5 Surgical Procedures to Suspend a Prolapsed Uterus

Christopher F. Maher, MD, Mickey Karram, MD

5-1 Sacrospinous Hysteropexy Anterior Mesh and Posterior Repair

5-2 Sacrospinous Hysteropexy, Anterior Perigee Mesh, Posterior Repair, and Tension-Free Vaginal Tape—the Transobturator Approach

5-3 Sacrospinous Hysteropexy and Posterior Repair

5-4 Large Prolapse Suitable for Anterior and Posterior Colporrhaphy and a Sacrospinous Hysteropexy

5-5 Overactive Bladder Animation

5-6 Abdominal Sacral Colpohysteropexy (Dual-Mesh Technique)

5-7 Uphold Uterine Suspension

5-8 Uterine Prolapse with Vaginal Laceration

Uterine preservation in prolapse surgery is an attractive option for women for a variety of reasons, including the ability to retain fertility, the desire not to remove a normal organ (the perception is that the cervix is an important structure for pelvic floor stability and sexual satisfaction), and that hysteropexy is a less invasive procedure than hysterectomy with reduced blood loss and surgical time. Because the rate of hysterectomy for menorrhagia is decreasing after the introduction of progesterone-releasing intrauterine devices, all pelvic floor surgeons need to be proficient in uterine preservation techniques for the management of uterine prolapse (Figure 5-1). Table 5-1 lists the advantages and disadvantages of uterine preservation.

Figure 5-1 Lateral view of the pelvis demonstrates uterine procidentia with significant bladder prolapse.

Table 5-1 Perceived and Factual Advantages and Disadvantages of Uterine-Preserving Prolapse Surgery

Advantages	Disadvantages
Retains fertility.	Retains fertility.
Retains a healthy organ.	Menses are ongoing.
Perceived role of the uterus and cervix is important in pelvic stability and sexual satisfaction.	Ongoing Gynaecological surveillance of cervix and endometrium is required.
Is a less invasive procedure.	Small, ongoing risk for cervical or endometrial cancer exists.
Reduces surgical time and blood loss.	If oopherectomy performed at hysterectomy there is no risk of ovarian cancer
Offers a quicker recovery.	Sampling cervix or endometrium is difficult.
If mesh utilised concomitantly the risk of mesh exposure is reduced at hysteropexy as compared to hysterectomy	Subsequent hysterectomy is difficult, especially if mesh is incorporated in the original prolapse surgery.
Retention of the cervix allows continuity between level 2 (native tissue or graft) and level 1 apical compartment repair.
Outcomes are similar with hysterectomy (four case control studies).	Higher failure rate of hysteropexy in one randomized control trial, as compared with hysterectomy.

Women with increased risk of cervical or endometrial cancer are not candidates for uterine preservation and are excluded if they have any abnormal uterine bleeding, are taking tamoxifen for breast cancer, and have had prior cervical dysplasia abnormalities; they must be prepared to have ongoing routine gynecologic surveillance. Because 0.8% of postmenopausal women undergoing vaginal hysterectomy for prolapse have an incidental finding of endometrial cancer, it has been recommended that all women considering uterine preservation should undergo either transvaginal ultrasound assessment or a histologic assessment of the endometrium before surgery to minimize the risk of preserving a uterus with endometrial cancer (Frick et al, 2010; Renganathan, Edwards, Duckett, 2010). Box 5-1 lists the contraindications to uterine preservation surgery.

Box 5-1

Possible Contraindications for Uterine Preservation

Uterine abnormalities

Fibroids, adenomyosis, endometrial pathologic sampling

Current or recent cervical dysplasia

Abnormal menstrual bleeding

Postmenopausal bleeding

Familial cancer BRAC1 and 2 x increased risk of ovarian cancer and possibly serous endometrial cancers

Hereditary nonpolyposis colonic cancer; 40% to 50% lifetime risk for endometrial cancer

Tamoxifen therapy

Inability to comply with routine gynecologic surveillance

In women desiring uterine preservation, a variety of surgical options are available including the Manchester repair, vaginal sacrospinous hysteropexy, and abdominal uterosacral or sacral hysteropexy (e.g., laparoscopically, robotic, open). More recently, vaginal mesh kits such as the Uphold system (Boston Scientific) have been promoted as uterine-preserving procedures. The Manchester repair has largely been abandoned as a result of the recurrence of prolapse in excess of 20% of patients in the first few months, a decrease in fertility, pregnancy wastage as high as 50%, and future sampling of the cervix. In addition, the endometrium can be difficult to access due to vaginal re-epithelialization or cervical stenosis.

In four case control studies, the sacrospinous hysteropexy (Figure 5-2) was shown to be as effective as hysterectomy for the management of prolapse with a reduction in surgical time, admission time, and a quick return to activities of daily living (Maher, 2001a; Hefni et al, 2003; van Brummen et al, 2003; Dietz et al, 2007). More recently in a randomized controlled trial (RCT), Dietz and colleagues (2007) demonstrated at 12 months a significantly higher recurrence rate after hysteropexy (9 of 34; 27%), as compared with a hysterectomy group (2 of 31; 7%) (p < 0.01). The postoperative total vaginal length was significantly longer in the hysteropexy group, as compared with the hysterectomy group (8.8 and 7.3 cm, respectively; p < 0.001). The failures in this study were all grade 4 uterine prolapse. Clinicians need to be mindful of this latest result and, if verified in further studies, consider it evidence that perhaps uterine preservation in women with large procidentia should be avoided.

Figure 5-2 A, Native tissue sacrospinous hysteropexy with the distal posterior cervix attached to right sacrospinous ligament (SSL) and anterior and posterior colporrhaphy are demonstrated. B, Lateral view of the pelvis demonstrates the relationship of sacrospinous hysteropexy suspension to vessels (internal pudendal and inferior gluteal arteries) and pudendal and levator ani nerves.

