Chapter Outline
Considerations for Uterine Preservation
Lack of Data Supporting Hysterectomy to Treat Prolapse
Role of Hysterectomy in Menopause Timing and Sexual Function
Transvaginal Uterosacral Ligament Suspension/Plication—Techniques and Outcomes
Sacrospinous Ligament Hysteropexy—Techniques and Outcomes
Introduction
Uterine prolapse is a common disorder in women. It represents the third leading cause of hysterectomy for benign disease and is responsible for approximately 70,000 hysterectomies annually in the United States. Traditionally, operations to treat uterine and uterovaginal prolapse include a hysterectomy to initiate the surgery even when no specific uterine disease is present. It remains unknown whether the addition of hysterectomy to prolapse surgery is integral to the effective cure of this condition and few randomized clinical trials of hysterectomy versus no hysterectomy have been done.
The surgical treatment of uterovaginal prolapse using uterine-sparing techniques dates back to the late 1800s and has evolved from vaginal procedures using native tissue to pre-packaged mesh kits and laparoscopic and robotic procedures using polypropylene mesh. Although many of these operations use the same techniques and principles as those used to treat vaginal vault prolapse, the outcome data are fewer and direct comparisons are lacking. As the interest in uterine conservation among patients and physicians is growing worldwide, the objective of this chapter is to review and summarize the medical literature describing the role of uterine preservation during the surgical management of uterovaginal prolapse.
Historical Perspective
The origins of the vaginal hysteropexy date back to the late 1800s when techniques were developed to treat uterine retroversion. Initial accounts describe a procedure that began with excision of the anterior lip of the cervix followed by dissection of the bladder from the uterus. The uterine fundus was delivered through the anterior cul-de-sac and the anterior surface of the uterine fundus was then sutured to the anterior wall of the vagina. Various modifications to this technique were made, including blind suturing of the fundus to the anterior vaginal wall, although no modification obtained published endorsement. Despite this, vaginal fixation of the uterus had taken hold and outcomes were endorsed by Mackenrodt’s numerous publications and a comprehensive report by detailing 207 operations. These techniques were later translated into treatment for vesicovaginal fistula (using the fundus as a plug) and later, in 1896, as treatment for prolapse.
In 1899, Thomas Watkins, M.D., was the first to publish descriptions of the interposition operation as it is known. The uterus was separated from the vagina using a circumferential incision and the bladder was separated from the uterus using blunt dissection. Once anterior colpotomy was achieved, the fundus of the uterus was grasped and anteverted through this defect. Approximately 2 in of the upper portion of the anterior vaginal wall was sutured to the fundus. The posterior vaginal wall was opened from the cervix downward for approximately 1 in so as to allow the cervix to be displaced upward and backward. Once this was achieved, the incision was then closed. Although no outcomes, with the exception of one patient, were described, this procedure was quite popular during the early twentieth century. However, as concerns developed regarding potential pregnancy in younger patients and difficult endometrial access in the older patients, the interposition operation gradually became less popular and was largely supplanted by the Manchester procedure.
The Manchester procedure was first performed in 1888 by Dr. Archibald Donald of Manchester, England, with several modifications introduced by Dr. W.E. Fothergill. The procedure was first described for uterovaginal prolapse in patients with cervical elongation and intact uterosacral-cardinal ligaments. This procedure begins by making a circumferential incision around the cervix, dissecting the vaginal epithelium similar to the first steps of vaginal hysterectomy, and clamping and transecting the cardinal ligaments bilaterally. The elongated cervix is then amputated, and the remaining cervix is retracted downward and the cardinal ligament pedicles are sutured to the anterior aspect of the cervix. This serves to retract the cervix posteriorly and elevates the uterus anteriorly. The transformation zone is then recreated with the invagination of vaginal epithelium into the cervical os.
