Aust N Z J Obstet Gy~ero1MW)l; 41: 1: 61-64

GENERALGYNAECOLOGY

A review of 165 cases of transvaginal sacrospinous colpopexy performed by the Endo Stitch'" technique

Anna Rogers, Glen Barker, John Viggers, Terry Mason, James Swan and Peter Mayall

The Geelong Hospital, Ryrie Street, Geelong, Victoria, Australia

SUMMARY

The Endo StitchTM technique has been in use in Geelong since 1994 as the method of performing transvaginal sacrospinous colpopexy (TSC). This article looks at the outcome of 165 of these proce- dures as assessed by a questionnaire. As the opera-

tion is technically easy, has a low complication rate and a high level of patient satisfaction we suggest that the Endo StitchTM technique may be the method of choice for TSC.

INTRODUCTION Transvaginal sacrospinous colpopexy (TSC) is an operation used to support the vaginal vault. It is almost always performed with other operations to repair vaginal prolapse, and is traditionally per- formed for post-hysterectomy vault prolapse where the patient wishes to preserve coital function.

The Endo StitchTM method of TSC was first used in 1994 and reported in a letter to the editors of this Journal in 1995.l A subsequent study of the f i s t 63 patients to undergo the procedure was later published in 19972

This article reviews the results of this operation in 165 patients. It includes patients who were included in the fiist study and subsequently had longer follow up.

METHOD

The operations were performed by consultant gynae- cologists or gynaecology registrars (third or fifth year) according to the following technique, which has been slightly changed since our 1997 report and in which we now recommend that only a unilateral oper- ation be done. 1 Local or general anaesthesia, lithotomy position. 2 The prolapse is assessed. In planning the operation

the surgeon takes into account the symptoms, the examination findings whilst the patient is awake

Address for correspondence

D r GK Barker 337 Ryrie St Geelong Victoria 3220 Australia

and straining and also anaesthetised, and possibly the Rampley test. This involves holding the tip of the closed Rampley's forceps in the vaginal fornk and pushing it against the sacrospinous ligament.

3 An anterior repair is done in the usual fashion. Because the risk of recurrent symptomatic cystocoele is reported to be significant? this is done in most cases, even prophylactically if the cystocoele is minor.

4 A posterior repair is begun in the usual fashion, with an incision along the posterior vaginal wall. Some lateral dissection is done in the usual manner, but on the side where the colpopexy is planned a tunnel is made to the ischial spine using blunt dissection with the index finger. The tunnel is broadened, to accommodate the index and middle finger. The rectum is swept medially and the operator uses sense of touch to be sure that there is no tissue between the finger and the ligament. Only very rarely is any sharp dissection needed and this should be done with great care.

5 The Autosuture Endo Stitchm is loaded with size 0 Dacron (SurgidacTM) and the device tested.

6 A suture is placed 1-2 cm medhl to the ischial spine through the ligament using the following technique: The index and middle fingers of the right hand (for the patient's right sacrospinous ligament) are inserted along the tunnel created as above. The middle finger is kept against the ligament while the Endo StitchTM is passed along the palmar aspect of that hand with the jaws closed until it is pushing against the ligament (in much the same way as one would insert a pudendal nerve block). The jaws of the device are then

62 ANzloG

opened widely, with the index finger feeling the position of the needle in the anterior jaw, and the Endo Stitchm is pushed in enough so that it will close on the ligament. The jaws are closed, the toggle lever is flipped to transfer the needle, the jaws are opened and the suture is drawn through by tilting and withdrawing the device. If the bite through the ligament is satisfactory, then pulling on the stitch will move the patient slightly on the table. Two sutures are inserted, which requires only one loading of the device. The sutures are then attached to the predetermined point at the vaginal angle, without crossing the midline as this tends to twist the vagina. These should be through the subdermal connective tissue and not penetrate the skin. The Endo Stitchm can be used for this or alternatively a loose Mayo needle can be used. Ideally the point of attachment is at the extreme lateral angle at the very top of the vagina. The posterior wall repair is then performed with sutures in the pre-rectal fascia and trimming of excess vaginal skin. Care is needed to avoid tangling with the sacrospinous sutures. Any perineorrhaphy is best left until the last step of the operation as it will reduce access. The skin edges are closed from the vault to about half way down the vagina.

