Chapters Transcript The Vaginal Hysterectomy for Prolapse Course: Urogynecology and Reconstructive Pelvic Surgery The future of surgery and surgical corrections are robotics. Um, but I guess I tasked myself with the, the, the sort of the old tried and true method for treating prolapse, which is vaginal hysterectomy for prolapse. Uh, here are my disclosures. So, I wanna uh talk a little bit about trends in hysterectomy in general, um, vaginal hysterectomy, talk about the history. I always get a kick out of looking at where we were and where we'll potentially go, um, after vaginal hysterectomy, what are our options to treat prolapse and then uh talk a little bit about the data and if we have some time, the recovery after prolapse and conclude. So this shows the hysterectomy rate over time. It's an interesting study where they brought all sorts of different studies together to plot what hysterectomies are being done in the United States, and you can see that overall there has been a decline over the last many years, and there is a suggestion that hysterectomy will go down in spite of our aging population. And what I realized in preparing the talk on vaginal hysterectomy is there really are quite a few hysterectomy options we have out there, um, transvaginal open, a pure straight stick laparoscopy, uh, single port, multi-port robotics, and even uh vaginal natural orifice surgery. But when we look at a confusing topic, we look at guidelines because people um take a lot of time and effort to put these guidelines and and position statements together, and the ACOG statement, which was originally in 2009, then reaffirmed again 2 and 3 and 4 times and continues to this day to be the actual ACOG statement on how we should choose the route for hysterectomy for benign disease, and it says the vaginal approach is preferred among the minimally invasive approaches. And there are some things that might influence ultimately what makes us decide one surgery for another, but surgeon training experience one of those things, as well as the patient, and I think that those are important factors. So where were we? And if we look at the recent past, uh, you can see that the route of hysterectomy had not really changed over many, many years with abdominal hysterectomy or open hysterectomy being quite common with the blue boxes, the vaginal hysterectomy making up about 20%. I think it's also important to think about how indications for surgery and hysterectomy type have changed over time, and we can see that again, if we look at pelvic organ prolapse, the reason we're all gathered here today, uh, the green sort of circles, uh, we can see that the indications really had not really budged all that much over the ensuing several years. So, in 2007, 2008, 2009, right around the time when this first position statement came out, we did start to see an expansion of laparoscopic, uh, and laparoscopic assisted hysterectomy. But let's look overall with a bit of a higher time horizon. So just another paper, again, this gray line here, vaginal hysterectomy, this is our open hysterectomy. And if we fast forward to after the position statement, which probably in my mind should have resulted in people doing more vaginal hysterectomies, we actually see the vaginal hysterectomy rate continue to decline and what we see here is the green and the red. Lines, the laparoscopic and the robotic, uh, different routes of hysterectomy starting to increase up to about 2015. So something doesn't quite add up. But if we look and figure, well, what else influences people and how they do hysterectomies, what about the FDA warning on power morselation? Another area where I thought vaginal hysterectomy would now become. More popular once again and you can see this is a really boring graph when you look at it, nothing happens after the warning so it might have changed practice patterns for some of our minimally invasive gynecology colleagues, but we really didn't see a whole lot of change. And I also wanted to just get a sense of what's out there in the public and, and sort of is the maybe um the universe searching for vaginal hysterectomy any different. And just looking on Google, we see the blue liner vaginal hysterectomy as our search term really has not changed and it's a little bit small, but this is 2004, again, maybe there were fewer people on Google back then to admittedly, and then up to 2001 where there really is not much change, but during that time frame, we do see robotics get searched for more and we do see laparoscopy getting searched for. So what does all of this actually mean? Um, in 2004, hysterectomy for benign pathology is still one of the most common surgical procedures with close to half a million cases done in the United States. Um, at this point, it's estimated that 65% of our hysterectomies in the US are performed with a minimally invasive approach, and 40% of those laparoscopic surgeries are done with robotic assistance as we just heard about. But what about the history of vaginal hysterectomy? And I got a little bit lost when I started going into this, and I guess I, I just sort of really started to enjoy myself. But I'm not gonna tell you all of the history here. I'll just mention sort of the first planned. Uh, transvaginal hysterectomy. It was intended to be done extraperitoneally and it's