Prophylactic vaginal apex suspension at the time of hysterectomy

INTRODUCTION — There is concern that hysterectomy, particularly when performed for the indication of pelvic organ prolapse (POP), increases the risk of subsequent POP [1-3]. Prophylactic suspension of the vaginal apex at the time of hysterectomy has been recommended in an attempt to reduce this risk. This topic will review the impact of hysterectomy on subsequent POP and the role of vaginal apical support procedures for preventing this outcome.

SUPPORT OF THE VAGINAL APEX — The rationale for performing a vaginal apical suspension at the time of hysterectomy is to recreate the support provided by the cardinal and uterosacral ligament complexes (Level 1 support) and thereby prevent or reduce the risk of future POP (figure 1) [4]. However, a study of a United States national database reported that of the over 2.7 million benign inpatient hysterectomies performed between 2004 and 2013 for a diagnosis other than prolapse, only 3 percent had a concomitant prophylactic apical support procedure [5]. Loss of Level 1 support results in apical prolapse of the vagina, which also contributes to more than 50 percent of anterior vaginal wall prolapse (the most common site of POP) [6,7]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Anatomy of pelvic support'.)

Potential mechanisms for post-hysterectomy prolapse include alteration in connective tissue or surgical injury to the innervation and vascularization of the pelvic floor muscles. (See "Hysterectomy (benign indications): Patient-important issues and surgical complications", section on 'Risk of pelvic organ prolapse'.)

IMPACT OF HYSTERECTOMY ON FUTURE PROLAPSE RISK — Studies have reported inconsistent results regarding the role of hysterectomy in the development of subsequent POP [1,8-16]. This variability likely reflects inter-study differences in patient populations (eg, proportion of patients with preexisting prolapse, age, menopause status), surgical technique (ie, type of cuff closure and incorporation of support ligaments), study design and size, outcomes criteria, and length of follow-up.

●Impact of prolapse – The risk of future prolapse appears to be increased when hysterectomy is performed for the indication of POP, while the risk of future POP repair in women with normal pelvic support is less clear [2,3,14,15].

For example, a retrospective review of over 2600 women who underwent vaginal or abdominal hysterectomy for benign indications at a single institution over a four-year period reported the incidence of subsequent vaginal vault prolapse was nearly 12 percent when hysterectomy was performed for POP (all vaginal hysterectomies) versus nearly 2 percent when hysterectomy was performed for other indications [17]. Information on apical support procedures at the time of hysterectomy was not available. The mean duration of follow-up was 11 years. However, the surgeries were performed between 1983 and 1987, which may have impacted the outcomes as guidelines requiring apical suspension at the time of hysterectomy for POP were not in place in the US until 2015 (see bullet on apical suspension below) [18].

●Impact of hysterectomy - In attempt to clarify the impact of hysterectomy on recurrent prolapse, a retrospective cohort study of nearly 100,000 women undergoing POP surgery in California between 2005 and 2011 reported a 30 percent lower risk of repeat POP repair in women who underwent concomitant hysterectomy compared with those who did not (absolute repeat POP rates of 3 versus 4 percent, respectively) [16]. In multivariate modeling, hysterectomy decreased the risk of future POP surgery for all compartments (ie, anterior, apical, and posterior). While repeat POP surgery rates were reduced, women undergoing hysterectomy had significantly higher complication rates, including increased length of hospital stay (mean 2.2 versus 1.8 days), rate of blood transfusion (2.5 versus 1.5 percent), rate of perioperative hemorrhage (1.5 versus 1.1 percent), rate of urologic injury or fistula (0.9 versus 0.6 percent), rate of infection or sepsis (0.9 versus 0.4 percent), and rate of readmission for infectious cause (0.7 versus 0.3 percent). However, with the exception of hospital stay, the absolute rates of postoperative complications remained low for both groups.

