Vaginal Hysterectomy, Uterosacral Ligament Suspension, and Excision of Redundant Vaginal Tissue
Table of Contents
Uterine prolapse refers to the uterus descending into the vaginal canal because of weakened pelvic floor muscles and overstretched ligaments. It can occur at any age, but most often affects post-menopausal women. Common causes of uterine prolapse include childbirth, surgery, menopause, aging, extreme physical activity, and heavy lifting. There is also a genetic component. Uterine prolapse can be categorized as incomplete or complete: Incomplete uterine prolapse refers to a partial displacement of the uterus into the vagina without protrusion to the exterior; complete prolapse refers to the uterus protruding from the vaginal opening. The severity of uterine prolapse is graded by how far the uterus descends: Grade I refers to the uterus descending to the upper vagina; Grade II refers to the uterus descending to the introits; Grade III refers to the cervix descending outside of the introitus; in Grade IV, the cervix and uterus have both descended outside the introitus. Symptoms depend on the severity of the prolapse; however, most women have a feeling of fullness or heaviness in the pelvic area that often worsens when coughing, standing, or lifting. Other symptoms include lower back pain, urinary incontinence or retention, bulging in the vagina, and problems with sexual intercourse. Uterine prolapse is generally diagnosed during a pelvic examination. Treatment depends on the severity of the prolapse. Self-care measures include Kegel exercises, avoidance of heavy lifting, managing chronic cough, and treatment of constipation. These can reduce the risk of uterine prolapse and prevent it from worsening. Nevertheless, in severe cases, a vaginal pessary, reduction of the uterus to its normal position, or hysterectomy may be needed. Here, we present a patient with a severe case of uterine prolapse. A vaginal hysterectomy with uterosacral ligament suspension and excision of redundant vaginal tissue was performed.
Uterine prolapse is the downward descent of the uterus into or beyond the vagina secondary to global pelvic floor weakening and dysfunction.1, 2 Postmenopausal women are at the highest risk, although it can occur at any age. Development of uterine prolapse is multifactorial, but risk factors include vaginal childbirth, multiparity, prior hysterectomy, and conditions that result in increased intra-abdominal pressure, such as high body mass index, chronic cough, constipation, and heavy lifting.2, 3 It is difficult to quantify the frequency of uterine prolapse due to variable definitions and criteria. It is reported that loss of vaginal or uterine support is seen in up to 30–76% of women presenting for a routine gynecological exam, but only a small fraction of these women report symptoms.1, 4 Women in the United States have a 13% lifetime risk of requiring surgery for pelvic organ prolapse.1
The classification system for uterine prolapse is based on the level of distension of the uterus and ranges from grade I–IV5">5:
- Grade I refers to the uterus descending to the upper vagina.
- Grade II refers to the uterus descending to the introits.
- Grade III refers to the cervix descending outside of the introitus.
- Grade IV refers to the cervix and uterus both having descended outside the introitus.
This patient is a middle-aged, indigent, multiparous, Filipino female with a symptomatic procedencia/total uterine-vaginal vault prolapse and stress urinary incontinence.
In this case, total uterine-vaginal vault prolapse is visualized on a general inspection of the external genitalia. This degree of anatomic defect is rarely seen today in advanced countries; thus, a pelvic examination in the dorsal lithotomy position is generally required for diagnosis and to determine the severity of the uterine prolapse.