One traditional problem associated with sacrospinous colpopexy has been the high rate of postoperative anterior compartment prolapse. With increasing data available that support the efficacy of anterior compartment mesh augmentation, utilising anterior transvaginal mesh in women……is tempting. Hysteropexy and anterior compartment mesh is possibly further appealing when the alternative of vaginal hysterexomy and mesh procedure in a single study increased the risk of vaginal mesh erosion by a factor of 5, compared with those not undergoing hysterectomy (Collinet et al, 2006). The authors of this text recently reported their experience using anterior mesh and hysteropexy in 100 women. At 12 months, the subjective success rate of 84% was achieved with an objective success rate in all vaginal compartments of 75% with a 10% mesh erosion rate. Three women have subsequently undergone vaginal hysterectomy and vault suspension for recurrent uterine prolapse. This surgery requires further evaluation.

Only limited data are available on pregnancy outcome after sacrospinous hysteropexy in the literature. Fourteen women successfully gave birth from 15 pregnancies (1 twin); 6 women delivered by elective cesarean birth, and 9 gave birth vaginally. One in each group underwent subsequent prolapse surgery (Kovac, Cruikshank, 1993; Maher et al, 2001b).

Alternative abdominal approaches include laparoscopic suture hysteropexy and sacral hysteropexy. The plicated uterosacral ligament and cardinal ligaments are resutured to the cervix during laparoscopic suture hysteropexy (Maher, 2001a). Although the procedure is simple and safe, the objective success rate was only 79% at 12 months with the main problem being cervical elongation. The authors of this text rarely perform this technique.

The sacral hysteropexy is often suggested as the abdominal approach to uterine preservation (Table 5-2) and has been described since 1997. Because of excellent outcomes with sacral colpopexy anecdotally, this procedure is gaining in popularity. Less than 180 cases with a relatively long period of review (12 to 94 months) are reported in the literature (Table 5-3). Three pregnancies have been reported, but no data on deliveries or on the impact of pregnancy or childbirth on prolapse surgery are available. Reoperation for prolapse has been reported in 10 patients. Standardization in the choice of graft and the surgical technique of attaching the graft to the uterus or vagina is distinctly lacking. Three surgeons used a single sheet of mesh attached to the posterior cervix or vagina and three used two sheets of mesh attached to the anterior and posterior vagina connected via the broad ligament. Two case series reported satisfactory outcomes after the laparoscopic approach with early follow-up and with different surgical techniques. Rosenblatt et al, 2008 attached the mesh to the uterosacral ligaments and posterior cervix, whereas Price et al, 2010 attached the mesh to the anterior cervix. The paucity of data on this technique may reflect a reluctance of surgeons to perform this relatively technical and challenging surgery when an effective vaginal approach is available; secondarily, any future hysterectomy and or prolapse surgery would be difficult.

Table 5-2 Efficacy of Abdominal Sacral Hysteropexy

Table 5-3 Comparative Studies on Efficacy of Suburethral Tapes for Intrinsic Sphincter Deficiency

Several authors have reported objective success rates of over 90% with sacral hysteropexy (Leron, Stanton, 2001; Barranger, Fritel, Pigne, 2003), in which mesh secures the cervix to the sacrum. In one RCT, Roover and associates (2004) compared sacral hysteropexy with vaginal hysterectomy and repair. They reported a significantly higher resurgical rate for prolapse in the hysteropexy group. Cosson has advocated uterine preservation as part of the total vaginal mesh repair because hysterectomy was an independent risk factor for mesh complications (Collinet et al, 2006); however, little data are available for total vaginal mesh with uterine preservation.

Uterine preservation at prolapse surgery is feasible, safe, and effective. The reconstructive pelvic surgeon has a variety of surgical options available that can be individualized to meet the needs of the patient.

Case 1: Sacrospinous Hysteropexy Anterior Mesh and Posterior Repair

View: Video 5-1

A 67-year-old woman with uterine procidentia exhibited symptoms of voiding difficulties but no bowel dysfunction. No urinary tract infections were reported, and urodynamic testing before surgery demonstrated a stable bladder without stress urinary incontinence (SUI). The postvoid residual urine was 150 ml, and maximum urinary flow rate was 12 ml/sec. With the prolapse reduced, no occult stress incontinence was demonstrated.

After the various surgical options were discussed, including hysterectomy, the patient elected to undergo sacrospinous hysteropexy, anterior Prolift mesh, and posterior vaginal repair (Figure 5-3).

Figure 5-3 Lateral aspect of the pelvis demonstrates sacrospinous hysteropexy, anterior mesh repair, and posterior colporrhaphy.

Surgical Steps

1. Hydrodissection with 50 ml Marcaine solution 0.25% and adrenalin floods the anterior and posterior vaginal walls.

2. A midline incision is made in the anterior vaginal mucosa, and the bladder is reflected medially from the vaginal mucosa out to the inferior pubic rami to create a paravesical space. The bladder is also mobilized from the anterior cervix.

3. The anterior Prolift mesh is introduced with care to ensure that the bladder is protected from inadvertent damage during the introduction of trocars to the paravesical spaces (see Chapter 8, Surgical Management of Anterior Vaginal Wall Prolapse). The distal tail of the mesh is secured to the anterior cervix, and the proximal mesh is fixed to the paraurethral mucosa with 2.0 Vicryl suture. Initial tensioning of the mesh is performed to ensure that the mesh sits loosely below the bladder. The anterior vaginal mucosa is closed with a continuous 2.0 Vicryl suture.