Fig. 7.1
Hysteropexy (a) vs. cervicopexy (b) vs. sacrocolpopexy (c)
More recently, a retrospective study of 34 patients who underwent total laparoscopic hysterectomy with laparoscopic sacrocolpopexy (TLH with LSC) compared with 65 patients who underwent laparoscopic sacrohysteropexy by the same group of surgeons found significantly higher subjective patient satisfaction and impact on quality of life based on validated questionnaires in the TLH with LSC cohort [3]. The rate of recurrent vaginal vault or uterine prolapse ≥stage 2 was significantly higher in the laparoscopic sacrohysteropexy group. Ten women (15.4%) in this cohort had recurrent, symptomatic prolapse, while no patients in the TLH with LSC cohort experienced recurrent, symptomatic prolapse.
Aside from the issues of increased durability, other potential advantages of hysterectomy for the patient include elimination of the need for further contraceptive use for those of reproductive age, eradication of menses, and discontinuation of ongoing gynecologic surveillance of the endometrium and cervix if a total hysterectomy is performed. It is also now standard to perform salpingectomy at the time of hysterectomy, thereby reducing the patient’s risk not only of endometrial and cervical, but also ovarian malignancy in a single operation.
When to Consider Uterine Preservation
As overall hysterectomy rates decline, hysteropexy is gaining attention. While it remains not as well-studied as hysterectomy-based repairs for the treatment of prolapse and additional research is needed to assess long-term outcomes, there are patients for whom a uterine-sparing procedure such as sacrohysteropexy may be better suited. Compared with hysterectomy and prolapse repair, hysteropexy is associated with a shorter operative time, less blood loss, and a faster return to work [4, 5]. Other advantages include patient preference for retaining a healthy organ and maintenance of fertility. There have been several reports of cesarean section delivery following hysteropexy [6, 7].
Importantly, however, there are several contraindications to uterine-sparing procedures. Women who have uterine abnormalities, endometrial hyperplasia, or neoplasia are not appropriate candidates. Other considerations for uterine preservation include current or recent cervical dysplasia, familial cancer syndromes such as BRCA 1 and 2 or hereditary nonpolyposis colonic cancer syndrome, tamoxifen therapy, large fibroids, adenomyosis, and inability to comply with routine gynecologic surveillance.
A more detailed discussion of sacrohysteropexy can be found elsewhere in this textbook.
Preoperative Considerations in Patients Undergoing Hysterectomy
Preoperative Evaluation and Informed Consent
Pregnancy must always be ruled out in women of reproductive age on the day of surgery. A recent normal Papanicolaou test (Pap smear) should be documented before performing a hysterectomy. A transvaginal ultrasound examination should be performed if a pelvic mass or any other abnormality, such as an enlarged or globular uterus, is palpated during the bimanual pelvic examination. Sampling of the endometrium or pelvic ultrasound should be performed in patients with irregular or intermenstrual vaginal bleeding, postmenopausal bleeding, and those who have risk factors for malignancy such as polycystic ovarian syndrome (PCOS). In women with abnormal uterine bleeding (AUB), it is generally recommended that all women older than 45 years of age and women 45 years or younger with a risk of unopposed estrogen exposure (such as seen in obesity or PCOS), failed medical management, persistent AUB, or other risk factors for endometrial malignancy undergo endometrial biopsy (after excluding pregnancy) [8, 9]. If there are any suspicious findings, consultation with a gynecologic oncologist is recommended prior to surgery.
As many have stated, informed consent for hysterectomy is not a single event but a process. Documentation must clearly state that the patient has completed childbearing. If mesh is going to be used for concomitant sacrocolpopexy, the risks and benefits of mesh use for this application as well as alternative non-mesh procedures should be thoroughly discussed.
Risk of Unanticipated Uterine Malignancy
While the uterus is the most common site of gynecologic malignancy in the United States, several studies have examined the risk of unanticipated uterine malignancy and demonstrate the overall rate is low, approximately 0.3–0.6% [10–12]. While routine screening of all asymptomatic postmenopausal women with endometrial evaluation via endometrial biopsy or transvaginal ultrasound improves the preoperative detection of endometrial cancer, universal preoperative screening is not cost-effective given the low overall risk [13]. Screening methods also have poor sensitivity, with most cases of occult malignancy following hysterectomy for prolapse being found in asymptomatic women [10]. Thus, currently, there is no strong evidence to support performing routine preoperative endometrial assessment in asymptomatic women undergoing hysterectomy for prolapse.
