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Prophylactic vaginal apex suspension at the time of hysterectomy

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


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.


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]. 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 [6]. 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) [7,8]. (See "Pelvic organ prolapse in women: 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'.)


Studies have reported discordant results on the role of hysterectomy in the development of prolapse [1,4,9-13]. 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 [2,3,14,15], while the risk in women with normal pelvic support is less clear. For example, a retrospective review of over 2600 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 [16].

Subsequent evidence suggest that patients who are undergoing hysterectomy for uterine prolapse often do not have apical suspension performed routinely, which contribute to the high rate of recurrent prolapse following hysterectomy. A retrospective review of the Michigan Surgical Quality Collaborative, including over 1500 women who underwent hysterectomy for uterine prolapse, reported that only 24 percent had an apical support procedure (colpopexy with or without colporrhaphy) and 43 percent had hysterectomy-only [17]. An expert panel recommended including apical suspension at the time hysterectomy for uterine prolapse as one of 14 quality indications for pelvic organ prolapse. Likewise, the National Quality Forum has endorsed performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse as one of three endorsed prolapse quality indicators [18]. Incorporation of the uterosacral ligaments into the vaginal cuff closure and uterosacral shortening was documented at the time of hysterectomy in all cases.

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Literature review current through: Nov 2017. | This topic last updated: Sep 28, 2017.
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