DOI: 10.1111/tog.12220 2016;18:17–23 Review The Obstetrician & Gynaecologist http://onlinetog.org

Management of uterine : is necessary?

a b b, Helen Jefferis MRCOG, Simon Robert Jackson MD FRCOG, Natalia Price MD MRCOG * aSubspeciality Trainee in Urogynaecology, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK bConsultant Urogynaecologist, Department of Urogynaecology, Women’s Centre, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK *Correspondence: Natalia Price. Email: [email protected]

Accepted on 1 June 2015

Key content  Fertility preservation remains the one absolute indication for  Management of is currently heavily influenced by hysteropexy. Other potential advantages include stronger apical patient and surgeon preferences. support and reduced vaginal .  The traditional approach to uterine prolapse is vaginal  remains a valid option for a small cohort of patients. hysterectomy. However, this does not address the underlying Learning objectives deficiency in connective tissue pelvic floor support, and prolapse  Options for the management of uterine prolapse. recurrence is common.  How to help patients decide on a management plan.  Uterine preservation surgery is increasing in popularity, both with surgeons and patients; there is currently little evidence to show Keywords: colpocleisis / hysteropexy / / superior outcome to hysterectomy. uterine preservation surgery / vaginal hysterectomy

Please cite this paper as: Jefferis H, Jackson SR, Price N. Management of uterine prolapse: is hysterectomy necessary? The Obstetrician & Gynaecologist 2016;18: 17–23. DOI: 10.1111/tog.12220

Introduction significantly associated with regression of prolapse, leading the authors to suggest that the damage obesity causes to the When a woman presents with pelvic organ prolapse, the pelvic floor may be irreversible. management options are doing nothing, offering Women are often given advice regarding pelvic floor conservative treatment such as physiotherapy and vaginal muscle training and may receive targeted physiotherapy. A , or surgery. Many women will ask for their 2014 multicentre randomised controlled trial (RCT)2 gynaecologist’s opinion as to the best course of action. This comparing individualised pelvic floor muscle training with will depend on symptomatology, impact on quality of life, no intervention found a statistically significant improvement desire for sexual function and medical comorbidities, among in subjective assessment of prolapse symptoms in the other factors. It is important that gynaecologists are aware of intervention group. No significant improvement in all available treatment modalities and can counsel objective assessment of anatomy, as assessed by the pelvic women about the potential benefits and risks. Some organ prolapse quantification system (POP-Q), patients will simply require reassurance that there is no was reported. sinister pathology. Women have used mechanical devices to reduce pelvic organ prolapse since ancient times, and the use of vaginal Conservative management pessaries remains a simple and satisfactory treatment. One study of 100 women using this method3 showed a 92% Gynaecologists will often recommend lifestyle measures to satisfaction rate in terms of prolapse symptoms and a 50% patients presenting with symptomatic pelvic organ prolapse. improvement in urinary symptoms. Of particular interest is the correlation between increasing Studies have shown that older women and those with body mass index and prevalence of prolapse. Weight loss is comorbidities are most likely to persist with the use of therefore often recommended to patients as part of a vaginal pessaries. Women more likely to pursue surgery are conservative approach to managing prolapse symptoms. younger, more likely to be sexually active and more likely to However, one large study1 showed that weight loss was not have more advanced prolapse.4 Factors predicting failure of

ª 2016 Royal College of Obstetricians and Gynaecologists 17 Management of uterine prolapse treatment are short vaginal length, deficient perineal organs. The request frequently arises after women have body and a wider vaginal introitus. conducted an internet literature search and become aware of The side effects associated with vaginal pessary use are alternatives to hysterectomy. usually minor and include , odour and vaginal erosions. More serious complications such as fistulae The history of uterine preserving prolapse are predominately seen in neglected or forgotten pessaries. surgery

