Special Article AAGL Practice Report: Practice Guidelines on the Prevention of Apical Prolapse at the Time of Benign Hysterectomy AAGL ADVANCING MINIMALLY INVASIVE GYNECOLOGY WORLDWIDE ABSTRACT Pelvic organ prolapse may adversely impact physical, sexual and emotional health. Women with symptomatic prolapse often experience altered bladder and bowel function, increased pelvic pressure, diminution of sexual satisfaction, and altered body image. With increasing vaginal descent, various bladder, bowel, and prolapse symptoms are increased. Approximately 200,000 women undergo inpatient procedures for prolapse in the United States each year, with regional and racial differences in rates of surgery reported. The demand for health care services related to pelvic floor disorders will increase at twice the rate of the population itself. Journal of Minimally Invasive Gynecology (2014) 21, 715–722 Ó 2014 AAGL. All rights reserved. Keywords: Apical; Hysterectomy; Pelvic organ prolapse; Posthysterectomy prolapse; Richardson angle stitch; Sacrospinous ligament fixation Use your Smartphone to scan this QR code DISCUSS You can discuss this article with its authors and with other AAGL members at and connect to the http://www.AAGL.org/jmig-21-5-JMIG-D-14-00183 discussion forum for this article now* * Download a free QR Code scanner by searching for ‘‘QR scanner’’ in your smartphone’s app store or app marketplace. Hysterectomy is the most commonly performed gyneco- population itself [12]. The number of women who will un- logic surgical procedure. In 2005, .500 000 hysterectomies dergo surgery to treat prolapse is projected to increase were performed in the United States [1]: 64% abdominally, from 166 000 in 2010 to 245 970 in 2050 [13]. 22% vaginally, and 14% laparoscopically [1]. Pelvic organ The true prevalence of pelvic organ prolapse is difficult to prolapse is one of the most common reasons that hysterec- ascertain because many women with prolapse do not seek tomy is performed [2]; however, evidence suggests that hys- medical care. Various studies report the prevalence of symp- terectomy may also be a cause of future prolapse [3–6]. tomatic prolapse to be between 6% and 8% among adult Pelvic organ prolapse may adversely affect physical, sex- women [14,15]. Population-based studies report that during ual, and emotional health. Women with symptomatic pro- their lifetime, 11% to 19% of women will undergo surgery to lapse often experience altered bladder and bowel function, treat prolapse or incontinence [16,17]. increased pelvic pressure, diminution of sexual satisfaction, The role of hysterectomy in the development of prolapse and altered body image. With increasing vaginal descent, has been debated. Some studies have associated hysterec- various bladder, bowel, and prolapse symptoms increase tomy with a risk of subsequent surgery to treat pelvic organ [7]. Personal and health care–related costs of prolapse are prolapse [3,4], in particular when performed in women with high, with the annual cost of ambulatory care of pelvic floor existing prolapse [5,6]. Other studies have not found a disorders in the United States from 2005 to 2006 almost correlation between hysterectomy and subsequent prolapse. $300 million [8]. Annual direct costs for prolapse surgery Baseline data from the Women’s Health Initiative of 10 in the United States are estimated to exceed $1 billion [9]. 727 women who underwent hysterectomy, for any reason, In the United States, approximately 200 000 women each compared with 16 616 women with a uterus showed year undergo inpatient procedures to treat prolapse [10], and similar rates of cystocele (33% vs 34%) and rectocele regional and racial differences in rates of surgery have been (18% vs 19%) [18,19]. Only parity and obesity affected reported [11]. The demand for health care services related to prolapse in that large observational comparison. pelvic floor disorders will increase at twice the rate of the Although some studies have suggested that post- hysterectomy prolapse is more common after vaginal hyster- Submitted April 8, 2014. Accepted for publication April 9, 2014. ectomy than after the abdominal approach [4,5] it is unclear Available at www.sciencedirect.com and www.jmig.org whether this association is due to selection bias or whether 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.04.001 716 Journal of Minimally Invasive Gynecology, Vol 21, No 5, September/October 2014 the technique of vaginal hysterectomy is more prone to cause Some of the potential mechanisms for post-hysterectomy surgical trauma to the vaginal support tissues. Rates of prolapse include surgical injury to the innervation and development of post-hysterectomy prolapse are com- vascularization of the pelvic floor muscles