Clinical Review

Options and outcomes for uterine preservation at the time of prolapse surgery

OBG Manag. 2022 October;34(10):38-42, 52 | doi: 10.12788/obgm.0229

References

DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 pt 1):1717-1724; discussion 1724-1728. doi:10.1016/0002-9378(92)91562-o.
Madsen AM, Raker C, Sung VW. Trends in hysteropexy and apical support for uterovaginal prolapse in the United States from 2002 to 2012. Female Pelvic Med Reconstr Surg. 2017;23:365-371. doi:10.1097/SPV.0000000000000426.
Korbly NB, Kassis NC, Good MM, et al. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol. 2013;209:470.e16. doi:10.1016/j.ajog.2013.08.003.
Frick AC, Barber MD, Paraiso MF, et al. Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2013;19:103-109. doi:10.1097/SPV.0b013e31827d8667.
Farquhar CM, Sadler L, Harvey SA, et al. The association of hysterectomy and menopause: a prospective cohort study. BJOG. 2005;112:956-962. doi:10.1111/j.1471-0528.2005.00696.x
Gutman R, Maher C. Uterine-preserving POP surgery. Int Urogynecol J. 2013;24:1803-1813. doi:10.1007/s00192-0132171-2.
Frick AC, Walters MD, Larkin KS, et al. Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse. Am J Obstet Gynecol. 2010;202:507. e1-4. doi:10.1016/j.ajog.2010.01.077.
Meriwether KV, Balk EM, Antosh DD, et al. Uterine-preserving surgeries for the repair of pelvic organ prolapse: a systematic review with meta-analysis and clinical practice guidelines. Int Urogynecol J. 2019;30:505-522. doi:10.1007/s00192-01903876-2.
Meriwether KV, Antosh DD, Olivera CK, et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol. 2018;219:129-146. e2. doi:10.1016/j.ajog.2018.01.018.
Lin TY, Su TH, Wang YL, et al. Risk factors for failure of transvaginal sacrospinous uterine suspension in the treatment of uterovaginal prolapse. J Formos Med Assoc. 2005;104:249-253.
Hyakutake MT, Cundiff GW, Geoffrion R. Cervical elongation following sacrospinous hysteropexy: a case series. Int Urogynecol J. 2014;25:851-854. doi:10.1007/s00192-013-2258-9.
Thys SD, Coolen AL, Martens IR, et al. A comparison of long-term outcome between Manchester Fothergill and vaginal hysterectomy as treatment for uterine descent. Int Urogynecol J. 2011;22:1171-1178. doi:10.1007/s00192-011-1422-3.
Ridgeway BM, Meriwether KV. Uterine preservation in pelvic organ prolapse surgery. In: Walters & Karram Urogynecology and Reconstructive Pelvic Surgery. 5th ed. Elsevier, Inc; 2022:358-373.
FitzGerald MP, Richter HE, Siddique S, et al; for the Pelvic Floor Disorders Network. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:261-271. doi:10.1007/s00192005-1339-9.
Winkelman WD, Haviland MJ, Elkadry EA. Long-term pelvic f loor symptoms, recurrence, satisfaction, and regret following colpocleisis. Female Pelvic Med Reconstr Surg. 2020;26:558562. doi:10.1097/SPV.000000000000602.
Lu M, Zeng W, Ju R, et al. Long-term clinical outcomes, recurrence, satisfaction, and regret after total colpocleisis with concomitant vaginal hysterectomy: a retrospective single-center study. Female Pelvic Med Reconstr Surg. 2021;27(4):e510-e515. doi:10.1097/SPV.0000000000000900.
Wang X, Chen Y, Hua K. Pelvic symptoms, body image, and regret after LeFort colpocleisis: a long-term follow-up. J Minim Invasive Gynecol. 2017;24:415-419. doi:10.1016/j. jmig.2016.12.015.
Schulten SFM, Detollenaere RJ, Stekelenburg J, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational followup of a multicentre randomised trial. BMJ. 2019;366:I5149. doi:10.1136/bmj.l5149.
Schulten SF, Detollenaere RJ, IntHout J, et al. Risk factors for pelvic organ prolapse recurrence after sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol. 2022;227:252.e1252.e9. doi:10.1016/j.ajog.2022.04.017.
Hemming C, Constable L, Goulao B, et al. Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs. Health Technol Assess. 2020;24:1-220. doi:10.3310/hta24130.
Romanzi LJ, Tyagi R. Hysteropexy compared to hysterectomy for uterine prolapse surgery: does durability differ? Int Urogynecol J. 2012;23:625-631. doi:10.1007/s00192-011-1635-5.
Rosen DM, Shukla A, Cario GM, et al. Is hysterectomy necessary for laparoscopic pelvic floor repair? A prospective study. J Minim Invasive Gynecol. 2008;15:729-734. doi:10.1016/j.jmig.2008.08.010.
Bedford ND, Seman EI, O’Shea RT, et al. Effect of uterine preservation on outcome of laparoscopic uterosacral suspension. J Minim Invasive Gynecol. 2013;20(2):172-177. doi:10.1016/j.jmig.2012.10.014.
Diwan A, Rardin CR, Strohsnitter WC, et al. Laparoscopic uterosacral ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:79-83. doi:10.1007/s00192-005-1346-x.
de Boer TA, Milani AL, Kluivers KB, et al. The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:13131319. doi:10.1007/s00192-009-0945-3.
Thomas AG, Brodman ML, Dottino PR, et al. Manchester procedure vs. vaginal hysterectomy for uterine prolapse. A comparison. J Reprod Med. 1995;40:299-304.
Husby KR, Larsen MD, Lose G, et al. Surgical treatment of primary uterine prolapse: a comparison of vaginal native tissue surgical techniques. Int Urogynecol J. 2019;30:18871893. doi:10.1007/s00192-019-03950-9.
Husby KR, Tolstrup CK, Lose G, et al. Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: an activity-based costing analysis. Int Urogynecol J. 2018;29:1161-1171. doi:10.1007/s00192-0183575-9.
Nager CW, Visco AG, Richter HE, et al; National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial. Am J Obstet Gynecol. 2021;225:153.e1-153.e31. doi:10.1016/j. ajog.2021.03.012.
Rahmanou P, Price N, Jackson SR. Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study. Int Urogynecol J. 2015;26:1687-1694. doi:10.1007/s00192-0152761-2.
Roovers JP, van der Vaart CH, van der Bom JG, et al. A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function. BJOG. 2004;111:50-56. doi:10.1111/j.1471-0528.2004.00001.x.
Roovers JP, van der Bom JG, van der Vaart CH, et al. A randomized comparison of post-operative pain, quality of life, and physical performance during the first 6 weeks after abdominal or vaginal surgical correction of descensus uteri. Neurourol Urodyn. 2005;24:334-340. doi:10.1002/nau.20104.
Schulten SFM, Enklaar RA, Kluivers KB, et al. Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study). BMC Womens Health. 20192;19:49. doi:10.1186/ s12905-019-0749-7.

