The Obstetrician & Gynaecologist http://onlinetog.org
Management of uterine prolapse: is hysterectomy necessary? Helen Jefferis
Simon Robert Jackson
b MD FRCOG,
Subspeciality Trainee in Urogynaecology, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK b Consultant Urogynaecologist, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK *Correspondence: Natalia Price. Email: [email protected]
Accepted on 1 June 2015
Management of uterine prolapse is currently heavily influenced by patient and surgeon preferences. The traditional approach to uterine prolapse is vaginal hysterectomy. However, this does not address the underlying deficiency in connective tissue pelvic floor support, and prolapse recurrence is common. Uterine preservation surgery is increasing in popularity, both with surgeons and patients; there is currently little evidence to show superior outcome to hysterectomy.
Fertility preservation remains the one absolute indication for hysteropexy. Other potential advantages include stronger apical support and reduced vaginal surgery. Colpocleisis remains a valid option for a small cohort of patients. Learning objectives
Options for the management of uterine prolapse. How to help patients decide on a management plan.
Keywords: colpocleisis / hysteropexy / pelvic organ prolapse /
uterine preservation surgery / vaginal hysterectomy
Please cite this paper as: Jefferis H, Jackson SR, Price N. Management of uterine prolapse: is hysterectomy necessary? The Obstetrician & Gynaecologist 2016;18: 17–23. DOI: 10.1111/tog.12220
Introduction When a woman presents with pelvic organ prolapse, the management options are doing nothing, offering conservative treatment such as physiotherapy and vaginal pessaries, or surgery. Many women will ask for their gynaecologist’s opinion as to the best course of action. This will depend on symptomatology, impact on quality of life, desire for sexual function and medical comorbidities, among other factors. It is important that gynaecologists are aware of all available treatment modalities and can counsel women about the potential benefits and risks. Some patients will simply require reassurance that there is no sinister pathology.
Conservative management Gynaecologists will often recommend lifestyle measures to patients presenting with symptomatic pelvic organ prolapse. Of particular interest is the correlation between increasing body mass index and prevalence of prolapse. Weight loss is therefore often recommended to patients as part of a conservative approach to managing prolapse symptoms. However, one large study1 showed that weight loss was not
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significantly associated with regression of prolapse, leading the authors to suggest that the damage obesity causes to the pelvic floor may be irreversible. Women are often given advice regarding pelvic floor muscle training and may receive targeted physiotherapy. A 2014 multicentre randomised controlled trial (RCT)2 comparing individualised pelvic floor muscle training with no intervention found a statistically significant improvement in subjective assessment of prolapse symptoms in the intervention group. No significant improvement in objective assessment of anatomy, as assessed by the pelvic organ prolapse quantification system (POP-Q), was reported. Women have used mechanical devices to reduce pelvic organ prolapse since ancient times, and the use of vaginal pessaries remains a simple and satisfactory treatment. One study of 100 women using this method3 showed a 92% satisfaction rate in terms of prolapse symptoms and a 50% improvement in urinary symptoms. Studies have shown that older women and those with comorbidities are most likely to persist with the use of vaginal pessaries. Women more likely to pursue surgery are younger, more likely to be sexually active and more likely to have more advanced prolapse.4 Factors predicting failure of
Management of uterine prolapse
pessary treatment are short vaginal length, deficient perineal body and a wider vaginal introitus. The side effects associated with vaginal pessary use are usually minor and include vaginal discharge, odour and vaginal erosions. More serious complications such as fistulae are predominately seen in neglected or forgotten pessaries.
