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Bilan des prises en charge thérapeutiques d’un prolapsus utérin

Uterine prolapse treatment. A review

  • Pratique Médicale / Medical Practice
  • Published:
Pelvi-périnéologie

Résumé

Le prolapsus utérin (hystéroptose) correspond à la descente de l’utérus dans la cavité vaginale puis à l’extérieur de l’orifice vulvaire. Cette pathologie fréquente est principalement due à la défaillance du système de suspension utérine par les ligaments utérosacrés. La recherche d’une pathologie utérine ou cervicale associée doit être systématique (échographie, frottis), ainsi que la recherche d’un autre trouble de la statique pelvienne au niveau de l’étage antérieur (cystocèle) ou postérieur (rectocèle). Le bilan des fonctions vésicosphinctérienne et anorectale, et notamment la recherche d’une incontinence urinaire ou anale, doit également être réalisé avant traitement. L’utilisation d’un pessaire doit être proposée avant la chirurgie, y compris chez les femmes jeunes, en raison de son efficacité relative et de son innocuité. Le traitement chirurgical est le traitement de référence du prolapsus utérin, mais il n’est indiqué que pour les prolapsus symptomatiques. La promontofixation reste actuellement le gold standard de la chirurgie réparatrice du prolapsus utérin. La promontofixation est plus efficace et entraînerait moins de dyspareunies que la sacrospinofixation par voie vaginale (intervention de Richter). L’abord cœlioscopique donne des résultats comparables à l’abord par laparotomie et représente actuellement la technique de choix. Chez les femmes âgées, la chirurgie vaginale présente des avantages incontestables, et la sacrospinofixation est alors la technique de référence. La réalisation d’une hystérectomie associée à la suspension du fond vaginal n’apporte pas de bénéfice en termes de correction du trouble de la statique pelvienne par rapport à la sacrospinofixation avec conservation utérine (intervention de Richardson). La sacropexie infracoccygienne (technique « IVS postérieur ») est aussi efficace que la sacrospinofixation à moyen terme, avec une réduction des douleurs postopératoires précoces et du taux de récidive de cystocèle.

Abstract

Uterine prolapse is an intra-vaginal or extra-vulvae uterine descent. That frequent pathology is mainly due to the weakness of the uterosacral complex suspension system. Preoperatively, cervical cytology and ultrasound should be performed looking for an associated uterine pathology, and other pelvic floor disorders should be systematically checked. A pessary should be proposed before surgery, even for young women, because of its relative efficacy and safety. Surgical treatment is still the reference management, but is only indicated for symptomatic cases. Abdominal sacrocolpopexy is currently the gold standard for uterine suspension. Sacrocolpopexy is more efficient than vaginal sacrospinous suspension (Richter procedure), with a decreased rate of postoperative dyspareunia. Laparoscopic approach seems to be as efficient as open abdominal surgery, and is currently recommended as the first line. On elderly, vaginal reconstructive surgery has well known advantages. For the vaginal route, sacrospinous suspension is the reference technique. Sacrospinous suspension with uterine conservation (Richardson procedure) is as efficient as sacrospinous suspension associated with hysterectomy. Infracoccygeal sacropexy (“posterior IVS” procedure) is as efficient as sacrospinous suspension at medium-term, with a decreased rate of early postoperative pain and cystocele recurrence.

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Authors and Affiliations

  1. Service de gynécologie-obstétrique, CHU Carémeau, place du Pr-Robert-Debré, F-30029, Nîmes cedex 09, France

    R. de Tayrac, M. -L. Mathé & P. Marès

  2. Service d’urologie, CHU Carémeau, place du Pr-Robert-Debré, F-30029, Nîmes cedex 09, France

    L. Wagner & P. Costa

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  1. R. de Tayrac
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  2. L. Wagner
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Correspondence to R. de Tayrac.

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de Tayrac, R., Wagner, L., Mathé, M.L. et al. Bilan des prises en charge thérapeutiques d’un prolapsus utérin. Pelv Perineol 4, 218–225 (2009). https://doi.org/10.1007/s11608-009-0257-6

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  • DOI: https://doi.org/10.1007/s11608-009-0257-6

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