Total vs. Subtotal Hysterectomy
A total hysterectomy refers to removal of the uterus and cervix. A subtotal hysterectomy (supracervical hysterectomy) indicates uterine corpus removal only. The cervix is preserved. The ovaries and fallopian tubes are not a part of the term hysterectomy. Terms such as “partial” hysterectomy are imprecise; however, these terms are often used by patients to imply that the uterus was removed but ovaries were left in situ.
Impact of Choice on Outcomes
Risk of Prolapse Recurrence
The effect of leaving the cervix in situ on 1-year prolapse recurrence rates following total robotic hysterectomy (TRH) vs. supracervical robotic hysterectomy (SRH) at the time of robotic sacrocolpopexy has been examined [14]. In a retrospective analysis of 83 women presenting with preoperative stage II or greater uterovaginal prolapse, women who underwent an SRH were 2.8 times more likely to have a recurrent prolapse, defined as ≥stage II in any compartment, at 1 year, compared with those who underwent a TRH. When a composite score was used, however, with success defined as no mesh exposure, no prolapse at or beyond point 0 on the Pelvic Organ Prolapse Quantification System (POP-Q), and an answer of “no” to the prolapse-specific questions in the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), there was no difference between the groups. More women in the SRH group reported feeling or seeing a bulge at 1 year after surgery and described it as “somewhat bothersome,” although this difference was not statistically significant (18.6% vs. 10.3%, p = 0.29).
As the main difference in postoperative POP-Q score was seen in the mean values of point Ba, the authors of this study postulate their observations may be due to differences in technique of anterior and apical vaginal wall dissection, and that this may be more challenging when the cervix remains in situ. While in this study, as is the case in the authors’ practice, the extent of the anterior dissection was reportedly carried down to the level of the trigone, it may be theorized that redundant or an excessively long anterior vaginal wall may be more difficult to affix to the mesh with the additional length of the cervix in situ. In other words, those patients with greater anterior vaginal wall length, or predominantly anterior prolapse, may be at greater risk of recurrence.
Others, however, have suggested that retention of the cervix may be beneficial as it allows continuity between DeLancey level 2 and level 1 apical support. Regardless of the potential role in recurrence, which needs further study, retention of the cervix has the important benefit of reducing the risk of postoperative mesh exposure, which will be discussed further in this chapter.
Sexual Function
Small studies in the past have suggested improvements in sexual function for women undergoing supracervical hysterectomy compared to those undergoing total hysterectomy. These improvements have been attributed to less vaginal vault pain, less vaginal shortening, potential advantages in cervicovaginal innervation, and continued production of cervical mucus in patients undergoing supracervical hysterectomy [15–17]. More recent and robust studies have not shown a difference in sexual function [18, 19]. In a cohort of 237 premenopausal women undergoing total laparoscopic, supracervical laparoscopic, or total vaginal hysterectomy for benign uterine pathology, hysterectomy in general, regardless of technique, had significant positive effects on postoperative sexual function and quality of life as measured by Female Sexual Function Index (FSFI) and EuroQol five dimensions questionnaire (EQ-5D) scores, but postoperative scores did not differ among those women who retained their cervix versus those who did not [20]. One benefit worth mentioning, however, is that patients may return to vaginal intercourse more quickly following supracervical hysterectomy.
Risk of Mesh Complications
The risk of mesh exposure following sacrocolpopexy with poly-propylene mesh is significant, ranging from 3.4 to 27% [21–24]. Development of mesh exposure is likely multifactorial, as reflected in the wide variation in these reported rates. However, several consistent risk factors have emerged from the available data including the use of non-Type I polypropylene mesh (those with microporous or multi-filamentous structure) and smoking, both of which increase the risk of mesh exposure [22, 25].
