Introduction
Prolapse – Latin word – slipping Pelvic organ prolapse has remained an issue of major health concern affecting a large population of women in both developing and developed countries.1
The need for expertise and specialised care for pelvic floor disorders would gradually increase in the ensuing decades.
Though pelvic organ prolapse is more common in older women, it is now seen with an increased frequency even in reproductive age group.1
There is a noticeable and gradual shift towards minimally invasive procedures even for surgeries of prolapse. Conservative surgeries play an active role in young nulliparous women where menstrual and reproductive function in desired.
The present study was carried out at a tertiary referral centre over a period of two years from January 2003 to December 2004. There were 1380 admissions for prolapse. Out of which 10.07% underwent conservative surgeries for prolapse i.e. 139 patients. Out of which 64 patients were treated with Shirodkar’s posterior abdominal sling surgery, almost around (72.72%).
Out of 64 cases treated with Shirodkar’s sling surgery, 31 cases underwent round ligament plication, 6 patients were operated for tubal ligation, 8 patients underwent A-P repair and two patients underwent simple ovarian cyst aspiration at the same time.
Aims and Objectives
- To evaluate the place of Shirodkar’s abdominal sling operation in modern Obstetrics and Gynaecology in the treatment of utero-vaginal prolapse in child bearing age group.
- To discuss the pregnancy outcome and fertility in patients who have undergone the Shirodkar’s sling surgery.
Observations and Results
| Table 1: Table showing distribution of patients with uterovaginal descent |
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Total 1380 patients of uterovaginal descent were admitted at LTMGH and LTMMC, Sion, Mumbai, from January 2003 to December 2004 over period of two years.
One hundred and thirty nine patients were treated conservatively out of which 64 patients (72.72%) underwent Shirodkar’s sling surgery.
| Table 2: Distribution of patients in the management of prolapse; |
Table 3: Distribution of patients treated conservatively includes |
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Total patients treated by conservative surgical management were 139. Out of which 64 (46.67%) patients underwent a Shirodkar’s posterior sling, 6 patients underwent tubal ligation at the same time.
In one patient tuboplasty was done. Eight patients underwent anterior colporrhaphy and posterior colpoperineorrhaphy at the same time.
Two patients underwent drainage of simple ovarian cyst at the same time.
| Table 4: Age wise distribution of patients from child bearing age group treated conservatively by Shirodkar’s sling |
Table 5: Parity wise distribution of patients from child bearing age group treated by conservative surgeries. |
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Maximum patients treated conservatively by Shirodkar’s sling belonged to 21-35 age group i.e. from child-bearing age group.
- Incidence of prolapse is fewer in-patients with age group less than 20 years of age.
- Patients below 20 years of age or unmarried or nulliparous patients not excluded from the prolapse.
Most of the patients belong to reproductive age group 21 to 35 years. The more the parity greater was the degree of descent. Maximum patients belong to second and /or third parity.
All patients from our study belong to the childbearing age group. Out of which almost all patients belong to I, II and III degree of uterovaginal descent (Table 6).
Shirodkar’s sling was the preferred surgery in the younger age group. Total 64 patients were treated with Shirodkar’s sling out of which 44 patients were under 30 years of age (Table 7).
| Table 6: Distribution of patients according to degree of descent and number of patients treated conservatively |
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| Table 7: Distribution of patients according to age group in relation with different modalities of conservative surgical management of prolapse during child bearing age group |
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| Table 8: Relation of the degree of descent to the surgery preferred |
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| Table 9: Relation between the parity and the preferred conservative surgical modality of the management of prolapse in case of child bearing age groupd |
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Shirodkar’s posterior abdominal sling surgery is preferred in child bearing age group of patients, who desire to retain childbearing or menstrual functions.
Most patients with II and III descent i.e 36 (56.25%) and 24 (37.50%) underwent a sling operation for uterovaginal descent with laxity of uterosacral ligaments and transverse cervical ligament (Table 8).
Shirodkar’s Sling surgery (Table 9) is preferred in cases of
- younger / child bearing age group 25-35 years of age group
- II and III degree of uterovaginal descent
- Most of the patients belong to second or third para.
| Table 10: Table showing the different intraop and post operative complications during Shirodkar’s sling surgery |
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Anaesthesia related complications
Include
- post spinal headache
- infections
- meningitis
Proper techniques and aseptic precautions considerably reduce anaesthesia complications.
