What are the treatment options for uterine prolapse, including surgical interventions like hysterectomy and uterine preservation surgery?

Surgical Management of Uterine Prolapse

For symptomatic uterine prolapse requiring surgery, vaginal hysterectomy with vault suspension is the recommended approach, though uterine-preserving procedures (hysteropexy) are appropriate alternatives for women who desire to retain their uterus. 1

Primary Surgical Options

Vaginal Hysterectomy with Vault Suspension

• This remains the traditional gold standard for uterine prolapse, addressing both the prolapsed uterus and providing apical support to prevent subsequent vault prolapse 1, 2
• Vaginal hysterectomy offers shorter operating times, faster return to normal activities, better quality of life, lower infection rates, and shorter hospital stays compared to abdominal approaches 3
• The critical component is concurrent vault suspension (uterosacral ligament suspension, sacrospinous fixation, or iliococcygeus fixation), as hysterectomy alone fails to address the underlying apical support defect 4, 2

Uterine-Preserving Surgery (Hysteropexy)

• Hysteropexy should be offered to all patients considering prolapse surgery unless contraindications exist 5
• Women may desire uterine preservation for fertility, gender identity, belief in functional benefits, or personal preference 5, 2, 6
• Available approaches include:
  • Vaginal hysteropexy (sacrospinous hysteropexy, uterosacral hysteropexy, Manchester procedure) 7, 2
  • Laparoscopic/robotic sacrohysteropexy 7, 4
  • Abdominal sacrohysteropexy 7

Comparative Outcomes: Hysterectomy vs. Hysteropexy

Efficacy

• Laparoscopic suture hysteropexy demonstrates 81% symptom resolution and 79% objective cure at 12-month follow-up, with mean operating time of 42 minutes 4
• Both approaches show comparable success rates for prolapse correction in short to medium term (up to 5 years) 7, 5
• No significant difference in sexual function between uterine-preserving surgery and hysterectomy-based repairs 5

Safety Considerations

• The rate of subsequent hysterectomy after hysteropexy is low, most commonly performed for recurrent prolapse rather than uterine pathology 5
• Patients must continue cervical cancer screening and evaluation of abnormal uterine bleeding following hysteropexy 5
• If cervical elongation is present, trachelectomy should be considered at the time of uterine-preserving surgery 5

Route Selection Algorithm

Factors Favoring Vaginal Approach

• Adequate vaginal access and uterine mobility 3
• Prior vaginal deliveries 3
• Presence of concomitant vaginal prolapse requiring repair 3
• Patient preference for faster recovery 3

Factors Favoring Abdominal/Laparoscopic Approach

• Limited vaginal access or mobility 7
• Desire for sacrocolpopexy/sacrohysteropexy (higher anatomic success rates) 7
• Concomitant abdominal pathology requiring treatment 7
• Surgeon expertise with minimally invasive techniques 7

Critical Counseling Points

For All Patients

• Hysterectomy provides the benefit of cancer detection and prevention, eliminating future risk of endometrial and cervical cancer 5
• Vaginal hysterectomy alone has relatively high subsequent vault prolapse rates without concurrent vault suspension 4, 2
• The Manchester repair (cervical amputation with cardinal ligament plication) has high failure rates and may complicate future cervical/uterine sampling 4

For Patients Considering Hysteropexy

• Fertility preservation is possible; limited data show successful term pregnancies after laparoscopic hysteropexy, though cesarean delivery is typically recommended 4
• Ongoing need for gynecologic surveillance including cervical cancer screening 5
• Small risk of future hysterectomy for recurrent prolapse or uterine pathology 5

Important Caveats

• Surgeon expertise is paramount—surgeons should only perform procedures they are properly trained and comfortable performing 3
• Patient-specific factors (body habitus, medical comorbidities, concomitant pathology) must guide individualized surgical planning 3, 7
• Obliterative procedures (colpocleisis) remain options for elderly patients or those with significant comorbidities who do not desire vaginal intercourse 7
• Prospective randomized trials comparing hysterectomy with hysteropexy are still needed to provide definitive comparative data 2, 6