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Aug 18

“Plumbing and Renovations” Preview – Uterine resuspension and other hysterectomy-free options for vaginal prolapse

(c) 2007 Urogynics PLLC, all rights reserved

Excerpted and adapted from “Plumbing and Renovations” by Dr. Lauri Romanzi

Published by Beauty Call Books
release date: January 2009, all rights reserved
Every year in the United States 200,000 women undergo surgery for vaginal pelvic organ prolapse. In many of these cases, hysterectomy is recommended, particularly when uterine prolapse is part of the problem. This hysterectomy mandate comes as a shock to many women with prolapse, who don’t understand why the problem cannot be fixed without hysterectomy, or without any surgery at all. These women represent a new trend in gynecologic reconstructive surgery; they want the prolapse fixed without removal of any gynecologic organs.

In fact, there is no scientific data at all that proves that hysterectomy is the best way to fix prolapse. Yet in gynecologic circles, hysterectomy is considered the standard surgical technique for for this condition. That tradition is increasingly scrutinized by the women it serves and the doctors who care for them, as well it should be, because it is possible and very reasonable to re-suspend a prolapsed uterus, avoiding hysterectomy, and get the same if not better results than when the uterus is removed.
And there are non-surgical ways to treat vaginal prolapse, some around for thousands of years, which can help a woman avoid surgery altogether.

WHAT IS PROLAPSE
Pelvic organ prolapse is an umbrella term for the different components of vaginal prolapse, including uterine prolapse, dropped bladder (cystocele) vaginal laxity (perineal body atrophy), rectocele and enterocele. Some women have a bit of each, others have only one or two components, but which ever and to whatever degree, pelvic organ prolapse is “a woman’s hernia”.

NORMAL ANATOMY

Normal pelvic anatomy (shown here) is a harmony of bodily functions buttressed by the Kegel muscles of the Levator ani. The uterus drapes gently over the top of the bladder, and the bladder, vagina and rectum are separated from each other by thin, sturdy fibromuscular walls composed of collagen, skin cells and smooth muscle. These walls hold the rectum and bladder in place, and tend to weaken with childbearing and age. At the vaginal opening, below the level of the muscles, is the perineum, a connective tissue separator of the anus and vagina which tends to thin out with childbearing and age. Above the muscles we find the uterus, held in place by the uterosacral ligaments much as a chandelier is held up by strong cables. The female pelvic support system is considered in compartments when doctors are figuring out what is out of place and how best to amend the condition. The anterior compartment contains the bladder and urethra; the posterior compartment contains the rectum and anus, the basement is the perineum and the ceiling contains the uterus.

A cystocele is a dropped bladder, often noticed during sex or toileting as a balloon like bulge at the vaginal opening:

CYSTOCELE (DROPPED BLADDER)

This happens when the connective tissue between bladder and vagina wears out or pulls off of the sidewall of the pelvis, leaving only the vaginal skin to hold up the bladder, which is too elastic to do the job well, and so the bladder bulges down toward the vaginal opening.

A similar thinning of connective tissue can occur between rectum and vagina causing a rectocele. In this illustration we see a rectocele along with an absence of perineum connective tissue between the anus and vagina with a bulging of the vaginal opening. Rectocele and perineum atrophy are often seen together, with symptoms of vaginal laxity, looseness during sex , a bearing down pelvic pressure with strenuous activity, and difficult defecation. In fact, many women with rectocele will press up on the perineum or backward on the vaginal wall toward the rectum during bowel movements to compensate for the bulging and make defecation easier. Doctors call this “splinting”. If you are doing this, you may have a rectocele or a thin perineum.

RECTOCELE WITH PERINEAL ATROPHY (VAGINAL LAXITY):

When the uterosacral ligaments stretch out, the uterus descends inside the vagina, and is often reported by patients as a firm mass at the vaginal opening, coming down either on the toilet or during strenuous activities like jogging or heavy lifting. This is uterine prolapse.

UTERINE PROLAPSE:

It is very common for women with uterine prolapse to report that the uterine slippage waxes and wanes, not there some days and very low and bothersome on others. It usually pulls back in when you lie down, and is often “in in the morning and out by the evening”. It is sometimes associated with a low back ache in the area of the tailbone.

