May 8, 2009 Leave a comment
In the United States hysterectomy is the second most commonly performed operation on women following cesarean section. It may be indicated for a variety of gynecologic conditions including symptomatic uterine leiomyomas, endometriosis, carcinoma of the female genital tract, endometrial hyperplasia, and uterine prolapse. Many of these conditions have confounding diagnostic and therapeutic implications outside the realm of urology; thus, in this chapter the discussion is limited to vaginal hysterectomy only as it pertains to the surgical treatment of uterine prolapse. Uterine prolapse is particularly well suited to vaginal hysterectomy as the laxity of the ligamentous support of the uterus resulting in the prolapse allows excellent operative exposure transvaginally.
Uterine prolapse may be classified anatomically into four stages based on the position of the cervix relative to the vaginal outlet. It is rarely an isolated condition and is more commonly associated with the other manifestations of generalized pelvic relaxation, which may include cystocele, rectocele, enterocele, perineal laxity, and/or urethral hypermobility.
Multiple etiologic factors contribute to uterine prolapse, including congenital, neurologic, racial, social, and coexisting medical factors; however, the most important factor is parity.1 Stretching of the various paravaginal, parauterine, and paracervical supports during parturition causes significant trauma. Most patients recover from this initial insult; however, with advancing age and loss of estrogens postmenopausally, the effects of the multiparity may manifest as uterine prolapse.
Normal uterine support is provided primarily by the sacrouterine and cardinal ligaments. The cardinal ligaments extend from the upper vagina and cervix laterally to the pelvic sidewall in the base of the broad ligament. The sacrouterine ligaments extend from the posterolateral aspect of the cervix and extend below the peritoneal folds in the pouch of Douglas on either side of the rectum to insert onto the periosteum of the sacrum. These ligaments tether the cervix posteriorly such that the corpus of the uterus lies over the levator plate in its normal anteverted position. Increased intra-abdominal pressure is thus exerted on the posterior surface of the uterus, further assisting in the maintenance of uterine anteversion as the uterus is compressed into the levator plate. The round ligaments provide little support to the uterus but do assist in maintaining the uterus in its anteverted position. Other structures also assisting in support of the uterus include the bony pelvis and the urogenital diaphragm including the central tendon of the perineum.
Uterine prolapse results from weakening and laxity of its anatomic supports, including the sacrouterine and cardinal ligaments. With weakness of the sacrouterine ligaments the cervix may shift anteriorly over the levator plate. This may result in a change in the uterine axis as the corpus of the uterus swings backward. In addition, the predominant intra-abdominal forces may now be exerted on the anterior surface of the uterus, resulting in a tendency toward retroversion and further prolapse. Weakness of the cardinal ligaments allows further loss of support over the levator plate, and uterine prolapse results.
Uterine prolapse may present as an isolated mass or a bulge in the vagina. It also may be found when the patient is assessed for other urologic complaints such as irritative or obstructive voiding symptoms, urinary incontinence, or retention. A history of pelvic pain, back pain, dyspareunia, or recurrent urinary tract infections may be present. Classically, back pain caused by uterine prolapse is aggravated by standing as the uterus prolapses further through the introitus and is relieved by resuming a recumbent position.
The diagnosis is confirmed by physical examination, which reveals significant uterine descent. During pelvic examination, the prolapsed uterus should be assessed for mobility, size, and ligamentous laxity. Associated manifestations of pelvic relaxation, including cystocele, rectocele, and enterocele, should be noted and included in a comprehensive pelvic reconstruction plan when discussed with the patient. Sometimes significant uterine prolapse is not detected by physical examination, and it is not until examination under anesthesia before repair for other associated pelvic prolapse that the degree of uterine prolapse is fully appreciated. For example, in some patients presenting for repair of grade IV cystocele, the full extent of uterine prolapse may not be appreciated in the preoperative office evaluation. It is only when the patient is under anesthesia and fully relaxed that the degree of uterine prolapse becomes evident. Thus, patients who present for repair of grade IV cystocele should be advised of the strong association with uterine prolapse and the potential need for vaginal hysterectomy.
With complete uterine prolapse (procidentia), the upper tracts should be assessed for hydronephrosis, as ureteral obstruction can be insidious in onset and yet quite severe. Patients may present with recurrent pyelonephritis, upper tract calculi, or renal failure. This is usually reversible if the hydronephrosis has not progressed to complete renal parenchymal destruction.
