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, double the operation rate on women posed by mastectomies with reconstruction for breast cancer ( ). Given this large surgical volume, measures to increase the efficiency and safety of prolapse surgeries are paramount. Traditionally, operations to treat uterine and uterovaginal prolapse include a hysterectomy, even when no specific uterine disease is present. It is known from anatomical studies that the uterus is not the cause of prolapse, and that hysterectomy itself is a risk factor for prolapse formation ( ; ). A recent systematic review that included a dozen randomized trials and 41 nonrandomized trials comparing prolapse surgery with hysterectomy to prolapse surgery with uterine preservation found no differences in prolapse outcomes in the short to medium term and found that the morbidity of some procedures (such as blood loss and operative time) decreased with preservation of the uterus ( ).
The surgical treatment of uterovaginal prolapse using uterine-sparing techniques has evolved from vaginal procedures using native tissue to 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 lack rigorous or long-term follow-up. The interest in uterine conservation among patients and physicians is growing worldwide, despite some data from a large population study indicating that hysterectomy may be protective against repeat prolapse surgery ( ). Overall, there are limited guidelines regarding the choice of uterine preservation in prolapse surgery. 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.
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 delivered the fundus of the uterus through an anterior colpotomy and sutured the anterior fundus to the anterior vaginal wall. Various modifications to this technique were made, 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 Duhrssen in 1894 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 was the first to publish descriptions of what came to be known as a uterine interposition operation ( ). The uterus was separated from the vagina using a circumferential incision, and the bladder was separated from the uterus using blunt dissection. The fundus of the uterus was grasped and anteverted through the anterior colpotomy and sutured to the proximal 2 inches of the anterior vaginal wall. The posterior vaginal wall was opened to 1 inch distal to the cervix to allow the cervix to be displaced upward and backward by this inversion. Although outcomes were only reported for one patient, this procedure was quite popular during the early twentieth century. However, as theoretical concerns developed regarding potential pregnancy in younger patients and difficult endometrial access in 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 Archibald Donald of Manchester, England, with several modifications introduced by 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 cephalad similar to during performance of a vaginal hysterectomy, and clamping and transecting the cardinal ligaments bilaterally. The distal, elongated cervix is then amputated, and the remaining proximal cervix is retracted downward while the cardinal ligament pedicles are sutured to the anterior cervix. This serves to retract the cervix posteriorly and elevate 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 the largest study on hysteropexy to date), by , reported on 960 patients. Based on a review of medical records and a mailed questionnaire with a 52% response rate, the prolapse recurrence rate was determined to be 4.3%. Other studies note a reoperation rate of 21%, including reoperation for prolapse, as well as abnormal bleeding and cervical carcinoma. More recent data include a retrospective chart review by that compared the outcomes of 88 consecutive patients who underwent Manchester procedures with the outcomes of 105 randomly selected patients who underwent vaginal hysterectomy with anterior and posterior repair as indicated. The Manchester group was older and had worse uterovaginal prolapse compared with the hysterectomy group. The Manchester procedure was noted to be quicker (30 minutes shorter) and to have less blood loss (200 vs. 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, but no follow-up data for the vaginal hysterectomy group were reported. Despite relatively limited outcomes data, the Manchester procedure is still considered a safe option for treating uterovaginal prolapse without requiring hysterectomy. In fact, a recent study that analyzed data from a nationwide database in Denmark reported that the Manchester procedure had less than a fourth of the risk for anterior recurrence of prolapse compared with sacrospinous hysteropexy and a much lower reoperation for prolapse, bringing into question the relatively low utilization of this procedure in modern practice ( ).
Complications of the Manchester procedure need to be taken in the context of when the procedures were performed. In the series describing 960 patients ( ), the procedures were performed from 1936 to 1955, and the following complications were reported: cystotomy and proctotomy less than 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 medical and surgical practices of the era than directly to the Manchester procedure itself. In another series, complications were not noted to be significantly different when compared with 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 a concern for all uterine-sparing procedures. Furthermore, cervical amputation is related to infertility, miscarriage, and preterm 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, and over half of these patients 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, the patients who are optimal candidates for the Manchester procedure must weigh this against good safety data for other approaches to hysteropexy, as well as hysterectomy with vault suspension. In the recent large Danish study, the 5-year reoperation rates for vaginal hysterectomy and the Manchester procedure were comparable (11% and 7%, respectively) ( ).