WHY DOES PROLAPSE HAPPEN?
In other areas of the body, people accept connective tissue defects as something that can happen to anyone, and if it happens to you, get it fixed! Tear your knee ligaments, get it fixed and go to rehab. Develop and inguinal hernia, see the surgeon. Damage your rotator cuff, it’s either physical therapy or reconstructive surgery. But for some reason, when it comes to connective tissue disorders in the female pelvis, the common response is … to do nothing. And to blame something. Women often live with severe prolapse for decades, believing nothing can be done. They blame themselves; “I never did those Kegel exercises”. Or they blame the medical system; “my last baby came out so fast right in the bed. That’s why my uterus dropped”. Many are convinced that the prolapse “should not be happening to me; I eat right, exercise and stay healthy”. It’s none of those things, it’s just the same as all other wear and tear conditions; a little bit of nature and a little bit of nurture. If your connective tissue is extra-elastic (are you double jointed or can do splits with no problem?), and you birth children and live long enough, you are at risk for pelvic organ vaginal prolapse.

Pelvic organ prolapse affects 30% of all women and half of women who have borne children. One in nine women will have prolapse severe enough to warrant reconstructive surgery in the course of her lifetime. Women over aged 80 are the fastest growing segment of the North American populations, and liver far more active lives than preceding generations. This population bubble and quality of life expectation is expected to drive a growth in demand for prolapse health-care services that will be double the rate of population growth over the next three decades. Our great grandmothers bore this condition with stoicism and reticent modesty; our mothers and sisters are far more likely to seek help.

As with most hernias and ligament tears, prolapse is more likely to happen to you as you get older whether you stay in shape or never exercise at all, because all connective tissue regenerates more slowly and with less strength in older people than in younger people. But when it comes to women and vaginal prolapse, a growing body of research yields some fascinating explanations as to why some women can birth many children with no prolapse whatsoever, while other women’s bladders drop after the very first baby is born. Medical research shows that women with prolapse have different proportions of collagen (connective tissue) Type I vs Type III and biochemical differences in the enzymes that modify collagen regeneration compared to women without prolapse. And the second factor in this nature vs. nurture paradigm is childbirth. Big babies and long labors make a woman more prone to pelvic floor disorders. In other words, women who are super-elastic are prone to prolapse, particularly if they give birth to large babies with long labors.

TREATMENT
Prolapse is recognized in texts of all eras. The Guide to Women’s Health, written circa 1900, outlines the causes and treatments in this way:

Notice the causes: “improper manner of dress such as tight lacing, or the weight of heavy clothing or mismanagement of difficult childbirth…” to be treated with extract of Belladonna, chamomile, and homeopathic preparations such as Nux Vom, a remedy for stomach and digestive symptoms.

These days we have two treatment options for severe prolapse; prosthetic support or reconstructive surgery. A third option looms largely unproven, and this is the possibility that Kegel exercises, which condition and tone the levator ani muscles, will prevent prolapse from happening or will pull prolapse back into position.

PESSARIES
Prosthetic devices for vaginal prolapse are called pessaries. They come in a variety of shapes and sizes, and these days are made of latex or silicone. Pessaries are an ancient therapy. The best pessary is one that the patient can insert and remove herself, that fits with no discomfort and that holds the prolapse in place without fail during all levels of activity.

Pessaries from the early 20th century made of various metals:

Pessary options today:
Your gynecologist can help you find a pessary that works for you. My personal favorite is the ring plate pessary (O) because it is the easiest for the patient to insert and remove, particularly for women who have used diaphragms in the past; the configuration, insertion and removal techniques are similar. There is less likelihood of vaginal reaction if you can take the pessary out every night. But the ring rests on the levator ani muscles; if the muscles are thin and weak, this pessary will be difficult or impossible to retain, in which case I move on either to the Gelhorn for uterine prolapse (L,M,N) or the Gehrung for severe cystocele (J), neither of which need levator muscles to rest on, being retained through other, painless, means. Some pessaries come with bolsters along the rim (A, P, Q, S, V, T) designed to reduce urine leakage in women with the pelvic disorder combination of urinary incontinence and prolapse, a combination I fondly refer to as “plumbing and renovations”.