The current debate Vaginal hysterectomy has long been the standard approach for the management of uterine prolapse, with the first successful planned case being credited to Langenback in 1813. It remains a safe and readily available surgical solution to uterine prolapse. Various techniques are described for reducing the risk of subsequent vaginal prolapse. The McCall culdoplasty (which involves approximating the uterosacral ligaments so as to obliterate the peritoneum of the posterior cul-de-sac as high as possible) is considered superior to a vaginal Moschowitz procedure, or closure of the peritoneum of the cul-de-sac in preventing enterocoele formation.5 Suturing the cardinal and uterosacral ligaments to the vaginal cuff may also reduce subsequent vault prolapse.6 While vaginal hysterectomy has served patients and gynaecologists well for many years, its continued routine use has been subject to debate. Many gynaecologists argue that the uterus itself is healthy and the underlying pathophysiology is a connective tissue deficiency,7 whether congenital or acquired through childbirth or ageing, and that uterine prolapse is merely a symptom, not the disease. Vaginal hysterectomy fails to address this underlying deficiency in connective tissue, with relatively high recurrence rates of 10–40% described in the literature.8,9 Recurrence can manifest with vaginal vault eversion, or more commonly recurrent enterocoele or cystocoele. We know that cystocoele commonly arises because of loss of apical (type 1) vaginal support, and until apical support is established, a cystocoele will recur after surgery. Furthermore, hysterectomy removes a healthy organ that may play a role in a woman’s individual and sexual identity. On the other hand, vaginal hysterectomy has been part of core gynaecology training for decades; more recently part of the popular vaginal surgery advanced training skills module (ATSM). Most gynaecologists are therefore well trained and comfortable doing the procedure with good outcomes. In addition, there is evidence that the procedure is associated with high patient satisfaction rates, which are not significantly different from uterine preservation.10 Some uterine preservation procedures have also been associated with high rates of recurrent anterior wall prolapse.11 Women are increasingly requesting uterine conservation. This may be because of the wish to preserve fertility, or the belief that female identity is bound up in the female genital
organs. The request frequently arises after women have conducted an internet literature search and become aware of alternatives to hysterectomy.
The history of uterine preserving prolapse surgery Uterine preservation surgery can be considered when it is appropriate to offer a surgical remedy for uterine prolapse. The most obvious indication is fertility preservation in women who have not yet completed childbearing. However, this is a small group of patients. Most women requiring surgery for prolapse have no desire for further children; indeed the majority are postmenopausal. In the authors’ experience other more prevalent indications for uterine preservation include patient request and superior outcome. The latter is a contentious statement as clinical data remains sparse and will be discussed in this article. However, when there is loss of apical support, traditional vaginal hysterectomy will not correct the defect. This is most readily apparent when women present with procidentia; it is self-evident that hysterectomy will not treat vaginal eversion. The Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guideline, ‘Management of Post Hysterectomy Vaginal Vault Prolapse’,12 recommends sacrospinous fixation if the vaginal vault is at the introitus at the end of a vaginal hysterectomy procedure. The concept of uterine preservation surgery for pelvic organ prolapse is not new, but it has attracted a resurgence in interest over recent years. In 1888 Archibald Donald first described the Manchester repair as an alternative to vaginal hysterectomy for patients with uterine prolapse, although this may have been a more useful technique for patients with an elongated cervix rather than true uterine descent. In 1930 Victor Bonney highlighted the passive role of the uterus in uterovaginal prolapse, which underpins the theory behind uterine preservation surgery. Subsequent surgeons have developed techniques for uterine preservation using a vaginal, abdominal or laparoscopic approach.
