Slings

1. Uterus sparing techniques for
Prolapse for young
DR Rajesh Gajbhiye
Consultant Gynecologist & Lap Surgeon
Mauli Women’s Hospital.
Nagpur

2. Introduction
⚫Conservative surgeries- young
nulliparous women where menstrual
and reproductive function in desired.
⚫Vaginal hysterctomy with repair.
⚫Advent of minimal invasive surgery
⚫Resuspend
⚫Uterine conserving re-suspension
surgery
⚫Augmenting weak connective tissue
⚫ Stronger apical support

3. Laparoscoic assisted vaginal
tape

12. Complications
⚫ Presacral bleeding. Hence a vascular
sacral plexus is a relative
contraindication for this surgery.
⚫Sigmoid colon and sigmoid mesocolon
injury hence short sigmoid
mesocolon is relative contraindication
for this surgery.
⚫ Geintofemoral nerve irritation,
damage to ureter, recto-vaginal fascia,
recurrence, osteomyelitis and bowel

13. ⚫ Reproductive performance following Shirodkar's
abdominal sling operation.
Allahbadia GN1, Ambiye VR.
⚫ Over a period of 4 years from January 1986 to
December 1989, 79 cases in whom Shirodkar's
abdominal sling operation carried out, were studied. All
the patients were admitted either in active labour or as
cases of abortions or for the treatment of infertility. The
incidence of full term normal vaginal delivery in this
study was 69.56% and the incidence of caesarean
section was only 2.9%. There was one case of posterior
wall rupture following previous Shirodkar's sling
operation. The recurrence rate of prolapse was only
8.69%

14. ⚫Evaluation of Shirodkar’s Sling
Surgery for Conservative
Management of Uterovaginal
Descent During Child Bearing Age
Group
Suchitra Narayan Pandit, Vaman Babu Ghodake,
Vijay Chandrakant Pawar

15. ⚫ Observations: One thousand three hundred and
eighty patients having uterovaginal descent were
admitted at L.T.M. General Hospital, Sion, Mumbai,
from Jan ‘03 - Dec ‘04. 139 patients underwent
conservative surgery. Sixty four (46.67%) patients
were in the child-bearing age group and underwent
Shirodkar’s sling surgery. Twenty four patients
(41.37%) conceived post surgery. Nineteen patients
delivered normally. Only three patients required
L.S.C.S. for obstetric indications.
⚫ Conclusion: Shirodkar’s Sling operation plays an
important role in the conservative management of
prolapse in the child bearing age group. It does not
affect fertility and course of normal labour in fact it
improves it by maintaining the pelvic anatomy.

17. ⚫Hysteropexy should not be performed
by using the ventral abdominal wall for
support because of the high risk for
recurrent prolapse, particularly
enterocele.
⚫Lecel B evidence

21. Khanna sling

28. ⚫The present study demonstrates the
long-term safety and effectiveness of
pectineal ligament suspension for
vaginal vault prolapse by the open and
the laparoscopic routes.

38. Sacrohysteropexy
⚫-Open
-Laparoscopic
-Robotic
⚫Advantages-
◦ Effective correction of descent
◦ Anteversion
◦ No compression on rectum or ureter.
◦ Improved quality of life and sexual
function

40. LSH

41. LSC
⚫ Int Urogynecol J. 2014 Jan;25(1):131-8. doi:
10.1007/s00192-013-2209-5. Epub 2013 Nov 6.
⚫Laparoscopic hysteropexy: 1- to 4-
year follow-up of women
postoperatively.
⚫Rahmanou P1, White B, Price N,
Jackson S.

42. ⚫Laparoscopic hysteropexy is a safe
and effective treatment.
⚫ High patient satisfaction and low rates
of apical prolapse recurrence.
⚫Longer term follow-up and randomized
controlled studies are required.

43. ⚫ Younger patients are best treated with
procedures with better efficacy like
sacral colpopexy to prevent
recurrence.

45. ⚫ Risk of mesh extrusion and other mesh-related
complications after laparoscopic sacral
colpopexy with or without concurrent
laparoscopic-assisted vaginal hysterectomy:
experience of 402 patients.
Stepanian AA1, Miklos JR, Moore RD, Mattox TF
⚫ J Minim Invasive Gynecol. 2008 Mar-Apr;15(2):188-96. doi:
10.1016/j.jmig.2007.11.006.