Pessaries don’t really cure prolapse, but they can provide a very effective long term treatment. Whether or not pessary use slows the progress of prolapse is not known. On a few occasions, I have seen women “shrink wrap” around a pessary left in for years without medical monitoring, and upon extraction, the prolapse is effectively gone with no pessary or surgery needed, but this is uncommon. Most pessary users have to be refitted for a bigger size within 5 years.

There is one promising new treatment that may help remodel the vagina and reduce prolapse while silently exercising the levator ani muscles;

the Colpexin device
(http://www.colpexin.com/)
Colpexin is the only vaginal device with data showing that it actually reduces prolapse in addition to increasing pelvic muscle fitness. It is worn for 16 weeks, during which time it tones and stimulates the levator ani muscles. At the end of the 16 week pre-clinical trial, 81% of the women had measurably lesser prolapse on examination by the doctor, 63% had stronger, more fit levator muscles, and 92-100% were happy with their results, reporting better vaginal muscle fitness and bladder control, stating they would recommend Colpexin to a friend.

KEGEL EXERCISE
Kegels are the dental floss of the female pelvis. Keeping these muscles strong and bulked with exercise is a very large pound of prevention that all women of all ages should practice. It makes sense that Kegel exercise prevents prolapse, but medical researchers have yet to answer that question. Other than the single study on the Colpexin device, we are not sure if Kegel exercises prevent or treat pelvic organ prolapse. No other device or Kegel exercise technique has been tested for prolapse treatment. There is plenty of data, by the way, showing that Kegels are good for bladder control and a few studies that show Kegels will give you a stronger orgasm, but none shedding light on whether or not Kegels will hold your vaginal parts in place nor even how best to do Kegels. If you have moderate prolapse, Kegels make pessary use more successful. On the other hand, if you have severe prolapse, it is very unlikely that Kegels will do much to pull your parts back into position, any more than sit-ups would help a large groin hernia.When it comes to Kegels and prolapse, one can only apply a healthy dose of common sense; it is probably very helpful to keep your levator ani muscles in good shape with Kegel exercises.

PELVIC RECONSTRUCTIVE SURGERY
But some women cannot be successfully fit for a pessary, or simply don’t want to use one, in which case the only other alternative is an operation that puts everything back in place. Female pelvic reconstructive surgery is much like hernia surgery in that the goal is to restore support and contour to a body part that is bulging out of normal position, causing pain or disability and interfering with body – image, quality of life or range of motion. And like all reconstructive surgeries, it carries with it the potential for recurrence. Knee repairs may have to be re-done, as might face lifts, rotator cuff repairs and abdominal hernias. But unlike other hernia surgery, pelvic reconstructive surgery involves organs that might turn malignant as a woman ages, highlighting the first argument in favor of the unwritten rule that prolapse surgery should include hysterectomy(removal of the uterus) and/or oophorectomy (removal of the ovaries).

Traditional gynecologic training is predicated on the notion that the uterus is only good for childbearing, and that the uterus and ovaries should be removed at the time of any gynecologic surgery in any woman over age 45 since she is unlikely to bear more children and removal of the gynecologic organs will prevent cancer. The average woman has a 2-3% lifetime risk of uterine or ovarian cancer, both of which peak in incidence around age 60. And with no reliable screening test for ovarian cancer, it is obvious why gynecologic tradition favors hysterectomy and removal of ovaries if you are close to or already in menopause (average age 51), when the ovaries stop producing eggs and estrogen. If the ovaries aren’t doing anything, why not remove them and reduce the woman’s cancer risks? Ovarian cancer is an aggressive, difficult to diagnose, high mortality cancer, with post-diagnosis morbidity and mortality similar to that of melanoma and pancreatic cancer. By the time you have symptoms, ovarian cancer is typically in an advanced stage. Women with increased gynecologic cancer risks (personal history of breast cancer, strong family history of colon, breast or ovarian cancer, BRCA gene positive women, exposure to high dose radiation or DES) have up to a 50% risk of gynecologic cancer and often welcome the opportunity to take care of two health concerns at once. Whether average or high risk, this cancer concern is the most salient of pro-hysterectomy arguments and deserves thoughtful consideration by any woman undergoing prolapse surgery.