Injury to blood vessels of sigmoid mesocolon and sacral plexus may lead to haemorrhage.
If the knot of the psoas loop is not kept laterally, there is irritation to genitofemoral nerve.
No patient had any ureteric or colonic injury.
No patient with cutting through of the sling or incisional hernia.
Total 5 patients from our study landed up with complications, out of which four had fever, one had wound infection, three had urinary tract infection and two had post spinal headache.
| Table 11: Table showing the pregnancy outcome in our study |
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- Forceps was applied to preterm delivery, the new born died after 2 days due to severe prematurity the patient who had premature rupture of membrane (PROM) delivered normally.
- LSCS was performed for placenta previa, foetal distress and transverse lie respectively.
Total 24 patients conceived i.e. 41.37%.
The overall fertility rate was 41.37%.
Nineteen of the pregnant patients delivered vaginally. There was minimal recurrence of utero vaginal descent in 1 patient after delivery, which does not require any further corrective surgery.
LSCS were performed for obstetric causes and were not related to initial surgery.
| Table 12: Comparison of various studies with Shirodkar’s sling surgery |
Table 13: Comparison of various studies with Shirodkar’s sling surgery in relation with pregnancy outcomes |
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Discussion
Utero-vaginal descent is a common problem in the Indian women. The best reconstructive surgery for the women in the childbearing age group is going to be a dogma for many obstetrician and gynaecologists.
The aim of conservative surgery.
- To relieve the symptoms
- To restore the anatomy to normal
- To restore the functions to normal
- To prevent recurrence in future
- To maintain child bearing potential
- To maintain menstrual function
The operative treatment of prolapse in young women in the childbearing age poses three important problems.
- Repair of prolapse should not in any way, hamper the fertility of the patients.
- The surgery must not hamper the course of normal labour and delivery.
- Most importantly, the repair must not give way and cause recurrence of the prolapse after the childbirth.
Traditionally patients with prolapse have been treated doing vaginal Hysterectomy along with anterior colporrhaphy and posterior colpoperineorrhaphy. But in the child bearing age group conservative surgeries play a definitive role.
We evaluated the age related distribution of patients treated conservatively by Shirodkar’s sling surgery. It was found that most of the patients were between 20-35 yrs of age group.
Dr. Shirodkar had advised these surgery for patients desirous for maintaining fertility and menstrual function.4 In the present study four patients were primiparous, 28 second para and 24 third para; 36 patients had second degree descent while 24 patients had third degree descent.
Shirodkar’s posterior sling operation is by far the best operative technique for management of uterovaginal descent during childbearing age group. It is evident from the fact that the patients undergoing the sling have minimal complications and recurrence of symptoms.
Nulliparous prolapse occurs due to congenital weakness of ligments, spina-bifida-occulta or associated neurological abnormalities. In the present study no patients had nulliparous prolapse.
Dr. V.N. Shirodkar the Pioneer of Shirodkar’s abdominal sling surgery, used fascia lata femoris to strengthening the uterosacral ligments and fixation to the sacral promontary retroperitoneally.
Over a period of time fascia lata was replaced by Nylon strips and presently mersilene (inert material) tape is used. Mersilene tape has a definite advantage over fascia lata as it is inert material, non-absorbable, non-irritant with predictable tensile strength.5
Shirodkar’s sling surgery was performed using mersilene tape in all the patients in the present study.
As discussed in the review of literature Shirodkar’s sling surgery anteverts the uterus and thus maintains normal anatomical and physiological position of the uterus.6
It is prudent to perform vaginal surgeries for anterior and posterior compartmental defects preferred before proceeding to abdominal sling surgery.7
Complications of Shirodkar’s sling8 include presacral bleeding. Hence a vascular sacral plexus is a relative contraindication for this surgery. In the present study no patient had sacral pluxus haemorrhage.
Sigmoid colon and sigmoid mesocolon injury can occur with this surgery, hence short sigmoid mesocolon is relative contraindication for this surgery. In the present study no patient had this complication.
Other complications that can occur include geintofemoral nerve irritation, damage to ureter, recto-vaginal fascia, recurrence, osteomyelitis and bowel obstruction.8 However these complications were not seen in this study.
In the present study two patients with anaesthesia related complications i.e. post spinal headache.