In the 1950s, as the abdominal approach to hysterectomy became popular, cases describing an abdominal approach to hysteropexy were published. Sacrocervicopexy, in this instance indicating suspension of the cervix as still attached to a preserved uterine body, was first described by Stoesser in 1955 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 outcome measurement. 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 involved 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 postoperative examination findings were not described. Notably, seven women conceived within 6 months of the operation, five of whom delivered vaginally at term. Procedures using Cooper’s ligament suspension are no longer routinely used for uterine preservation and have been replaced by transvaginal native tissue or minimally invasive approaches to 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, and the rates of uterine removal increased 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 and symptomatic leiomyoma, effective strategies for cervical cancer screening, the human papilloma virus (HPV) vaccine, and an emphasis on quality of life have led physicians and patients to modify their thoughts on hysterectomy. Please see Box 22.1 for perceived and studied advantages and disadvantages of uterine preservation at the time of prolapse surgery.
|Reduction in surgical time and blood loss||Fewer surgical outcome data available|
|Maintenance of fertility||Maintenance of fertility|
|Natural menopausal timing||Small, ongoing risk for cervical or endometrial cancer|
|Avoidance of an unnecessary procedure||Subsequent hysterectomy may be difficult|
|Perceived role of the uterus and cervix in pelvic stability and sexual satisfaction||Continuation of menses|
|Less invasive||Ongoing surveillance of cervix and endometrium (which may be difficult)|
|Association with a quicker recoveryDecreased blood loss||Colpopexy may be easier for surgeon after hysterectomy|
|Decreased risk of mesh exposure||Worse POPQ C point|
|Similar short-term outcomes|
|Longer total vaginal length on POPQ|
A study by investigated attitudes towards 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 the 100 women who completed the questionnaire, 60% indicated they would decline a hysterectomy if presented with an equally efficacious prolapse repair that preserved the uterus. In a scenario in which the prolapse repair after hysterectomy was considered “probably more successful,” 54% preferred a hysterectomy if it offered any benefit, while 32% desired hysterectomy for “substantial benefit,” and 14% did not desire hysterectomy in this situation. Those patients who were younger and who were considered active decision-makers were more likely to decline hysterectomy. Additionally, those with family and friends who had 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 acknowledged the importance of patient autonomy and the increased access to information in a Committee Opinion published in 2013. 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.
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, 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. Now that a systematic review has investigated the utility of hysterectomy in prolapse repair and found no notable differences in outcomes and decreased morbidity in some surgeries (such as lower mesh exposure following mesh surgeries), there still appears to be no good evidence that hysterectomy improves incomes for women seeking surgery with prolapse ( ).
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 with a nonsurgical control group basing menopause on follicle-stimulating hormone levels of 40 IU/L or higher. In these cohorts, approximately twice as many women who underwent hysterectomy compared with the control group became menopausal during the 5-year study period. The difference persists even when preoperative anti-Mullerian hormone levels are similar ( ). Sexual function is also often cited as a reason to avoid hysterectomy. compared sexual function after randomizing women with uterovaginal prolapse to transvaginal hysterectomy or transvaginal sacrospinous uterine suspension for uterine prolapse, and found 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. Despite a large body of data on uterine preservation surgery, there are little data on occult uterine malignancy or risk of later development of malignancy in preserved uteri. In a recent systematic review on uterine preservation prolapse surgery that included 94 studies (with 53 comparing uterine preservation with hysterectomy for prolapse), only two studies, one randomized and one nonrandomized, reported clearly on uterine pathology. Cvach et al. reported that 1/18 (5.5%) patients needed subsequent surgery owing to uterine pathology (hysteroscopy and curettage with benign findings), and 4/18 (22%) needed some type of workup because of abnormal bleeding, with all having benign findings on workup. Rahmanou et al. reported that 1/50 (2%) patients randomized to vaginal hysterectomy had an incidental finding of uterine malignancy, but no subsequent findings of uterine malignancy were seen in patients randomized to uterine preservation.