The current debate Uterine preservation surgery can be considered when it is appropriate to offer a surgical remedy for uterine prolapse. Vaginal hysterectomy has long been the standard approach The most obvious indication is fertility preservation in for the management of uterine prolapse, with the first women who have not yet completed childbearing. However, successful planned case being credited to Langenback in 1813. this is a small group of patients. Most women requiring It remains a safe and readily available surgical solution to surgery for prolapse have no desire for further children; uterine prolapse. Various techniques are described for indeed the majority are postmenopausal. reducing the risk of subsequent vaginal prolapse. The In the authors’ experience other more prevalent McCall culdoplasty (which involves approximating the indications for uterine preservation include patient request uterosacral ligaments so as to obliterate the peritoneum of and superior outcome. The latter is a contentious statement the posterior cul-de-sac as high as possible) is considered as clinical data remains sparse and will be discussed in this superior to a vaginal Moschowitz procedure, or closure of the article. However, when there is loss of apical support, peritoneum of the cul-de-sac in preventing enterocoele traditional vaginal hysterectomy will not correct the defect. formation.5 Suturing the cardinal and uterosacral ligaments This is most readily apparent when women present with to the may also reduce subsequent procidentia; it is self-evident that hysterectomy will not treat vault prolapse.6 vaginal eversion. The Royal College of Obstetricians While vaginal hysterectomy has served patients and and Gynaecologists (RCOG) Green-top Guideline, gynaecologists well for many years, its continued routine ‘Management of Post Hysterectomy use has been subject to debate. Many gynaecologists argue Prolapse’,12 recommends sacrospinous fixation if the that the itself is healthy and the underlying vaginal vault is at the introitus at the end of a vaginal pathophysiology is a connective tissue deficiency,7 whether hysterectomy procedure. congenital or acquired through childbirth or ageing, and that The concept of uterine preservation surgery for pelvic uterine prolapse is merely a symptom, not the disease. organ prolapse is not new, but it has attracted a resurgence in Vaginal hysterectomy fails to address this underlying interest over recent years. In 1888 Archibald Donald first deficiency in connective tissue, with relatively high described the Manchester repair as an alternative to vaginal recurrence rates of 10–40% described in the literature.8,9 hysterectomy for patients with uterine prolapse, although this Recurrence can manifest with vaginal vault eversion, or more may have been a more useful technique for patients with an commonly recurrent enterocoele or cystocoele. We know that elongated rather than true uterine descent. In 1930 cystocoele commonly arises because of loss of apical (type 1) Victor Bonney highlighted the passive role of the uterus in vaginal support, and until apical support is established, a uterovaginal prolapse, which underpins the theory behind cystocoele will recur after surgery. Furthermore, uterine preservation surgery. Subsequent surgeons have hysterectomy removes a healthy organ that may play a role developed techniques for uterine preservation using a in a woman’s individual and sexual identity. vaginal, abdominal or laparoscopic approach. On the other hand, vaginal hysterectomy has been part of core training for decades; more recently part of Vaginal approach the popular vaginal surgery advanced training skills module In 1966 Williams13 described a technique for transvaginal (ATSM). Most gynaecologists are therefore well trained and uterosacral-cervical ligament plication. He reported on the comfortable doing the procedure with good outcomes. In outcomes of 20 women undergoing this procedure, with addition, there is evidence that the procedure is associated three ‘failures’ encountered within a 6-month follow-up with high patient satisfaction rates, which are not period. His method involved a posterior colpotomy with significantly different from uterine preservation.10 Some division of the uterosacral ligaments from the cervix, uterine preservation procedures have also been associated plication across the midline and reinsertion into the cervix. with high rates of recurrent anterior wall prolapse.11 The cardinal ligaments are then plicated anteriorly across Women are increasingly requesting uterine conservation. the midline. This may be because of the wish to preserve fertility, or the The concept of sacrospinous hysteropexy was first belief that female identity is bound up in the female genital described by Richardson14 in 1989. The cervix or

