Surgical management for treating apical pelvic organ prolapse in elderly women remains a challenge. This study aims to report the results of the novel uterus-sparing procedure -- Transvaginal Uterus Sling for the treatment of apical pelvic organ prolapse in elderly women.

This is a prospective study exploring the efficacy of Transvaginal Uterus Sling in elderly patients with apical pelvic organ prolapse. Surgical technique was described as follows: The procedure was performed under general anaesthesia. The patient was placed in a lithotomy position with the Trendelenburg position. A 10 x 15cm of polypropylene mesh Gynemesh (Ethicon, Somerville, NJ) was cut into a 10 x 2 cm Double-Y shape along the long axis (Figure1-A). After vaginal irrigation and catheterization, a customized needle was inserted through the cervix into the uterine cavity(Figure1-B). Then the uterus was pushed upwards the midline of the abdominal wall under laparoscopic surveillance(Figure1-C). After that the needle was used to pierce through the myometrium into the peritoneal cavity(Figure1-D) and then punctured through the peritoneum, fascia, and skin at the level of Hunter's line(Figure1-E). Subsequently, the needle was withdrawn and a suture was passed from skin piercing port to the cervix through the passage. And then one end of the mesh was fixed with the suture and the mesh was passed from the cervix to skin piercing port with the guide of the suture(Figure1-F). Cystoscopy was then performed to ensure that there was no injury to the bladder. A transverse incision was made at the external cervical orifice and the ends of the ‘Y’ shaped mesh were embedded and secured on each side of the cervix with non-absorbable 2-0 sutures(Figure1-G). A 2 cm longitudinal incision was made through the skin port site. The subcutaneous tissue was dissected layer by layer to the level of the anterior rectus sheath. The cervix was then lifted up to the highest portion of vagina with the assistance of fingers placed in the vagina. The ends of the ‘Y’ shaped mesh were fixed on each side of the anterior rectus sheath with non-absorbable 4-0 sutures(Figure1-H). The excess mesh was trimmed and the skin incision was then closed. Sketch of the Transvaginal Uterus Sling procedure was shown in Figure 2. Validated questionnaires were conducted to estimate the improvement of quality of life. POP-Q score and questionnaires were collected before and after the surgery. Surgical parameters and intra- and post-operative complications were also recorded.

Seven elderly patients diagnosed with apical pelvic organ prolapse underwent the transvaginal uterus sling procedure. The objective cure rate was 100%, with a mean follow-up of 3.4 months (range 1-6). There was a significant improvement in all POP-Q points (p<0.05), of which the mean C score changed from baseline (4.4 ± 1.1) to -8.9 ± 0.7 at follow-up. Significant improvement was also observed in PFIQ-7 and PFDI-20 at follow-up. The mean operative time was 56 ± 25.2 minutes (range 41-112), and the mean blood loss was 10.7 ± 5.3 ml (range 5-20). Most patients reported a dragging sensation at the point of mesh fixation on the abdominal wall within two weeks postoperatively, but no further intervention was required. No intraoperative complications or other postoperative complications were observed.

The Transvaginal Uterus Sling procedure (TVUS) is effective and safe in achieving anatomic restoration of cervix in the treatment of apical prolapse in elderly patients. Our new surgical procedure is highlighted in the following areas. (1) Anatomic restoration of cervix, (2) Integrity of the vaginal anatomy, (3) Simple operation, (4) Minimal invasion, and (5) less blood loss. We believed that Transvaginal Uterus Sling procedure could further simplify uterus-preserving pelvic reconstruction surgery. Long-term efficacy and safety of this procedure is being observed.

The Transvaginal Uterus Sling procedure (TVUS), characterized by minimal invasion, simple operative procedure, and less complication, will be of great value for the treatment of apical pelvic organ prolapse in elderly patients.