The risk of cervical carcinoma has not been well 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 (<0.3%). With improved cytologic and viral screening, as well as 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 had negative diagnostic evaluations.
Contraindications to uterine-sparing prolapse procedures are listed in Box 22.2 .
Current or recent cervical dysplasia
Familial cancer syndrome ( BRCA1 and BRCA2 mutations, HNPCC, etc.)
Symptomatic uterine abnormalities
Fibroids, adenomyosis, abnormal endometrial sampling
Abnormal uterine bleeding
Inability to comply with routine gynecologic surveillance
Cervical elongation (relative contraindication)
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, and hysterectomy by any route added further morbidity. Current data continue to support this, as vaginal hysteropexy is associated with less operative time, less blood loss, faster recovery, and better cosmesis than other approaches ( ). 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. Of these procedures, the sacrospinous hysteropexy is the most popular, and data are available supporting satisfactory anatomic, subjective, and functional outcomes. Prepackaged mesh prolapse kits were used in the past to correct uterovaginal prolapse without requiring hysterectomy, but these kits are no longer available. For this reason, interest in mesh-free uterine preservation procedures by the least invasive route (vaginally) is currently reemerging.
Transvaginal uterosacral ligament suspension/plication
This procedure was first reported in 1966 and was described 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. Following this, a transverse incision was made at the junction of the bladder reflection and cervix, and the cardinal ligaments were plicated across the midline anteriorly, drawing the cervix upward. Follow-up data for this procedure are limited ( ). A case series by of 20 women aged 21 to 37 years, all of whom had uterovaginal prolapse at least to the introitus, noted a failure rate of 15.5%; all of these cases were treated with vaginal hysterectomy within 6 months of the original surgery. Three additional patients (15%) required subsequent hysterectomy for continued vaginal bleeding. Although 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 and uterosacral ligament suspension with 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 (or less) prolapse using the Baden–Walker system, and average 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 statistically similar to the hysterectomy group.
demonstrates the surgical technique for a uterosacral hysteropexy.
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, BRCA1/2 mutation carrier, enlarging fibroid). One pregnancy was reported.
Sacrospinous ligament hysteropexy
The sacrospinous hysteropexy is the best-studied native tissue vaginal approach to uterine-sparing prolapse repair. The literature contains anatomic outcomes data with a larger number of patients, as well as functional, reproductive, and sexual outcomes. 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 ( Fig. 22.1 and 22.2 ). 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, or with disposable suture-capturing devices. 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 preterm birth. Furthermore, it may provide higher suspension compared with the transvaginal uterosacral ligament suspension/plication. demonstrates the surgical technique of a sacrospinous hysteropexy.
Results of this procedure were first presented in a 1989 case series by Richardson et al. Five patients ranging in age from 24 to 31 years underwent this procedure to treat uterovaginal prolapse and had follow-up ranging from 6 to 24 months. No recurrences or pregnancies were reported. These data, however, lack descriptions of preoperative prolapse and definitions of success.
The first descriptions of pregnancy following this procedure were reported by . The authors detailed 19 patients with a mean age of 27 years with uterovaginal prolapse at least to the hymen with Valsalva who wished to maintain childbearing capacity. Four patients underwent unilateral fixation of the uterosacral ligaments to the right sacrospinous ligament, with the remainder undergoing bilateral fixation. At a mean follow-up of 3.1 years, the majority of patients were doing well. Of the patients not attempting pregnancy, 11 of 12 had good objective results with excellent uterovaginal support. One patient with unilateral fixation presented with recurrent prolapse 6 weeks following surgery and underwent bilateral fixation with good anatomic results. Over the 3 years, slight cervical descensus was generally noted; however, no patient had prolapse past the midvagina. Five of the nineteen patients became pregnant, with all having uncomplicated vaginal deliveries. Of these patients, only one noted moderate uterovaginal prolapse after her delivery and, subsequent to a second delivery, underwent vaginal hysterectomy and sacrospinous ligament fixation of the vaginal vault.
