Reproductive Performance Following Sleeve Excision Anastomosis Operation for Genital Prolapse

EDITORIAL COMMENT : We accepted this paper for publication, not because we consider that the unique operation it describes has a multitude of prolapsed young nulliparas with the required indications waiting for it, but because the description of the operation and the population it serves will interest readers. The Sleeve operation seems a sophisticated procedure for women who dwell in a community with limited resources (‘the largest slum in Asia’). This paper will also interest gynaecological surgeons, and those with an interest in the anatomy of the female pelvis, especially in the most dangerous of areas, the 2 cm x 2 cm area lateral to the supravaginal cervix where uterine vessels and ureters share their exquisite relationship. The Sleeve operation is the opposite of the Spalding‐Richardson operation since it removes the only part of the uterus, the supravaginal cervix, that the former procedure leaves intact (A). The Spalding‐Richardson operation was performed in former years by the Royal Melbourne Hospital gynaecologists (B). The main objectives of this procedure were to remove the hypertrophied or diseased cervix, and the fundus of the uterus, but the ‘hub of pelvic support was preserved’. The editor has seen neither of these operations performed but both seem formidable. The 2‐way operation (Manchester repair with abdominal subtotal hysterectomy) seems a better procedure to achieve the same result. How important is the cervix for conception? The Sleeve operation was devised because it was considered that its amputation in the Manchester repair was a significant impediment to future fertility. The literature examining this point is not recent, prospective or definitive. Most women having a Manchester repair are multiparas, and it is unlikely that many wish to conceive again. The author does not provide data supporting his belief that the Sleeve operation is superior to the Manchester repair in maintenance of fertility and the ability of the woman to have a ‘normal vaginal delivery in her rural surroundings’. In the author's series of 24,861 confinements, 1 in 235 women had had a previous repair for prolapse and 1 in 2,072 had had the Sleeve operation ‐1 of the latter developed a ruptured uterus in early labour and was treated conservatively by uterine repair and internal iliac artery ligation. For comparison the statistics from the Mercy Hospital for Women, Melbourne, for the years 1979–1989 were analyzed: 71 of the 56,687 women confined (I in 798) had had a previous operation for prolapse and 20 of these (1 in 2,834) had had a previous Manchester repair. In these 20 pregnancies the methods of delivery were normal (7), forceps (3), assisted breech delivery (1), and Caesarean section (9; 8 elective and 1 because of premature rupture of the membranes plus breech presentation); there was no case of uterine rupture. This paper also highlights the entity of cervical elongation and the author suggests that it is more likely to occur in a population afflicted by malnutrition. We respect his opinion, although the editor for one does not understand the aetiology of cervical elongation, and suspects that it is ‘congenital’ or an innate response by the cervix to ovarian hormones, compounded by pregnancy or the contraceptive pill. The author provides a very good review of the various theories. Certainly one sees cervical elongation in women who are not malnourished, and it is fairly common to see a long cervix in a young nullipara without uterine prolapse. However, such women are asymptomatic and do not require surgery for the condition, the exception being those with paraplegia. A. Te Linde's Operative Gynecology. Sixth Edition. JB Lippincott Coy Philadelphia. RF Mattingly, JD Thompson. Figure 23‐16, p564. B. LW Gleadell. Experiences with the composite operation. Aust NZ J Surg 1949–1950; 19: 246–250. Summary: Genital prolapse is a disorder of pelvic support and is one of the most frequent disorders encountered in our gynaecological practice. Our social and cultural background predisposes to this condition to occur at an age which is reported to be earlier than any other part of the world. Over a period of 4 years, 1986–1989, 17 cases were studied in whom the Sleeve Excision anastomosis operation was carried out, either at the Lokmanya Tilak Municipal General Hospital, Sion, Bombay, India or in some other hospital. All these patients were either admitted in active labour or as cases of abortions or were being treated for infertility. The incidence of full‐term normal vaginal delivery in our study was 66.6% and the incidence of Caesarean section was 8.3%. There was 1 case of posterior wall rupture following previous sleeve excision anastomosis operation. The recurrence rate of prolapse in our series was only 7.7%. The Sleeve excision anastomosis operation has given excellent anatomical and obstetric results in our study and future multicentric trials will be necessary to study its effect on subsequent fertility to arrive at any final conclusion.