18 ª 2016 Royal College of Obstetricians and Gynaecologists Jefferis et al. uterosacral ligament is transfixed to the sacrospinous sacrocolpopexy. Sacrohysteropexy was associated with a ligament using either permanent or delayed absorbable shorter operative time and hospital stay and a reduction in sutures. In 2001 Maher15 reported a small comparison intraoperative blood loss. It is difficult to interpret data study between sacrospinous hysteropexy and vaginal reporting comparisons between abdominal sacrohysteropexy hysterectomy with sacrospinous vault fixation, with no and hysterectomy because of variations in surgical techniques differences in objective or subjective outcomes at follow-up. and differences in mesh type, size, shape and Other studies have suggested that sacrospinous hysteropexy attachment points. has a shorter operative time and less blood loss than vaginal hysterectomy.16 One study also reported fewer postoperative Laparoscopic approach incidences of overactive bladder symptoms in the While initial experience with abdominal hysteropexy was sacrospinous hysteropexy group.17 Dietz et al.11 described obtained via laparotomy, open abdominal surgery has now, an increased risk of anterior compartment prolapse following in many units, been largely replaced with laparoscopic sacrospinous hysteropexy, with an incidence of up to 40%. techniques. The laparoscope confers better vision than Sacrospinous hysteropexy, is the most studied vaginal laparotomy, allowing a magnified, high definition view. technique for uterine preservation prolapse surgery; Furthermore, the long instruments allow better pelvic access, however, in general, the studies assessing it are of poor particularly behind the uterus, than conferred by laparotomy. quality, with small numbers, short follow-up periods,18 a lack General advantages of laparoscopic compared with open of controls and limited functional outcome data. surgery are reduced hospital stay, reduced need for analgesia, The technique of posterior vaginal slingplasty was first quicker recovery and minimal blood loss. There is a described in 2001,19 using a mesh kit to create ‘neo- suggestion that formation is also reduced. uterosacral ligaments’. One prospective comparison study The main disadvantage of laparoscopic surgery is the quoted a 91.4% patient satisfaction rate post-surgery,20 but initial increase in operating time while the surgeon learns the cumulative data suggest a high incidence of mesh laparoscopic techniques. Focused training and use of skills complications with up to a 21% mesh erosion rate.21 laboratories and laparoscopic simulators can help to address this issue. As a new generation of surgeons develop, trained Abdominal approach from the outset in laparoscopic techniques, such concerns Several methods for open abdominal hysteropexy have been will become obsolete. In fact, many skilled laparoscopic described, including transfixing the uterus to the anterior surgeons find that if they are in a situation where open abdominal wall and ventral fixation to the pectineal surgery is required, the operating times are slower and ligaments. Most techniques use the sacral promontory as visualisation of the anatomy is poorer. the fixation point, giving rise to the term Several laparoscopic uterine suspension procedures have ‘abdominal sacrohysteropexy’. been described using different methods. Laparoscopic Abdominal suture sacrohysteropexy was described as early ventrosuspension involves suturing the round ligaments to as 1957,22 with the uterine fundus being fixed to the sacral the rectus sheath. However, the round ligament is not promontory with silk sutures. More recent techniques have particularly robust, and perhaps, as expected, it has been utilised a variety of synthetic meshes to aid fixation. In 1993, shown to have poor outcomes, with one case series of nine Addison23 first described a technique for resuspending the women reporting recurrent prolapse in all but one patient uterus to the sacrum using MersileneTM (Ethicon US, LLC, within 6 months.27 Chen et al.28 used mesh to suspend the USA) polyester fibre mesh. Leron and Stanton24 followed-up uterus by attachment to the anterior abdominal wall. While 13 women undergoing abdominal sacrohysteropexy and they reported good outcomes, all patients experienced found it to be a safe and effective surgery for the significant or dragging sensations over the mesh management of uterine prolapse. Farkas et al.25 described a attachment site. technique for uterine suspension using a ‘wrap-around’ insert Laparoscopic uterosacral ligament plication was first of Gore-Tex (W.L. Gore & Associates, Inc., Newark, USA) described by Wu et al.29 in 1997, with good results in a for women with prolapse secondary to bladder exstrophy. small case series. Maher et al.30 modified this technique to Roovers et al.10 reported on a comparison between include reattachment of the uterosacral ligaments to the sacrohysteropexy and vaginal hysterectomy with vault cervix and closure of the pouch of Douglas, with an objective fixation; recurrence was higher in the abdominal surgery success rate of 79% in 43 women at 12 months. group (22%) than in the vaginal hysterectomy group (2.5%). Recent techniques have focused on use of the sacral Constantini et al.26, however, found no subjective or promontory as a point of fixation. Krause et al.31 followed- objective difference in functional outcomes when up 81 women undergoing laparoscopic sacral suture comparing a group of patients undergoing hysteropexy, placing sutures through the posterior aspect of sacrohysteropexy with those undergoing hysterectomy with the cervix and transfixing to the sacral promontory via the