Additional data using medical records, patient surveys, validated questionnaires, and follow-up Pelvic Organ Prolapse Quantification (POPQ) exams confirm these positive outcomes. A study published by Dietz et al. in 2007 described 133 women who underwent unilateral sacrospinous hysteropexy and anterior/posterior repair as indicated. Ninety-nine women responded to the postal questionnaire, and 60 followed up for detailed POPQ examination. At a mean follow-up time of 22.8 months, 6% of the 133 women were diagnosed with recurrent uterovaginal prolapse to at least 1 cm above the hymen. Of women undergoing gynecologic examination with POPQ measurements, 30% had a stage II cystocele, and 8% had a stage III cystocele. Of all patients, only three (2.8%) women required surgical treatment of recurrent prolapse. The great majority of patients were very satisfied with the results of the surgery, and 91% would recommend the procedure to other women.
The first comparison of sacrospinous hysteropexy to hysterectomy with sacrospinous vaginal vault suspension was reported by . This small, nonrandomized study of 11 women with sacrospinous hysteropexy and 13 with vaginal hysterectomy and sacrospinous vaginal vault suspension demonstrated that 3/11 women with uterine preservation had “marked cervical elongation,” and 1/11 had “dependent ulceration of the cervix” at a mean follow-up of 4 months. There were 3/11 women in the hysteropexy group and 1/13 women in the hysterectomy group who had “small asymptomatic cystocele” in this short time period. A larger subsequent study by also showed promising results. Seventy women with uterovaginal prolapse at or beyond the vaginal introitus self-selected to hysterectomy with sacrospinous ligament fixation or sacrospinous hysteropexy. Although not randomized, the groups were similar with regard to demographics, grade of vault prolapse, history of previous surgery for prolapse or incontinence, sexual activity, and length of follow-up. The operative time and intraoperative blood loss were significantly less for the hysteropexy group. With a mean follow-up of 33 months for the hysterectomy group and 26 months for the hysteropexy group, subjective and objective outcomes were similar between groups. The subjective success rate (no awareness of prolapse) was 86% in the hysterectomy group and 78% in the hysteropexy group ( P = .70), while the objective success rate (no prolapse beyond the midvagina) was also similar between groups, at 72% and 74% respectively ( P = 1.00). Only two women became pregnant in this cohort, both delivering by cesarean section, with one requiring additional surgery for prolapse postdelivery. This study collected specific outcomes, used a blinded evaluator, and had a control group, lending credibility to these findings.
Subsequent randomized trials by , , and compared sacrospinous hysteropexy to transvaginal hysterectomy and uterosacral ligament colpopexy. The largest, by Detollenaere et al., included 208 women, 103 randomized to sacrospinous hysteropexy. There were apical compartment recurrences to stage 2 in none of the hysteropexy patients and 4% of the hysterectomy patients, and this difference was not significant. At 12 months’ follow-up, overall anatomic recurrences, function outcomes, quality of life, sexual function, and recovery parameters were all similar between groups. Dietz et al. randomized 71 women to one of the procedures described earlier, with return to activities at home and work as the primary outcome. They also looked at complications, anatomic outcomes, functional outcomes, and quality of life as secondary outcomes. Women who were assigned to hysteropexy returned to work 23 days earlier compared with those who underwent hysterectomy and prolapse repair. There were very few complications in both groups. At 1 year, 27% of women who underwent hysteropexy had uterine descensus of POPQ stage II or greater, with about half of these women electing repeat surgery. This was a statistically significant difference compared with those who underwent hysterectomy and prolapse repair (11%). Of women with stage IV prolapse who underwent hysteropexy, all recurred within a year. Between groups, there were no differences in validated questionnaires for prolapse symptoms, incontinence symptoms, or quality of life. The Jeng et al. study randomized 80 of 158 total patients to sacrospinous hysteropexy, and although this trial only investigated sexual function outcomes (see later), the safety of the two procedures were similar, with neither group experiencing major complications.