On the other side of this cancer-prevention argument, I paraphrase my patients’ concern: “if you did not have any prolapse, would you have any reason to remove your uterus or ovaries?” If the answer is no, and she is willing to go on living with her average ovarian and uterine cancer risks, she is an ideal candidate for uterine resuspension prolapse repair, which leaves all organs in place while fixing the prolapse just as well, if not better, than prolapse repair done with hysterectomy.

Which introduces the second classic justification for hysterectomy at the time of prolapse repair is that the uterus is going to “fall back down again”. This argument is as flimsy as the cancer prevention argument is worthy. The uterus is held in place by strong ligaments called the uterosacral ligaments. The uterus is like a chandelier in the ceiliing, and the uterosacral ligaments the cables holding it in place. The uterus does not fall down because it is heavy, it prolapses because the ligaments give way. Repair of the ligaments is crucial to successful uterine prolapse surgery; if not taken care of, the surgeon will simply turn the uterine prolapse into a vaginal inversion.

Vaginal Inversion Prolapse:

The uterosacral ligaments stretch during childbirth, making uterine prolapse a childbirth injury, even though it may take place 20 or 30 years later. The uterus is not a weight and it will not stretch the ligaments out again after surgery. Fix the ligaments and you fix the prolapse. and the latest data shows that the new, uterine-sparing prolapse repair versions of the traditional hysterectomy-based operations are just as successful.

The final argument for removing the uterus at time of hysterectomy is that it will help your sex life. There are many studies showing that hysterectomy has no effect or even improves sexual function, although if you read between the lines, you often find that this “benefit” is “probably due to the amelioration of the symptoms that have previously had a negative effect on sexual function.” (Mokate T, et al; Hysterectomy and Sexual Function, J Br Menop Soc, 2006) and other researchers caution us that “There are reasons to believe that removal of the uterus can have adverse effects on female sexual functioning by disrupting the anatomical relations in the pelvis. …A critical attitude towards the indications of hysterectomy remains mandatory.”(Maas CP et al; The effect of hysterectomy on sexual functioning. Annu Rev Sex Res 2003).

So what happens if a woman has a uterus removed that is not in and of itself a source of pain or discomfort? One very troubling study showed a serious impact on sexuality in women ages 39-45 who underwent hysterectomy for irregular bleeding as compared to women with the same condition who underwent a uterine-sparing treatment called endometrial ablation, with 70-82% of the hysterectomy patients reporting extreme negative impact on sexual arousal, libido and vaginal lubrication. Other research shows that hysterectomy reduces blood flow to the vagina and ovaries and this reduction in blood flow correlates with a drop in sex hormone levels in the bloodstream. Decreased blood flow to the vagina may also diminish capillary bloodflow, sexual engorgement and sexual pleasure, but this theory remains to be proved.

This holy trinity of hysterectomy advocacy is, in each and every facet, open to challenge. Hysterectomy may well have a negative impact on your sex life unless your uterus is a source of pain or sexual dysfunction all by itself, the prolapse repair holds up just as well whether you leave the uterus in or take it out, and gynecologic cancer risk in the average woman is quite low. It is very reasonable to decide to leave the uterus and ovaries in at time of prolapse surgery unless there is good and specific gynecologic reason to take them out; prolapse alone is simply not one of those reasons.

And remember the argument that the ovaries are “doing nothing” after menopause and are therefore no more than potential sites of future cancer?

Compelling new data shows that the menopausal ovary may well lengthen your life.
A recent epidemiologic study showed that removing ovaries before age 70 has a negative impact on life expectancy, in other words, for reasons we do not yet understand, removing the ovaries before that age appears to shorten a woman’s life. (Parker et al; Ovarian Conservation at the Time of Hysterectomy for Benign Disease. Obstet Gynecol 2005 Aug). This controversial and fascinating research will surely beget more research that will confirm or refute the original work. In the meantime, beware the mighty menopausal ovary; it may do you more good than harm.

Operations to fix uterine prolapse usually involve hysterectomy followed by resuspension of the top of the vagina where the cervix used to be, which is called the “vaginal cuff”. Each operation to suspend the vaginal cuff can be modified to resuspend a prolapsed uterus. There are three basic approaches.

