Uterine preservation in pelvic organ prolapse surgery

Introduction

Uterine prolapse is a common disorder in women. It represents the third leading cause of hysterectomy for benign disease and is responsible for approximately 70,000 hysterectomies annually in the United States, double the operation rate on women posed by mastectomies with reconstruction for breast cancer ( ). Given this large surgical volume, measures to increase the efficiency and safety of prolapse surgeries are paramount. Traditionally, operations to treat uterine and uterovaginal prolapse include a hysterectomy, even when no specific uterine disease is present. It is known from anatomical studies that the uterus is not the cause of prolapse, and that hysterectomy itself is a risk factor for prolapse formation ( ; ). A recent systematic review that included a dozen randomized trials and 41 nonrandomized trials comparing prolapse surgery with hysterectomy to prolapse surgery with uterine preservation found no differences in prolapse outcomes in the short to medium term and found that the morbidity of some procedures (such as blood loss and operative time) decreased with preservation of the uterus ( ).

The surgical treatment of uterovaginal prolapse using uterine-sparing techniques has evolved from vaginal procedures using native tissue to laparoscopic and robotic procedures using polypropylene mesh. Although many of these operations use the same techniques and principles as those used to treat vaginal vault prolapse, the outcome data are fewer, and direct comparisons lack rigorous or long-term follow-up. The interest in uterine conservation among patients and physicians is growing worldwide, despite some data from a large population study indicating that hysterectomy may be protective against repeat prolapse surgery ( ). Overall, there are limited guidelines regarding the choice of uterine preservation in prolapse surgery. The objective of this chapter is to review and summarize the medical literature describing the role of uterine preservation during the surgical management of uterovaginal prolapse.

Historical perspective

The origins of the vaginal hysteropexy date back to the late 1800s when techniques were developed to treat uterine retroversion. Initial accounts describe a procedure that delivered the fundus of the uterus through an anterior colpotomy and sutured the anterior fundus to the anterior vaginal wall. Various modifications to this technique were made, although no modification obtained published endorsement. Despite this, vaginal fixation of the uterus had taken hold, and outcomes were endorsed by Mackenrodt’s numerous publications and a comprehensive report by Duhrssen in 1894 detailing 207 operations. These techniques were later translated into treatment for vesicovaginal fistula (using the fundus as a plug) and later, in 1896, as treatment for prolapse ( ).

In 1899, Thomas Watkins was the first to publish descriptions of what came to be known as a uterine interposition operation ( ). The uterus was separated from the vagina using a circumferential incision, and the bladder was separated from the uterus using blunt dissection. The fundus of the uterus was grasped and anteverted through the anterior colpotomy and sutured to the proximal 2 inches of the anterior vaginal wall. The posterior vaginal wall was opened to 1 inch distal to the cervix to allow the cervix to be displaced upward and backward by this inversion. Although outcomes were only reported for one patient, this procedure was quite popular during the early twentieth century. However, as theoretical concerns developed regarding potential pregnancy in younger patients and difficult endometrial access in older patients, the interposition operation gradually became less popular and was largely supplanted by the Manchester procedure.

The Manchester procedure was first performed in 1888 by Archibald Donald of Manchester, England, with several modifications introduced by W.E. Fothergill. The procedure was first described for uterovaginal prolapse in patients with cervical elongation and intact uterosacral-cardinal ligaments. This procedure begins by making a circumferential incision around the cervix, dissecting the vaginal epithelium cephalad similar to during performance of a vaginal hysterectomy, and clamping and transecting the cardinal ligaments bilaterally. The distal, elongated cervix is then amputated, and the remaining proximal cervix is retracted downward while the cardinal ligament pedicles are sutured to the anterior cervix. This serves to retract the cervix posteriorly and elevate the uterus anteriorly. The transformation zone is then recreated with the invagination of vaginal epithelium into the cervical os.

The largest study on the Manchester procedure (and the largest study on hysteropexy to date), by , reported on 960 patients. Based on a review of medical records and a mailed questionnaire with a 52% response rate, the prolapse recurrence rate was determined to be 4.3%. Other studies note a reoperation rate of 21%, including reoperation for prolapse, as well as abnormal bleeding and cervical carcinoma. More recent data include a retrospective chart review by that compared the outcomes of 88 consecutive patients who underwent Manchester procedures with the outcomes of 105 randomly selected patients who underwent vaginal hysterectomy with anterior and posterior repair as indicated. The Manchester group was older and had worse uterovaginal prolapse compared with the hysterectomy group. The Manchester procedure was noted to be quicker (30 minutes shorter) and to have less blood loss (200 vs. 300 mL). Follow-up consisted of questionnaires mailed to the surgeons who performed the operations. With a mean follow-up of 2.5 years, and a 76% response rate, only 6% of patients were noted to have recurrent prolapse after the Manchester procedure, with time to recurrence ranging from 8 weeks to 5.5 years, but no follow-up data for the vaginal hysterectomy group were reported. Despite relatively limited outcomes data, the Manchester procedure is still considered a safe option for treating uterovaginal prolapse without requiring hysterectomy. In fact, a recent study that analyzed data from a nationwide database in Denmark reported that the Manchester procedure had less than a fourth of the risk for anterior recurrence of prolapse compared with sacrospinous hysteropexy and a much lower reoperation for prolapse, bringing into question the relatively low utilization of this procedure in modern practice ( ).