Thus, while it is biologically plausible that the risk of prolapse persists because of connective tissue or other factors, it is unclear if the underlying prolapse or the surgical approach confers the greater recurrence risk.

●Role of apical suspension – Evidence suggests that patients undergoing hysterectomy for uterine prolapse often did not have apical suspension performed routinely, which likely contributed to the high rate of recurrent prolapse following hysterectomy, and further confounds determining the impact of hysterectomy on recurrent prolapse risk.

•Rates of apical suspension – Retrospective data have reported prophylactic apical suspension rates of 24 to 55 percent at the time of hysterectomy for benign indications, including patients for whom prolapse was the surgical indication.

-A retrospective chart review of nearly 2500 hysterectomies performed at a tertiary care hospital reported that only 55 percent had a concomitant apical support procedure performed at the time of hysterectomy [19]. Of the procedures performed without apical suspension, 96 percent were performed by general gynecologists. By contrast, 96 percent of hysterectomies performed by urogynecologists also included an apical procedure.

-A different retrospective review of the Michigan Surgical Quality Collaborative, including over 1500 women who underwent hysterectomy for uterine prolapse between January 2013 and May 2014, reported that only 24 percent had an apical support procedure (colpopexy with or without colporrhaphy) and 43 percent had hysterectomy only [20]. Subsequently, in response to recommendations of an expert panel, the National Quality Forum selected vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse as prolapse quality indicators for United States hospitals [18].

●Impact on future prolapse surgery – A prospective Danish cohort study including over 7600 patients undergoing hysterectomy for non-prolapse and benign indications reported similar rates of subsequent prolapse surgery in the two years following index surgery for patients with and without apical vault suspension at the time of hysterectomy (0.9 versus 0.5 percent, respectively) [21]. The authors concluded that prophylactic vault suspension was not associated with an increased risk of subsequent prolapse surgery. Apical suspension procedures included prophylactic apical suspension, low uterosacral vault suspension, high uterosacral vault suspension, suspension to the cardinal ligament, suspension to the uterosacral ligament, and laparoscopic cardinal/uterosacral ligament ligation.

●Impact of hysterectomy route – The route of hysterectomy is another variable that may impact future prolapse risk. Vaginal hysterectomy has been reported to increase the risk of subsequent POP compared with abdominal hysterectomy [1-3,17,22]. However, the impact of vaginal hysterectomy on risk of future prolapse is unclear because the choice of surgical route is determined, in part, by the presence of underlying prolapse, which appears to be a major risk for subsequent prolapse [14,23,24]. The Danish nationwide cohort study, which included over 178,000 women undergoing hysterectomy for benign indications over a 40-year period, reported a threefold increase in prolapse after hysterectomy. However, when correcting for POP at the time of hysterectomy, the risk of POP only slightly increased for vaginal hysterectomy compared with abdominal hysterectomy (hazard ratio 1.25) [25].

The incidence of POP after laparoscopic or robot-assisted hysterectomy has not been established. However, evidence from a large cohort study reported no additional risk of POP with laparoscopic hysterectomy versus total abdominal hysterectomy [25]. There is concern that these techniques may be associated with an increased risk of post-hysterectomy POP because the traditional technique of clamping and suturing has largely been replaced with electrosurgical devices, which do not incorporate the uterosacral complex into the cuff closure.

OUR APPROACH — Women with symptomatic prolapse are treated with a pelvic reconstructive procedure. At the time of hysterectomy, the optimal approach for women who have prolapse symptoms with normal apical support, asymptomatic prolapse, normal pelvic support, or risk factors for prolapse is controversial.

