Suspensi Ligamen Uterosakaral Vaginal

Apeks vagina dapat ditangani secara efektif dengan berbagai operasi vaginal atau abdominal.
Dari jumlah tersebut, penjahitan apeks ke bagian proksimal dari masing-masing ligamentum
uterosakral (LUS), yaitu, suspensi ligamentum uterosakral (SLUS), lebih sering dilakukan
pervaginal, meskipun pendekatan abdominal dan laparoskopi dapat dilakukan. Walau sering
dimodifikasi, tujuan utama SLUS adalah restorasi penyangga apeks vagina dengan
menempelkan dinding vagina anterior dan posterior ke ligamen uterosakral pada dan di atas
spina ischiadika. Langkah-langkah yang dijelaskan menguraikan pendekatan pilihan kami,
yang merupakan modifikasi dari prosedur SLUS yang dijelaskan oleh Shull et al (2000).

Prosedur suspense apikal vagina lainnya, fiksasi ligamentum sakrospinosa (FLSS), juga
bertujuan untuk mengkoreksi prolaps apikal. Namun, jika SLUS dan FLSS dibandingkan,
SLUS mempertahankan orientasi aksis normal vagina dan dianggap menurunkan tingkat
dispareunia juga prolaps dinding vagina anterior. Namun, penulis dari uji Operations and
Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL)
membandingkan hasil dari keduanya dan menemukan bahwa setelah 2 tahun, keduanya
menunjukkan skor keberhasilan yang sama mendekati 60 persen (Barber, 2014). Angka ini
lebih rendah dari angka keberhasilan 70-90% yang umumnya dilaporkan untuk prosedur
suspense apikal ini, tetapi tingkat perawatan ulang tetap rendah yaitu 5 persen (Margulies,
2010). Dari komplikasi dalam uji OPTIMAL, nyeri neurologis persisten pada 4% kasus FLSS,
tetapi obstruksi ureter lebih sering terjadi setelah SLUS dan diperkirakan 3%.

Selain koreksi prolaps apikal, SLUS vaginal efektif memperbaiki enterokel apikal, dan dengan
demikian perbaikan enterokel lainnya tidak diperlukan. Namun, prolaps apikal umumnya
berkembang bersamaan dengan prolaps kompartemen anterior dan posterior. Dengan
demikian, SLUS vagina sering dilakukan dengan operasi lain seperti kolporapi dan perineorapi
untuk mengkoreksi defek ini.

PREOPERATIF

Evaluasi Pasien

Prolaps apikal sering berdampingan dengan prolaps organ lainnya, dan penilaian pra operasi
dilakukan dengan hati-hati. Juga sebelum SLUS vaginal, pasien dengan gejala inkontinensia
urin menjalani tes urodinamik sederhana atau kompleks untuk memperjelas jenis inkontinensia.
Bagi mereka dengan SUI, operasi antiincontinence umumnya dilakukan bersamaan. Koreksi
prolaps dapat mengungkapkan inkontinensia okultisme. Wanita dengan SUI okultisme
dikonseling dengan hati-hati dan mungkin juga memilih untuk menjalani operasi
antiincontinence. Wanita yang menjalani operasi prolaps vagina juga berisiko atau lebih lambat
mengembangkan SUI pasca operasi.

Untuk mengevaluasi apakah profilaksis midurethral sling (MUS) perlu ditempatkan selama
operasi prolaps vagina apikal dan anterior mengurangi risiko SUI, uji OPUS (Outcomes
Following Vaginal Prolapse Repair and Midurethral Sling) telah dilakukan. Peneliti
menyimpulkan bahwa profilaksis MUS pada wanita tanpa gejala ini mengarah pada 27%
kejadian SUI pasca operasi pada 1 tahun dibandingkan dengan 43% tanpa MUS profilaksis
yang bersamaan. Yang penting, menambahkan prosedur antiincontinence dapat menurun,
tetapi tidak menghilangkan, risiko de novo SUI. Langkah pra operasi lainnya, beberapa orang
berpendapat bahwa estrogen dapat meningkatkan ketebalan dinding vagina atau memudahkan
diseksi dan penempatan jahitan. Namun, uji RCT yang menganalisis perawatan ini untuk
mengurangi erosi jahitan atau risiko kekambuhan prolaps masih kurang.

