Introduction

Pelvic organ prolapse (POP) is a common condition usually affecting middle-aged and elderly women. However, it tends to also manifest itself in women under the age of 45, requiring surgical correction in order to preserve fertility. Laparoscopic Sacral colpopexy (LSC) is one of the most effective surgical procedures for treating POP, especially in young women who wish to remain sexually active. We report the clinical and radiological results observed after a pregnancy and following delivery of a young woman who previously underwent an LSC for POP.

Case report

A 38-year-old woman, para 2, one caesarean, was referred to us for medical consultation complaining of discomfort, exterior prolapse and difficulty during sexual intercourse. She also complained of symptoms of stress urinary incontinence (SUI). This condition occurred after her vaginal delivery.

Physical examination, including POP quantification (POP-Q), was performed [1]. A stage 4 cystocele, stage 2 utero-vaginal prolapse and stage 2 rectocele were diagnosed. The urinary disease clinical examination exhibited stage 3, grade 3 SUI (Ingelman–Sundberg classification and Sandvik’s Incontinence Severity Index). Urodynamic testing was also performed. The use of two pessaries had failed due to expulsion. The next therapeutic approach was a laparoscopic uterine ventrosuspension (LUV) consisting of uterine fundus suspension to the abdominal aponeurosis using no. 0 non-absorbable suture.

Shortly after surgery, the patient showed a procedure failure with signs and symptoms of an immediate relapse. Dynamic pelvic magnetic resonance (PMR) confirmed POP relapse (Fig. 1). For this reason, both an LSC and trans-obturator tape procedure were carried out. LSC was performed as previously described [2]. The first follow-up was done 1 month after the procedure. The patient was asymptomatic with no symptoms of prolapse. Using the POP-Q classification system, the stage of the cystocele was 1 and the utero-vaginal prolapse and rectocele was 0. A second PMR showed no signs of POP (Fig. 1). Moreover, no signs and symptoms of SUI were observed.

Fig. 1
figure 1

Dynamic pelvic resonance performed before, immediately after LSC and after pregnancy. This examination was executed at rest and in stress conditions

Full size image

One year after surgery, the patient conceived spontaneously and carried out a normal pregnancy concluding in delivery at gestational week 38 by elective caesarean section. The post-partum follow-up performed after 8 months exhibited a stage 2 cystocele and rectocele. The patient did not show symptoms or complaints related to POP. This condition did not justify a new surgical intervention. There were no signs of SUI observed during the clinical examination or urodynamic testing. The ensuing follow-up visits at 24 and 48 months showed no changes in the results. In particular, the PRM, performed 48 months after surgery, confirmed equivalent results (Fig. 1).

Discussion

Sacral colpopexy is the gold standard for vaginal vault suspension throughout the literature. The laparoscopic approach is not only effective but can also have minimal morbidity in the appropriate surgeon’s hands. Moreover, long-term follow-up studies have shown that this treatment in women of childbearing age has a high success rate in correcting prolapse without a time-dependent decrease in efficiency [3]. In light of these considerations, the current case confirms the efficacy of LSC in the treatment of POP in young women.

However, the main target of this research was to focus on clinical and radiological results observed after pregnancy and especially after delivery. Although several studies regarding the role of LSC in young women have been published, there are not many reports regarding delivery following laparoscopic surgery for POP.

The case series published by Maher et al. indicated the efficacy of laparoscopic suture hysteropexy in two cases of pregnancy and following delivery by caesarean section. This procedure, without mesh, involves the closure of the pouch of Douglas and plication of the uterosacral ligaments with reattachment to the cervix [4]. Seracchioli et al. published a positive outcome of LSC on a group of 15 young women with genital prolapse. The techniques described were the same with the use of the two meshes. Two of these women became pregnant and delivered by caesarean section [5]. One of these is the first study which described pregnancy after LSC; however, there are no detailed descriptions of the individual cases and their specific outcome. In fact, the results were referred collectively to the entire study group.

Our first surgical choice after failure of medical treatment was LUV. This intervention was considered transitory from the perspective of a definitive LSC following pregnancy. In the presence of severe POP and a concomitant childbearing desire, a transitory, less invasive approach seems to be appropriate in the absence of a large case series showing the true impact of pregnancy and delivery on prolapse surgery.

LSC surgical technique is standardised and relatively easy to perform by trained surgeons; however, it should be reserved for women without a desire to become pregnant in order to avoid, in case of post-delivery relapse, a second and more complex surgery. In fact, a laparoscopic approach is very difficult to perform if the vesico-vaginal and recto-vaginal dissection were already done. Moreover, a surgery on the sacral promontory previously treated is both potentially complicated and dangerous. Therefore, a temporary surgery can represent a good chance to restore the clinical discomfort without detrimental effects on successive, definitive intervention.

However, after delivery, we observed an acceptable maintenance of the prolapse correction. The absence of symptoms and the moderate clinical and radiological worsening did not justify a new intervention. Moreover, the long-term radiological assessment performed before and after surgery allows objective evaluation of the actual POP stage and the LSC efficacy. This evidence confirmed the effectiveness of LCP in terms of duration, endurance and reliability. Regarding the modality of delivery, in accordance with previous reports, elective caesarean section at gestational week 38 represents a solution to avoid the stress of labour and delivery. The development of the lower uterine segment adds an ulterior advantage to prevent cutting the meshes.

In conclusion, a surgical procedure for the correction of POP is possible in women with a desire to become pregnant. The result is variable and linked to the POP stage and other surgical interventions. Further studies are necessary to confirm the role of LSC in these cases.