Before hysterectomy, we evaluate women for pelvic organ prolapse (POP) both objectively and subjectively. For the objective evaluation, we use the Pelvic Organ Prolapse Quantification System (POP-Q), the standardized system for classification and measurement of uterovaginal prolapse [26]. We also assess for subjective POP symptoms with the validated short form Pelvic Organ Prolapse Distress Inventory (POPDI-6) [27]. Clinicians who are not familiar with the POP-Q or POPDI-6 can ask two questions instead: (1) do you have a vaginal bulge? and (2) do you have a sensation of pelvic pressure? These questions screen for POP in the majority of women diagnosed with POP on POP-Q [27-29]. (See "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Classification of pelvic organ prolapse'.)

Symptomatic pelvic organ prolapse — Women with symptomatic POP require a restorative procedure (eg, uterosacral ligament suspension, sacrospinous ligament fixation, or sacrocolpopexy), not routine hysterectomy or prophylactic apical suspension [13]. All areas of prolapse are addressed at the same time. (See "Pelvic organ prolapse in women: Choosing a primary surgical procedure".)

Symptoms, no apical prolapse — Women with prolapse symptoms but no demonstrable apical prolapse on physical examination may have prolapse symptoms related to loss of level 2 support structures (figure 1) [30,31]. While hysterectomy is not indicated in the absence of apical prolapse, an apical suspension at the time of the hysterectomy performed for other indications may be reasonably performed, and repair of any distal prolapse should be performed in these women. Although the data are limited, we believe apical suspension is beneficial as it restores support along the entire vaginal length. Patients are informed of the lack of data regarding this approach as well as the risks of increased operative time, bleeding, and organ injury.

For these women, we suggest a McCall culdoplasty or a uterosacral ligament suspension at the time of hysterectomy. In our practice, we prefer the uterosacral suspension because these procedures do not pull the uterosacral ligaments to the midline and therefore may cause less pain or risk of ureteral injury compared with the McCall culdoplasty. There is good evidence to suggest that these are safe and effective methods of apical suspension at the time of hysterectomy. (See 'Description of prophylactic vaginal suspensions' below.)

Asymptomatic prolapse — It is not known if women with prolapse on examination, but no prolapse symptoms, benefit from apical support procedures at the time of hysterectomy. In our practice, we offer these women concomitant apical suspension after counseling regarding surgical risks as compared with recurrent prolapse risk. A retrospective cohort study of over 2700 women reported that women who had a concomitant apical support procedure at the time of prolapse repair had lower reoperation rates for prolapse compared with women who did not have an apical support procedure (20 versus 12 percent) [32]. One limitation of this study is that it included women undergoing multiple types of prolapse repair and was not limited to women undergoing hysterectomy.

In these women, we perform a native tissue suspension (uterosacral ligament suspension or sacrospinous ligament suspension) and do not use synthetic mesh for repair because of the risk for mesh-related complications. In 2019, the US Food and Drug Administration (FDA) halted the sale and distribution of transvaginal synthetic mesh kits for POP [33]. (See "Transvaginal synthetic mesh: Management of exposure and pain following pelvic surgery".)

Normal pelvic support — The best approach for women with normal pelvic support at the time of hysterectomy is not known. We do not routinely perform a separate apical suspension at the time of hysterectomy in women without prolapse symptoms or physical examination findings. However, we do counsel women regarding the option and it is reasonable to perform an apical repair in the absence of symptoms or overt prolapse. Patient counseling includes a discussion weighing the 0 to 3.6 percent potential for future prolapse versus the similar risk of complications related to the repair, primarily to the urinary tract [34]. For women who elect an apical support procedure, we perform a McCall culdoplasty or uterosacral ligament suspension. (See 'Ligament suspension procedures' below.)

Prolapse risk factors — We discuss prophylactic vaginal suspension in women with prolapse risk factors because of the increased risk of future POP. There are no data to support the use of apical suspension in these women, or which procedure to choose. Risk factors for POP include family history of POP, previous vaginal delivery, menopause, advancing age, prior pelvic surgery, connective tissue disorders, and factors associated with elevated intraabdominal pressure (eg, obesity, chronic constipation, chronic cough) [13]. As noted in the prior paragraph, we counsel women regarding the 0 to 3.6 percent risk of future prolapse compared with the similar risk of surgical complications [34]. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Risk factors'.)