Imaging typically does not play a role in the evaluation of mild uterine prolapse as diagnosis and grading are usually achieved based on history and physical exam alone. In cases of recurrent, complicated, multicompartment uterine prolapse where performing a complete physical exam may be challenging, both magnetic resonance imaging and translabial ultrasound have been reported as valuable imaging modalities.6, 7
Further research is needed on the natural progression of uterine prolapse. Based on the limited reports available, prolapse will typically both progress and relapse. In postmenopausal women, prolapse tends to progress more than relapse.8
Conservative treatment is effective for many women and includes Kegel exercises and the avoidance of increasing intra-abdominal pressure by minimizing chronic cough, heavy lifting, and constipation. These actions can both reduce the risk of developing uterine prolapse and prevent existing prolapse from further progressing. A vaginal pessary is a non-surgical intervention that may be used in women with symptomatic prolapse refractory to conservative methods or for women who prefer not to undergo surgery. Although robust studies assessing the effectiveness of pessaries are limited, the American College of Obstetricians and Gynecologists (ACOG) and the American Urogynecologic Society (AUGS) both endorse the use of pessaries in the treatment of uterine prolapse.1 Surgical treatment is reserved for patients who are bothered by their prolapse and who have failed or declined conservative treatment options.1
Surgical repair typically falls into two categories: obliterative and reconstructive. Obliterative surgery will narrow or close off the vagina to support the prolapsed uterus. Vaginal sexual intercourse will no longer be possible after this procedure. Conversely, reconstructive surgery aims to restore the natural anatomy of the pelvic organs. Worldwide, vaginal hysterectomy is the most commonly performed surgical method to correct uterine prolapse and is largely considered the technique of choice by practitioners.9 Other techniques exist to correct uterovaginal prolapse including uterine-preserving hysteropexy with mesh reinforcement and the Manchester operation, which involves excision of the cervix and suture of the cervical stump to the cardinal ligament.10, 11 None of these techniques have been reported to yield superior outcomes when compared.10, 12
Once conservative approaches are no longer able to adequately manage a patient’s symptoms, surgery should be considered to correct the anatomical deformity and remove pressure from the pelvic floor.
A surgical approach should only be decided on after discussing the expectation of future fertility and sexual function with the patient.
This case presents a vaginal hysterectomy with uterosacral ligament suspension and excision of redundant vaginal tissue to treat a severe, grade IV uterine prolapse on a middle-aged, multiparous Filipino female. Recovery time is highly variable and is dependent upon the severity of the disease. For a few weeks following surgery, rest and avoidance of both sexual intercourse and movements that will increase intra-abdominal pressure, such as vigorous exercise and straining, is typically necessary for healing.13
Complications associated with this procedure include hemorrhage, hematoma, nerve damage, dyspareunia, and prolapse recurrence.5 The uterine prolapse recurrence rate following surgery is difficult to quantify due to significant variability in disease severity and the potential for anatomical failure that remains asymptomatic.14-16 Various factors, such as age, body weight, and prolapse severity have all been reported to influence the likelihood of recurrence.15
The best technique for the repair of severe uterine prolapse remains unclear and is largely dependent upon patient preference, disease severity, and surgeon expertise. In this case, the most widely used vaginal hysterectomy with uterosacral ligament suspension using a native tissue repair in place of a mesh repair. Mesh repairs have not been used as frequently since the release of a joint statement issued by AUGS and ACOG that stated that the use of transvaginal mesh should not be first-line therapy due to an increased risk of recurrence and complications.17 Conversely, for patients who do not desire future vaginal intercourse, colpocleisis shows the highest cure rate and the lowest morbidity of any surgical approach.13 Due to the wide range of surgical and nonsurgical approaches to alleviate uterine prolapse, further research is necessary to characterize the optimal use for each strategy.
No special equipment used.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
The authors would like to thank the Operating Room staff for their help in making this video.
1. Pelvic organ prolapse. Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi: 10.1097/spv.0000000000000794.
2. Barber MD. Pelvic organ prolapse. BMJ. 2016;354:i3853. doi: 10.1136/bmj.i3853.
3. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB. Risk factors for pelvic organ prolapse and its recurrence: A systematic review. Int Urogynecol J. 2015;26(11):1559-1573. doi: 10.1007/s00192-015-2695-8.
4. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. Women. Obstet Gynecol. 2014;123(1):141-148. doi: 10.1097/aog.0000000000000057.
5. Bordman R, Telner D, Jackson B, Little D. Step-by-step approach to managing pelvic organ prolapse: Information for physicians. Can Fam Physician. 2007;53(3):485-487. PMID: 17872686
6. Yoon I, Gupta N. Pelvic prolapse imaging. Statpearls. Treasure Island (FL): StatPearls Publishing. Copyright © 2020, StatPearls Publishing LLC.; 2020.
