int Urogynecol J Pelvic Floor Dysfunct 17(4): 378-381.

Kupelian, A. S., A. Vashisht, N. Sambandan and A. Cutner
(2016). “Laparoscopic wrap round mesh sacrohysteropexy for
the management of apical prolapse.” Int Urogynecol J.

Maher, C. F., M. P. Carey and C. J. Murray (2001).
“Laparoscopic suture hysteropexy for uterine prolapse.” Obstet
Gynecol 97(6): 1010-1014.

Rahmanou, P., B. White, N. Price and S. Jackson (2014).
“Laparoscopic hysteropexy: 1- to 4-year follow-up of women
postoperatively.” Int Urogynecol J 25(1): 131-138.

Royal College of Anaesthetists (2015). Information leaflets.
[online] Available at: http://www.rcoa.ac.uk/node/3324.

Sutkin, G., M. Alperin, L. Meyn, H. C. Wiesenfeld, R. Ellison and
H. M. Zyczynski (2010). “Symptomatic urinary tract infections
after surgery for prolapse and/or incontinence.” Int Urogynecol J
21(8): 955-961.25

13 Contact details

Urogynaecology nursing team
(For medical problems and questions only)
Direct line: 020 3447 6547
Mobile: 07951 674140
Fax: 020 3447 6590
Email: urogynaecology@uclh.nhs.uk

Gynaecology outpatient appointments
(Contact for outpatient clinic appointments only)
Direct line: 020 3447 9411
Fax: 020 3447 6590

Preoperative Assessment Clinic (PAC)
(Contact for questions about PAC only)
Direct line: 020 3447 3167
Fax: 020 3383 3415

Gynaecology Admissions
(Contact for surgery dates and scheduling only)
Direct line: 020 3447 2504
Urogynaecology secretary
Direct line: 020 3447 2516
Fax: 020 3447 9775

University College Hospital
Switchboard: 020 3456 7890
Website: www.uclh.nhs.uk

14 How to find us

The Urogynaecology and Pelvic Floor Unit
Clinic 2, Lower Ground Floor
Elizabeth Garrett Anderson (EGA) Wing
University College Hospital
25 Grafton Way
London
WC1E 6DB