DESCRIPTION OF PROPHYLACTIC VAGINAL SUSPENSIONS — There is no robust evidence to guide the clinician as to the best surgical technique for prevention of prolapse after hysterectomy. Techniques include incorporation of the uterosacral ligaments into the cuff closure, culdoplasty, and ligamentous suspensions.

Vaginal cuff closure techniques — Numerous techniques have been described for closure of the vaginal cuff. To improve apical support, the apices of the vaginal cuff are typically attached to the uterosacral ligament pedicles. A culdoplasty can be done at the same time as the cuff closure. (See "Hysterectomy: Abdominal (open) route", section on 'Treatment of the vaginal cuff'.)

Data on the impact of vaginal cuff closure are sparse. During abdominal hysterectomy, the intrafascial closure technique preserves the uterosacral attachment and incorporates it into the vaginal cuff closure. A prospective study of 867 women with a median follow-up of 45 months revealed high safety profile and no post-hysterectomy vaginal prolapse [35].

At the time of vaginal hysterectomy, the lateral vaginal cuff suture incorporates the uterosacral ligaments, and some advocate plicating them in the midline, while others may perform a McCall type culdoplasty (see "Hysterectomy: Vaginal", section on 'Closure'). There are no data on uterosacral ligament incorporation into the vaginal cuff at the time of vaginal hysterectomy to prevent future prolapse [9].

We typically close the cuff with 0-polyglactin, 0-polydioxanone, or 0-polyglyconate suture in an interrupted or running fashion, with incorporation of the uterosacral ligaments in the closure when operating transvaginally. Suture choice is based on surgeon preference. (See "Principles of abdominal wall closure", section on 'Sutures'.)

In a total laparoscopic hysterectomy, the cervix and uterus are removed through the vagina and the closure is performed by transvaginal closure, or laparoscopic suturing either by traditional suturing techniques or a specialized suturing device (picture 1). Many surgeons advocate separate shortening or re-attachment of the uterosacral ligaments to the vaginal cuff with an additional suture (picture 2 and picture 3) [36]. At our institution, laparoscopic closure of the cuff is performed with 0-polyglactin suture in a running or interrupted fashion using a free needle. Alternately, the cuff can be closed using a polyglyconate barbed suture [30]. The uterosacral ligaments can be easily identified and marked by a cautery device prior to transection of the vagina. The lateral vaginal cuff is attached to the uterosacral ligament and tied into place to support the vaginal cuff. The ureter is identified prior to tying the suture to ensure that it has not been incorporated into the closure. Suture preference is largely surgeon specific. We recommend at least a 0 caliber suture and at least six weeks of pelvic rest postoperatively to decrease the likelihood of cuff dehiscence [31].

Culdoplasty — The factor common to all culdoplasty techniques is the incorporation of the uterosacral ligament complex into the repair. The rationale is that reattaching the vaginal apices to the uterosacral ligaments will prevent future apical prolapse. During vaginal and abdominal hysterectomy, performing these techniques requires little additional time and is low risk. Postprocedure cystoscopy is typically done when performing a prophylactic vaginal culdoplasty because of the risk of urinary tract injury [37].

Outcome data — Of the limited studies, the available data suggest that the McCall culdoplasty is superior at preventing future prolapse compared with the Moschcowitz culdoplasty or simple peritoneal closure. Two cohort studies that recorded women's pelvic anatomy pre- and postoperatively reported that women with McCall culdoplasty maintained apical support up to three years postoperatively [38,39]. In one trial, 100 women were randomly assigned to receive a McCall culdoplasty, a Moschcowitz-type culdoplasty, or a peritoneum-only closure [40]. At three years of follow-up, the McCall culdoplasty was associated with lower rates of apical prolapse (6 percent for McCall, 30 percent for Moschcowitz, and 39 percent for peritoneum-only).