7. Dietz HP. Ultrasound in the assessment of pelvic organ prolapse. Best Pract Res Clin Obstet Gynaecol. 2019;54:12-30. doi: 10.1016/j.bpobgyn.2018.06.006.
8. Bradley CS, Zimmerman MB, Qi Y, Nygaard IE. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol. 2007;109(4):848-854. doi: 10.1097/01.AOG.0000255977.91296.5d.
9. Jha S, Cutner A, Moran P. The uk national prolapse survey: 10 years on. Int Urogynecol J. 2018;29(6):795-801. doi: 10.1007/s00192-017-3476-3.
10. Bradley S, Gutman RE, Richter LA. Hysteropexy: An option for the repair of pelvic organ prolapse. Curr Urol Rep. 2018;19(2):15. doi: 10.1007/s11934-018-0765-4.
11. Gutman R, Maher C. Uterine-preserving pop surgery. Int Urogynecol J. 2013;24(11):1803-1813. doi: 10.1007/s00192-013-2171-2.
12. Nager CW, Visco AG, Richter HE, et al. Effect of vaginal mesh hysteropexy vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: A randomized clinical trial. Jama. 2019;322(11):1054-1065. doi: 10.1001/jama.2019.12812.
13. Iglesia CB, Smithling KR. Pelvic organ prolapse. Am Fam Physician. 2017;96(3):179-185. PMID: 28762694
14. Lavelle ES, Giugale LE, Winger DG, Wang L, Carter-Brooks CM, Shepherd JP. Prolapse recurrence following sacrocolpopexy vs uterosacral ligament suspension: A comparison stratified by pelvic organ prolapse quantification stage. Am J Obstet Gynecol. 2018;218(1):116.e111-116.e115. doi: 10.1016/j.ajog.2017.09.015.
15. Diez-Itza I, Aizpitarte I, Becerro A. Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: A review at 5 years after surgery. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(11):1317-1324. doi: 10.1007/s00192-007-0321-0.
16. Patel DN, Anger JT. Surgery for pelvic organ prolapse. Curr Opin Urol. 2016;26(4):302-308. doi: 10.1097/mou.0000000000000288.
17. Committee opinion no. 513: Vaginal placement of synthetic mesh for pelvic organ prolapse. Obstet Gynecol. 2011;118(6):1459-1464. doi: 10.1097/AOG.0b013e31823ed1d9.
Table of Contents
- Dissection and Identification of Uterosacral Ligaments
- Excise Redundant Tissue
- Excise Redundant Tissue
The purpose of this is to try to keep it as dry as we possibly can, because it's a vascular region. Okay, save that, we might need some more. Okay, let's just… This is the cervix, by the way. It's the cervix? Okay Lester, if you just kind of hold that up like that, please. Okay, I'll take a knife. And have a Metzenbaum ready please.
Okay, watch this blade, and I'll take Metzenbaum and pickups.
I'm just trying to dissect this tissue we're on. What I want to do is try to identify the uterosacral ligaments where they come on in, try to get in safely, within the cul-de-sac do a colpotomy, and kind of work backwards. Because it's hard to, you can feel it, it's hard to really feel any, any anatomy, but the uterosacrals come in like that. Feel that peritoneum there it's... Yeah. Okay, I'll tell you what, let's, let's go ahead and get me a- give me a Heaney. You can feel the uterus there, Lester. Okay. So what I'm going to do is… This is- I'm- this is the uterosacral ligament. at least it's some of it. And okay, here's easy, now take a suture.