Ultrasonography of the pelvis may be helpful in patients suspected of having large uterine leiomyomas, as their size may preclude vaginal hysterectomy because of size disproportion.
INDICATIONS FOR SURGERY
The decision to perform vaginal hysterectomy is based on the patient’s symptoms, the degree of uterine prolapse, the associated manifestations of pelvic relaxation requiring repair, and the patient’s desire to remain fertile.
Vaginal hysterectomy is indicated in symptomatic patients with significant discomfort and/or dyspareunia as a result of the prolapsed uterus as well as asymptomatic patients with severe prolapse and urinary obstruction. Patients with moderate or severe prolapse and significant associated cystocele or enterocele should undergo simultaneous hysterectomy and repair of the associated pelvic pathology.
Vaginal hysterectomy should not be performed in the presence of significant size disproportion (i.e., large uterus or leiomyomata with stenotic vagina), adnexal or uterine malignant tumor, acute or subacute pelvic inflammatory disease, extensive endometriosis, and/or known obliteration of the cul-de-sac. Confounding factors such as uterine or cervical dysplasia or dysfunctional bleeding should be addressed before vaginal hysterectomy is done, as these situations may mitigate against a vaginal approach. Finally, in patients who desire continued fertility, uterus-preserving procedures should be considered.
Vaginal hysterectomy is not indicated in patients with stress incontinence and adequate uterine and pelvic support. Isolated removal of the uterus in these patients will have no impact on continence.
Asymptomatic or mildly symptomatic patients with uterine prolapse may not require any therapy. Minimal degrees of uterine prolapse may respond to Kegel exercises or hormonal therapy. The primary nonsurgical alternative to hysterectomy for significant uterine prolapse involves the use of a pessary, which may be used in patients who are unable or unwilling to undergo surgery. This device is inserted transvaginally and requires suitable perineal support for efficacy. Unfortunately, many of the patients with uterine prolapse have significant perineal laxity, and thus, a pessary may not be effective.
Many uterus-sparing procedures have been described as alternatives to vaginal hysterectomy. These include both transabdominal and transvaginal procedures. The uterus may be fixed to the sacrospinous ligament either transvaginally (sacrospinous fixation) or abdominally (abdominal sacral colpopexy). Many other operations have been devised in the past to be expeditious and low risk in order to avoid hysterectomy and its historically high morbidity in the elderly population. These include the Manchester–Fothergill operation and the LeFort procedure. These operations are rarely employed now, as the technique of vaginal hysterectomy has evolved into a simpler operation with low associated morbidity. The Manchester–Fothergill operation involved amputation of the cervix, anterior and posterior colporrhaphy, combined with plication and suturing of the cardinal ligaments to the anterior surface of amputated cervix for uterine support. The LeFort procedure essentially involved excision of rectangular strips of vaginal wall on the anterior and posterior vaginal walls with reapproximation of the denuded areas over the cervix. This procedure was quite expeditious but left the patient with a very shallow vagina that was usually too short for coitus.
Many techniques of vaginal hysterectomy exist. This chapter focuses on the technique that we have utilized with success for many years.
Antibiotics are administered parenterally 1 hour before incision. General anesthesia is preferentially used in all our vaginal surgery unless medically contraindicated.
The patient is brought to the operating room and placed in the dorsal lithotomy position with candy-cane stirrups. The buttocks are placed just off the end of the operating room table. All pressure points are padded, and care is taken to ensure that no lower extremity joint is flexed more than 90 degrees. The lower abdomen and perineum are shaved. A povidone/iodine vaginal scrub and painting are performed. A povidone/iodine-soaked pediatric lap sponge is packed into the rectum, and the anus is draped out of the field with a self-adherent clear plastic drape. The remaining drapes are secured with silk suture across the perineum to ensure separation of the fecal and urinary streams. A weighted vaginal speculum is placed, and labial retraction sutures of 3-0 silk are used for maximal exposure. A ring retractor with hooks can be utilized to assist in retraction. If a cystocele repair or bladder neck suspension is planned, a suprapubic tube is placed at this time. A Foley catheter is placed per urethra to empty the bladder.