The largest study on the Manchester procedure (and hysteropexy) was published by and reported on 960 patients who underwent the Manchester procedure. Based on a review of the medical records and mailed questionnaires with a 52% response rate, the prolapse recurrence rate was noted to be 4.3%. Other studies note a reoperation rate of 21%, including reoperation for prolapse, abnormal bleeding, and cervical carcinoma. More recent data include a retrospective chart review by that compared the outcomes of 88 consecutive Manchester procedures to the outcomes of 105 randomly selected patients who underwent vaginal hysterectomy and anterior and posterior repair as indicated. The Manchester group was older and had worse uterovaginal prolapse compared to the hysterectomy group. The Manchester procedure was noted to be quicker (30 min shorter) and have less blood loss (200 versus 300 mL). Follow-up consisted of questionnaires mailed to the surgeons who performed the operations. With a mean follow-up of 2.5 years, and a 76% response rate, only 6% of patients were noted to have recurrent prolapse after the Manchester procedure with time to recurrence ranging from 8 weeks to 5.5 years. Comparative follow-up data for the vaginal hysterectomy group were not reported. Data from these studies are the only data available on the Manchester procedure; however, the retrospective nature, undefined outcomes, lack of appropriate control group, and surgeon-reported outcomes are subject to much bias. Despite these issues, the Manchester procedure remains one option to treat uterovaginal prolapse without requiring hysterectomy. In fact, a recent case report by describes a 22 year old nulligravida with a history of myelomeningocele at birth who presented with recurrent uterovaginal prolapse after failing laparoscopic uterosacropexy. Although no follow-up is available, the immediate postoperative results were considered successful.
Complications related to the Manchester procedure need to be taken in context of when the procedures were performed. In the series describing 960 patients, the procedures were performed from 1936 to 1955 and report the following complications: cystotomy and proctotomy <0.5%, blood transfusion 20%, febrile morbidity 63%, urinary retention 15.2%, and mortality 0.7%. Clearly, the high rates of some complications are related more to the medical and surgical practices of the era as opposed to the Manchester procedure. In another series, complications were not noted to be significantly different when compared to vaginal hysterectomy with anterior and posterior repair with the exception of decreased cuff abscess and cellulitis in the Manchester procedure. Other complications noted in these series include abnormal uterine bleeding and carcinoma, both of which are of concern for all uterine-sparing procedures. Furthermore, cervical amputation is related to infertility, miscarriage, and pre-term delivery. specifically examined uterine disease 6 to 12 years after the Manchester procedure in 82 patients, finding that 35% of women complained of menorrhagia and dysmenorrhea, over half of which required treatment. Additionally, 2.4% of patients developed adenocarcinoma of the uterus, and 4% of patients experienced unplanned pregnancies. Interestingly, 27% of patients stated that they would have welcomed hysterectomy at the time of the operation and many patients stated that contraception was unsatisfactory. Vaginal hysterectomy has become more popular since that time as antibiotics and improved surgical technique have led to decreased morbidity and mortality related to pelvic reconstructive surgery. In the twenty-first century, there are few patients who are ideal candidates for the Manchester procedure, given the apparently acceptable outcomes and morbidity data for other approaches to hysteropexy, as well as hysterectomy with vault suspension.
In the 1950s, as the abdominal approach to hysterectomy became popular, cases describing an abdominal approach to hysteropexy were published. Sacrocervicopexy was first described by as the attachment of a band of external oblique fascia from the cervix to the sacral periosteum. The case series of 22 patients reported “good” results, but provided limited information on methodology and results obtained. A combined vaginal-abdominal procedure targeting both uterovaginal prolapse and stress urinary incontinence was described by in a case series of 16 patients. The procedure involves vaginal mobilization of the bladder neck, periurethral tissue, uterine isthmus, and uterosacral-cardinal ligament complex, followed by a Moschcowitz culdoplasty, and transabdominal suspension of the periurethral endopelvic fascia and uterosacral ligaments to Cooper’s ligament. There were no complications or failures noted at a follow-up interval of over 5 years, although the study was limited by its size and lack of control group. published a case series of 20 patients who underwent a transabdominal Cooper’s ligament uterine suspension using mersilene tape. There were no complications reported, nor were there any cases of recurrent prolapse. However, the follow-up was limited to a range of 6 to 30 months and the exact postoperative examination findings were not described. Notably, seven women conceived within 6 months of the operation, five of whom delivered vaginally at term. Currently, these procedures are no longer routinely used for uterine preservation and have been replaced by uterosacral ligament fixation or sacrohysteropexy using polypropylene mesh.