Consent

Prolaps berulang sering terjadi setelah operasi korektif. Dengan demikian, operator harus
memahami tingkat rekurensi dari literatur dan dari pengalaman pribadi. Inkontinensia urin atau
disfungsi defekasi dapat terjadi setelah SLUS. SLUS juga memperbaiki vagina bagian atas ke
LUS dan memiliki potensi untuk memperpendek kanal vagina. Dengan demikian, dispareunia
adalah risiko pasca operasi. Selain itu, cedera saraf pleksus sakralis dengan neuropati dapat
terjadi pada hingga 7% wanita yang menjalamo SLUS vaginal. Dengan demikian, wanita
diedukasi tentang kemungkinan kebutuhan pelepasan jahitan jika nyeri bokong parah yang
menjalar ke posterior paha muncul pasca operasi. Nyeri bokong ringan tanpa penjalaran dan
tanpa defisit motorik umumnya sembuh selama beberapa minggu penatalaksanaan ekspektan
dengan menggunakan analgesik. Erosi jahitan suspensi apikal dan jaringan granulasi vagina
merupakan komplikasi yang sering dilaporkan.

Persiapan Pasien

Persiapan puasa bervariasi tergantung pada preferensi operator. Pasien dapat diminta untuk
hanya konsumsi air putih sehari sebelum operasi dan menyelesaikan satu atau dua enema
malam sebelumnya atau pagi sebelum operasi. Antibiotik dan tromboprofilaksis diberikan.
Anestesi dan Posisi Pasien

SLUS vaginal biasanya dilakukan dengan anestesi umum. Pasien ditempatkan dalam posisi
litotomi standar menggunakan candycane atau boot stirrups. Pemeriksaan dengan anestesi
dilakukan untuk menilai tingkat prolaps dan mengkonfirmasi kebutuhan atau rencana operasi.
Vagina dan abdomen disiapkan, dan kateter dimasukkan.

Insisi Apeks Vagina

Insisi awal dapat dibuat dengan berbagai cara. Jika untuk melengkapi histerektomi vaginal,
manset vagina sudah terbuka, dan setiap jahitan transfusi LUS sudah dipegang oleh hemostat.
Namun, jika pasien pernah menjalani histerektomi, apeks vagina dijepit dengan klem Allis, dan
epitel atasnya diinsisi secara vertikal atau horizontal tergantung keadaan. Sebagai contoh,
untuk colporrhaphy bersamaan, sayatan apikal garis tengah vertikal yang memanjang secara
distal sepanjang dinding vagina anterior dan / atau posterior lebih disukai.

Alternatively, in patients with large apical enteroceles and redundant apical tissue, a diamond-
shaped portion of epithelium can be excised and a new apex created. However, excessive tissue
excision that may result in vaginal shortening is avoided. Stitches may then be placed at the
lateral boundaries of the intended new apex or later identification. With enterocele, epithelial
dissection at the apex typically reveals a peritoneal sac, which is incised to allow peritoneal
cavity entry. Last, if a clear dissection plane is not identified, SLUS can be performed by an
extraperitoneal approach, or FLSS may be performed instead.

Identifikasi

Bowel must be adequately packed away or proper LUS visualization to avoid bowel injury
when high uterosacral sutures are placed. First, a Deaver retractor displaces the bladder upward.
Then, a right-angle retractor or two fingers in the posterior cul-de-sac gently displace the
posterior peritoneum and underlying rectum downward to avoid peritoneum tearing, which
creates bleeding and difficult LUS identification. Two moist laparotomy sponges tied together
are then gently threaded into the posterior cul-desac to pack bowel into the upper pelvis. The
Deaver retractor is then repositioned to cover the laparotomy sponges. Gentle upward retractor
traction exposes the mid and proximal LUS portions and the deep posterior culdesac close to
the sacrum.

Two Allis clamps are next placed at approximately 5 and 7 o’clock positions on the posterior
vaginal wall and incorporate the posterior peritoneum. Gentle downward Allis clamp traction
tenses the SLUS, which are then traced with the contralateral index finger. The strong ligament
fibers can be traced from their distal attachments in the vagina to their proximal sacral
attachment. Concurrently, the ischial spines, which protrude from the lateral pelvic walls and
lie anterolateral to the SLUS, are palpated. Ureters are usually indistinct to touch, but they
course anterolateral to the SLUS. A lighted Breisky-Navratil retractor is useful for retracting
the rectum medially to further expose the SLUS. A second similar retractor is often positioned
on the opposite side for improved visualization o the proximal LUS.

Penjahitan Ligamen Uterosacral

Following adequate exposure, two to three sutures are placed through one LUS. Sutures are
equally spaced along the mid to proximal length of each ligament. Long, straight needle drivers
are useful for this. The sutures are individually tagged as they are placed, preferably with
labeled clamps numbered 1 through 3 or one side and 4 through 6 for the other. Sutures are
then loosely secured to the ipsilateral surgical drape. For the most distal stitch, we use a 2-0
gauge delayed-absorbable suture (black) with a swaged on SH needle. For the more proximal
stitch(es), a similar gauge permanent material (blue) is selected instead.