Vaginal approach In 1966 Williams13 described a technique for transvaginal uterosacral-cervical ligament plication. He reported on the outcomes of 20 women undergoing this procedure, with three ‘failures’ encountered within a 6-month follow-up period. His method involved a posterior colpotomy with division of the uterosacral ligaments from the cervix, plication across the midline and reinsertion into the cervix. The cardinal ligaments are then plicated anteriorly across the midline. The concept of sacrospinous hysteropexy was first described by Richardson14 in 1989. The cervix or
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uterosacral ligament is transfixed to the sacrospinous ligament using either permanent or delayed absorbable sutures. In 2001 Maher15 reported a small comparison study between sacrospinous hysteropexy and vaginal hysterectomy with sacrospinous vault fixation, with no differences in objective or subjective outcomes at follow-up. Other studies have suggested that sacrospinous hysteropexy has a shorter operative time and less blood loss than vaginal hysterectomy.16 One study also reported fewer postoperative incidences of overactive bladder symptoms in the sacrospinous hysteropexy group.17 Dietz et al.11 described an increased risk of anterior compartment prolapse following sacrospinous hysteropexy, with an incidence of up to 40%. Sacrospinous hysteropexy, is the most studied vaginal technique for uterine preservation prolapse surgery; however, in general, the studies assessing it are of poor quality, with small numbers, short follow-up periods,18 a lack of controls and limited functional outcome data. The technique of posterior vaginal slingplasty was first described in 2001,19 using a mesh kit to create ‘neouterosacral ligaments’. One prospective comparison study quoted a 91.4% patient satisfaction rate post-surgery,20 but cumulative data suggest a high incidence of mesh complications with up to a 21% mesh erosion rate.21
Abdominal approach Several methods for open abdominal hysteropexy have been described, including transfixing the uterus to the anterior abdominal wall and ventral fixation to the pectineal ligaments. Most techniques use the sacral promontory as the fixation point, giving rise to the term ‘abdominal sacrohysteropexy’. Abdominal suture sacrohysteropexy was described as early as 1957,22 with the uterine fundus being fixed to the sacral promontory with silk sutures. More recent techniques have utilised a variety of synthetic meshes to aid fixation. In 1993, Addison23 first described a technique for resuspending the uterus to the sacrum using MersileneTM (Ethicon US, LLC, USA) polyester fibre mesh. Leron and Stanton24 followed-up 13 women undergoing abdominal sacrohysteropexy and found it to be a safe and effective surgery for the management of uterine prolapse. Farkas et al.25 described a technique for uterine suspension using a ‘wrap-around’ insert of Gore-Tex (W.L. Gore & Associates, Inc., Newark, USA) for women with prolapse secondary to bladder exstrophy. Roovers et al.10 reported on a comparison between sacrohysteropexy and vaginal hysterectomy with vault fixation; recurrence was higher in the abdominal surgery group (22%) than in the vaginal hysterectomy group (2.5%). Constantini et al.26, however, found no subjective or objective difference in functional outcomes when comparing a group of patients undergoing sacrohysteropexy with those undergoing hysterectomy with
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sacrocolpopexy. Sacrohysteropexy was associated with a shorter operative time and hospital stay and a reduction in intraoperative blood loss. It is difficult to interpret data reporting comparisons between abdominal sacrohysteropexy and hysterectomy because of variations in surgical techniques and differences in mesh type, size, shape and attachment points.
Laparoscopic approach While initial experience with abdominal hysteropexy was obtained via laparotomy, open abdominal surgery has now, in many units, been largely replaced with laparoscopic techniques. The laparoscope confers better vision than laparotomy, allowing a magnified, high definition view. Furthermore, the long instruments allow better pelvic access, particularly behind the uterus, than conferred by laparotomy. General advantages of laparoscopic compared with open surgery are reduced hospital stay, reduced need for analgesia, quicker recovery and minimal blood loss. There is a suggestion that adhesion formation is also reduced. The main disadvantage of laparoscopic surgery is the initial increase in operating time while the surgeon learns the laparoscopic techniques. Focused training and use of skills laboratories and laparoscopic simulators can help to address this issue. As a new generation of surgeons develop, trained from the outset in laparoscopic techniques, such concerns will become obsolete. In fact, many skilled laparoscopic surgeons find that if they are in a situation where open surgery is required, the operating times are slower and visualisation of the anatomy is poorer. Several laparoscopic uterine suspension procedures have been described using different methods. Laparoscopic ventrosuspension involves suturing the round ligaments to the rectus sheath. However, the round ligament is not particularly robust, and perhaps, as expected, it has been shown to have poor outcomes, with one case series of nine women reporting recurrent prolapse in all but one patient within 6 months.27 Chen et al.28 used mesh to suspend the uterus by attachment to the anterior abdominal wall. While they reported good outcomes, all patients experienced significant pain or dragging sensations over the mesh attachment site. Laparoscopic uterosacral ligament plication was first described by Wu et al.29 in 1997, with good results in a small case series. Maher et al.30 modified this technique to include reattachment of the uterosacral ligaments to the cervix and closure of the pouch of Douglas, with an objective success rate of 79% in 43 women at 12 months. Recent techniques have focused on use of the sacral promontory as a point of fixation. Krause et al.31 followedup 81 women undergoing laparoscopic sacral suture hysteropexy, placing sutures through the posterior aspect of the cervix and transfixing to the sacral promontory via the
Management of uterine prolapse
right uterosacral ligament. Objective correction of prolapse was seen in 94% of patients at a mean of 20.3 months follow-up. Cutner et al.32 developed the technique of laparoscopic uterine sling suspension. The peritoneum is opened over the sacral promontory and the rectum is reflected laterally. A tunnel is created by blunt dissection underneath the peritoneum from the sacral promontory to the insertion of the uterosacral ligament complex into the cervix on either side. MersileneTM tape on a needle is placed through the cervix, through the uterosacral ligaments and through the peritoneal tunnels on each side, before being bilaterally tacked to the sacral promontory to suspend the uterus. This technique aims for the sling to resemble newly created uterosacral ligaments. The theoretical advantage is that this type of repair, by augmenting weak connective tissue with prosthetic material, provides stronger apical support resulting in lower recurrence rates. It allows the patient to retain their fertility and, by avoiding vaginal surgery, there is a lower potential for dyspareunia and sexual dysfunction. However, evidence is lacking to support this technique as it has not been evaluated in clinical trials.