Uterine preservation surgical techniques and outcomes

Le Fort colpocleisis

First described in 1840 by Neugebauer of Poland and later by Le Fort in Paris in 1877, the Le Fort colpocleisis repair technique remains the most reliable prolapse surgery to date.¹⁴ The uterus is left in place while the vagina is narrowed and shortened. It typically also is performed with a levator plication to reduce the genital hiatus.

This procedure is quick and effective, with a 90% to 95% success rate. If necessary, it can be performed under local or regional anesthesia, making it a good option for medically frail patients. It is not an option for everyone, however, as penetrative intercourse is no longer an option after surgery. Studies suggest an approximately 13% dissatisfaction rate after the procedure, with most of that coming from postoperative urinary symptoms, such as urgency or stress incontinence,¹⁵ and some studies show a dissatisfaction rate as low as 0% in a well-counseled patient population.^16,17

Vaginal native tissue hysteropexy

Many patients who elect for uterine preservation at the time of prolapse surgery are “minimalists,” meaning that a vaginal native tissue procedure appeals to them due to the lack of abdominal incisions, decreased operating room time, and lack of permanent graft materials.

Of all the hysteropexy procedures, sacrospinous hysteropexy (SSHP) has the most robust data available. The approach to SSHP can be tailored to the patient’s anatomy and it is performed in a manner similar to posthysterectomy sacrospinous ligament fixation. The traditional posterior approach can be used with predominantly posterior prolapse, while an apical approach through a semilunar paracervical incision can be used for predominantly apical prolapse. Expert surgeons agree that one key to success is anchoring the suspension sutures through the cervical stroma, not just the vaginal epithelium.

Researchers in the Netherlands published the 5-year outcomes of a randomized trial that compared SSHP with vaginal hysterectomy with uterosacral ligament suspension.¹⁸ Their data showed no difference between groups in composite failure, reoperation rates, quality of life measures, and postoperative sexual function. Adverse events were very similar to those reported for posthysterectomy sacrospinous ligament fixation, including 15% transient buttock pain. Of note, the same authors explored risk factors for recurrence after SSHP and found that higher body mass index, smoking, and a large point Ba measurement were risk factors for prolapse recurrence.¹⁹

A randomized, controlled trial in the United Kingdom (the VUE trial) compared vaginal hysterectomy with apical suspension to uterine preservation with a variety of apical suspension techniques, mostly SSHP, and demonstrated no significant differences in outcomes.²⁰ Overall, SSHP is an excellent option for many patients interested in uterine preservation.