And I do what's called Heaney sutures, I- it's inter- interlocking suture. So you can take, and you hold it- hold this one up there. You hold that up. Yes. No, yes. You hold that up, I'll hold the clamp. I'll take the clamp, thanks. Okay, I got it Lester, thanks. Hey, this is 0, isn't it? Yes. Okay, off. And then we're going to tag this. We're gonna tag this with a- Mosquito. Okay, tag this one, down here. Okay. Okay. Okay, I'll tell you what, give me a… Boy, there- she has such redundant uterosacrals, you can't even feel them, so it's, not much here, give me a- if you want to put your finger up in there and see if you can feel them. Thank you. Yes, that's good. Scissors? Do you have a Mayo scissors on there? Yes, that's good. Metzenbaums are a little bit weak. Oh, that's pretty short, isn't it- I'll make it work. Pickups? Thank you. No, no, I'm tagging it. Okay.
See if I can come across- see, it's blanched where we injected. Yes. Lester, see that, it's really tough scar tissue in there. Okay, watch the blade.
Just- not taking big bites, just kind of, so I can- scissors- I can control, you know? Suture. Pickups? You can hold that, just like that. Pickups. Here, you got it. Okay, I have this now. I'm going to give it back to you right now. Okay, let's- you take that, and I get this. Okay, off. Take this, I'll use this- no, no, I'm going to just incorporate it into this one. That way we don't have too many instruments here, it gets confusing. Okay, why don't we go to the other side. If you'd hold that up for us..., and give me the... Heaney. Heaney. You guys are doing good, I appreciate it. I'll tell you, maybe I ought to just use one, these things are pretty short, aren't they? Okay, now take that around this way. Okay, you cut that one off. Watch this needle. Okay, that's fine. Actually, those little ones work pretty good. Yes, let me just see this, Lester. What is it on? It's working, okay, it's good. What we want to avoid is getting the bladder here. Scissors? Suture, good, thank you. I'm going to come behind you here. These are Heaney sutures, it's just interlocking, that's all. Okay, off. Scissors. It should be coming up to the peritoneal fold here, pretty soon. Peritoneum there, see? Okay. Heaney. Okay guys, we're moving along okay. Well that's what you're giving me, isn't it? This is 0 Vicryl. Huh? Oh, is this 2-0? I thought it was… Asking for more. Okay. I'm taking small bites intentionally. Yes, taper. Scissors. You don't have any curved Mayos, huh? Pretty short, isn't it? Okay, I'm a- yes, come behind, you take that. Okay, off. Let's see, uterine artery there. Okay. Metzenbaum? Metz? You see, the bladder. Let me see, here. The bladder's right up there, but that's just occurred to me. Okay, you hold that, just like that. Heaney? Much better. Smaller needles. It's okay though, we'll make it work. No, it's okay. Okay, maybe give this to… Okay, you hold that. Okay, give me a Heaney. It's really tough tissue, isn't it? Oh boy, that's short. Go behind, under. Wow! Okay, off. We won't- when they're that short, no, we won't use them again. Okay, watch the needle. This is the round ligament here, okay, give me a Heaney. Army-Navy?
I think I'll take it in 2- I think I'll take it in 2 bites. One more Heaney. No- I'll get it with the next one. Okay. Suture ready. We'll tag this one. Suture. We removed the vagina already, we're going to cut it out? No. Yes, no, once I get this side, we'll take it out. I'll take that, and you take this one. Okay, off. Scissors? Okay, Heaney? What causes the prolapse? What causes it? Yes. Oh, it's- there's probably a genetic element to it, but you know, stress, mostly- she's only a gravida 2, but… Yes, you hold that up there like that, that's good. Okay, off. Scissors, please? I'll tell you what, just cut this one. Let's tag this. Okay, get me a sponge.
So we're going to suspend the uterus back up. Yes- well I'm going to see if I can get one of the ligaments where I could get sutures in it that just- to give it some support, and then we'll do- try to do like an anterior repair on it, and posterior repair. And then we can reduce the skin here? Yes, we will cut some off, but- but if you've cut too much off, she won't have any vagina. This is her whole vagina. Yes. So, she won't have a vagina. Okay, give me a suture. You can feel- put your finger here, and you can feel it, that's the ligament. Okay. That's it. Yes. Uterosacral ligaments. And you go high up? Yes, I'm going to go as high as I can. Okay, I'm going to leave this needle on, and- tag? Okay, another one? Okay, you hold that. Okay, yes. Can you hold this, please? Suture? Yes, just hold that. Okay, tag? And you can take that off, you can take that off. Okay. Okay, now let's see if I can- get a- anything else besides that, because they're not that- they're not that prominent. There's nothing really prominent, except a lot of redundant vaginal tissue. If we take it, you know, a lot off, she's not going to have any vagina. Yes. Uh. Okay, let's just take this out.