To begin, the distal absorbable suture perorates the LUS at its midlength, which lies at
approximately the level of the ischial spine. The subsequent, more proximal sutures are placed
approximately 0.5 cm to 1 cm cephalad from each prior suture. Two or three sutures are placed
on each side, and this number is guided by surgeon preference, the extent of LUS exposed, and
vaginal cuff width.

With each stitch placement, the needle tip ideally passes through the most medial portion of
the ligament in a lateral-to-medial direction. These specifics attempt to minimize ureteral
entrapment or kinking risks. Moreover, to lower rectal injury rates, an assistant retracts the
rectum to the contralateral side, and suture purchases do not extend too medial, that is, beyond
the ligament width. Similarly, suture bites that are too deep risk injury to internal iliac vessels
or sacral nerves. At completion, gentle traction on each suture should confirm correct
placement and incorporation of adequate LUS tissue. Excess laxity during such LUS traction
usually indicates insufficient tissue to provide adequate apical support, and the suture is
replaced.

Hematomas form occasionally following inadvertent laceration of pelvic sidewall veins.

Application of pressure with a sponge stick will typically control bleeding.
Prosedur Lainnya

Once all the suspensory sutures are placed through each LUS, colporrhaphy is completed if
indicated. If a perineorrhaphy or midurethral sling procedure is planned, we defer these until
the SLUS operation is completed.

Penjahitan Dinding Vagina

Vaginal packing is first removed, and ultimately, four to six sutures (two or three from each
LUS) are placed along the vaginal cuff width. If one begins on the patient’s left side, the free
end of the left distal absorbable SLUS suture (suture 1) is threaded into a Mayo needle. The
needle and suture then pierce the left lateral anterior vaginal wall at the apex. The other needle-
bearing suture end similarly penetrates the posterior wall. Each suture strand traverses the full
vaginal wall thickness, including the epithelium.

Next, the proximal (permanent) SLUS suture(s) are similarly passed through the anterior and
posterior vaginal walls, each medial to the previous suture. To lower suture erosion rates,
permanent sutures traverse the full thickness of the bromuscular layer but not the epithelium.
However, a substantial thickness of bromuscular wall is incorporated to prevent tissue tearing,
which can create suture bridges that are bowel obstruction risks. The same steps are then
repeated on the right.

Ultimately, on each side, the most cephalad SLUS sutures (sutures 3 and 6) are placed most
medially on the vaginal cuff. The most distal SLUS sutures (sutures 1 and 4) are placed most
laterally on the vaginal cuff. For organization, all completed sutures are held within numbered
clamps on their respective sides.

At this point, indigo carmine or methylene blue dye is given intravenoLUSy in preparation or
cystoscopy that follows knot tying. Knots are secured starting with most medial cuff sutures
(sutures 3 and 6) and ending with the most lateral (sutures 1 and 4). The vaginal wall is
confirmed to approximate the ULSs. Both this approximation and the order in which sutures
are tied may prevent suture bridges. All sutures are held with their corresponding numbered
clamps after tying until cystoscopy is completed.

Cystoscopy
This is performed to document ureteral patency and exclude bladder to the lower portion of the
LUS. Thus, if ureteral obstruction is suspected, the most distal SLUS suture on the ipsilateral
side is released first, and cystoscopy is repeated. If no flow is noted, the next most proximal
suture is released, and this is continued cephalad in a stepwise fashion until efflux is seen.

Pemeriksaan Rektal

The rectum is digitally explored to confirm approximation of the cuff against the SLUS and
exclude sutures entering the rectum.

Closure of the Vaginal Cuff

The suspension suture ends are now cut, and the vaginal cuff is reapproximated in a running
fashion with 2-0 gauge delayed-absorbable suture. Alternatively, four interrupted 2-0
absorbable sutures are placed through the full thickness of the anterior and posterior vaginal
cuff prior to tying o the LUS sutures and held or later cuff closure. This practice aids cuff
closure with high suspensions, in which vaginal edges may be inaccessible without pulling that
in turn disrupts the repair.

POSTOPERATIVE

Following vaginal SLUS, postoperative care mirrors that for vaginal surgery. Postoperative
activity in general can be individualized, although intercourse is usually delayed until after 6
weeks following surgery. A voiding trial can be completed on postoperative day 1, depending
on the patient’s condition and general progress. Some patients have urinary retention after
apical suspension, even without an antiincontinence procedure. If unable to void spontaneously
by the time of discharge, the patient can be discharged with a catheter and followed up within
a week for removal. Patients are screened or lower extremity neuropathy prior to discharge.
Suture erosion with granulation tissue can be a short- or long-term complication and is
managed.