Pelvic Floor Reconstruction Without Uterine Removal

It is not necessary to remove the uterus in order to surgically manage uterine prolapse with an apical suspension procedure. It’s just how the procedure has always been taught, says Cleveland Clinic urogynecologic surgeon Marie Fidela Paraiso, MD.

“It’s become dogma. You don’t have to remove the uterus if the patient wants to keep it and there is no gynecologic pathology to require its removal,” she says, adding that “some people would argue the uterus is an innocent bystander.”

Dr. Paraiso has performed uterine-preservation pelvic floor reconstruction procedures since the mid- to late-90s. Now, as Head of Cleveland Clinic’s Center for Urogynecology and Reconstructive Pelvic Surgery, she offers the option whenever appropriate.

“Patients who feel strongly about leaving the uterus in place should have that option if it’s safe for them,” she says.

Pros, cons and unknowns

The option to preserve the uterus is particularly important to women of reproductive age. In order to help patients make an informed decision, Dr. Paraiso is frank about pros, cons and unknowns.

“I tell patients most literature involves removing the uterus. The evidence to support keeping it isn’t as robust,” she says.

If the patient has severe uterine prolapse, cystocele and a weak pelvic floor, and is amenable to vaginal mesh placement, Dr. Paraiso is likely to recommend uterine suspension with vaginal mesh. “If the patient hopes to become pregnant in the future, I would use a single mesh and perform the procedure laparoscopically or with robotic assistance,” she adds.

She feels it’s important for patients to know that when a graft is implanted for uterine suspension, hysterectomy later in life may be more difficult. “I also recommend she deliver by Cesarean section,” she says.

Many good options available

Dr. Paraiso performs pelvic floor reconstruction through all available routes: abdominally through an open incision, laparaoscopically with or without robotic assistance and vaginally with mesh suspension or sacrospinous ligament fixation.

A review of all options she conducted in 2008 reinforced there is no gold standard for treating uterine prolapse.

“The optimal procedure for any patient depends on multiple factors, including the presence of specific defects, the patient’s age, comorbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, and, of course, the skill and comfort level of the surgeon with the particular procedure. However, all procedures work just as well as when the uterus is removed as when it is not,” she says.

The risk of bowel obstruction from scar tissue is slightly higher with abdominal procedures and lower when the uterine suspension is performed vaginally. A recent study found no difference in the rate of complications whether mesh is placed vaginally or laparoscopically at the time of hysterectomy.

One myth Dr. Paraiso is quick to dispel involves the supposed need to retain the uterus in order to preserve sexual function. “Although some women think their sexual function will be better if they keep their uterus, we have no data to prove or disprove it,” she says.