Take and do a repair here. Get rid of a lot of that in the posterior repair, get a lot of- get rid of a lot of this. I think that's the best I can do is just try to eliminate as much of the redundancy as I can, and then close it, because there's not that much… What I'm going to do is do that and then take all this out. Okay. You know, bring these ligaments together and bring the tissue together in layers. And do the same up here. You know, the thing to maybe do is just do not- not too much tissue destruction, and then at a later date, somebody can even- you put a scope in, do a laparoscopy, and go above, and- and pull everything up, and attach it to her upper sacrum. Well, Well I can't do that vaginally, I mean that's too far up. One more? Are you gonna use Vicryl 0 for this one? Huh? Are you going to use Vicryl 0 for this one? Vicryl, yeah, is that what you're asking? Vicryl ready. You got 2 more- 2 more long clamps. Okay. Suture. Give me a 0-Vicryl.
Tag this. Mosquito? Okay, let's see here. Pretty short, isn't it? I'll tell you, you can take that off. Suture? Watch that needle. Watch your finger there. Scissors? You got this? Yes. Pickups? Okay.
I'll tell you, I think the better part of valor is to just kind of do a smaller of the same on the anterior wall. Okay. And hitch that to the- to the round ligaments that I have marked here, and hitch the posterior one to the uterosacral, and just close it up. It's going to- it's going to give her support, but she's got so much redundancy, I just- I just hate to cut a lot because I think eventually somebody might be able to do an abdominal procedure and attach it to her sacrum. Okay, 2 straight- long clamps again. Okay, scissors?
Okay, you can cut this. Okay. Okay, I have this. See, if I had a bigger needle, I could just do one swipe. They're puny needles for this, it's a tough tissue. We have CT-1, we got you a bigger one. Yes, CT-1 would be much better. Take that one off. You can relax on that here, that, Allis. Okay, I got it. Okay, and cut. Okay, watch this needle.
Okay, this is my round ligament on the left. So what I'm going to do is take this… Needle holder? Okay, let me see this. Okay, you can cut that. Okay, that's round ligament on the right. Cut this needle off. Scissors? What I'm going to do is put a bite, then I'll tie it to this. We'll make it work. Okay, you can cut that. I can use this suture again. You can cut this. Sponge? Okay, you can that out, take this out. You can take that off- I'm just going to- that's all I'm going to do.
She'll have a lot of natural retraction from here too, but... Okay. But still, I think probably eventually, someone is going to have to secure this up high, up in the sacrum. Where do they normally anchor- anchor the- in the sacral area, what part in the sacrum? Oh, you know, I'd go as high as I could. Okay. I mean, it depends on how much tissue, you know you want to- you don't want to stretch it too much, but I'd go as high as I could. Usually, when they use it- a sacrospinous, or a sacroiliac, they- they usually go up around the- almost up to the- well, right up as high as you can go. You got to stay out of this vessels and all that. See, there's nothing- there was nothing I can hitch it to down there. It's gotta be way high. Okay. And then the only way to do that is through the abdomen- through a scope, you could do it through a scope. You wouldn't have to open her abdomen up. Well, thanks everyone.
We did a- trans-vaginal hysterectomy, and a reduction of vaginal tissue, both anterior and posterior, and we did a high uterosacral suspension, and a- a round ligament suspension to the distal vaginal cuff. But the redundancy of the vagina was just so great that we couldn't get high enough. She eventually might need a laparoscopic sacrospinous fixation of the vaginal cuff.