Uterosacral ligament hysteropexy (USHP), when performed vaginally, is very similar to uterosacral ligament suspension at the time of vaginal hysterectomy, with entry into the peritoneal cavity through a posterior colpotomy. The uterosacral ligaments are grasped and delayed absorbable suture placed through the ligaments and anchored into the posterior cervical stroma. Given the maintenance of the normal axis of the vagina, USHP is a good technique for patients with isolated apical defects. Unfortunately, the least amount of quality data is available for USHP at this time. Currently, evidence suggests that complications are rare and that the procedure may offer acceptable anatomic and symptomatic outcomes.²¹ Some surgeons approach the uterosacral suspension laparoscopically, which also has mixed results in the literature, with failure rates between 8% and 27% and few robust studies.^22–24

The Manchester-Fothergill operation, currently not common in the United States but popular in Europe, primarily is considered a treatment for cervical elongation when the uterosacral ligaments are intact. In this procedure, trachelectomy is performed and the uterosacral ligaments are plicated to the uterine body. Sturmdorf sutures are frequently placed to close off the endometrial canal, which can lead to hematometra and other complications of cervical stenosis. Previous unmatched studies have shown similar outcomes with the Manchester procedure compared with vaginal hysterectomy.^25,26

The largest study currently available is a registry study from Denmark, with matched cohort populations, that compared the Manchester procedure, SSHP, and total vaginal hysterectomy with uterosacral ligament suspension.²⁷ This study indicated less morbidity related to the Manchester procedure, decreased anterior recurrence compared with SSHP, and a 7% reoperation rate.²⁷ The same authors also established better cost-effectiveness with the Manchester procedure as opposed to vaginal hysterectomy with uterosacral ligament suspension.²⁸

Continue to: Vaginal mesh hysteropexy...

