(1)
Service de Gynécologie et Obstétrique, Centre d’Études Périnatales de l’Océan Indien (CEPOI) – EA7388, CHU Réunion, Hôpital Félix Guyon, Saint Denis de la Réunion, France
Removing the uterus has been the first treatment for POP performed successfully by vaginal approach in 1521 by Berengarius de-Capri [1]. Since, hysterectomy has become systematic for many authors. Pretty soon, surgeons found out that hysterectomy was not enough to treat POP, replacing a descending uterus with an enterocele. They noticed also that hysterectomy of the non prolapsed uterus was increasing the risk of POP.
At the end of the nineteenth century, dissections showed the crucial role of the fascias and ligaments, especially their pericervical attachments that were playing the role of a keystone. This fact led to the introduction of supracervical hysterectomy (SCH). I will not debate here about the supracervical hysterectomy in general. I just want to explain that it was the best solution for SCP because opening of the vagina (necessary in total hysterectomy) could be avoided as well as the induced complications related to sepsis or mesh erosion.
The debate about hysterectomy or not is not closed. In concerns vaginal as well as abdominal or laparoscopic approach. Of course, in some patients, hysterectomy is mandatory: lesions of the cervix (CIN 2 or 3), adenomyosis, symptomatic myomas, hypertrophic uterine body or cervix, atypical lesions of the endometrium, etc. For the other patients, there are many pros and cons for systematic supracervical hysterectomy (SCH) during LSCP. Let’s have a look at the main of them.
5.1 The Pros
- (a)
SCH facilitates the procedure. Right, the mesh is easier to apply because you don’t have to channelize the broad ligament. Thus, you take no risk of injuring the uterine vessels. On the other hand, you have to do the SCH and morcellate the uterine body. This makes the procedure more sophisticated.
- (b)
SCH avoids a further hysterectomy that might be difficult. Right and wrong. Yes, you will never have to perform hysterectomy, but in case of bleeding, adenomyosis or HPV related lesions, you may have to remove the cervix, which is much more difficult, because the mesh is sutured to it. In fact, having personally performed more than 20 laparoscopic hysterectomies (including three Wertheim operations for cervical cancer), after SCP or LSCP, I noticed that this procedure was not to be feared. Adhesions are usually very tiny after LSCP. The mesh is easy to visualize. The right ureter is frequently very close to the mesh and has to be properly dissected. Then the mesh can be cut close to the uterine isthmus and the rest of the operation is identical to the hysterectomy in the non operated patients. Careful closure of the vagina has to be performed in order to avoid any extrusion of the remaining synthetic mesh. It is advisable after vaginal closure to suture the distal and proximal parts of the mesh together in order to avoid a further vault prolapse. If the cervix has to be removed, vaginal extra peritoneal approach is still possible and advisable.
- (c)
SCH improves the results. Very difficult to say if right or wrong. There are no randomized series, only retrospective studies [2]. Most of these papers show no significant difference in the functional or anatomical results between LSCP patients with or without hysterectomy. There is probably a selection bias in these retrospective series because in current practice, when the uterus is big, myomatous, it is usually removed. It is very difficult to access the rectovaginal space if the uterus is large sized. Further, a very heavy uterus may put the meshes under tension, inducing pain and, maybe, suture disruption.Related posts:
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