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Prophylactic vaginal apex suspension at the time of hysterectomy

Authors
Jasmine Tan-Kim, MD
Shawn A Menefee, MD
Section Editor
Linda Brubaker, MD, FACS, FACOG
Deputy Editor
Kristen Eckler, MD, FACOG

INTRODUCTION

There is concern that hysterectomy, particularly when done for the indication of pelvic organ prolapse (POP), increases the risk of subsequent POP [1-4]. 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 pelvic organ prolapse (figure 1) [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 pelvic organ prolapse) [6,7]. (See "Pelvic organ prolapse in women: An overview of the 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 "Choosing a route of hysterectomy for benign disease", section on 'Pelvic organ prolapse'.)

IMPACT OF HYSTERECTOMY ON FUTURE PROLAPSE RISK

Studies have reported discordant results on the role of hysterectomy in the development of prolapse [1,4,8-12]. This discordance likely reflects inter-study differences in population of patients (ie, proportion of patients with pre-existing prolapse, age, menopausal status), surgical technique (ie, type of cuff closure and incorporation of support ligaments), lack of standardized outcome criteria, and length of follow-up. The risk of future prolapse appears to be highest when hysterectomy is performed in women with existing prolapse [2,3,13,14], while the risk in women with normal pelvic support is less clear. For example, a retrospective review of 2670 women who underwent vaginal and abdominal hysterectomy for benign indications at a single institution over a four-year period reported the incidence of vaginal vault prolapse was 11.6 percent when hysterectomy was performed for POP (all vaginal hysterectomies) and 1.8 percent when hysterectomy was performed for other indications [15]. Incorporation of the uterosacral ligaments into the vaginal cuff closure and uterosacral shortening was documented at the time of hysterectomy in all cases.

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 [1-3,15,16]. 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 [13,17,18].

              

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Literature review current through: Nov 2016. | This topic last updated: Tue Oct 27 00:00:00 GMT+00:00 2015.
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