down here, the picture of this guy, Conrad Langenback, and he actually knew it was gonna be difficult, so he asked one of his colleagues, a general surgeon, uh, to help out with the case. And unfortunately, the general surgeon had a gout attack during the case and was not able to stand up from his chair. And there's a. Pretty, you know, graphic account of this guy not being able to help. So Langenback's doing the vaginal hysterectomy alone, holding a suture with his teeth, tying with another hand. And people actually doubted the validity of this, but they subsequently, about 20 years later, the patient died. They did a postmortem on her and confirmed that she did not have a uterus. So he was vindicated at the end of the day. Um, we do know that in England and in the US there were champions of vaginal hysterectomy, so this was a, um, a series back then, uh, Vivian, um, Barley Green armitage, uh, 500 vaginal hysterectomies, and what's amazing is the mortality rate even back in in 18 and 1900s, um, or 19 and uh and and. Starting sort of at the turn of the century, uh, mortality rate was only 1.2. In the United States, the other champion of the sort of vaginal hysterectomy was a surgeon that you may know from some of the clamps that he had defined, but Heaney out of Chicago did 630 vaginal hysterectomies and the mortality rate again less than 1%. Um, and there were a couple of other sort of real notable, um, achievements. But when we look back at the history, we need to sort of modernize and say, OK, what's the data today? And when we're looking to try to summarize, we look for meta-analysis and Cochrane data and the. Advantage of vaginal hysterectomy over um abdominal hysterectomy is pretty clear. Um, and we know that there's better quality of life if we're doing it vaginally versus an open procedure, shorter operative time, less hospitalization, and patients get back to work a little sooner. But what about the data for vaginal versus laparoscopic, and this is based out of over 1000 women, 16 different trials, um, and it turned out that the time to return to work was actually the same. Satisfaction was pretty similar. We did have a little bit of a shorter length of stay for hospitalization. And what really does stand out is the cost. And if we look at cost, I think what you start to realize is regardless of how busy a surgical center is, in all cases, the vaginal hysterectomy ends up being less expensive. And this is a modern sort of look at premier healthcare database, uh, over a 20 year time period, vaginal hysterectomy was costing less. You'll see things like robotics get a little bit cheaper the more cases you do, but vaginal hysterectomy. Still wins out. Uh, this was another sort of interesting uh paper and looking at the cost of uh minimally invasive or sort of our, our other option here, um, Katherine Matthews, one of the authors here, and what ends up happening is the higher initial cost, even if we take into account failure rates and if you say, hey, well, the failures may be more common with a vaginal sort of native tissue repair than a robotic sacro culpaplexy, uh, the initial higher cost. Really still does end up driving the fact that it's more cost effective to do it transvaginally. So this 2009 statement, the choosing the route, um, I would agree and they based this off of many of the studies I showed you shorter operative time vaginally compared to laparoscopically, lower cost, um, and no real evidence in the dis the difference between different, um, return to normal activities or injury to the urinary tract. So when we're talking about prolapse and talking about hysterectomy, we have to realize that most of the time we're dealing with a level one Delancy level of support issue. And if we look at the ACOG bulletin, these are really our options after vaginal hysterectomy, utero sacral ligaments suspension or sacrospinous ligament suspension, and this is just the anatomy of our different options. So the high utero sacral suspension, obviously very well suited at the time of a transvaginal hysterectomy cause we're intraperitoneal, and it allows us to uh really preserve vaginal length. So here's a video of the plays of a transvaginal hysterectomy and a uterosacral suspension. So just to highlight some of the key points here, we're making our circumvential incision, um, and then on the next video here, we're gonna see actually lifting up and entering into the anterior um um space. And so now we're going to, once we've done that anteriorly, um, and sweep everything back, make sure our bladder is out of the way. We're gonna enter posteriorly again a curved mayo scissor, and we're gonna. Make sure that we're now in control both anterior and posterior. Pretty straightforward for those of you that do transvaginal hysterectomy. Of course, we filmed the ones that are smaller uteruses and easier to do rather than the disaster ones. Um, but in any event, once we're done using uh a device here using the ligature to take the pedicle on either side, making sure that we're free of the vaginal wall, and we're gonna again take our bites. Now, once we're done taking the uterus out transvaginally. Um, we're going to actually, uh, go ahead and in this case, put our stitches with the aid of the capo needle over here, um, that's not working. Control L maybe. Yeah, there