ª 2016 Royal College of Obstetricians and Gynaecologists 19 Management of uterine prolapse right uterosacral ligament. Objective correction of prolapse was seen in 94% of patients at a mean of 20.3 months Box 1. Aims of hysteropexy follow-up.  32 To restore and reinforce uterine support by suspending the uterus Cutner et al. developed the technique of laparoscopic from the sacral promontory using type 1 polypropylene mesh. Two uterine sling suspension. The peritoneum is opened over the strong attachment points are used: the cervix and the anterior sacral promontory and the rectum is reflected laterally. longitudinal ligament overlying the sacral promontory. A tunnel is created by blunt dissection underneath the  To restore vaginal length without compromising calibre. peritoneum from the sacral promontory to the insertion of By restoring apical support a reduction in anterior prolapse is seen, the uterosacral ligament complex into the cervix on either consistent with the importance of restoring level 1 support in side. MersileneTM tape on a needle is placed through the cystocoele repair. A reduction in enterocoele is also seen. cervix, through the uterosacral ligaments and through the peritoneal tunnels on each side, before being bilaterally tacked to the sacral promontory to suspend the uterus. This technique aims for the sling to resemble newly created fixation. A peritoneal relaxing incision is then used, medial to uterosacral ligaments. the right ureter, to retract it from the surgical site; this is then The theoretical advantage is that this type of repair, by extended into the , lateral to the rectum. The right augmenting weak connective tissue with prosthetic material, uterosacral ligament is identified and the peritoneum is provides stronger apical support resulting in lower opened over this, where the uterosacral ligaments insert into recurrence rates. It allows the patient to retain their fertility the cervix. A flap of peritoneum is mobilised to facilitate and, by avoiding vaginal surgery, there is a lower potential for reperitonealisation. The vesico-uterine peritoneum is incised and . However, evidence is to reflect the bladder away and bilateral avascular windows lacking to support this technique as it has not been evaluated are created in the broad ligament, lateral to the uterine in clinical trials. arteries, at the level of the internal os. A bifurcated polypropylene type 1 macroporous non- TM Authors’ technique; the Oxford absorbable mesh (ProLite ; Atrium Medical Corporation, hysteropexy USA) is brought through the broad ligament windows. This is transfixed to the anterior cervix using non-dissolvable, The laparoscopic polypropylene cervical encirclage non-absorbable polyester 2-0 sutures (Ethibond ; Ethicon hysteropexy was modified in Oxford from previously US, LLC, USA). The mesh is attached to the sacral described open abdominal surgery techniques. The authors’ promontory under moderate tension using two to three experience with hysteropexy has shown that mesh, when 5 mm helical fasteners (Pro-TackTM; Covidien, CT, USA). The attached to the posterior aspect of the cervix, or to the mesh is then completely reperitonealised using Monocryl cervical stump following hysterectomy, has a high avulsion (Ethicon US, LLC, USA) sutures. rate. Therefore, a method of complete cervical encirclage was 33 developed using a bifurcated polypropylene mesh. The Outcomes after laparoscopic hysteropexy technique has evolved; initially the abdominal polypropylene was not completely peritonealised; previous reports from Outcome data post-laparoscopic hysteropexy is sparse. We open abdominal surgery suggested this was unnecessary. performed a prospective observational study34 and reported However, it subsequently became apparent that exposed outcomes following laparoscopic sacrohysteropexy in 140 intraperitoneal polypropylene causes marked bowel women. Follow-up time varied between 1 and 4 years, with adhesions, thus complete peritonealisation was adopted. 89% of women reporting that their prolapse was ‘very much’ Furthermore, a 3 cm width strip of polypropylene was or ‘much’ better. There was significant improvement initially used, but this resulted in several instances of (P<0.001) in all parameters of ICIQ-VS (International recurrent cervical descent because of mesh stretching. Consultation on Incontinence Questionnaire – Vaginal Subsequently, a 5 cm wide strip of polypropylene was used. Symptoms) and POP-Q scores post-surgery. Four percent of Other units within the UK have now adopted this Oxford women experienced further apical prolapse, of which half hysteropexy technique; it is not exclusive to Oxford. The underwent further surgical intervention. This compares aims of this technique are outlined in Box 1. favourably with the risk of vault prolapse following vaginal A four-port laparoscopic technique is used with a 10 mm hysterectomy.35 The rate of serious complications was 4%, and umbilical, two 5 mm lateral and a 12 mm suprapubic port comprised bowel adhesions (prior to the modified inserted. After identifying the sacral promontory, the reperitonealisation technique), broad ligament vascular peritoneum is incised with bipolar graspers and monopolar injury and one pulmonary embolus. When asked, 92% of scissors to identify a safe window of periosteum for mesh women said they would recommend the operation to a friend.