The sacrospinous ligament may be used as an anchor point(sacrospinous fixation), a ribbon of permanent mesh can be used to connect the apical compartment of the vagina, or “ceiling”, to the sacrum bone of the spine (sacrocolpopexy), or the uterosacral ligaments may be used to lift the apex back up in an anatomically correct manner(uterosacral fixation). In each instance, these procedures are traditionally done immediately after removal of the uterus, and in each instance, uterine sparing modifications are now available for women who prefer to avoid hysterectomy. Each procedure has it’s benefits and it’s risks, so that selection is done to meet the individual needs of each patient with prolapse.

There is a fourth procedure that has fallen by the wayside of gynecologic training, a handy vaginal operation called a Manchester procedure. The classic Manchester-Fothergill uterine resuspension was first introduced in 1888, presumedly to resuspend the uterus in young women toiling in the sheep shearing industry. Repetitive lifting of sheep would cause the uterus to drop in some women, making childbearing difficult, and so this procedure was originally devised to resuspend the uterus and preserve fertility. Manchester procedure involves wrapping the less robust “cardinal” ligaments of the uterus in front of the cervix, then shortening the cervix so that it cannot be seen or felt at the vaginal opening. Over the years the Manchester went from an operation used in young women to an operation typically reserved for elderly sedentary women, in part because it carries a high rate of cervical scarring from the vaginal skin sealing over the cervical opening, which can trap menstrual blood in the uterus,a condition called hematometra (hee-matt-oh-meetrah).

In my training I was fortunate to work with a surgeon who specialized in this Manchester operation, and it became clear that the evolution from ‘young woman’s operation” to “sedentary seniors” operation was a most practical one; the cervical stenosis alone is unacceptable in a menstruating woman, and on careful anatomic follow-up, I found that it did not do a great job of replacing the uterus at the very top of the vagina. Rather the Manchester procedure seemed to pull the uterus back up about mid-way, leaving a lot of laxity in the untouched uterosacral ligaments.

Mechanics of Prolapse Surgery
As with all reconstructive operations, pelvic prolapse repair carries with it the risk that the prolapse may recur. The sacrospinous ligament repair has the greatest tendency to recur, while the sacrocolpopexy (using the mesh ribbon)and uterosacral fixation are considered more reliable, but are a bit more complicated to perform.
Sacrospinous Fixation

Sacrospinous fixation is a vaginal operation that connects the top of the vagina with suture to the sacrospinous ligament, a deep pelvic connection between the bottom of the spine and the hip bones. When it is done along with hysterectomy, the operation holds up in 80% (and in one study 90%) of patients. When the uterus is left in, success rates are comparable, with only 2.3% of patients in one study requiring more prolapse surgery after sacrospinous uterine resuspension. In another study from the Netherlands, women who underwent sacrospinous fixation of the vaginal cuff had higher rates of urinary incontinence than did those who underwent the uterine-sparing sacrospinous uterine resuspension. Sacrospinous fixation does carry a risk of pelvic pain, presumedly from the suture irritating the sciatic nerve, and in some series is associated with rectal complaints as well.

Sacrocolpopexy

Sacrocolpopexy is an abdominal operation that connects the top of the vagina with a strip of permanent synthetic mesh to the sacrum bone. This operation is sturdy, with many studies showing success rates of over 90%.

When done with the uterus left in, sacrohysteropexy, it holds up in 93-100% of  patients. This operation, being abdominal, takes longer that vaginal resuspensions, taking anywhere from 45 minutes when done through a bikini cut incision, to 3-5 hours when done laparoscopically or robotically. And on rare occasion this operation can cause hemorrhagic blood loss if the middle sacral artery, located on the sacrum in the area where the mesh is attached to the bone, is disrupted.
Or, again rarely, the mesh can erode into the top of the vagina or cause problems with the intestines if it is not covered properly, although there is one study that showed no problems with mesh and intestines in women where the mesh was not covered at all.

Sacrohysteropexy

Uterosacral fixation is another method of fixing uterine prolapse, or fixing vaginal apex prolapse in women who have had hysterectomy. Typically done abdominally, laparoscopically or robotically, it can now be done, without removing the uterus, in the most minimally invasive way, that being through the vagina.