Complications of the Manchester procedure need to be taken in the context of when the procedures were performed. In the series describing 960 patients ( ), the procedures were performed from 1936 to 1955, and the following complications were reported: cystotomy and proctotomy less than 0.5%; blood transfusion 20%; febrile morbidity 63%; urinary retention 15.2%; and mortality 0.7%. Clearly, the high rates of some complications are related more to medical and surgical practices of the era than directly to the Manchester procedure itself. In another series, complications were not noted to be significantly different when compared with vaginal hysterectomy with anterior and posterior repair, with the exception of decreased cuff abscess and cellulitis in the Manchester procedure ( ). Other complications noted in these series include abnormal uterine bleeding and carcinoma, both of which are of a concern for all uterine-sparing procedures. Furthermore, cervical amputation is related to infertility, miscarriage, and preterm delivery. specifically examined uterine disease 6 to 12 years after the Manchester procedure in 82 patients, finding that 35% of women complained of menorrhagia and dysmenorrhea, and over half of these patients required treatment. Additionally, 2.4% of patients developed adenocarcinoma of the uterus, and 4% of patients experienced unplanned pregnancies. Interestingly, 27% of patients stated that they would have welcomed hysterectomy at the time of the operation, and many patients stated that contraception was unsatisfactory. Vaginal hysterectomy has become more popular since that time, as antibiotics and improved surgical technique have led to decreased morbidity and mortality related to pelvic reconstructive surgery. In the twenty-first century, the patients who are optimal candidates for the Manchester procedure must weigh this against good safety data for other approaches to hysteropexy, as well as hysterectomy with vault suspension. In the recent large Danish study, the 5-year reoperation rates for vaginal hysterectomy and the Manchester procedure were comparable (11% and 7%, respectively) ( ).

In the 1950s, as the abdominal approach to hysterectomy became popular, cases describing an abdominal approach to hysteropexy were published. Sacrocervicopexy, in this instance indicating suspension of the cervix as still attached to a preserved uterine body, was first described by Stoesser in 1955 as the attachment of a band of external oblique fascia from the cervix to the sacral periosteum. The case series of 22 patients reported “good” results but provided limited information on methodology and outcome measurement. A combined vaginal-abdominal procedure targeting both uterovaginal prolapse and stress urinary incontinence was described by ) in a case series of 16 patients. The procedure involved vaginal mobilization of the bladder neck, periurethral tissue, uterine, isthmus, and uterosacral-cardinal ligament complex, followed by a Moschcowitz culdoplasty and transabdominal suspension of the periurethral endopelvic fascia and uterosacral ligaments to Cooper’s ligament. There were no complications or failures noted at a follow-up interval of over 5 years, although the study was limited by its size and lack of control group. published a case series of 20 patients who underwent a transabdominal Cooper’s ligament uterine suspension using Mersilene tape. There were no complications reported, nor were there any cases of recurrent prolapse. However, the follow-up was limited to a range of 6 to 30 months, and postoperative examination findings were not described. Notably, seven women conceived within 6 months of the operation, five of whom delivered vaginally at term. Procedures using Cooper’s ligament suspension are no longer routinely used for uterine preservation and have been replaced by transvaginal native tissue or minimally invasive approaches to sacrohysteropexy using polypropylene mesh.

Considerations for uterine preservation

With the advent of antibiotics and improved surgical techniques, the morbidity and mortality related to hysterectomy were greatly reduced, and the rates of uterine removal increased in the later part of the twentieth century. Additionally, hysterectomy was considered favorable, given the potential to reduce endometrial and cervical cancer risks. Since that time, improved conservative treatment for abnormal bleeding and symptomatic leiomyoma, effective strategies for cervical cancer screening, the human papilloma virus (HPV) vaccine, and an emphasis on quality of life have led physicians and patients to modify their thoughts on hysterectomy. Please see Box 22.1 for perceived and studied advantages and disadvantages of uterine preservation at the time of prolapse surgery.