Most relevant to the discussion in this chapter, however, is that concomitant hysterectomy increases the risk of mesh exposure. Based on multiple retrospective studies, it is now widely accepted that performing total hysterectomy at the time of sacrocolpopexy with mesh increases the risk of mesh-related complications following surgery compared with supracervical hysterectomy [23, 24, 26–28]. In a retrospective study of 102 women who underwent hysterectomy and sacrocolpopexy, a significantly higher mesh exposure rate of 14% was observed in the women who underwent total hysterectomy and sacrocolpopexy compared to a rate of 0% when supracervical hysterectomy was performed with sacrocolpopexy at 3 months follow-up [23]. In a similar retrospective analysis, total hysterectomy was associated with a sevenfold increase in mesh exposure rates compared to concomitant supracervical hysterectomy and sacrocolpopexy [28].
Therefore, if mesh sacrocolpopexy is indicated at time of hysterectomy, and presuming patient factors allow, it is recommended that a supracervical hysterectomy and sacrocervicopexy be performed. Despite the lessened risk of mesh complications with cervical preservation, it is still imperative that the surgeon has a thorough discussion of the risks of mesh placement and alternative native tissue repair options. Lastly, if the cervix cannot be spared and total hysterectomy must be performed, the patient must be informed of the elevated risk of mesh-related complications. Common-sense attention to technique, such as avoiding vaginotomy and avoiding mesh placement in a manner that overlaps the colpotomy suture line, may help minimize this risk.
Vaginotomy also increases the risk of mesh complications during sacrocolpopexy. Attention to preserving the integrity of the vaginal wall during dissection, particularly of the bladder off the anterior vagina, is paramount. Any defects or areas of devitalized tissue can result in vaginal mesh exposures.
Patient Selection and Evaluation
Candidates for cervical preservation include those with no history of abnormal cervical cytology and those with a remote history of abnormal cervical cytology, but recent normal screening. Regardless of history of cervical dysplasia, patients undergoing supracervical hysterectomy should be clearly counseled regarding the need to continue cervical cancer screening and only patients who are reliable for follow-up should be selected.
For those patients with a history of abnormal cervical cytology or high-risk human papillomavirus (HPV), the risk of cervical cancer or need to undergo future cervical excision must be assessed and considered when contemplating sacrocolpopexy with hysterectomy. The potential ramifications of not removing the cervix in a patient with prior abnormal cytology history should be thoroughly discussed with the patient including that subsequent surgery to remove the cervix may be challenging. The decision whether or not to perform total hysterectomy , and therefore the risk of mesh exposure, should be weighed against the risk of recurrent or progressive cervical dysplasia. Non-mesh, native tissue-based approaches to prolapse repair, both vaginal and laparoscopic, should also be considered and discussed with all patients.
Technique of Robotic Hysterectomy and Sacrocervicopexy
Principles of the Laparoscopic Approach
The benefits of laparoscopic surgery with regard to length of hospital stay and patient recovery across surgical disciplines are now well-established. Although the laparoscopic approach is associated with favorable outcomes and minimal morbidity, the use of rigid laparoscopic instruments can constrain accessing and suturing in the deep pelvis. The surgical robot and its articulating instruments clearly provide an advantage in this setting. Nevertheless, many of the same principles first used for the laparoscopic approach can be applied to robotic hysterectomy. Many descriptions of the technique exist in the literature [29]. Here we will briefly describe our technique and tips for this approach.
Key Technical Steps
Surgical Team, Patient Positioning, and Port Placement
At least one proficient bedside assistant is needed. The use of steep Trendelenburg position is key to optimize exposure. Limited bowel preparation prior to surgery is routinely performed to minimize rectosigmoid distension, which may impact visualization of the sacral promontory. It is our practice to use enemas on the day prior to surgery. For women with chronic constipation, a magnesium citrate bowel cleansing regimen may be more effective. After preparing and draping the patient, a Foley catheter is inserted. The uterine manipulator is then placed at this time (based on surgeon’s preference). To maximize efficiency, this can be done by the surgeon or qualified assistant, while another member of the surgical team is setting up the required instruments and accessories for laparoscopy. Pneumoperitoneum is established. Ports are placed in a radial fashion as shown in Fig. 7.2.
Fig. 7.2
Port placement (CT)
After confirming the feasibility of the procedure laparoscopically, the robot is docked. We prefer a parallel (side) docking approach, which has the advantage of providing more space for the assistant to manipulate the uterus more comfortably. The robotic cart (the patient-side component with the arms) is positioned just medial to the patient’s left lower extremity, which allows full range of motion of the robotic instruments as well as allowing the bedside surgeon access to the vaginal manipulator and right lateral port for assistance using laparoscopic instruments . This configuration may be reversed based on surgeon preference and/or handedness. Monopolar scissors are then typically placed in the surgeon’s dominant hand to facilitate dissection. ProGrasp™ forceps are then placed in the left lateral port, presuming the setup described above, and a bipolar energy device is placed in the remaining port.