Considerations for Uterine Preservation
With the advent of antibiotics and improved surgical techniques, the morbidity and mortality related to hysterectomy were greatly reduced, which led to increased hysterectomy rates in the later part of the twentieth century. Additionally, hysterectomy was considered favorable given the potential to reduce endometrial and cervical cancer risks. Since that time, improved conservative treatment for abnormal bleeding, symptomatic leiomyoma, effective strategies for cervical cancer screening, the human papillomavirus (HPV) vaccine, and an emphasis on quality of life has led to physicians and patients to modify their thoughts on the role of hysterectomy. Please see Box 26.1 for perceived and studied advantages and disadvantages of uterine-preservation at the time of prolapse surgery.
| Advantages | Disadvantages |
|---|---|
| Reduction in surgical time and blood loss Maintenance of fertility Natural menopausal timing Avoidance of an unnecessary procedure Perceived role of the uterus and cervix in pelvic stability and sexual satisfaction Less invasive Association with a quicker recovery Decreased risk of mesh exposure Similar short-term outcomes Patient preference | Fewer surgical outcome data available Maintenance of fertility Small, ongoing risk for cervical or endometrial cancer Subsequent hysterectomy may be difficult Continuation of menses Ongoing surveillance of cervix and endometrium (which may be difficult) Colpopexy may be easier for surgeon after hysterectomy |
Patient Interest
A study by , investigated attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Patients who were scheduled for evaluation were sent a questionnaire in the mail that queried their perceptions of the impact of hysterectomy on health, social life, and emotional well-being. It also presented hypothetical situations. Of 100 women, 60% indicated they would decline a hysterectomy if presented with an equally efficacious alternative to a hysterectomy-based prolapse repair. In a scenario in which the prolapse repair after hysterectomy was considered “probably more successful,” 54% preferred a hysterectomy if it offered any benefit, whereas 32% desired hysterectomy for “substantial benefit” and 14% did not desire hysterectomy in this situation. Those patients who were younger and were considered active decision-makers were more likely to decline hysterectomy. Additionally, those with family and friends who had a negative experience after hysterectomy were more likely to decline a hysterectomy-based procedure.
This perception of hysterectomy is also gaining significant media attention. Although not scientific journals, well-read publications for the lay public, such as Health Magazine and the American Association of Retired People magazine, have recently published articles citing hysterectomy as a “surgery to avoid.”
The American College of Obstetrics and Gynecology acknowledges the importance of patient autonomy and the increased access to information in a Committee Opinion published in 2008. Although urging that decision-making should be guided by the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, veracity, and justice, they recommend that it is important to take a broad view of the consequences of surgical treatment and to acknowledge the lack of firm evidence for the benefit of one approach over the other, when evidence is limited.
Lack of Data Supporting Hysterectomy to Treat Prolapse
The need for hysterectomy at the time of prolapse repair has never been proven. Removing the uterus fails to address the underlying deficiency causing prolapse. Additionally, removal of the uterus disrupts the uterosacral-cardinal ligament complex (pericervical endopelvic fascia), which may further weaken support. This is not a novel concept, as Bonney in the 1930s stated that the uterus only has a passive role in prolapse. Uterine preservation at the time of prolapse repair avoids an unnecessary procedure and has been associated with faster operative times and less blood loss.
Role of Hysterectomy in Menopause Timing and Sexual Function
There may be additional benefits to avoiding hysterectomy, including ovarian and sexual function. Even in women who undergo ovarian-sparing hysterectomies, ovarian function is affected. Two studies ( ) compared ovarian function after ovarian-sparing hysterectomies to a nonsurgical control group basing menopause on follicle-stimulating hormone levels greater or equal to 40 IU/L or higher. In these cohorts, approximately twice as many women who underwent hysterectomy became menopausal during the 5-year study period. Sexual function is also often cited as a reason to avoid hysterectomy. Two studies comparing sexual function after a hysterectomy-based or uterine-sparing prolapse repair have conflicting results. compared sexual function after randomizing women with uterovaginal prolapse to transvaginal hysterectomy or transvaginal sacrospinous uterine suspension for uterine prolapse, finding no significant difference between groups in sexual scores, sexual interest, and orgasm frequency. compared women who underwent hysterectomy and sacral colpopexy to those who underwent a uterine-sparing procedure, noting that although both groups had improved scores on a validated questionnaire, the uterine-sparing group was associated with a greater improvement.
