Sacrospinous Cervicocolpopexy with Uterine Preservation for Elderly Women

Abstract & Commentary

Synopsis: Sacrospinous cervicocolpopexy with uterine conservation in elderly women with prolapse can be used to avoid the morbidity of hysterectomy.

Source: Hefni M, et al. Am J Obstet Gynecol. 2003; 188:645-650.

Preservation of the uterus using this procedure has been previously described in younger women with uterovaginal prolapse.1,2 In this nonrandomized, prospective trial conducted in the United Kingdom, 109 women with symptomatic uterine prolapse underwent either sacrospinous cervicocolpopexy (n = 61) or vaginal hysterectomy with sacrospinous colpopexy (n = 48).

Patients were allocated to the uterine-conserving procedure if the patient expressed a desire to retain the uterus and also had no evidence of postmenopausal bleeding, abnormal Pap smear, or other uterine disease.

The group in which the uterus was preserved in each patient had less blood loss, shorter surgical times, and fewer complications. With a maximum of 34 months follow-up, the groups were similar with regard to upper vaginal or uterine support, recurrent cystocele formation, and need for repeat surgery for prolapse. Based on these data, it appears that the gynecologic surgeon need not feel compelled to perform hysterectomy in these patients.

Comment by Frank W. Ling, MD

It should be noted that some of the patients in the hysterectomy group were previously reported.3 In addition, the decision to perform a sacrospinous colpopexy at the time of the vaginal hysterectomy was made at the conclusion of the hysterectomy (ie, if the vault could be pulled to or beyond the hymen and/or a large enterocele were present). This weakens the methodology of the study, the learning points remain.

Thorough preoperative assessment is critical since the likelihood of a need for sacrospinous fixation can be determined in the office. As with these patients, objective measurements of the various areas for prolapse should be used as should urodynamic testing.

In those patients who had uterine conservation, No. 1 polydioxanone sutures were inserted in the right sacrospinous ligament with the Miya hook. The sutures were then loaded on a No. 4 Mayo needle and passed through each side of the posterior aspect of the cervix at the level of the insertion of the uterosacral ligament. These were then passed through the vagina and either side of the midline. Pulley sutures were created to ensure good contact between cervix and sacrospinous ligament.

As elderly patients are at greater risk for surgical and postoperative complications, the potential benefits of avoiding a more morbid procedure should be considered. Other even less-invasive options such as pessary use and colpocleisis are also viable options in properly selected patients. Although the success of pessaries is variable, it is clearly the treatment of least risk. Colpocleisis is a problem for some patients as it removes the option of subsequent vaginal penetration during sexual activity. There is also the limitation that this procedure prevents access to the uterus. Of note, using the described procedure, the uterus is still accessible for uterine sampling and/or Pap smears.

Although somewhat flawed methodologically, this paper does give the gynecologic surgeon caring for the elderly patient with symptomatic prolapse another option in addressing the many needs of these patients. Contrary to what has been taught in the past, hysterectomy for these patients is not a necessity.

Dr. Ling, UT Medical Group, is Professor and Chair, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN.

References

1. Richardson D, et al. J Reprod Med. 1989;34:388-392.

2. Kovac S, et al. Am J Obstet Gynecol. 1993;168: 1778-1786.

3. Hefni M, et al. J Obstet Gynecol. 2000;20:58-62.