McCall culdoplasty has also been compared with ligament suspension procedures. A retrospective study of 124 women reported no difference in prolapse recurrence rates between the McCall culdoplasty and the sacrospinous ligament suspension at four to nine years of follow-up [41]. In addition, a retrospective study of 693 women reported a patient satisfaction rate of 82 percent and a reoperation rate of 5.2 percent, which is similar to other techniques [42].

Techniques — The McCall culdoplasty approximates the uterosacral ligaments in the midline with a series of internal sutures followed by an external stitch that passes through the posterior vaginal cuff then through each uterosacral ligament and back through the opposite posterior vaginal cuff [43]. The use of permanent suture is not recommended because the knot remains in the vaginal cavity and can cause partner irritation during sex. A modification of the technique has also been described with both abdominal and endoscopic surgery (figure 2) [44].

The Moschcowitz culdoplasty closes the pelvic peritoneum with purse-string sutures that incorporate both the anterior and posterior peritoneum along with the uterosacral ligaments in order to obliterate the cul-de-sac. This technique may involve multiple circumferential sutures [45]. This technique has been described with both abdominal and vaginal hysterectomy and can be performed endoscopically (figure 3).

The Halban culdoplasty shortens each uterosacral ligament using a reefing stitch with vertical purse-string sutures placed between the uterosacral ligaments. This technique is traditionally performed in association with abdominal approach. The purpose of the Halban culdoplasty is to prevent enterocele formation; it has not been shown to prevent or treat vaginal vault prolapse [46]. We do not perform the Halban culdoplasty (picture 4).

Ligament suspension procedures — Uterosacral ligament suspension is an alternative to culdoplasty that results in a favorable anatomic repositioning of the vagina and is known as an effective treatment for POP (figure 4). This technique can be achieved vaginally, abdominally, or endoscopically [36,47]. However, there are no data on the use of uterosacral ligament suspensions to prevent vault prolapse after hysterectomy that is performed for non-prolapse indications [9]. We perform a uterosacral ligament suspension rather than McCall Culdoplasty because the uterosacral ligament suspension does not pull the ligaments toward the midline. The midline deviation caused by the McCall culdoplasty technique could result in pain or ureteral injury. In addition, we have more experience with the uterosacral suspension and find it more comfortable to perform.

A ureteral injury rate of up to 11 percent has been reported with this technique when done transvaginally [48]. Therefore, cystourethroscopy is performed to evaluate ureteral patency. The laparoscopic approach allows visualization of the ureters and may reduce the ureteral injury rate. A retrospective study of 22 patients undergoing laparoscopic uterosacral suspension for pelvic organ prolapse (POP) had no reported ureteral injury confirmed by postprocedure cystoscopy [36]. A clinical trial of prophylactic uterosacral ligament suspension at the time of hysterectomy is in process [49].

Other apical support procedures use the iliococcygeus and sacrospinous ligaments as anchor points (see "Pelvic organ prolapse in women: Surgical repair of apical prolapse (uterine or vaginal vault prolapse)", section on 'Surgical planning'). In a study of 374 women with vaginal prolapse randomly assigned to either sacrospinous ligament suspension or uterosacral ligament suspension, there were no differences between surgical success rates (60.5 versus 59.2 percent, respectively) or adverse outcomes (16.7 versus 16.5 percent, respectively) [34]. However, because of the need for additional surgical dissection, potential for serious complications, and lack of data on outcomes when used as a prophylactic procedure, we suggest not performing iliococcygeus and sacrospinous ligament fixations for prevention of apical prolapse at the time of hysterectomy.