Ureteral Identification
The ureters should be identified early and the course of each ureter should be clearly delineated prior to surgical management of the adnexa and the uterine vessels. A careful incision in the peritoneum overlying the ureter in the ovarian fossa bilaterally is made and extended to follow the course of the ureter toward the cardinal ligament (Fig. 7.3). This provides ready identification of the ureters during dissection for the remainder of the case. We find this is best performed as one of the first steps in the case to avoid challenges that may be posed by anatomical distortion and visualization as the case proceeds.
Fig. 7.3
Creation of peritoneal window over left ureter near cardinal ligament
Consideration for Salpingectomy
Recent studies have suggested that high-grade serous ovarian cancer predominantly arises within the fallopian tubes [30, 31]. This data are strongly supported by observations of a decreased risk of ovarian cancer in women with a history of bilateral salpingectomy (BS) [32]. Therefore, risk reduction may theoretically be achieved by salpingectomy. In fact, although mainly based on data from three studies, a recent meta-analysis observed a 49% reduction in ovarian cancer risk among women who had undergone BS compared with those who had not [33].
These research findings are mainly applicable to two patient populations: those with genetic risk factors for ovarian cancer, and of interest to pelvic reconstructive surgeons, those women at population risk undergoing routine pelvic surgery for benign indications, who may benefit from incidental salpingectomy.
Salpingectomy is favorable to salpingo-oophorectomy at the time of hysterectomy for premenopausal women because it avoids the subsequent health risks associated with iatrogenic premature menopause after oophorectomy, including coronary artery disease and osteoporosis [34]. Recent studies have indicated that BS performed simultaneously with hysterectomy does not lead to impaired ovarian function and, aside from a minimal increase in operative time, does not increase surgical morbidity [35–37].
Thus, based on the available evidence, after thorough counseling of the risks and benefits of performing this procedure, it is the authors’ practice to recommend prophylactic salpingectomy to patients undergoing hysterectomy at the time of sacrocolpopexy. This practice is also supported by recently published opinions from the American Congress of Obstetricians and Gynecologists and the Society of Gynecologic Oncology [38, 39].
Technique of Bilateral Salpingectomy
Salpingectomy requires only a minor change in surgical technique, yet does require meticulous attention in order to preserve ovarian vasculature. Salpingectomy should remove the tube completely from its fimbriated end up to the uterotubal junction. Any fimbrial attachments on the ovary should be dessicated or removed. Care should be taken not to interrupt blood supply to the ovary through the infundibulopelvic ligament because the collateral vasculature from the tubal mesosalpinx is occluded during the tubal removal.
Technique of Hysterectomy
An energy device is typically used to desiccate and divide the round ligament, utero-ovarian ligament, and the fallopian tube. After the round ligament is transected, the incision is continued over the anterior leaf of the broad ligament toward the vesicouterine fold. The bladder is dissected from the lower uterine segment, at least 2 cm distal to the cervix. The bladder flap is created using monopolar cautery. The energy source is used to divide the broad ligament down to the cardinal ligament, and then to skeletonize the uterine artery, which is desiccated at the level of the uterocervical junction. The uterine artery is divided high on the uterocervical junction and medially hugging the “cup” of the uterine manipulator to avoid the ureter (Fig. 7.4). Identification of the uterocervical junction can also be done in cases without a manipulator by visualization and assistant port palpation of the small bulk of the proximal surface that creates an identifiable “knuckle” on the anterior surface of the uterovaginal interface.
Fig. 7.4
Relative position of uterine vessels and ureter on left. Distance between uterine artery and ureter is increased cephalad displacement of uterine manipulator
Removal of the Uterine Corpus
Many approaches have been described for retrieval of the uterine corpus including simple mechanical, manual, and electromechanical morcellation [40–43]. Techniques have been described to extract tissue fragments through an extended abdominal port incision, posterior colpotomy, transcervically, through an abdominal port, or through the morcellator itself [44–46].
