Indications and Techniques for Vaginal Hysterectomy for Uterine Prolapse

5 Indications and Techniques for Vaginal Hysterectomy for Uterine Prolapse




Although the role of hysterectomy in the treatment of benign gynecological conditions has come into question since the early 2000s, with increasing emphasis on medical therapy for fibroid tumors, endometriosis, and benign uterine bleeding, there remains an important role for vaginal hysterectomy in the treatment of advanced pelvic organ prolapse (POP). Specifically, symptomatic uterine prolapse is ideally corrected vaginally with simple hysterectomy, usually in conjunction with enterocele repair, vault suspension, and appropriate repairs of the anterior and posterior vaginal wall. Uterine size, surgeon preference, obesity, age, and the need for concurrent prolapse repair or incontinence procedures are all important factors in the decision to choose a vaginal route for hysterectomy. Benefits of a vaginal approach to hysterectomy compared with an abdominal approach include a shorter hospital stay, more rapid return to normal activities, and fewer postoperative complications. A high level of patient satisfaction following vaginal hysterectomy for POP has been reported in several studies. Vaginal hysterectomy offers a safe, efficient, and effective method of surgically correcting advanced uterine prolapse.


Uterine prolapse is multifactorial in most women, some of whom may be predisposed genetically. Direct damage to the uterosacral-cardinal ligament complex as well as the levator ani muscular complex leads to loss of uterine and apical vaginal support. These defects can occur following pregnancy and childbirth or can develop in certain types of connective tissue disorders. Conditions associated with chronically elevated intraabdominal pressures may also contribute to POP, especially in cases of recurrence following prior surgical repair. These conditions include chronic constipation, a common symptom complex in aging patients; chronic obstructive pulmonary disease; obesity; and occupations or situations associated with heavy lifting, such as caring for a disabled family member or spouse. Aging causes loss of muscular tone and dynamic function, decreased collagen quality, and endocrine abnormalities, which may play a role in POP.



Preoperative Evaluation


Patients being considered for vaginal hysterectomy as a definitive surgical therapy for symptomatic uterine or pelvic organ prolapse should be screened preoperatively for uterine fibroids, endometrial abnormalities, occult uterine or adnexal masses, and cervical dysplasia or carcinoma. Before vaginal hysterectomy is undertaken, a Papanicolaou test should be performed as indicated. In addition, if the patient has a history of abnormal uterine bleeding or if the surgeon desires to determine the size of the uterus and check for the presence and size of any fibroids, transvaginal pelvic ultrasonography should be done. Pelvic magnetic resonance imaging is an alternative option if further detailed imaging is warranted.


The presence of an enlarged uterus or sizable fibroids may preclude a vaginal route for hysterectomy if the uterus cannot be delivered vaginally after division of the pedicles. Endometrial thickening in a postmenopausal woman or the presence of endometrial polyps or masses requires preoperative biopsy to rule out dysplasia or carcinoma. The findings may lead to a change in operative planning. In addition, visualization of adnexal masses on pelvic ultrasonography could necessitate oophorectomy via abdominal or laparoscopically assisted hysterectomy. The patient’s family history, specifically a familial risk of breast and ovarian cancer, or a prior positive screening result for the BRCA gene should also be taken into account and may guide decision making regarding the advisability of concurrent oophorectomy.


As mentioned earlier, a preoperative Papanicolaou test is another essential component of evaluation before vaginal hysterectomy. Cervical dysplasia or carcinoma in situ should be identified before surgery so that enough surrounding vaginal tissue can be resected to ensure margins free of neoplastic disease. This is especially important in any woman who has had high-risk human papillomavirus disease that has previously been associated with the appearance of atypical or dysplastic endocervical cells.




Surgical Anatomy


The uterus is composed of two main parts: the uterine corpus (or body) and the cervix. The corpus consists of the endometrial cavity surrounded by the myometrium and the serosa. The cervix, attached to the lateral fornices of the vagina, leads from the vagina to the endometrial cavity via the cervical canal (Fig. 5-1). The main support of the uterus comes from the uterosacral and cardinal ligaments. These two integrated connective tissue structures extend from their origin at the cervix and upper vagina to the pelvic sidewall (cardinal ligament) and to the sacrum (uterosacral ligament) and provide level I support for the uterus. Above these support structures lies the broad ligament composed of anterior and posterior leaves of visceral and parietal peritoneum that connect the uterus to the adnexa (Fig. 5-2). The blood supply to the uterus comes from branches of the internal iliac artery (Fig. 5-3). The uterine artery travels through the cardinal ligament and crosses over the ureter 1 to 2 cm lateral to the cervix. Before it enters into the uterus near the junction of the corpus and the cervix, the uterine artery sends off the vaginal artery, which supplies the upper portion of the vagina (see Fig. 5-3). The ovarian arteries are direct branches of the aorta.






Surgical Technique for Simple Vaginal Hysterectomy


In this section we limit our discussion to vaginal hysterectomy for the treatment of POP. This technique (with some modifications) can be applied to uterine prolapse of varying degrees (Pelvic Organ Prolapse Quantification [POP-Q] stages II to IV) and uteri of different sizes. In addition the technique can be combined with vaginal oophorectomy when desired. In all cases in which vaginal hysterectomy is performed for the repair of POP, a procedure to address the cul-de-sac and restore and/or maintain apical support is necessary. (See Chapter 6 for discussion and demonstration of vaginal repair of enterocele and apical prolapse.)


May 30, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Indications and Techniques for Vaginal Hysterectomy for Uterine Prolapse
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