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

Patients who want to preserve their uterus during surgical repair for uterovaginal prolapse have a number of options for management. Here, guidelines for optimal patient counseling and tips for technique.

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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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CASE Patient desires prolapse repair

A 65-year-old postmenopausal patient (G3P3) presents to your office with symptoms of a vaginal bulge for more than 1 year. She has no urinary incontinence symptoms and no bowel dysfunction symptoms. On examination, you diagnose stage 2 uterovaginal prolapse with both anterior and apical defects. The patient declines expectant and pessary management and desires surgery, but she states that she feels her uterus “is important for me to keep, as my babies grew in there and it is part of me.” She denies any family or personal history of breast, endometrial, or ovarian cancer and has no history of abnormal cervical cancer screening or postmenopausal bleeding. What are the options for this patient?

Who is the appropriate hysteropexy patient, and how do we counsel her?

Uterine prolapse is the third leading cause of benign hysterectomy, with approximately 70,000 procedures performed each year in the United States. It has long been acknowledged that the uterus is a passive bystander to the prolapse process,¹ but modern practice often involves a hysterectomy as part of addressing apical prolapse. However, more and more uterine-preserving surgeries are being performed, with one study showing an increase from 1.8% to 5% from 2002 and 2012.²

When presented with the option to keep or remove their uterus during the time of prolapse surgery, 36% of patients indicated that they would prefer to keep their uterus with similar outcomes while 21% would still prefer uterine preservation even if outcomes were inferior compared with hysterectomy.³ Another study showed that 60% of patients would decline concurrent hysterectomy if there were equal surgical outcomes,⁴ and popular platforms, such as Health magazine (www.health.com) and AARP magazine (www.aarp.org), have listed benign hysterectomy as a “top surgery to avoid.”

Patients desire uterine preservation for many reasons, including concerns about sexual function and pleasure, the uterus being important to their sense of identity or womanhood, and concerns around menopausal symptoms. Early patient counseling and discussion of surgical goals can help clinicians fully understand a patient’s thoughts toward uterine preservation. Women who identified their uterus as important to their sense of self had a 28.2-times chance of preferring uterine preservation.³ Frequently, concerns about menopausal symptoms are more directly related to hormones and ovary removal, not uterus removal, but clinicians should be careful to also counsel patients on the increased risk of menopause in the 5 years after hysterectomy, even with ovarian preservation.⁵

There are some patients for whom experts do not recommend uterine preservation.⁶ Patients with an increased risk of cervical or endometrial pathology should be counseled on the benefits of hysterectomy. Additionally, patients who have abnormal uterine bleeding from benign pathology should consider hysterectomy to treat these issues and avoid future workups (TABLE). For postmenopausal patients with recent postmenopausal bleeding, we encourage hysterectomy. A study of patients undergoing hysterectomy at the time of prolapse repair found a rate of 13% unanticipated endometrial pathology with postmenopausal bleeding and negative preoperative workup.⁷

At this time, a majority of clinicians consider the desire for future fertility to be a relative contraindication to surgical prolapse repair and advise conservative management with pessary until childbearing is complete. This is reasonable, given the paucity of safety data in subsequent pregnancies as well as the lack of prolapse outcomes after those pregnancies.^8,9 Lastly, cervical elongation is considered a relative contraindication, as it represents a risk for surgical failure.^10,11 This may be counteracted with trachelectomy at the time of hysteropexy or surgeries such as the Manchester repair, which involve a trachelectomy routinely,¹² but currently there is no strong evidence for this as routine practice.

Continue to: Uterine preservation surgical techniques and outcomes...

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

CASE Patient desires prolapse repair

Who is the appropriate hysteropexy patient, and how do we counsel her?

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