A tenaculum is used to grasp the cervix and evert it through the vaginal introitus. Mobility of the uterus should be confirmed by this maneuver. Normal saline is injected circumferentially around the cervix in order to facilitate dissection. A circumferential incision is performed 1 cm proximal to the cervix, and the anterior dissection is begun.
Sharp dissection with Metzenbaum scissors is performed from the cervical incision anteriorly in the midline, developing a plane beneath the vaginal wall. Dissection is continued over the cervix, separating it from the posterior bladder wall and perivesical fascia. Care is taken not to dissect laterally. The point of the scissors should remain angled toward the uterus to avoid entry into the bladder. This dissection is aided by gently retracting the anterior vaginal wall and bladder cephalad with a Heaney retractor, especially when a significant cystocele is present. Dissection continues until the vesicouterine peritoneal fold (anterior cul-de-sac) is reached.
Similar dissection is now carried out posteriorly from the cervical incision in the midline, separating the vaginal wall from the posterior fascia of the uterine cervix. Again, a Heaney retractor may assist in visualization of the critical anatomic structures by retracting the vaginal wall and rectum downward. Dissection is continued until the posterior peritoneal fold (posterior cul-de-sac or pouch of Douglas) is identified. If difficulty is encountered in locating the posterior peritoneum, the hysterectomy is begun in an extraperitoneal fashion. The cardinal and uterosacral ligaments can be divided first, thus enabling more mobility of the uterus and easier identification of the posterior peritoneal fold.
Opening the Peritoneum
The posterior cul-de-sac is entered sharply through a small peritoneotomy. The posterior peritoneum is gently explored digitally for adhesions and masses. A retractor is placed into the peritoneal cavity elevating the cervix and uterus anteriorly. Adhesions in the posterior cul-de-sac are sharply divided. The peritoneum may be tagged at this point for later identification during closure.
Division of the Cardinal and Sacrouterine Ligaments
The cervix is retracted through the vaginal introitus and slightly laterally to one side. The tip of a large right-angle clamp is placed into the cul-de-sac with the tips directed anteriorly 1 to 2 cm from the cervix. The ligaments are bluntly dissected out and isolated at their point of attachment to the cervix as the right-angle tip is brought from posterior to anterior against the uterus. The ligaments are individually clamped, divided, and ligated 1 to 2 cm lateral to the cervix using a figure-of-eight suture ligature. The suture ends are left long and are anchored laterally to one of the grooves of the ring retractor. The cervix is now retracted slightly to the other side, and the opposite ligaments are taken in the same fashion.
Division of the Uterine Vascular Pedicle
The right angle is then passed again in the same direction slightly higher along the uterus isolating the uterine vascular pedicle on one side. The vascular pedicle is isolated, clamped, divided, and ligated in a similar manner as the ligaments. The sutures are left long and anchored to the ring retractor. The opposite vascular pedicle is taken in the same fashion. It should be noted that any traction on the cardinal ligaments implies traction on the uterine vessels. This traction will bring the ureters closer to the operative field.
At this point the uterus should be markedly mobile. If the uterus is somewhat fixed, confounding factors should be considered such as ventral fixation, endometriosis, adhesions, carcinoma, and size disproportion.
Incision of the Anterior Peritoneum
The fundus of the uterus is now rotated and everted through the posterior peritoneotomy and out through the vaginal introitus. A finger is passed over the fundus of the uterus to identify the anterior peritoneal reflection. The anterior peritoneum is then entered safely and sharply by incising the peritoneum tented up by the fingertip. Thin peritoneal attachments to the fundus of the uterus are identified by gentle upward retraction on the bladder and divided.
Division of the Broad Ligament
A Heaney retractor is placed into the anterior peritoneal space and is used to retract the bladder cephalad. At this point, only the broad ligament and its enclosed structures hold the uterus in place. The uterus is retracted laterally to better expose the broad ligament on one side. A large right-angle clamp is placed across the entire broad ligament next to its insertion into the uterus. Within this clamp lie the utero-ovarian ligament, the fallopian tube, and the round ligament in succession. The broad ligament and its enclosed structures are then divided and suture ligated. The opposite broad ligament is divided similarly. The sutures are again left long. The uterus is now removed.
Three pedicles are identified bilaterally: the anterior pedicle is the divided broad ligament; the middle pedicle is the uterine vessels; and the posterior pedicle is the sacrouterine and cardinal ligaments.
