Laparoscopic Douglasectomy in the treatment of painful uterine retroversion

Background: One of the etiologies of pelvic pain in women, often unrecognized, is the Masters-Allen syndrome, which was described in 1955 as the ''universal joint cervix'' syndrome. It has the following three elements: (1) etiology: obstetrics-related trauma; (2) clinical findings: uterine retroversion with hypermobile cervix following elongation or desinsertion of the uterosacral ligaments; (3) anatomy: visualization of a tearing of the posterior serosa and subperitoneal fascia of the ligamentum latum. Methods: Forty-one laparoscopic Douglasectomies with uterosacral ligamentopexy were performed in the department of Gynecology at the University Hospital of Caen during the period between 1990 and 1995 in patients with painful retroverted uterus. The patient selection was made thanks to the ''pessary test.'' The surgical endoscopic procedure, identical to the operation first promoted by Jamain and Letessier in 1976 by laparotomy, is described. Results: Total pain relief was experienced by 31 patients (75%) and partial relief by five patients (5%). Two main complications occurred, requiring one laparotomy (bleeding from a pelvic varicose vein with a concomitantly occurring breakdown of the washing-aspiration system) and one second laparoscopy at day 15 (one case of hematoma below the peritonization revealed by pain). Twenty-three women became pregnant again, and had normal deliveries except for two cesareans, with no recurrence of pain. Douglasectomy is compared to alternative techniques in the literature. Other indications for Douglasectomy are discussed. Conclusion: Douglasectomy is the only definitive procedure for restoring normal anatomy of the pelvic floor in case of painful uterine retroversion occurring in a setting of Masters-Allen syndrome. Additionally, it provides for pathological analysis of the excised peritoneum. The results of this procedure are excellent when the indication is correctly set, particularly as concerns positive pessary testing.