References

DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 pt 1):1717-1724; discussion 1724-1728. doi:10.1016/0002-9378(92)91562-o.
Madsen AM, Raker C, Sung VW. Trends in hysteropexy and apical support for uterovaginal prolapse in the United States from 2002 to 2012. Female Pelvic Med Reconstr Surg. 2017;23:365-371. doi:10.1097/SPV.0000000000000426.
Korbly NB, Kassis NC, Good MM, et al. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol. 2013;209:470.e16. doi:10.1016/j.ajog.2013.08.003.
Frick AC, Barber MD, Paraiso MF, et al. Attitudes toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Female Pelvic Med Reconstr Surg. 2013;19:103-109. doi:10.1097/SPV.0b013e31827d8667.
Farquhar CM, Sadler L, Harvey SA, et al. The association of hysterectomy and menopause: a prospective cohort study. BJOG. 2005;112:956-962. doi:10.1111/j.1471-0528.2005.00696.x
Gutman R, Maher C. Uterine-preserving POP surgery. Int Urogynecol J. 2013;24:1803-1813. doi:10.1007/s00192-0132171-2.
Frick AC, Walters MD, Larkin KS, et al. Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse. Am J Obstet Gynecol. 2010;202:507. e1-4. doi:10.1016/j.ajog.2010.01.077.
Meriwether KV, Balk EM, Antosh DD, et al. Uterine-preserving surgeries for the repair of pelvic organ prolapse: a systematic review with meta-analysis and clinical practice guidelines. Int Urogynecol J. 2019;30:505-522. doi:10.1007/s00192-01903876-2.
Meriwether KV, Antosh DD, Olivera CK, et al. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol. 2018;219:129-146. e2. doi:10.1016/j.ajog.2018.01.018.
Lin TY, Su TH, Wang YL, et al. Risk factors for failure of transvaginal sacrospinous uterine suspension in the treatment of uterovaginal prolapse. J Formos Med Assoc. 2005;104:249-253.
Hyakutake MT, Cundiff GW, Geoffrion R. Cervical elongation following sacrospinous hysteropexy: a case series. Int Urogynecol J. 2014;25:851-854. doi:10.1007/s00192-013-2258-9.
Thys SD, Coolen AL, Martens IR, et al. A comparison of long-term outcome between Manchester Fothergill and vaginal hysterectomy as treatment for uterine descent. Int Urogynecol J. 2011;22:1171-1178. doi:10.1007/s00192-011-1422-3.
Ridgeway BM, Meriwether KV. Uterine preservation in pelvic organ prolapse surgery. In: Walters & Karram Urogynecology and Reconstructive Pelvic Surgery. 5th ed. Elsevier, Inc; 2022:358-373.
FitzGerald MP, Richter HE, Siddique S, et al; for the Pelvic Floor Disorders Network. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:261-271. doi:10.1007/s00192005-1339-9.
Winkelman WD, Haviland MJ, Elkadry EA. Long-term pelvic f loor symptoms, recurrence, satisfaction, and regret following colpocleisis. Female Pelvic Med Reconstr Surg. 2020;26:558562. doi:10.1097/SPV.000000000000602.
Lu M, Zeng W, Ju R, et al. Long-term clinical outcomes, recurrence, satisfaction, and regret after total colpocleisis with concomitant vaginal hysterectomy: a retrospective single-center study. Female Pelvic Med Reconstr Surg. 2021;27(4):e510-e515. doi:10.1097/SPV.0000000000000900.
Wang X, Chen Y, Hua K. Pelvic symptoms, body image, and regret after LeFort colpocleisis: a long-term follow-up. J Minim Invasive Gynecol. 2017;24:415-419. doi:10.1016/j. jmig.2016.12.015.
Schulten SFM, Detollenaere RJ, Stekelenburg J, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational followup of a multicentre randomised trial. BMJ. 2019;366:I5149. doi:10.1136/bmj.l5149.
Schulten SF, Detollenaere RJ, IntHout J, et al. Risk factors for pelvic organ prolapse recurrence after sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol. 2022;227:252.e1252.e9. doi:10.1016/j.ajog.2022.04.017.
Hemming C, Constable L, Goulao B, et al. Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs. Health Technol Assess. 2020;24:1-220. doi:10.3310/hta24130.
Romanzi LJ, Tyagi R. Hysteropexy compared to hysterectomy for uterine prolapse surgery: does durability differ? Int Urogynecol J. 2012;23:625-631. doi:10.1007/s00192-011-1635-5.
Rosen DM, Shukla A, Cario GM, et al. Is hysterectomy necessary for laparoscopic pelvic floor repair? A prospective study. J Minim Invasive Gynecol. 2008;15:729-734. doi:10.1016/j.jmig.2008.08.010.
Bedford ND, Seman EI, O’Shea RT, et al. Effect of uterine preservation on outcome of laparoscopic uterosacral suspension. J Minim Invasive Gynecol. 2013;20(2):172-177. doi:10.1016/j.jmig.2012.10.014.
Diwan A, Rardin CR, Strohsnitter WC, et al. Laparoscopic uterosacral ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17:79-83. doi:10.1007/s00192-005-1346-x.
de Boer TA, Milani AL, Kluivers KB, et al. The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20:13131319. doi:10.1007/s00192-009-0945-3.
Thomas AG, Brodman ML, Dottino PR, et al. Manchester procedure vs. vaginal hysterectomy for uterine prolapse. A comparison. J Reprod Med. 1995;40:299-304.
Husby KR, Larsen MD, Lose G, et al. Surgical treatment of primary uterine prolapse: a comparison of vaginal native tissue surgical techniques. Int Urogynecol J. 2019;30:18871893. doi:10.1007/s00192-019-03950-9.
Husby KR, Tolstrup CK, Lose G, et al. Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: an activity-based costing analysis. Int Urogynecol J. 2018;29:1161-1171. doi:10.1007/s00192-0183575-9.
Nager CW, Visco AG, Richter HE, et al; National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial. Am J Obstet Gynecol. 2021;225:153.e1-153.e31. doi:10.1016/j. ajog.2021.03.012.
Rahmanou P, Price N, Jackson SR. Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study. Int Urogynecol J. 2015;26:1687-1694. doi:10.1007/s00192-0152761-2.
Roovers JP, van der Vaart CH, van der Bom JG, et al. A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function. BJOG. 2004;111:50-56. doi:10.1111/j.1471-0528.2004.00001.x.
Roovers JP, van der Bom JG, van der Vaart CH, et al. A randomized comparison of post-operative pain, quality of life, and physical performance during the first 6 weeks after abdominal or vaginal surgical correction of descensus uteri. Neurourol Urodyn. 2005;24:334-340. doi:10.1002/nau.20104.
Schulten SFM, Enklaar RA, Kluivers KB, et al. Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study). BMC Womens Health. 20192;19:49. doi:10.1186/ s12905-019-0749-7.

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Options and outcomes for uterine preservation at the time of prolapse surgery

References

Uterine preservation surgical techniques and outcomes

Le Fort colpocleisis

Vaginal native tissue hysteropexy

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