Uterosacral Fixation


Uterosacral fixation shortens the uterosacral ligaments to support the vaginal cuff or uterus, making it the most anatomically accurate of all these repairs, since the uterosacral ligaments were the original support structure of the uterus. Uterosacral fixation of the cuff holds up 90% of the time and is usually done at the time of vaginal hysterectomy. It’s uterine preserving corollary is done through an abdominal bikini cut incision or laparoscopically. It is possible to kink the ureter with this procedure, which happens in 1-2% of the cases, and surgeons always check for this during the operation, so that any kinks can be corrected.

Manchester Procedure
And then there is the Manchester Procedure, originally devised for those sheep- shearing young women, on which there is only one study reporting how well this operation holds up over time, despite the fact that the operation has been in use since 1888. This single Turkish study found a 4% recurrence of uterine prolapse in women who had undergone Manchester 3 years prior to the study evaluation. More troubling was the 12% incidence of cervical stenosis, that condition that traps blood in the uterus, requiring more surgery to open the cervix.

The Best of Both Worlds: Uterosacral Vaginal Hysteropexy
About 12 years ago I was consultant to a 38 year old divorcee with severe uterine prolapse and vaginal laxity. She wanted an operation that would preserve the uterus without any abdominal incisions or visible scars, and had come to me because she thought a Manchester procedure would be the best operation for her. I had been trained to do the Manchester only on women with very minimal levels of physical activity, with women in her age range advised to undergo hysterectomy. It was a challenge to consider, at that time, the possibility of prolapse repair on young women without resorting to hysterectomy, and I had no uterine-resuspension operation other than the Manchester in my repertoire.
And so it went, she would come in, we would review her options, she would leave to come back another time hoping that something new would crop up. On one of her visits, we were going over the operation techniques again when she asked “can’t you do that uterosacral fixation through the vagina without removing the uterus?”. This patient was a genius.

The operation she inspired combines the Manchester “cut and wrap” with the robust uterosacral fixation to create a 4 point suspension of the uterus, using the strong uterosacral ligaments instead of the flimsy cardinal ligaments.

The first part of the operation is exactly like the first step of a vaginal hysterectomy, where the uterosacral ligaments are detached from the back of the cervix so that the uterus can be removed vaginally. But with this new resuspension, the ligaments are cut so they can be wrapped around the front, lifting the uterus rather than pulling it out. Similar to the Manchester, but much stronger, this ligament detach-and-wrap is done without any cervical shortening (unless the cervix is extraordinarily long), avoiding the problem of cervical closure from overgrowth of vaginal skin.

Vaginal Uterosacral Hysteropexy close up of ligament cut-and-wrap component

Whenever a reconstructive operation is designed, it is best to spread out the tension over more than one spot, so that gravity is distributed over a wider surface area. Which works better, walking on snow in high heels, or walking on snow with snow shoes? Same concept. So to reinforce this Manchester-like cut and wrap using the ends of the uterosacral ligaments, this uterosacral hysteropexy incorporates standard uterosacral fixation technique in the mid-portion of the ligament above the level of the cervix. By combining techniques from these two operations, the double wrap is reinforced by a double tuck, giving 4 points of fixation rather than one, and spreading out the strain over a larger surface area in different anatomic planes.

It’s a bit tricky to do with the uterus “in the way”; remember a standard uterosacral fixation is done at the time of vaginal hysterectomy where you first take out the uterus and then suspend he vagina to the ligaments. But using special retractors shaped like shoe horns, the uterus is gently held aside through a vaginal incision, making the uterosacral ligaments accessible without removing the uterus. This last uterosacral fixation part pulls the uterus up to where it was when you were 18 years old. Where it’s supposed to be. Without belly scars and without synthetic mesh.
It looks like this:
Uterosacral Vaginal Hysteropexy (Uterosacral Uterine Resuspension)

When I last saw her in clinic 8 years after her reconstruction, this patient’s repair showed no signs of recurrence, as if she had never had a prolapse or vaginal laxity problem.

In 2004, data on the uterosacral vaginal hysteropexy operation short-term data was presented at a national urogynecology conference and a national pelvic surgery conference. The study looked at women who had the uterosacral vaginal hysteropexy (inspired by my visionary patient), and women who had the standard vaginal hysterectomy followed by uterosacral fixation to the top of the vagina; in essence the same operation either leaving the uterus in place or taking it out.