Unanticipated Uterine Pathology
One concern about uterine-sparing procedures is that the rate of abnormal uterine pathology may be high and that preserving the uterus may confer an increased cancer risk to women. The risk of cervical carcinoma has not been studied in hysteropexy, but data from studies evaluating supracervical hysterectomy can be extrapolated to hysteropexy. Even in studies that predated modern cytologic and viral screening techniques, the rate of cervical carcinoma was low (below 0.3%). With improved cytologic and viral screening, and the HPV vaccine, the true number is likely to be even lower. Studies evaluating uterine pathology also demonstrate a low risk for endometrial cancer. studied pathologic specimens from 517 women who underwent vaginal hysterectomy for prolapse and found the rate of endometrial cancer to be 0.8%. also evaluated the risk of unanticipated pathology at the time of hysterectomy for uterovaginal prolapse. Of 681 pathologic specimens, 2.6% had unanticipated premalignant or malignant uterine pathology, including 0.3% with low-grade cervical dysplasia, 0.8% with simple hyperplasia, 0.5% with complex hyperplasia, 1.1% with complex hyperplasia with atypia, and 0.3% with endometrial carcinoma. Interestingly, none of the premenopausal women had premalignant or malignant pathology, even those with preoperative bleeding concerns. In contrast, postmenopausal women with abnormal bleeding had a very high rate (13.3%) of unanticipated endometrial pathology, even though all had negative diagnostic evaluations.
Contraindications to uterine-sparing prolapse procedures are listed in Box 26.2 .
| Pregnancy |
| Postmenopausal bleeding |
| Current or recent cervical dysplasia |
| Familial cancer syndrome—BRCA 1 and 2 |
| Hereditary nonpolyposis colonic cancer syndrome |
| Tamoxifen therapy |
| Uterine abnormalities |
| Fibroids, adenomyosis, abnormal endometrial sampling |
| Abnormal uterine bleeding |
| Inability to comply with routine gynecologic surveillance |
| Cervical elongation (relative contraindication) |
Vaginal Approach
The vaginal approach to hysteropexy has a long history dating back to 1888. Vaginal surgery was highly preferable because of the high morbidity and mortality related to abdominal surgery. Furthermore, hysterectomy by any route added significant morbidity. The vaginal approach to surgery is typically associated with less operative time, less blood loss, faster recovery, and better cosmetics. Vaginal hysteropexy using native tissue consists of four surgical procedures: the Watkins interposition surgery, the Manchester procedure, the transvaginal uterosacral ligament suspension/plication, and the sacrospinous hysteropexy ( Table 26.1 ). Of these procedures, the sacrospinous hysteropexy is the only approach that has stood the test of time. As it gains popularity, additional data are becoming available supporting satisfactory anatomic, subjective, and functional outcomes. Additionally, pre-packaged mesh prolapse kits can be used as another technique to correct uterovaginal prolapse without requiring hysterectomy. However, the great majority of these kits are no longer available because of concerns of mesh erosion and other complications. Although these kits may provide another option to treat uterovaginal prolapse, long-term data for the available kits are lacking and outcomes related specifically to hysteropexy are needed.