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As this is still a relatively new technique, more outcome Sacrocolpopexy mesh extrusion rates of 2–11% have data over a longer time frame are needed to enable been reported.39,40 comparison with more traditional approaches. The The Medicines and Healthcare Products Regulatory outcomes of the Vault or Uterine prolapse surgery Agency (MHRA) and the RCOG12 have both issued Evaluation (VUE) study (a randomised, multicentre trial guidance for urogynaecologists surrounding the use of comparing uterine preservation surgery with vaginal mesh in prolapse and incontinence surgery.41 hysterectomy) are awaited and are likely to produce the In the authors’ experience, no cases of vaginal mesh best available evidence on this debate. However, the fact that extrusion were seen in a series of 700 women undergoing all surgical hysteropexy techniques (vaginal, abdominal and Oxford hysteropexy, even after up to 8 years of follow-up.42 laparoscopic) are incorporated into one uterine preservation One explanation would be the fact that the polypropylene arm may pose a challenge for the power of the study and the mesh does not approximate to the vaginal wall and lies at generalisability of the results. the level of the internal os. Following initial concerns regarding adhesions of the bowel to the mesh, the technique Hysterectomy or uterine preservation? has been modified to completely reperitonealise the mesh. Subsequent to this modification, no further bowel adhesions Vaginal hysterectomy eliminates the possibility of uterine or or other mesh complications have been reported. cervical pathology, and there are incidences of unexpected pathology being detected at pathological examination of the 36 Fertility following uterine preservation removed uterus. Careful patient selection is needed if surgery uterine preservation is planned – any abnormal or postmenopausal bleeding would certainly warrant further Theoretically one advantage of hysteropexy is retention of investigation in advance of hysteropexy. Contraindications to reproductive potential. It may therefore be the preferred uterine preservation include the presence of cervical approach for younger patients who have not completed dysplasia, abnormal uterine bleeding and possibly large their families. However, patients must be counselled that fibroids or uterine anomalies. In these cases hysterectomy data for pregnancy outcomes following the procedure are would be more appropriate. scarce and the impact of the pregnancy on the surgery, and The main contraindication to hysterectomy is the desire to indeed the effect of the surgery on the pregnancy, are retain fertility, although the majority of women being treated unknown. In some techniques, such as the Oxford for prolapse will be postmenopausal so this factor may not be hysteropexy, the mesh encircles the cervix and vaginal relevant. Another situation where uterine preservation is birth is therefore not possible; in effect the mesh acts as a recommended is in the presence of congenital anomalies such cervical suture. There is also concern that uterine blood flow as bladder exstrophy.37 may be compromised as the mesh potentially constricts the uterine arteries, although it is likely that a rich collateral Current mesh debate supply is formed. In the authors’ experience, three patients have The use of type 1 mesh is well established in pelvic subsequently conceived following an Oxford hysteropexy: reconstruction surgery and has common usage in one patient has been followed through to delivery in sacrocolpopexy and mid-urethral slings. However, the conjunction with her obstetrician. Uterine artery Doppler medical community has become aware of complications, studies at 23 weeks of gestation showed no compromise to such as with hip and breast implants, which have attracted a blood flow. Serial growth scans showed a normally grown high media profile – in many cases associated with litigation, fetus and the patient underwent elective caesarean delivery at particularly in the USA and Scotland. The use of mesh for 39 weeks of gestation, delivering a healthy infant of normal prolapse and incontinence in gynaecology is now under birthweight. The patient has since required surgical intense scrutiny. This has been secondary to a realisation that correction of anterior vaginal wall prolapse, although it is vaginal mesh extrusion rates are higher than not clear whether this is related to her pregnancy or whether previously thought. she would have had recurrence of prolapse anyway. The other Certainly the use of transvaginal mesh for vaginal prolapse two patients were in early pregnancy at the time of writing appears to have a relatively high complication rate, with mesh and will be reported on in the near future. erosion reported in up to 10% of cases.38 This is secondary to mesh lying adjacent to the vaginal wall that has been Obliterative procedures weakened by a surgical incision and subsequent scarring. With an abdominal approach, the mesh extrusion rate is Obliterative, rather than reconstructive, surgery aims to close considerably less, as the vaginal incision is avoided. off a portion of the vaginal canal, thereby reducing the