The followup was 1 1/2-2 years on average (range 1-8 years) . Whether we left the uterus in or took it out, there was no difference in complications, with 2 ureteral kinks in the hysterectomy group and none in the hysteropexy group. For women who were three years or more since their operations, the overall repair durability was worse in the hysterectomy group than in the hysteropexy (uterine preservation) group with 88% no recurrence in any area of repair and 91% no recurrence of uterine prolapse in the uterosacral vaginal hysteropexy group and a 75% no recurrence in any compartment and 90% no recurrence of vaginal cuff prolapse in the hysterectomy group. This difference in global repair durability was due to a greater recurrence of cystocele (dropped bladder) in the hysterectomy group than the hysteropexy group. This is no surprise; in the world of pelvic organ prolapse reconstructive surgery, if anything is going to fall back down again over time, it’s usually the bladder. Long term follow-up on this and other uterine resuspension (hysteropexy) and hysterectomy-based operations will help us understand how durable these various prolapse repairs are.

My favorite aspect of this uterosacral vaginal hysteropexy operation is that it restores normal vaginal architecture at the same time it resuspends the uterus by re-creating the pocket, called the fornix, of the vagina where the cervix rests, leaving a normal vaginal length and contour. It also creates a solid anchor for repair of cystocele and rectocele defects below the uterus, holds up well over time and allows total correction of any prolapse combination without any scars or abdominal incisions. Over the past 5 years I have taught this operation to a few colleagues, and we are all equally pleased with the results.

 

Both Sides of the Coin: Responsibility and Choice
Female pelvic prolapse is a by-product of childbearing, super-elastic connective tissue and vigorous living. It is a sign that you have lived a full life. It is not your fault, it is not something you have to live with and it is not a problem that hysterectomy will fix.

In 1940, a woman could expect to live a few years past menopause to the age of 59. If you lived long enough to develop vaginal prolapse, just about any operation was likely to last a lifetime, in large part because life expectancy was so short. And treatments for gynecologic cancer were rudimentary compared to today’s standards, so the “hysterectomy as cancer prevention” rule made a lot of sense at that time.

Today the most rapidly growing segment of the population are people over 80, the majority of whom are women. And these women have very different lifestyles and quality of life expectations than prior generations. One of these expectations is choice. Women are no longer willing to undergo hysterectomy unless it is the best choice. And when it comes to prolapse repair, other issues aside, hysterectomy is not mandatory, no matter how severe the prolapse and no matter how far past childbearing you may be. The choice is yours. Choose wisely.

Bibliography

Pathophysiology references:

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2. Liu YM, Choy KW, Lui WT, Pang MW, Wong YF, Yip SK. 17 beta-estradiol suppresses proliferation of fibroblasts derived from cardinal ligaments in patients with or without pelvic organ prolapse; Hum Reprod 2006 Jan;21(1):303-8.

3. Phillips CH, Anthony F, Benyon C, Monga AK. Collagen metabolism in the uterosacral ligaments and the vaginal skin of women with uterine prolapse. BJOG 2006 Jan; 113(1):39-46.

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Incidence and Prevalence References:

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7 comments

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  1. Louise

    I couldn’t help comparing the anatomical diagrams (based on cadaver orientation) that appear through the paper with the last illustration, Superb Womanhood. If Ms S Womanhood had POP I doubt that she would notice it much, because her bladder and uterus would flop forward and be supported by her pubic bone, right out of the way of her vagina. However, if she spent much of her evenings slumped in a lounge chair in front of a TV and her days driving around in a semi-recumbent car seat designed for a man, then she certainly would feel her symptoms, just like your diagrams. Perhaps posture has a crucial role in preventing symptoms from affecting a woman’s life?

    1. admin

      “Superb Womanhood” is also the closing image in my book on pelvic organ prolapse entitled Plumbing and Renovations. Ms. Superb’s hyper-extended posture most certainly places her locked knees at risk,if not her pelvic organs. Our anatomic concepts of the day do not support your theory that the pubic bone would “catch” a potentially prolapsing uterus. notorious for stubbornly abiding the laws of gravity and, like running water, prone to taking the path of least resistance. Your theory about posture, however, is somewhat neglected albeit active area of interest in urogynecology with, thus far, little clinical data one way or the other. My personal favorite image detail in Plumbing and Renovations is the ‘hand on the back’ of the pair of women, one without and one with pelvic organ prolapse, on pages 42 and 43. If only the good Dr. Pancoast would remove said hand, I suspect both women would fare better. I think my grandmother, who always told me to stand up straight, relax my shoulders, pull in my stomach and tuck in my bum, had the right idea. Many thanks Louise, and best health!