| Study | Procedure | Number of Patients | Study Type and Outcome Measures | Length of Follow-up | Anatomic Cure | Subjective Cure | Comments |
|---|---|---|---|---|---|---|---|
| Manchester | 960 | Retrospective chart review with patient questionnaire Success not defined | Unknown | Unknown | 95.7% | Complications: Cystotomy or proctotomy < 0.5%, blood transfusion 20%, febrile morbidity 63%, urinary retention 15.2%, and mortality 0.7% | |
| Manchester | 82 | Retrospective chart review with patient questionnaire Outcome measures not defined | 6-12 years | Unknown | Unknown | Uterine disease: Dysmenorrhea and menorrhagia 35%, adenocarcinoma of the uterus 2.4%, unplanned pregnancy 4% Reoperation rate: For recurrence, bleeding, cancer 21% | |
| Manchester | 88 | Retrospective chart review with patient questionnaire Surgeon questionnaire Comparison made to randomly selected TVH patients | Mean 2.5 years | 94% | Unknown | Complications: None Outcomes: Operative time and EBL was less compared to TVH | |
| Transvaginal uterosacral ligament suspension/plication | 20 | Retrospective chart reviewSuccess not defined | Unknown | 85% | Unknown | Complications: UTI, pelvic cellulitis, atonic bladder; 15% of patients required hysterectomy for abnormal bleeding Pregnancies: 6 patients had full-term pregnancies with no prolapse recurrence | |
| Transvaginal uterosacral ligament suspension | 100 | Retrospective chart review Compared to data from 100 subjects s/p TVH + uterosacral ligament suspension Success defined as ≤ grade 2 prolapse on Baden–Walker | Median 1.5 years, range 2.4 months to 10 years | Apex 96%, anterior wall 86.8%, posterior wall 97.8% | Unknown | Complications: Hemorrhage (4%), pericervical dehiscence (1%), rectal injury (1%) Outcomes: No differences between hysteropexy and TVH + suspension in anatomic outcomes or complications, 3 hysteropexy patients underwent TVH later for BRCA, enlarging fibroid, breast cancer Pregnancies: 1 pregnancy reported | |
| Sacrospinous hysteropexy (unilateral) | 5 | Retrospective chart review Success not defined | 6-24 months | 100% | Unknown | None | |
| Sacrospinous hysteropexy (unilateral and bilateral) | 19 | Retrospective chart review Success not defined | Mean 3.1 years | 88% | Unknown | Complications: Recognized rectal injury, no sequelae Pregnancies: 5 Patients had full-term pregnancies, one with prolapse recurrence | |
| Sacrospinous hysteropexy (unilateral) | 34 | Retrospective chart review Comparison made to randomly selected TVH/sacrospinous fixation patients Outcomes: anatomic examination by blinded investigator, standardized questionnaires Objective cure defined as no prolapse beyond mid-vagina | Mean 26 months | 72% | 78% | Complications: Buttock pain 5% Pregnancies: 2 patients had full-term pregnancies, one with prolapse recurrence | |
| Sacrospinous hysteropexy (unilateral) | 133 | Postal mailing using standardized questionnaires POP-Q examination in 45% of patients Success < stage II on POP-Q examination | Mean 22.5 months | 62% on POP-Q | 91.8% | Complications: Blood loss (>500 mL) 8%, rectal injury 0.8%, buttock pain 15%, buttock pain lasting greater than 2 weeks 4%, urinary tract infections 13%, urinary retention 27%, reoperation for recurrence 2.3% | |
| Sacrospinous hysteropexy (unilateral) | 54 | Retrospective chart review and mailed questionnaire Comparison made to TVH and vault suspension Success defined as < grade 2 prolapse on Baden–Walker | Mean 19.4 months | 89.6% | Unknown | Outcomes: Fewer patients with urge incontinence ( P = 0.05), faster recovery than TVH group, recurrence was similar to TVH group | |
| Sacrospinous hysteropexy (unilateral) | 80 | Prospective, randomized trail Face-to-face questionnaire regarding sexual function preop and postop | 6 months | Unknown | Unknown | Outcomes: Sexual interest, frequency of sexual intercourse, sexual satisfaction, vaginal dryness, and dyspareunia were not different preop and postop and comparable to TVH | |
| Sacrospinous hysteropexy (unilateral) | 60 | Prospective cohort Success defined as no uterine prolapse | 5-10 years | 85% | Unknown | Outcomes: Risk factors for failure identified: 3rd degree prolapse, cervical elongation Pregnancies: 6 patients had full-term pregnancies | |
| Sacrospinous hysteropexy (unilateral) | 72 | Prospective cohort Postop examination by independent investigator, validated questionnaires Success defined as < stage II prolapse on POP-Q | Mean 12.7 months | 78.8% | Unknown | Complications: Reoperation for bleeding 1.4%, buttock pain 6.9% Outcomes: Significant improvement on all quality of life domains (urogenital, defecatory, pain) | |