Vaginal Vault Fixation, Closure of the Cul-de-Sac, and Peritoneal Closure
Modified McCall culdoplasty sutures are used to support the vaginal vault and close the cul-de-sac. A #1 synthetic absorbable suture (SAS) is placed through the vaginal wall starting from within the vagina as high as possible on the lateral fornix. The suture is then passed successively through the area of the sacrouterine and cardinal ligament pedicle on the same side and then the prerectal fascia and the sacrouterine and cardinal ligament pedicle on the opposite side. The suture is brought back to the original side, traversing the same structures in reverse order, and finally exiting the vaginal wall 1 cm from the site of entry. An identical suture is placed in the other direction from the opposite fornix. These sutures are not tied down at this time.
The peritoneal cavity is closed with two pursestring sutures of #1 SAS incorporating the prerectal fascia, the prevesical fascia, the posterior peritoneal surface of the bladder, and the sacrouterine cardinal pedicle. High placement of the McCall and peritoneal closure sutures ensures adequate vaginal depth on closure.
The broad ligament pedicles are tied to each other across the midline. The sutures on the uterine pedicles are trimmed. Next, the peritoneal pursestring sutures are tied down snugly. If no other vaginal surgery is planned (i.e., cystocele repair, vaginal wall sling, etc.), then the McCall sutures are now cinched down and tied. The vaginal mucosa is trimmed and closed with a running interlocking 2-0 SAS. The vagina is packed with an antibiotic-impregnated gauze.
Patients are admitted for 24 to 48 hours postoperatively or until they are able to ambulate and are tolerating a regular diet.
Potential complications at the time of surgery include ureteral or bladder injury, bleeding, and rectal or other bowel injury. Injury to the urinary tract may be heralded by the sudden appearance of hematuria in the urinary drainage bag or a sudden gush of clear fluid into the wound. If an injury to the urinary tract is suspected intraoperatively cystoscopy may be performed or, alternatively, the bladder may be filled retrograde through the Foley catheter with indigo carmine and saline until the laceration or injury is seen. If these maneuvers fail to demonstrate the injury, then intravenous indigo carmine is given, and the ureteric orifices are observed cystoscopically for blue efflux.
Ureteral injury is much less common after vaginal hysterectomy than after abdominal hysterectomy. This may be because of superior retraction of the anterior vesicoperitoneal fold and thus a higher displacement of the ureters during dissection.2 Nonetheless, the ureters are most likely to be injured during the case at two distinct junctures: while the uterine vessels are being clamped and divided (the ureters lie just below and lateral to the vascular pedicle) or during pursestring closure of the peritoneal cavity. To avoid ureteral injury during clamping and division of the uterine pedicle, these vessels should be taken very close to the cervix and as distal as possible. During closure of the peritoneum, the ureters lie anterolaterally at the 2- and 10-o’clock positions; thus, the pursestring suture should not incorporate any tissue in the anterolateral peritoneal folds and should be placed rather shallow on the posterior peritoneal surface of the bladder in the midline. Many times, ureteral injury may not become evident until the postoperative period when anuria, fever, flank pain, and/or tenderness may manifest. A high degree of suspicion for ureteral injury should be maintained in this setting with the early use of adjunctive diagnostic studies and operative repair when necessary.
Bladder injury may result from retractor injury or from dissection misadventure during the development of the anterior peritoneal fold. This should be repaired at the time of hysterectomy with a multiple layer closure and maximal urinary drainage to prevent the formation of a vesicovaginal fistula. Significant bleeding may result from a laceration of a branch of the uterine artery. This should be controlled carefully with pinpoint accuracy as indiscriminate cautery may result in ureteral injury, tissue devitalization, and potential fistula. Bowel or rectal injury is rare if the uterus is freely mobile and there are minimal intraperitoneal adhesions in the pelvis. Careful, controlled dissection and peritoneal entry as described is the best way to avoid this unfortunate complication.
Late postoperative complications include urinary fistulas, vaginal stenosis or shortening, and the appearance of vaginal vault prolapse. A small, asymptomatic vault prolapse is common after hysterectomy and requires no further therapy, as this is usually self-limited. However, significant vault prolapse may indicate that an enterocele was missed at the time of hysterectomy and requires repair.