Additional studies have concentrated on functional outcomes, including effects on urinary symptoms and sexual function. sent postal questionnaires to 103 women who had undergone either vaginal hysterectomy or sacrospinous hysteropexy and possible anterior and posterior colporrhaphy for greater or equal to grade 2 pelvic organ prolapse according to the Baden–Walker system. The recurrence rate of grade 2 or higher vaginal prolapse was 6.7% after vaginal hysterectomy and 11.4% after sacrospinous hysteropexy (this difference was not significant). Recovery was faster ( P = .04), and fewer patients complained of urge incontinence ( P = .05) postprocedure following hysteropexy compared with vaginal hysterectomy. prospectively followed 72 patients undergoing sacrospinous hysteropexy using validated questionnaires and the POPQ exam pre- and postoperatively. At an average follow-up of 12.7 months, 22.2% of women had recurrent prolapse in one of the compartments, with the great majority having stage II prolapse. Quality-of-life questionnaires, including the Urogenital Distress Inventory, Incontinence Impact Questionnaire, and the Defecatory Distress Inventory, demonstrated improvement in all urogenital and quality-of-life domains, as well as constipation and obstructive defecation domains. Large effect sizes were noted on pain, genital prolapse, physical functioning, and emotional health. These studies provide additional data that demonstrate that, in addition to improving anatomic outcomes, sacrospinous hysteropexy leads to functional improvement and positive changes in quality of life.
Given that unilateral sacrospinous hysteropexy deviates and somewhat changes the axis of the vagina, dyspareunia and sexual function are concerns. Sexual functioning was evaluated using face-to-face interviews after vaginal hysterectomy and sacrospinous ligament hysteropexy by . Patients younger than 50 years of age who were sexually active were randomly assigned to hysterectomy or sacrospinous ligament hysteropexy to treat grade 2 or 3 uterine prolapse. Before surgical intervention and 6 months after surgery women were interviewed by a trained gynecologic nurse specialist using portions of Rosen’s Female Sexual Function Index. With the exception of orgasm frequency, which was slightly decreased postoperatively, sexual interest, frequency of sexual intercourse, and sexual satisfaction were not different pre- and postoperatively in either group or between groups. Neither group had changes in vaginal dryness or dyspareunia between pre- and postoperative data, and these outcomes showed no difference between groups. Although this study has some methodological flaws and did not investigate prolapse outcomes, it provides important data describing sexual function and supports that sexual function is not negatively affected by sacrospinous hysteropexy.
Now that sacrospinous hysteropexy has been established as an effective and long-lasting treatment for uterovaginal prolapse, researchers are looking for risk factors for those cases with less than ideal outcomes. A study by with follow-up of at least 5 years demonstrated that cervical elongation ( P = .007) and grade 3 uterine prolapse ( P = .007) are significant risk factors for failure, after sacrospinous hysteropexy. Using these findings to modify the surgical practice, the authors reported that concomitant partial trachelectomy for those with an elongated cervix significantly reduced the failure rate from 75% to 0% ( P = .024). No other risk factors were identified.
Complications of sacrospinous hysteropexy are much better documented than those for the other vaginal approaches to hysteropexy. The earliest reports note one case of proctotomy during the initial dissection that was recognized, repaired, and had no subsequent sequelae. Buttock pain has also been reported, with a rate of 5%. The most complete information on complications related to sacrospinous hysteropexy comes from data collected by from 133 consecutive women. Intraoperative complications included excessive blood loss (>500 mL) in 8% of patients and rectal injury in 0.8% of women. Postoperative complications included: buttock pain in 15%, buttock pain lasting greater than 2 weeks in 4%, urinary tract infections in 13%, and urinary retention in 27%. Of note, several patients experienced specific neurologic symptoms, including one patient with severe buttock pain based on nerve entrapment that required suture release and replacement, and another patient with introital numbness. The high proportion of right buttock pain (side of the suspension) was also seen in 12/80 women (15%) in the Jeng et al. study. Prospective data from Deitz et al. (2008) found similar rates and types of complications: reoperation for hemorrhage in 1.4%, buttock pain in 18.1%, vaginal hematoma in 2.8%, urinary tract infection in 9.7%, urinary retention in 27.8%, and vaginal adhesion 4.2%. This complication profile seems acceptable compared with other treatment options for uterovaginal prolapse.