or alterations in pounded in that there are low institutional compliance rates the connective tissues. DeLancey [24] has described a sys- with evidence-based guidelines to perform a concurrent sus- tem of 3 integrated levels of vaginal support. Level I consists pension procedure during hysterectomy to treat existing pro- of the cardinal and uterosacral ligaments, and suspends the lapse [20]. vaginal apex. Level II consists of the endopelvic fascia con- Randomized trials suggest that, over the short term, nections to the arcus tendineus fascia pelvis, which attaches cervical preservation or removal does not affect the rate of the vagina to the aponeurosis of the levator ani muscle. Level subsequent pelvic organ prolapse [21,22]. However, no III consists of the perineal body and includes interlacing studies have addressed the risk of pelvic organ prolapse muscle fibers of the bulbospongiosus, transverse perinei, many years after surgery, which may differ after total vs and external anal sphincter. Studies have suggested that it supracervical hysterectomy. is the paracolpium vertical fibers at Level I that prevent pro- The purpose of this Practice Guideline is to critically re- lapse of the vaginal apex [24]. Because the uterosacral– view the literature and provide recommendations designed cardinal ligament complex must be divided during hysterec- to reduce the incidence of de novo apical vaginal prolapse tomy, loss of Level I support contributes to subsequent after hysterectomy performed to treat benign disorders. prolapse of the vaginal apex. There is increasing recognition that anterior or posterior Identification and Assessment of Evidence vaginal prolapse may have an important apical component [25,26]. Even in cases in which the leading edge of the This AAGL practice guideline was produced with the prolapse represents the anterior or posterior vaginal com- following search method: electronic resources including partment, failure to recognize or address apical prolapse Medline, PubMed, EMBASE, EBM/Systematic Reviews, is likely to lead to suboptimal treatment outcomes for and ISI were searched for all English-language publications prolapse procedures and perhaps to iatrogenic problems. from 1945 to the present related to reduction of the risk of Midline colporrhaphy when undertaken for an apical post-hysterectomy vaginal vault prolapse. The MeSH terms support defect may inadequately address the symptoms included all subheadings, where keywords apical prolapse, and lead to new symptoms related to vaginal stricture, uterine prolapse, pelvic organ prolapse, vaginal vault pro- foreshortening, or scar tissue. lapse, or hysterectomy adverse effects occurred, with colpo- cleisis, colpopexy, vaginal suspension repair, culdoplasty, Diagnosis of Post-Hysterectomy Prolapse culdeplasty, or culdosuspension, and vaginal prolapse pre- vention or gynecologic surgical procedures. Additional pub- Assessment of women with symptoms of prolapse after lications were identified from a manual search of the hysterectomy should include the fundamental targeted his- references in the identified publications, yielding 262 arti- tory and physical examination. The current recommenda- cles. The full text of all publications was retrieved, tions for objective assessment of vaginal support include abstracted, tabulated, and added to a data table. Articles use of the Pelvic Organ Prolapse Quantification (POP-Q) were reviewed for relevance to the topic, and 58 publications system. The determination of apical prolapse is made by were identified including 6 randomized controlled trials. All measuring the location, relative to the vaginal hymen, of studies were assessed for methodologic rigor and graded ac- the cuff or hysterectomy scar (point C) during a maximal cording to the classification system outlined in the Appendix Valsalva maneuver and/or traction during examination. at the end of this article. Staging using the POP-Q system is an overall assessment ac- cording to the compartment of most severe prolapse and Clinical Presentation of Post-Hysterectomy Prolapse does not call for staging of individual compartments. As described, apical prolapse is frequently associated with As with any form of vaginal prolapse, post-hysterectomy more severe anterior or posterior compartment prolapse vaginal vault prolapse may be associated with a variety of but is essential to identify to formulate appropriate repara- signs and symptoms, including vaginal bulging, palpable tive strategies. Apical support during the POP-Q examina- or visible tissue protrusion, pressure, discomfort with tion may help to identify how much of the observed ambulation or activity, pelvic or back pain, dyspareunia, or prolapse is attributable to the apical component