| Sacrospinous hysteropexy (unilateral) | 35 | Randomized controlled trial comparing hysteropexy to TVH and uterosacral ligament colpopexy (n = 31) Return to work and activities, complications, anatomic outcome (apex POP-Q stage II-IV), validated symptom and quality of life questionnaires | 1 year | 79% hysteropexy; 97% TVH and repair (p = 0.03) | No difference between groups | Complications: Ureteral kinking after TVH in one patient Outcomes: Hysteropexy group returned to work 23 days sooner, symptoms and quality of life outcomes were similar between groups. All patients with stage IV prolapse who underwent hysteropexy recurred within 1 year |
Transvaginal Uterosacral Ligament Suspension/Plication—Techniques and Outcomes
This procedure was first described in 1966 as entering the peritoneal cavity via a posterior colpotomy, dividing the uterosacral ligaments from the cervix, plicating them across the midline, and then reinserting them into the cervix. After this, a transverse incision was made at the junction of the bladder reflection and cervix and the cardinal ligaments are plicated across the midline anteriorly, drawing the cervix upward. Follow-up data for this procedure are limited and consist of one published study. This case series by of 20 women aged 21 to 37, all of whom had uterovaginal prolapse at least to the introitus, noted a failure rate of 15.5%, all of whom were treated with vaginal hysterectomy within 6 months of the original surgery. Three additional patients (15%) required subsequent hysterectomy for continued vaginal bleeding. Although the length of follow-up is not clearly reported, six women subsequently had full-term pregnancies with no recurrence of prolapse. A more recent study by compared 100 cases of vaginal hysterectomy with uterosacral ligament suspension to 100 cases of uterosacral ligament hysteropexy. In this series, the surgeon performed a colpotomy, identified the high uterosacral ligament, and placed two delayed-absorbable sutures through each ligament, attaching them to the posterior vaginal cuff and lower uterine wall. Culdoplasty, trachelorrhaphy, and concomitant repairs were performed at the discretion of the surgeon. Anatomic success was defined as ≤ grade 2 prolapse on Baden–Walker and median follow-up was 1.5 years. In the hysteropexy group, apical success was noted to be 96%, anterior wall success was noted to be 86.8%, and posterior wall success was noted to be 97.8%, all which were statistically similar to the hysterectomy group.
Complications related to the transvaginal uterosacral ligament suspension/plication include genitourinary tract infection, pelvic cellulitis, and atonic bladder symptoms. The overall complication rate in the Williams study was 20%. In this series, three patients required hysterectomies for abnormal uterine bleeding. In the Romanzi study, the complication rate was much lower (6%). In this series, three women required hysterectomy for various unrelated reasons (breast cancer, BRCA carrier, enlarging fibroid). One pregnancy was reported.
Sacrospinous Ligament Hysteropexy—Techniques and Outcomes
The sacrospinous hysteropexy is the uterine-sparing procedure using a vaginal approach, which is the best studied. The literature contains anatomic outcome data with a larger number of patients, as well as functional, reproductive, and sexual outcomes. Data also exist on risk factors for failure. This procedure typically consists of performing an extraperitoneal dissection until the right sacrospinous ligament is identified and exposed. The right sacrospinous ligament is then attached to the posterior cervix or uterosacral ligaments and vagina using a combination of permanent and delayed absorbable sutures ( Figs. 26.1 and 26.2 ). Placing suture in the sacrospinous ligament can be achieved with free suturing, with the aid of reusable ligature carriers, such as the Miyazaki hook or the Deschamps needle ligature carrier. Alternatively, the Capio Suture Capturing Device (Boston Scientific, Natick, MA) can be quite useful when placing suture into the sacrospinous ligament. In many cases, an anterior and/or posterior colporrhaphy are performed as indicated. In patients wishing to maintain fertility, this procedure has advantages over the Manchester procedure as it does not require cervical amputation, which has been associated with infertility, miscarriage, and pre-term birth. Furthermore, it may provide higher suspension compared to the transvaginal uterosacral ligament suspension/plication.
