Supporting the Apex: A Critical Step in ALL Hysterectomies

It has been well established that with the increase in our aging population, we will have increased demands of patients symptomatic of pelvic floor disorders.^1, 2  Uterovaginal and vaginal vault prolapse is one of those disorders and negatively impacts the quality of life of millions of women each year.  Swift, et al, described in a community based population that almost 50% of asymptomatic women undergoing gynecologic exam had POP-Q Stage 2 pelvic organ prolapse.³  So common in fact, that Dr. Swift mentions this may be a variant of normal.  Many of these women subsequently seek consultation for gynecologic surgery and undergo hysterectomy for reasons other than pelvic organ prolapse.  While they may be asymptomatic of their pelvic floor weakness at the time of surgery, hysterectomy may predispose these women to becoming symptomatic in the future.  

Current evidence suggests that hysterectomy may be a risk factor for prolapse.^{4, 5}  These studies are limited by the length of follow-up, heterogeneity in the patient population, and differences in surgical technique during hysterectomy.   Furthermore, most studies do not evaluate for pelvic organ support at the time of hysterectomy.  While there is no current method to reverse the pelvic floor muscle injuries incurred during childbirth which likely precede symptomatic prolapse, identification of pelvic floor support and appropriate treatment of the vaginal apex should be a critical step of all hysterectomies performed by gynecologic surgeons.  

There are a variety of apical suspension techniques that can be used to incorporate support into the vaginal cuff closure during benign hysterectomy.  These techniques incorporate the Level 1 supportive structures of the uterosacral ligaments.  The McCall’s culdoplasty and uterosacral ligament suspension (USLS) are two such procedures.^{6, 7}  While traditionally done for symptomatic pelvic organ prolapse, these procedures can be incorporated as part of the hysterectomy to support the vaginal apex.  Traditionally, the McCall’s culdoplasty incorporates the vaginal cuff, peritoneum and bilateral uterosacral ligaments, plicating them in the midline.  The USLS avoids midline plication and supports the ipsilateral vaginal cuff to the intermediate portion of the ipsilateral uterosacral ligament.  While multiple suspension sutures are usually required for treatment of prolapse, prophylactic procedures may choose to minimize the support to 1-2 suspension sutures.  Both procedures were first described as vaginal procedures.  However, given the increase in laparoscopic hysterectomy, these procedures can also be performed from an abdominal approach.^{8, 9}  In fact, abdominal approach allows better visualization of the ureters and may minimize ureteral injury.  However, given the risk of ureteral injury, as with all hysterectomies, universal cystoscopy can be added as a safety measure to identify such injuries.¹⁰ 

Identifying lack of pelvic organ support prior to hysterectomy will likely improve the gynecologic surgeon’s ability to treat and prevent future pelvic floor disorders, such as pelvic organ prolapse.  Minimally invasive gynecologic surgeons should support the vaginal apex at the time of hysterectomy utilizing the uterosacral ligaments into their cuff closure, irrespective of the route of hysterectomy.¹¹

References

1. Wu, J.M., et al., Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol, 2014. 123(6): p. 1201-6.
2. Wu, J.M., et al., Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol, 2014. 123(1): p. 141-8.
3. Swift, S., et al., Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol, 2005. 192(3): p. 795-806.
4. Altman, D., et al., Pelvic organ prolapse surgery following hysterectomy on benign indications. Am J Obstet Gynecol, 2008. 198(5): p. 572.e1-6.
5. Aigmueller, T., et al., An estimation of the frequency of surgery for posthysterectomy vault prolapse. Int Urogynecol J, 2010. 21(3): p. 299-302.
6. Mc, C.M., Posterior culdeplasty; surgical correction of enterocele during vaginal hysterectomy; a preliminary report. Obstet Gynecol, 1957. 10(6): p. 595-602.
7. Shull, B.L., et al., A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol, 2000. 183(6): p. 1365-73; discussion 1373-4.
8. Restaino, S., et al., Laparoscopic Approach for Shull Repair of Pelvic Floor Defects. J Minim Invasive Gynecol, 2017.
9. Till, S.R., et al., McCall Culdoplasty during Total Laparoscopic Hysterectomy: A Pilot Randomized Controlled Trial. J Minim Invasive Gynecol, 2017.
10. Chi, A.M., et al., Universal Cystoscopy After Benign Hysterectomy: Examining the Effects of an Institutional Policy. Obstet Gynecol, 2016. 127(2): p. 369-75.
11. AAGL practice report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy. J Minim Invasive Gynecol, 2014. 21(5): p. 715-22.