we go, laser pointer. So, um, this is now our stitch, uh, placed sort of in this location, a high uterosacral to avoid any ureteral injury. Now, if we look at the uterosacral suspension versus the McCall stitch, uh, another way of suspending the apex, this was a nice review. About 200 patients and what we see here in blue is the recurrence rates are in fact lower for anterior recurrence, central recurrence, and posterior recurrence, those that had a vaginal hysterectomy with a vaginal cuff suspension with utero sacral versus a maca, which is just sort of this stitch again a little bit lower down and less effective. Sacro spinus ligament fixation, another option again, usually my preference if there's an issue where I. Can't find the utero sacrals easily, um, or perhaps I'm using a posterior approach or approach for um for prolapse and this is again sort of showing the direction of where we're going to be palpating, um, and in this case using both a permanent and a and an absorbable once I, I skipped over the uh capo needle driver to place it into ligament and then placing these stitches through the vaginal wall with the aid of a mayo needle. So if we compare the two approaches, the uterosacral ligament fixation versus the sacrospinous ligament fixation and look at the optimal trial, um, it was really doing two things. Part of the study was trying to figure out, hey, which one of these therapies is better, and the other was, does pelvic floor muscle exercises um after surgery actually help. But the outcome I wanted to look at was the differences between the two, and it turns out that there's really no difference in failure rates between uh. sacral and a sacrospinous ligament fixation. The rates of failure do increase over time. And so initially when we review this in, in a journal club with our fellows, they're like, wow, these surgeries you do are really not effective. But what you do is you have to read a little bit deeper into it and realize that though the prolapse, uh, may have sort of again anatomically failed, the symptoms scores remain steady. And so it's really important to realize in women when we're treating a condition, um. That's a quality of life condition and uh and really a subjective complaint that really may be the more appropriate measure to look at again, meta-analysis data looking at more than just this one optimal trial and it's fairly even throughout. The one thing is the ureteral injury rate does seem to favor the sacrospinous ligament fixation, but that's why we use agents and cystoscopy to ensure. We also could consider whether the hysterectomy is needed at all, um, and that's probably a whole another lecture, but I think that the one thing that I often will point to is the data point that says, hey, there possibly is less recurrence when a hysterectomy is done favoring the hysterectomy and apical suspension versus a hysteropexy. Um, we do know that there are other considerations, and here this is a study looking at cost effectiveness in, in ways of trying to actually reduce or prevent endometrial cancer. So when we have our older patients that are considering preservation of the uterus, I often do sort of mention to them that prolapse is part of it, but certainly if our rates may be a little bit better and we may prevent cancers, it is something that's worth a discussion. What about vaginal orifice natural, uh, vaginal natural orifice um surgery? And this is a Vote sort of picture again using a uh sort of a port in the vagina, and I think that there is still not enough data to really say whether this is necessary or not. Um, certainly in cases where the um the uh Adnexa needs to be removed, maybe something that is a little bit more important to go after, uh. Is potentially an option for us. So if we look at transvaginal hysterectomy and sort of this is what I'm touting and again trying to tell you, hey, this is the right way to fix prolapse, admittedly I do other forms of prolapse surgery as well, um, but for the sake of the argument, we wanna make sure that the recovery after vaginal surgery is appropriate and this was one of our, uh, former fellows, Carolyn Brandon, did a great thesis project asking patients about their return to. Full return to activities asking these two different questionnaires, the post-surgical recovery scale and the global surgery improvement scale and you can see that again by about 6 weeks, most women are recovered, but I do tell women in some cases it may take up to 12 weeks uh to fully recover, um, but I think that that just goes to show you that this is a repair that is certainly an appropriate uh way of treating prolapse, bring you back again to the. Guidelines and sort of what we know from the American College of Obstetrics and Gynecology, vaginal hysterectomy and vaginal apex suspension with vaginal repair anterior and posterior repair, um, as needed are effective treatments for most women with utero vaginal, anterior posterior wall prolapse and again when we compare them both to abdominal and laparoscopic, this is why the committee actually came forth and said this is really what should be offered to most women. And that's all that I have on that. Published September 20, 2024 Created by Related Presenters Benjamin Brucker, MD View full profile
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