10 The colpopexy sutures are then tied. Ideally the vault should be flush with the ligament. although we have found no problems when a gap remained.

11 The perineorrhaphy is performed and the remainder of the skin closure completed.

In our unit, as in some other centres, the operation is also used as a prophylactic procedure with vaginal hysterectomy in cases where there is severe pr~lapse .~

A questionnaire was sent out to patients identifled by medical record retrieval to have had a transvaginal sacrospinous colpopexy performed by the Endo StitchTM method (Table I). Of the 203 patients. 165 replied, making an 81% response rate. The results were analysed as detailed below.

The time between operation and the patient responding to this review questionnaire varied but over one-third had an interval of greater than 2 years (Table 2).

Table 2 Period of follow-up M d Number of uscs

6 months 6 months - 2 years

22years

32 72 61

Figure 1 Satisfaction overall and with regard to treat ment of vaginal lump.

60

50

? 40 f g

i 30 z' 20

10

0

Satisfaction -treatment Satisfaction overall

of lump i

ila h n. Table 1 Operation survey questionnaire

OPERATION SURVEY We are sending out thl, QuestkIMAh to get I d b a c k on t h operations that have been done and bopefdly I t will h l p tts Lmprove our techniques. We tbank y w for your tlmt.

Your Name:

Approximnte date of operation:

Please efirk what you feel b Irae: _II_

symPto= M O W As at operatton Jaw lesS

1 A lump at the entrance to the vagina Y n So Y n Sn

Y m No Y n 1'11 2 Leakage when cotq&lng

3 Frequency of pimqtng u r l n morr dtrn lhan 2 hnurl) by cfa) Y n S'J mnrr than 2 hnurl, by night YF. Sn tm %n

y m so sm Vn

S DltTlrulty rmptytna hcrwrl Y n Nl Y I I I Vrr

7 Dragging (irllng In plt Is Y m So Y m %I

Ym So

4 Havlng to rush to tb toilrt u r ~ n t l ) lo paw urlne or mlght ha%v I r m

B b u r r 'down hrlnw Y m Vo t m 1'')

Y n No t m \n R Paln wlth Intrmourr

9 Haw you had any furtbr gynanrohrg.lral opmoctans nr trwtnmt that you thlnk might k, rrkryanf' Details

ANNA ROGERS ET AL 63

RESULTS The presenting symptoms and symptoms prevailing postoperatively are recorded in Table 3. It is notable that 81% of those who complained of a vaginal lump prior to surgery were cured, as were 74% of those who complained of a dragging feeling, and 79% of those who complained of pressure ‘down below’. The other symptoms cited in the questionnaire also show signif- icant rates of resolution although these are less likely to be due to the TSC than to the accompanying opera- tions performed at the same time.

Table 3 Symptoms before and after surgery Original symptoms After surgery

Vaginal lump Urinary leakage with cough Daytime urinary frequency Nocturia Urinary urgency DiRiculty emptying bowel Pressure ‘down below’ Dragging feeling in pelvis Pain with intercourse

137 95 79 57 90 71 115 96 33

26 38 33 25 49 40 24

25 16

The number of patients requiring further opera- tion is recorded in Table 4. In spite of persistent symp- toms the numbers that resort to further surgery is small. Only 3 patients required abdominal sacro- colpopexy because of failure of the vault suspension.

Table 4 Subsequent procedures Burch colposuspension 1

Vaginal repair 4 Abdominal sacral colpopexy 3 No subsequent operation 157

The level of patient satisfaction is as recorded in Figure 1. As can be seen, the vast majority was satis- fied with the operation in terms of its treatment of the vaginal lump and also expressed overall satisfaction with their operative treatment.

Apart from recurrent prolapse, we have had two serious complications in our series of cases. The fist was the case reported in our Fist series where the patient developed a pararectal haematoma which necessitated transfusion. The second was a case where the pudendal nerve was injured and this was treated expectantly at first. The patient complained of anaes- thesia on one side of her perineum. After several months the surgeon was considering removing the suture when a gradual resolution of symptoms was noted and no further action was required.

Seven patients had vaginal granulations due to

penetration of the Dacron suture through the vaginal wall. This situation was successfully treated by either removal of the suture or by covering it with the vagi- nal epithelium.