46. ⚫ Risk of mesh extrusion or other mesh-related
complications after laparoscopic sacral
colpopexy using soft macroporous Y-shaped
polypropylene mesh is about 1% .
⚫ No significant increase in risk of mesh-
related complications was observed in
patients receiving concurrent hysterectomy
when compared with patients who had a
previous hysterectomy.
⚫ The sample size of almost 2000 patients was
needed to detect a statistically significant
difference in rate of mesh-extrusion in this
study.

47. ⚫Gutman and Maher reviewed the
literature on sacral colpopexy and
uterine prolapse in 2012 and in meta-
analysis found 339 cases of sacral
colpopexy with hysterectomy and 129
cases of sacral hysteropexy.
⚫While the success rate was over 90% in
each group the rate of mesh exposures
was more than five times higher after
sacral colpopexy and hysterectomy
as compared to hysteropexy (8.5%
versus 1.5%).

48. Sacral colpopexy: long-term mesh
complications requiring reoperation(s).
Arsene E1, Giraudet G, Lucot JP, Rubod C,
Cosson M.
Int Urogynecol J. 2015 Mar;26(3):353-8. doi: 10.1007/s00192-014-
2514-7. Epub 2014 Oct 17.
⚫ excellent success rates, there are
risks of complications and reoperation
may be required. The purpose of this
study was to evaluate the extent of
complications following SC, requiring
reoperation(s), and to describe the
reoperations performed.

49. ⚫ Surgery for complications after SC.-27
⚫ vaginal mesh exposures (VME)-19
⚫ intravesical mesh -4(including one with
VME)
⚫ ano-rectal dyschezia-1 one for
spondylodiscitis-1
⚫ mesh infection,-1
⚫ vaginal fistula communicating with a
collection in the ischio-coccygeal
muscle.-1.

50. ⚫The median time between the initial
SC and the first reoperation was
3.9 ± 5.7 years
⚫This case series provides a
description of surgical interventions for
complications related to sacral
colpopexy. These complications may
be serious and occur years after the
initial surgery

51. ⚫Cochrane Database Syst Rev. 2013
Apr 30;4:CD004014. doi:
10.1002/14651858.CD004014.pub5.
⚫Surgical management of pelvic
organ prolapse in women.
⚫Maher C1, Feiner B, Baessler K,
Schmid C
⚫Fifty-six randomised controlled trials
were identified evaluating 5954
women.

52. ⚫Sacral colpopexy has superior
outcomes to a variety of vaginal
procedures including sacrospinous
colpopexy, uterosacral colpopexy and
transvaginal mesh.
⚫These benefits must be balanced
against a longer operating time, longer
time to return to activities of daily
living, and increased cost of the
abdominal approach

53. Shirodkar’s Extended Manchester Repair:
A Conservative Vaginal Surgery for Geital
Prolapse in Young Women and Reinforcement of
Weak Uterosacral Ligaments with Merselene Tape:
Retrospective and Prospective Study
Roohi Shaikh,Suman Sardesai
1nternational Journal of Recent Trends in Science A
nd Technology, ISSN 2277-2812 E-ISSN 2249-8109, Vol
ume 10, Issue 2, 2014 pp 263-266
⚫

54. Conclusion:
Shirodkar’s Extended Manchester
Repair has a definite place in the
treatment of genital prolapse
especially during the
reproductive age, where child-bearing
function has to be preserved

56. ⚫Two randomized trials in women with
stage II or higher POP that compared
transvaginal sacrospinous
hysteropexy with vaginal hysterectomy
(with uterosacral or sacrospinous
ligament suspension of the vaginal
vault) yielded consistent results: the
rate of prolapse recurrence after 9 to
12 months was higher in women who
underwent hysteropexy in both trials.

57. Conclusions
⚫Consensus is growing that the uterus
can be preserved at the time of pelvic
reconstructive surgery in appropriately
selected women who desire it.
⚫Surgeons should be ready to respond
to the wishes of female patients who
want to preserve vaginal function and
the uterus.

58. conclusions
⚫In nulliparous prolapse, shirodkars
sling the operation of choice. If not
comfortable then Khanna sling, joshi
sling
⚫ Sacrohysteropexy is indicated in
young prolapse.
⚫It is better than vaginal SSF in terms
of recurrence and patient satisfaction.
⚫Mesh erosion compication is less as
compared to hysterectomy with SC.

59. ⚫Thankyou