The role of power morcellation and the recent controversy surrounding this technique will be discussed in detail in another chapter. In brief, it is the authors’ practice to have a thorough discussion of the current evidence and risks of morcellation, including power morcellation, and the risks associated with underlying malignancy, which allows the patient to make an informed decision. In general, it is the authors’ belief that the risk of occult uterine malignancy in the form of a leiomyosarcoma in women undergoing hysterectomy has been overestimated, particularly in women without suspected uterine myomas. However, the recent practice of contained morcellation is an enhancement as it reduces risk of the spread of benign myometrial and endometrial tissue, which can seed and become problematic for the patient. At the time of this writing, it is currently our practice to perform contained manual morcellation with a scalpel through the midline abdominal port incision after placing the uterus in a specimen pouch, using Lahey clamps to stabilize the uterus as it is morcellated. This allows for controlled morcellation and requires minimal extension of the midline port incision. It further removes the requirement for the application of a power morcellator device and its negative connotation, deserved or otherwise.
Modifications for Sacrocervicopexy
Uterine Amputation
The technique of robotic sacrocolpopexy has been discussed in a previous chapter, so this discussion will be limited to modifications of the standard sacrocolpopexy technique and considerations when a sacrocervicopexy is being performed following supracervical hysterectomy . As in a sacrocolpopexy procedure, one should start at the sacral promontory and expose the anterior longitudinal ligament. If the necessary exposure cannot be accomplished robotically, then time should not be wasted on pursuing the other steps of the procedure robotically.
As discussed above, leaving the cervix in situ reduces the risk of mesh exposure and provides a solid platform for mesh fixation. A dissection of the anterior and posterior vaginal walls is key (Fig. 7.5). This is most easily performed prior to uterine amputation, as traction on the uterine corpus can be used to improve visualization of the surgical planes. However, this dissection can be completed after uterine corpus amputation. After the vessels are secured, the uterus is transected at or just below the level of the internal os, the presumed junction between endometrium and cervical columnar epithelium. An important technique during division of the uterine vasculature is to ensure cephalad displacement of the uterus by the bedside assistant. This maneuver will increase the distance between the ureter and the uterine artery. After division of the uterine vasculature, the uterus is amputated from the cervix. Though there are devices for this procedure (LiNA Loop Gold™, Lina Medical, Norcross GA), it is the authors’ preference to use monopolar scissors. The pelvic sidewall makes a poor “work bench;” therefore, use of an instrument to provide a backboard for the cervix during amputation is suggested (Fig. 7.6). Cephalad traction on the fundus will help expedite the process. If a uterine manipulator has been used, it is generally removed after the midpoint or two thirds of the cervical width has been reached. The authors do not find it necessary to oversew the cervix, but care must be taken to ensure adequate hemostasis prior to mesh placement.
Fig. 7.5
After uterine amputation, anterior distension with vaginal manipulator assists dissection of anterior vagina and bladder
Fig. 7.6
Use of accessory instrument to serve as ‘backboard’ during amputation of uterine corpus to protect sidewall
Management of the Endocervix
Cauterization or excision of the remaining endocervix is often performed with the goal of decreasing post-hysterectomy cyclic bleeding. In a randomized study of 140 women who underwent laparoscopic supracervical hysterectomy either with or without “reverse cervical conization,” no differences in intermittent postoperative vaginal bleeding were observed at 12-month follow-up, occurring in 37% with conization and 33% without conization [47]. It remains the authors’ practice to perform reverse conization by cauterization of the endocervical canal with monopolar scissor electrocautery (Fig. 7.7). This procedure adds minimally to the operative time, has little to no associated risks, and has been shown by others in a larger retrospective series to have a much lower postoperative intermittent vaginal bleeding rate of 2% [47, 48].
Fig. 7.7
Cauterization of endocervix (reverse cone) after supracervical hysterectomy
Vaginal Manipulation
Once the cervix is amputated, vaginal manipulation can be challenging. Many methods have been described such as using a robotic tenaculum to apply traction to the cervix or using malleable retractors or an EEA sizer to delineate the vaginal fornices, but devices such as the Colpassist™ vaginal fornix manipulator (Boston Scientific, Marl-borough, MA) are also very useful for this purpose (Fig. 7.8). This device is specifically designed for this purpose and provides a strong suturing platform. Following these steps, sacrocervicopexy proceeds in a similar fashion to sacrocolpopexy.