Superficial wound gape seen in one patient while three patients had urinary tract infection and four patients had postoperative fever.
Thus in the present study, the overall complication rate was 7.81% which is slightly higher than the studies conducted by Dastur et al2 (4%) and Vijaykar et al3 (5.71%).
We also evaluated the fertility rate post surgery and found that, it was 41.37% in contrast to Vijaykar et al3; who found a fertility rate of 15.79%. However the rates were comparable to the study carried out by Dastur et al2 i.e.34.15%.
In the present study three patients underwent L.S.C.S. for obstetric indications. Normal delivery was conducted in 19 patients while Forceps was applied in one patient i.e. with preterm delivery.
Thus patients undergoing Shirodkar’s sling surgery have a good fertility rate. L.S.C.S. can be performed for obstetric indications. Shirodkar’s sling surgery is not associated with complications like adhesions in lower segment, as seen during lower segment L.S.C.S; as seen in Purandare’s Cervicopexy. Thus Shirodkar’s sling surgery has better results than Purandare’s cervicopexy, as far as complications of L.S.C.S. is concerned.
On analysis of the study the recurrence rate, it was found that one patient had recurrence i.e. 1.56%. This patient had post delivery recurrence, which did not require correction. A review of literature shows that the recurrence rate after Shirodkar’s sling surgery is less than 1%.3
Six patients underwent tubal ligation by Modified pomeroy’s method along with Shirodkar’s sling surgery.
Tubal patency by transfundal chromopertubation was done in two patients with secondary infertility.
Conclusion
The Shirodkar’s posterior abdominal sling operation satisfies the criteria for reconstructive surgery laid down by Nicols DH.
The advantages of this operation are:
- The prolapse is treated
- The cervix remains in the posterior fornix at its normal place
- In nulliparous prolapse, it is the operation of choice.
- Postoperative morbidity is significantly low
- The surgery does not affect the fertility of the patients, in fact it improves fertility by maintaining the pelvic anatomy to normal
- Pregnancy outcome is improved after the surgery
- The sling surgery does not affect the course of normal labour.
- The lower segment can be easily approached at the time of lower segment caesarean section.
- There is no or comparatively very very less recurrence of prolapse even after delivery.
Shirodkar’s posterior abdominal sling operation thus plays an important role in the conservative management of utero-vaginal descent during child bearing age group in modern obstetrics and gynaecology.
Their limitations are in severe degree of cystocoele, urethrocoele, enterocoele and rectocoele. In a supravaginal elongation of a severe degree Shirodkar’s sling surgery gives unsatisfactory result.
Intrinsic collagen abnormalities might explain nulliparous prolapse or recurrence of genital prolapse inspite of adequate surgical correction.
Pregnancy it self, results in a reduction of total collagen content including hydroxyproline and an increase in glycosaminogycans which may result in weakening of pelvic floor.9
We also would like to stress on the saying of old.
“Prevention is better than cure”.
To improve literacy and awareness about small family norms, proper intranatal care, antenatal and postnatal exercises described by Kegels and Mandelstorm, we hope, shall reduce the incidence of prolapse.
References
- Pandit SN. Pelvic organ prolapse – Chapter 1, Introduction; Pg 1.
- Dastur B, Gurubaxani G, Palnitkar SS. Shirodkar Sling operation in the treatment genital prolapse. Journal of Obstetrics and Gynaecology. British commonwealth 1967 February; 74 : 125-8.
- Vijaykar IV. Journal of Gynaecology and Obstetric, India 1974; 26 : 884.
- Shirodkar VN. Contribution to Obstetrics and Gynaecology. E and S Livingstone Ltd. Edinburg and London. 1960; Chapter-2 : Pg. 1846, 47.
- Pandit SN. Pelvic organ prolapse; First Edition 2005;7,49.
- Pandit SN. Pelvic Organ Prolapse, First edition 2005; 7 : 47.
- Parulekar Shashank V. Practical Gynaecology and Obstetric, first edition 1987; reprint 2000, 5 ; 260.
- Parulekar Shashank V. Practical Gynaecology and Obstetric, first edition 1987; reprint 2000; 5 ; 261.
- Pandit SN. Pelvic Organ Prolapse, First edition 2005; 4 : 24-6.
Deparment of Obstetrics and Gynaecology, L.T.M.M.College and General Hospital, Sion, Mumbai - 22.
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