  2. Louise

    Yes, her knees are locked, aren’t they? I didn’t see that at first. She doesn’t look very balanced; more like the figurehead on a boat. I couldn’t stand like that all day. However, by relaxing back a little onto the centre of her feet, letting her hands come forward and unlocking the knees it would be pretty good posture.

    It is encouraging to see that you accept that posture is a, “somewhat neglected albeit active area of interest in urogynecology”. How hard would it be to look for clinical evidence of the role of posture in supporting pelvic organs? If it was proved that the pubic symphysis could (or did) carry much of the vertical load of the prolapsing uterus and bladder, would that change the anatomic concepts of the day? I am not sure that the anatomic concepts of the day are wrong, simply incomplete. The configuration of the pelvic region and its organs when a woman is vertical is quite different from when she is recumbent like the cadavers on which our anatomical drawings are based. I think only good medical images or examination of active, vertical women with living, working muscles would provide information on the role of the pubic symphysis (arch?) in supporting the uterus and bladder. Simply rotating the picture to represent vertical orientation does not account for the semi-liquid behaviour of pelvic organs and how they move over each other in the pelvic cavity.

    BTW, I agree. The women would be much more comfortable if Dr Pancoast kept his hands to himself!

    1. admin

      You may be pleased to learn that much of contemporary anatomic renderings are indeed based on vertical imaging of living women using high-def sonography and dynamic MRI – women with and without prolapse, with and without incontinence – most revealing. Your concept of the pubic symphysis as a supportive shelf for the uterus is interesting. Having examined many women in the standing and upright seated position, both with and without prolapse, I am not sure that clinicians or dynamic radiologists who benefit from such a realtime-real life perspective share the belief that the boney symphysis plays any role in direct uterine or vaginal support. That said, Einstein was famous for his “thought experiments” – perhaps your anatomic opinions will yet prove true.

  3. Louise

    In reality, for modern Western women, the pubic symphysis often doesn’t provide much support for the bladder and uterus because we are encouraged to pull the tummy and butt under, and not lead the way with our breasts. This modern posture pushes the bladder and uterus backwards off the pubic symphysis. The result is that the bladder and uterus do end up resting on the pelvic floor. By reconfiguring our posture back to a more ‘primitive’ posture with our breasts and butt more prominently displayed and the lower belly relaxed, the bladder and uterus can fall forward onto the relaxed, front abdominal wall, underpinned by the pubic symphysis. For me, this posture definitely does throw both my bladder and uterus forwards. I have a prolapsed uterus, and significant cystocele and rectocele, and can feel the forward movement of my bladder and uterus, and the rising of my prolapses, with my own hands when I pull up into more primitive posture, compared with more androgenous, modern Western posture. I feel sure that this new upright scanning technology would enable clinicians and radiographers to see the difference and measure it for themselves. It would not be the first time that a new technology enabled fresh insight into current scientific thinking and changed ‘anatomical concepts of the day’.

    Re Thought Experiments, I understand that Thought Experiments are not valid if they draw out a contradiction in a theory, or if they conflict with other beliefs that are held, or if they undermine a central assumption or premise. Galileo made the mistake of undermining the central premise (and widely held belief) that the sun rotated around the earth, and was excommunicated for his trouble. The only problem was that the widely held belief was ultimately proved to be false.

    1. admin

      Your detailed and persistent commentary continues to intrigue. Thought experiments are designed to question established theory, and by nature tend to question central assumptions, otherwise, what’s the point? Should your theories prove true, I anticipate that the medical establishment would manage to refrain from drastic acts of retribution. All the best you you and your fellow- pelvic activists.

  4. Anonymous

    I loved going through the article, you totally knocked it out of the ballpark! I have sent a link to my dad, and shall definately be returning for more updates.

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