Authors’ technique; the Oxford hysteropexy The laparoscopic polypropylene cervical encirclage hysteropexy was modified in Oxford from previously described open abdominal surgery techniques. The authors’ experience with hysteropexy has shown that mesh, when attached to the posterior aspect of the cervix, or to the cervical stump following hysterectomy, has a high avulsion rate. Therefore, a method of complete cervical encirclage was developed using a bifurcated polypropylene mesh.33 The technique has evolved; initially the abdominal polypropylene was not completely peritonealised; previous reports from open abdominal surgery suggested this was unnecessary. However, it subsequently became apparent that exposed intraperitoneal polypropylene causes marked bowel adhesions, thus complete peritonealisation was adopted. Furthermore, a 3 cm width strip of polypropylene was initially used, but this resulted in several instances of recurrent cervical descent because of mesh stretching. Subsequently, a 5 cm wide strip of polypropylene was used. Other units within the UK have now adopted this Oxford hysteropexy technique; it is not exclusive to Oxford. The aims of this technique are outlined in Box 1. A four-port laparoscopic technique is used with a 10 mm umbilical, two 5 mm lateral and a 12 mm suprapubic port inserted. After identifying the sacral promontory, the peritoneum is incised with bipolar graspers and monopolar scissors to identify a safe window of periosteum for mesh
Box 1. Aims of hysteropexy To restore and reinforce uterine support by suspending the uterus from the sacral promontory using type 1 polypropylene mesh. Two strong attachment points are used: the cervix and the anterior longitudinal ligament overlying the sacral promontory. To restore vaginal length without compromising calibre. By restoring apical support a reduction in anterior prolapse is seen, consistent with the importance of restoring level 1 support in cystocoele repair. A reduction in enterocoele is also seen.
fixation. A peritoneal relaxing incision is then used, medial to the right ureter, to retract it from the surgical site; this is then extended into the pelvis, lateral to the rectum. The right uterosacral ligament is identified and the peritoneum is opened over this, where the uterosacral ligaments insert into the cervix. A flap of peritoneum is mobilised to facilitate reperitonealisation. The vesico-uterine peritoneum is incised to reflect the bladder away and bilateral avascular windows are created in the broad ligament, lateral to the uterine arteries, at the level of the internal os. A bifurcated polypropylene type 1 macroporous nonabsorbable mesh (ProLiteTM; Atrium Medical Corporation, USA) is brought through the broad ligament windows. This is transfixed to the anterior cervix using non-dissolvable, non-absorbable polyester 2-0 sutures (Ethibond; Ethicon US, LLC, USA). The mesh is attached to the sacral promontory under moderate tension using two to three 5 mm helical fasteners (Pro-TackTM; Covidien, CT, USA). The mesh is then completely reperitonealised using Monocryl (Ethicon US, LLC, USA) sutures.
Outcomes after laparoscopic hysteropexy Outcome data post-laparoscopic hysteropexy is sparse. We performed a prospective observational study34 and reported outcomes following laparoscopic sacrohysteropexy in 140 women. Follow-up time varied between 1 and 4 years, with 89% of women reporting that their prolapse was ‘very much’ or ‘much’ better. There was significant improvement (P