DISCUSSION Transvaginal sacrospinous colpopexy is one of sev- eral operations that are options for supporting the vault in severe prolapse. The alternatives include sacrocolpopexy (either open or laparoscopic), and colpocleisis. Critics of the transvaginal operation have argued that it is an un-anatomical operation.

We would contend that the most important criterion by which an operation should be judged is not its abil- ity to restore anatomy but its effectiveness in relieving the patient’s symptoms, balancing its risks and mor- bidity However, in some ways the TSC does restore anatomy because the angle of the lateral vaginal fornix normally passes very close to the ischial spine.

The lateral vagina is attached along its length to the ‘white line’ that is the junction of obturator inter- nus and levator ani. The white line ends at the ischial spine and thus the attaching of the vaginal fornix to the sacrospinous ligament is actually very close to its original position. Admittedly, the operative attach- ment is usually unilateral, the reason being in our experience the bilateral TSC leaves a central weakness which predisposes to recurrent central vault prolapse. One of the authors did a small series of cases with bilateral attachments and returned to the unilateral operation when he found a higher short-term inci- dence of recurrent prolapse.

One could also reasonably argue that the other operations that deal with severe prolapse (sacro- colpopexy and colpocleisis) are not anatomical either.

As can be seen from Table 3 the operation affords good figures in terms of resolution of symptoms. The 26 patients who had a vaginal lump and 24 who felt pressure almost certainly had some degree of recur- rence of their prolapse and we have noted in accord with other studies that this is usually recurrent cyst@ coele? It should be remembered all patients had severe prolapse prior to surgery

It is also notable that a signSicant number had res- olution of their bladder symptoms, although this is probably due to the anterior colporrhaphy that is done in most cases. Only a small number came to an incon- tinence procedure such as Burch colposuspension. This has been noticed in another recent study of TSC5 and may reflect that the degree of incontinence is not bothersome, or that patients are reluctant to undergo another operation.

Anecdotdlx some surgeons are reluctant to do a TSC at the same time as a Burch colposuspension and

64 ANWOG

the authors of this paper have differing views on this subject. Some hold that the TSC and a Burch proce- dure pull the vagina in opposite directions and conse- quently each operation diminishes the success of the other. It is also possible that the use of a Burch opera- tion at the same time as a TSC increases the risk of a recurrent cystocoele, due to the large area that is exposed to the downward force of the abdominal con- tents. This issue is not resolved in the literature, although one article advised against concurrent nee- dle suspension." Recurrent cystocoele is recognised in many studies to be a significant problem no matter what method is used for TSC.7

Pudendal nerve damage is reported in the litera- ture. One article relates how removal of the suture two years after the operation resulted in a resolution of the symptoms.8 It would be wise for any surgeon who is contemplating adding TSC to their operative repertoire to be familiar with the relevant anatomyg

Vaginal granulation secondary to the penetration of the suture through the vaginal epithelium is uncommon but emphasises the need to keep the suture subepithelial. It is possible to use absorbable sutures with the Endo StitchTM but we have not done so for fear that it would increase the rate of recurrent prolapse.

Apart from recurrent prolapse, the number of com- plications is pleasingly low. This is despite a reasonable number of the cases being performed by registrars as a teaching procedure. Apart from doing away with retrac- tors (and therefore reducing the risk of damage to the pre-sacral vessels2), we feel one of the advantages of the Endo StitchTM procedure is the ease with which it is learned, especially as skills similar to inserting a pudendal block are used. Our feedback confirms this, although the fact that the sutures are placed by touch rather than direct vision means that the procedure must be taught 'hands on' rather than by video or lec- ture. We have now run three teaching courses at the Geelong Hospital and, under guidance. all participants have managed to insert a suture in the ligament.

CONCLUSION We feel the Endo Stitch'" method of TSC has come of age as a surgical technique, and believe our study shows it to be as safe and effective as other methods of TSC. It has the great advantage of being easy to learn because it uses skills that are already familiar to the obstetrician and gynaecologist, and theoretical advan- tages in terms of avoiding damage to the pre sacral vessels.

ACKNOWLEDGEMENT The authors acknowledge the support of Tycho Healthcare for the courses we have run on the Endo Stitch'" technique.

Trademark Endo Stitch'" is a registered trademark of Unitcxi States Surgical Corporation.