ª 2016 Royal College of Obstetricians and Gynaecologists 21 Management of uterine prolapse prolapsing viscera back into the pelvis. Colpocleisis (from the Supporting Information Greek kolpos meaning folds, and cleisis meaning closure) was first reported by Gerardin in 1823. The technique in use Single Best Answer questions are available for this article at today is a modification of that described by Lefort in 1877. https://stratog.rcog.org.uk/tutorial/tog-online-sba-resource Epithelium is removed from the anterior and posterior vaginal walls, with subsequent imbrication to create a tissue References septum providing a platform of support. Bilateral drainage channels are usually left to allow passage of vaginal and 1 Kudish BI, Iglesia CB, Sokol RJ, Cochrane B, Richter HE, Larson J, et al. Effect of weight change on natural history of pelvic organ prolapse. Obstet cervical secretions. Gynecol 2009;113:81–8. By definition, obliterative procedures result in loss of 2 Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A, et al. fl sexual function; accordingly they are used for a cohort of Individualised pelvic oor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. Lancet patients for whom this is not an issue. For example, 2014;383:796–806. colpocleisis is often reserved for elderly patients, in 3 Clemons JL, Aguilar VC, Tillinghast TA, Jackson ND, Myers DL. Patient particular those with comorbidities that may render them satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J unsuitable for the longer operating times and more invasive Obstet Gynecol 2004;190:1025–9. procedures associated with reconstructive surgery. 4 Clemons JL, Aguilar VC, Sokol ER, Jackson ND, Myers DL. Patient Studies suggest that colpocleisis is a successful and characteristics that are associated with continued pessary use versus surgery after 1 year. Am J Obstet Gynecol 2004;191:159–64. 43 acceptable procedure. One large retrospective case series 5 Cruikshank SH, Kovac SR. Randomized comparison of three surgical reported an anatomical success rate of 98% and a patient methods used at the time of vaginal hysterectomy to prevent posterior – satisfaction rate of 92%. One disadvantage is the loss of access . Am J Obstet Gynecol 1999;180:859 65. 6 Cruikshank SH. Preventing post hysterectomy vaginal vault prolapse and to the cervix and uterus in the event of future pathology. It is enterocele during vaginal hysterectomy. Am J Obstet Gynecol therefore important to assess individual risk prior to surgery. 1987;155:1433–40. 7 Jackson SR, Avery NC, Tarlton JF, Eckford SD, Abrams P, Bailey AJ. Changes in metabolism of collagen in genitourinary prolapse. Lancet 1996;347:1658–61. Conclusion 8 Symmonds R, Williams T, Lee R, Webb M. Post hysterectomy entero-cele While vaginal hysterectomy is adopted by the majority of and vaginal vault prolapse. Am J Obstet Gynecol 1981;140:852. 