INEFFECTIVE TECHNIQUES — When choosing a route of hysterectomy, supracervical hysterectomy does not appear to offer any advantages over total hysterectomy when the main consideration is POP prevention. Although supracervical (subtotal) hysterectomy preserves the cervix, upper vagina, and pelvic attachments, it does not prevent subsequent prolapse. Randomized trials comparing total abdominal versus supracervical hysterectomy have reported no difference in vaginal support, regardless of cervical preservation or removal [50,51]. Further, a retrospective review of 711 women operated on for POP found a higher rate of prolapse following supracervical hysterectomy (6.2 percent) compared with total hysterectomy (2.2 percent) [52]. Supracervical hysterectomies can be combined with a high uterosacral ligament suspension or a sacrospinous ligament fixation in cases where an apical suspension is warranted.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse".)

SUMMARY AND RECOMMENDATIONS

●The risk of future prolapse appears to be highest when hysterectomy is performed in women with existing prolapse. For women with normal pelvic support, the impact of hysterectomy for benign disease on future prolapse risk is unclear. (See 'Impact of hysterectomy on future prolapse risk' above.)

●The impact of vaginal hysterectomy on future prolapse risk is controversial because surgical route is determined, in part, by the presence of underlying prolapse, which appears to be a major risk for subsequent prolapse. The incidence of pelvic organ prolapse (POP) after laparoscopic or robot-assisted hysterectomy has not been established. (See 'Impact of hysterectomy on future prolapse risk' above.)

●Prior to hysterectomy, we assess for POP with the Pelvic Organ Prolapse Quantification System (POP-Q) during physical examination. All identified areas of prolapse are addressed at the time of hysterectomy. (See 'Our approach' above.)

●Women with symptomatic POP require a restorative procedure, not a prophylactic apical support procedure. The performance of vaginal apical suspension at time of hysterectomy to address POP has been endorsed by the National Quality Forum as a quality indicator. (See 'Symptomatic pelvic organ prolapse' above.)

●For women with prolapse symptoms but no demonstrable apical prolapse on physical examination who are planning hysterectomy for indications other than POP, we suggest an apical suspension at the time of the hysterectomy and repair of any distal prolapse rather than no apical suspension (Grade 2C). We perform a uterosacral ligament suspension in these women. (See 'Symptoms, no apical prolapse' above.)

●In women with asymptomatic prolapse, we suggest a native tissue suspension (uterosacral ligament suspension or sacrospinous ligament suspension) rather than no suspension or suspension with synthetic mesh (Grade 2C). (See 'Asymptomatic prolapse' above.)

●For women with normal pelvic support who are undergoing hysterectomy, we suggest not performing prophylactic suspension surgery (Grade 2C). Women who hope to minimize the risk of future prolapse and who are willing to accept the risks of this surgery despite the uncertain benefit may reasonably choose to proceed with prophylactic surgery. For women with risk factors for prolapse, the higher the expected risk of prolapse, the more likely we are to proceed with an apical support procedure.

●Culdoplasty incorporates the uterosacral ligament complex into the repair. The limited studies on culdoplasty techniques report the McCall culdoplasty has improved apical support at up to three years postoperatively compared with Moschcowitz culdoplasty or simple peritoneal closure. Postprocedure cystourethroscopy is performed to evaluate for urinary tract injury. (See 'Description of prophylactic vaginal suspensions' above.)

●Uterosacral ligament suspension is the proven procedure for POP and can be achieved vaginally, abdominally, or endoscopically. There are limited outcome data on this procedure as a prophylactic procedure. Cystourethroscopy is performed to evaluate ureteral patency. (See 'Ligament suspension procedures' above.)

●In cases where the uterosacral ligaments are inaccessible or inadequate, alternate procedures are the iliococcygeus or sacrospinous ligament fixation. We balance the risks of additional surgical dissection required for the procedure against the potential for serious complications and the patient’s tolerance for additional surgery. (See 'Ligament suspension procedures' above.)

●Supracervical hysterectomy compared with total hysterectomy does not prevent prolapse and should not be performed as a prophylactic procedure. (See 'Ineffective techniques' above.)