Prolapse mesh kits
From 2001 to 2008, there was a growing popularity of mesh kits for the correction of pelvic organ prolapse. One advantage of these kits was that they easily accommodated uterine preservation. The majority of these kits involved the blind passage of insertion needles through small perineal incisions into the obturator foramen and ischiorectal fossa to facilitate the tension-free vaginal placement of mesh or graft. Others used suturing devices to assist with the attachment of mesh to anatomic landmarks. The US Food and Drug Administration (FDA) noted adverse events and safety concerns in 2006. An investigation of these issues led to a 2008 Public Health Notification regarding the safety and efficacy of mesh kits for prolapse and incontinence. Over the last 12 years, the notification has been updated twice regarding the safety of the mesh kits used to treat prolapse, as well as the lack of clear evidence demonstrating superior prolapse outcomes compared with native tissue repair. The companies who manufacture the trocar-based mesh kits voluntarily removed the devices from the market. The mesh kits were reclassified to “high risk” by the FDA in 2016, requiring preapproval studies. Data did not demonstrate reasonable assurance of safety and effectiveness, and the FDA required that the companies stop selling and distributing the devices. Despite this, it is worth noting that, when vaginal mesh kits were available, systematic review evidence supported that uterine preservation with these kits had a lower risk for mesh exposure [17/337 (5%) uterine preservation vs. 29/192 (15%) hysterectomy, odds ratio (OR) 0.34, 95% confidence interval (CI) 0.18–0.67] and reoperation for mesh exposure [5/378 (1.3%) preservation vs. 12/154 (7.3%) hysterectomy, OR 0.16, 95% CI 0.05–0.46] than mesh kits placed with concurrent hysterectomy ( ).
One of the last vaginal mesh kits to leave the marketplace was the Uphold Vaginal Support System (Boston Scientific, Natick, MA). A retrospective study by followed 115 women, including 53 women who elected hysteropexy for a median of 11.8 months. Anatomic outcomes demonstrated a recurrence rate, defined as POPQ of –1 or more in any segment, of 1.89%. There was one mesh exposure noted in this group, and self-reported dyspareunia rates decreased from preoperative rates. Ironically, although vaginal mesh kits are no longer in the marketplace, this is the largest group of studies describing uterine preservation procedures and comparing them to procedures with hysterectomy (18 studies, including five randomized trials) ( ; ). In fact, over 30 other studies looking at outcomes from formerly available mesh kits detail hysteropexy outcomes, but most involve older kits that have long left the market, and many of these studies did not include a comparison group.
The abdominal approach to uterovaginal prolapse includes open, laparoscopic, and robotic procedures. Open abdominal approaches to uterovaginal prolapse with uterine preservation include combined vaginal-abdominal retropubic uterine suspension, pectineal ligament uterine suspension, abdominal uterosacral hysteropexy, and sacrohysteropexy. Outcome data for these procedures are limited, with small, retrospective studies representing the bulk of the existing literature. Although the earliest reports describe procedures using autologous grafts and retropubic suspensions, more contemporary literature focuses on sacrohysteropexy using synthetic mesh.
A laparoscopic or robotic approach to uterovaginal prolapse with uterine preservation presents potential benefits, including improved visualization of pelvic anatomy, decreased postoperative pain, and a shorter hospital stay and recovery period compared with the open abdominal approach. Numerous small studies published over the past 20 years have examined outcomes in laparoscopic and robotic approaches to uterovaginal prolapse with uterine preservation. Procedures described include uterine suspension to the round ligaments, plication of the uterosacral ligaments, and sacrohysteropexy.
Open abdominal sacrohysteropexy
The evidence supporting sacrohysteropexy is more robust compared to other open abdominal uterine conservation procedures. However, variations in the operative technique, including sites of mesh attachment and type, size, and shape of mesh make comparison difficult. All authors describe placing synthetic mesh between the vagina and/or cervico-uterine junction and the sacral promontory after mobilization of the bladder, rectum, and peritoneum. The distal mesh attachment site is described as either the vaginal wall or the uterus at the level of the uterosacral ligament. The type, size, and shape of mesh are not consistent across studies, and Teflon, polyester, and polypropylene systems are described. Although no authors elaborate on the size, shape, and configuration of mesh in detail, several studies describe placing the body of a Y-shaped mesh anteriorly with the arms passing through the broad ligament, followed by placement of a rectangular piece of mesh posteriorly ( Figs. 22.3 and 22.4 ). Finally, both are affixed to the sacral promontory. Each procedure includes peritoneal closure after mesh placement.