Uterine Preservation During Pelvic Reconstructive Surgery

Uterine Preservation During Pelvic Reconstructive Surgery

Robert E. Gutman

Katherine L. Woodburn


Pelvic organ prolapse is one of the most common indications for hysterectomy in the United States, although the uterus is a passive structure in the development of prolapse.1,2,3 In recent years, there has been a growing acknowledgment of the desire of many patients for uterine preservation, or hysteropexy, at the time of prolapse surgery. Patient surveys have demonstrated that, assuming equal surgical outcomes, 36% to 60% of women undergoing prolapse surgery in the United States would choose uterine preservation.4,5 International patient surveys show similar rates of interest in uterine preservation.6,7 Patient demographics are associated with preference for hysteropexy, with college-educated women 3 times more likely to choose uterine preservation, whereas women living in the Southern United States were less likely to request hysteropexy (odds ratio 0.7).5

There are a variety of reasons that patients are interested in uterine preservation including concerns about decreased libido, weight gain, hormonal changes, sense of feminine identity, cultural importance, and increased risk for hysterectomy complications. Interestingly, many reasons that patients report interest in uterine preservation are more closely related to ovarian function and conservation.4 Proven benefits of uterine preserving surgery compared to hysterectomy include decreased blood loss, shorter operating room time, and a decreased risk of early menopause.2,8,9 Consequently, it is important to fully elicit patient goals and their understanding of the surgical risks, benefits, and alternatives to provide patient-centered counseling during the informed consent process.

Uterine conservation may not be the best surgical options for many patients, and strict selection criteria should be maintained. Given the limited outcomes data, we prefer to avoid hysteropexy procedures for patients who desire future fertility. Instead, we encourage conservative management with observation, physical therapy, or a pessary until childbearing is complete. Additionally, uterine preservation is not recommended when there is an increased risk of subsequent cervical, uterine, or endometrial pathology, given the potential technical challenges of a subsequent hysterectomy. Women with recent or current cervical dysplasia should not be considered hysteropexy candidates, and patients undergoing hysteropexy should be up-to-date on cervical screening. Those with increased risks for endometrial cancer due to obesity, genetic syndromes such as Lynch syndrome, endometrial hyperplasia, or current tamoxifen use are also poor candidates for uterine preservation. Even with a negative workup, uterine preservation in patients with postmenopausal bleeding is discouraged because there remains a 13% lifetime risk of endometrial pathology, which may impact subsequent treatment.10 Current estimates of overall rates of endometrial cancer in patients who have undergone uterine preservation during prolapse surgery is 0.3% to 0.8%.10,11 Additionally, there is limited to no access to adnexal structures during the majority of hysteropexy procedures; thus, women who have BRCA1 or BRCA2 mutations or a history of estrogen receptor-positive breast cancer should be offered hysterectomy and bilateral salpingo-oophorectomy. Patients should also be counseled on the inability to perform opportunistic salpingectomy at the time of most hysteropexy procedures, which decreases ovarian cancer risk up to 20%.12 Lastly, there are anatomic factors to consider; women with abnormal uterine bleeding, fibroids, or adenomyosis are at a higher potential risk for future interventions, whereas women with cervical elongation may experience worse outcomes in uterine preserving prolapse procedures unless a partial trachelectomy is performed.13

As hysteropexy procedures and patient desire for uterine preservation increases, it is important to determine patient goals and expectations while maintaining strict selection criteria to limit potential surgical risks, uterine or cervical pathology, and recurrent prolapse.


LeFort Colpocleisis

LeFort colpocleisis is one of the oldest and most successful prolapse repairs. Patient selection is extremely important for women undergoing a LeFort colpocleisis
given that the proximal vagina is closed and the vaginal introitus is shortened and narrowed, limiting access for future uterine evaluation. Specifics regarding the technique are covered elsewhere in the textbook. Colpocleisis is intended for women who are no longer sexually active and are not interested in preserving the option for penetrative intercourse. With a high success rate and low morbidity, this procedure is ideal for an older population with advanced prolapse and multiple medical comorbidities. There are two retrospective cohort studies comparing LeFort colpocleisis to total vaginal hysterectomy (TVH) with colpocleisis, showing no overall difference in adverse events except for urinary tract infections.14,15 A study using the National Surgical Quality Improvement Program database demonstrated a shorter operating time and fewer serious medical complications in patients undergoing LeFort colpocleisis compared to vaginal hysterectomy and colpocleisis.15


The Manchester procedure is an older hysteropexy procedure with a recent resurgence, especially in Europe. It is primarily a treatment for cervical elongation. During this procedure, the cervix is amputated and the uterus reattached to the cardinal ligaments. A modified Manchester includes the plication of the uterosacral ligaments posteriorly and the cardinal ligaments anteriorly. Frequently, Sturmdorf sutures are used to close the amputated cervical stump, which can lead to problems related to cervical stenosis. The literature supporting the use of the Manchester procedure is dated and limited, with only retrospective studies that include short-term follow-up, heterogenous anatomic outcomes, and inadequate comparison groups lacking apical support procedures performed at the time of vaginal hysterectomy. These studies generally demonstrated no difference in anatomic or symptomatic outcomes, with shorter operative time and decreased estimated blood loss in the Manchester group.16,17,18 A systematic review estimated the rate of repeat surgery for prolapse to be 1.1% to 5.4% with recurrent prolapse from 5.4% to 19.4%.19 An ongoing multicenter randomized controlled trial in the Netherlands comparing the Manchester procedure to sacrospinous hysteropexy (SSHP) for milder uterine prolapse should provide valuable information about the role of this procedure for uterine conservation.20

Vaginal Mesh Hysteropexy

Although vaginal mesh hysteropexy products are no longer on the market in the United States, this procedure is reviewed for historical purposes. Originally developed in an effort to decrease recurrent prolapse after vaginal native tissue repairs, vaginal mesh hysteropexy was performed with mesh placed vaginally, anchored to the sacrospinous ligament (SSL) to provide apical support and then attached to the anterior cervix and fibromuscular layer overlying the bladder (Fig. 50.1). A variety of mesh kits were available, with varying delivery systems, anchor points, and mesh types. Although overall mesh complication rates were lower in mesh procedures with uterine preservation, the rate of mesh-associated complications such as erosion, exposure, bleeding, pain, contractures, and scaring was high enough to prompt reclassification of the devices by the U.S. Food and Drug Administration21 and eventual complete removal from the United States marketplace in April 2019. When compared to vaginal native tissue repairs, vaginal mesh prolapse repairs resulted in less prolapse awareness (relative risk [RR] 0.66, 95% confidence interval [CI] 0.54 to 0.81), fewer anatomic recurrences (RR 0.4, 95% CI 0.30 to 0.53), and fewer reoperations for prolapse (RR 0.53, 95% CI 0.31 to 0.88) in a Cochrane review. Unfortunately, overall reoperations were more common (RR 2.4, 95% CI 1.51 to 3.81) due to an 8% reoperation rate for mesh complications, leading the Cochrane review to not support vaginal mesh repairs for apical prolapse.22

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May 1, 2023 | Posted by in GYNECOLOGY | Comments Off on Uterine Preservation During Pelvic Reconstructive Surgery

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