9 Marchionni M, Bracco GL, Checcucci V, Carabaneanu A, Coccia EM, gynaecologists as the preferred approach for surgical Mecacci F, et al. True incidence of vaginal vault prolapse. Thirteen years’ treatment of uterine prolapse, there is an increasing move experience. J Reprod Med 1999;44:679–84. towards alternative techniques. However, robust evidence to 10 Roovers JP, van der Vaart CH, van der Bom JG, van Leeuwen JH, Scholten PC, Heintz AP. A randomised controlled trial comparing abdominal and support a change in practice is lacking. The change in vaginal prolapse surgery: effects on urogenital function. BJOG practice is currently being driven by patient preference and 2004;111:50–6. clinical expert opinion (evidence level 4). Gynaecologists 11 Dietz V, Huisman M, de Jong JM, Heintz PM, van der Vaart CH. Functional outcome after sacrospinous hysteropexy for uterine descensus. Int must be aware of all treatment modalities to facilitate patient Urogynecol J Dysfunct 2008;19:747–52. choice and be able to counsel women about their options. It 12 Royal College of Obstetricians and Gynaecologists, British Society of may not be appropriate for all units to offer specialised Urogynaecology. The management of post hysterectomy vaginal vault prolapse. RCOG Green-top Guideline No. 46. London: RCOG; 2007. surgery because this requires adequate training, experience 13 Williams BFP. Surgical treatment for uterine prolapse in young women. Am and patient numbers. J Obstet Gynaecol 1966;95:967–71. Uterine preservation surgery is increasing in popularity 14 Richardson DA, Scotti RJ, Ostergard DR. Surgical management of uterine prolapse in young women. J Reprod Med 1989;34:388–92. with both surgeons and patients. Fertility is preserved, and 15 Maher CF, Cary MP, Slack CJ, Murray CJ, Milligan M, Schluter P. Uterine this remains the one absolute indication for hysteropexy. preservation or hysterectomy at sacrospinous colpopexy for uterovaginal – Other theoretical advantages include stronger apical support, prolapse? Int Urogynecol J 2001;12:381 4. 16 Hefni M, El-Toukhy T, Bhaumik J, Katsimanis E. Sacrospinous cervicocolpopexy reduced vaginal surgery and associated vaginal dysfunction with uterine conservation for uterovaginal prolapse in elderly women: an and psychological wellbeing. More good quality data are evolving concept. Am J Obstet Gynecol 2003;188:645–50. needed to enable clinicians to make evidence-based decisions 17 Van Brummen HJ, van de Pol G, Aalders CI, Heintz AP, van der Vaart CH. Sacrospinous hysteropexy compared to vaginal hysterectomy as primary regarding choice of prolapse surgery. surgical treatment for a descensus uteri: effects on urinary symptoms. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:350–5. Disclosure of interests 18 Dietz V, van der Vaart CH, van der Graaf Y, Heintz P, Schraffordt Koops SE. One-year follow-up after sacrospinous hysteropexy and vaginal There are no conflicts of interest. hysterectomy for uterine descent: a randomized study. Int Urogynecol J 2010;21:209–16. 19 Petros PE. Vault prolapse II: restoration of dynamic vaginal supports by Contribution to authorship infracoccygeal sacropexy, an axial day-case vaginal procedure. Int NP and HJ researched and wrote the article. SJ reviewed the Urogynecol J Pelvic Floor Dysfunct 2001;12:296–303. article for surgical detail and approved the final version 20 Neuman M, Lavy Y. Conservation of the prolapsed uterus is a valid option: for publication. medium term results of a prospective comparative study with the posterior

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