International Journal of Gynecology and Obstetrics 132 (2016) 224–228

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Medium-term outcomes after combined trachelectomy and uterosacral

ligament suspension among young women with severe
uterine prolapse☆
Zhixing Sun a,b, Lan Zhu a,⁎, Huiying Hu a, Jinghe Lang a, Honghui Shi a, Xiaoming Gong a
a
Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
b
Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To evaluate anatomic and sexual outcomes among young women with severe pelvic organ
Received 28 January 2015 prolapse undergoing combined trachelectomy and laparoscopic high uterosacral ligament suspension (LHUS).
Received in revised form 25 June 2015 Methods: In a prospective study in Beijing, China, patients (aged ≤50 years) with pelvic organ prolapse of stage
Accepted 23 October 2015 III or higher according to the Pelvic Organ Prolapse Quantification (POP-Q) were enrolled between November
2007 and August 2011. After combined trachelectomy and LHUS, patients were followed up at 6 weeks,
Keywords:
6 months, 12 months, and yearly thereafter. Anatomic success was defined as POP-Q lower than stage II. Sexual
Clinical outcome
High uterosacral ligament suspension
outcomes were assessed at 6 months via the validated Short-Form Prolapse/Urinary Incontinence Sexual Ques-
Laparoscopy tionnaire (PISQ-12), and compared with a control group of 39 healthy age-matched women. Results: Among
Severe 49 patients, surgical success and patient satisfaction rates were 100% after a median follow-up of 54 months.
Uterine prolapse Among 48 patients who were sexually active at follow-up, 39 (81%) completed the PISQ-12 questionnaire.
The 6-month PISQ-12 score was higher than the preoperative score overall (38.1 vs 26.4, P b 0.001) and
for all three subscale domains (P ≤ 0.001). The PISQ-12 score of postoperative patients was similar to that of control
women (36.8, P = 0.52). Conclusion: Trachelectomy combined with LHUS produced satisfactory medium-term
anatomic and functional outcomes for young women with severe uterine prolapse.
© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

1. Introduction who also have significant cervical elongation [7]. Many of these
women continue to feel a symptomatic bulge after surgery, and the pro-
Uterine prolapse is a common problem for women of all ages world- lapse can recur.
wide, affecting approximately 50% of women who have undergone Although there is no exact definition of cervical elongation, many
childbirth [1]. Among nulliparous young women with a uterus, approx- textbooks describe the “normal” length of the uterine cervix to be
imately 2% have had some form of prolapse [2], which highlights the im- about 3–4 cm. In a previous magnetic resonance imagining study [7],
portance of finding a safe and feasible treatment approach with uterine cervical elongation was defined as greater than 33.8 mm.
preservation and maximum protection of sexual function. At Peking Union Medical College Hospital (PUMCH), a tertiary refer-
In 1927, Miller [3] first described attachment of the uterosacral liga- ral center in China, more than 500 patients with uterine prolapse are
ment to the vaginal apex (high uterosacral ligament suspension). In treated each year. During clinical practice it has been observed that,
1997, Wu [4] performed laparoscopic high uterosacral ligament suspen- for most young women with uterine prolapse of Pelvic Organ Prolapse
sion (LHUS) for seven women with uterine prolapse. Subsequently, the Quantification (POP-Q) stage III or higher, the prolapse is associated
anatomic success rate of LHUS among larger samples has been reported with cervical elongation (cervical length ≥4 cm). Previous data also in-
to range from 79% to 87% [5,6]. The success rate varies widely, in part be- dicate that younger, premenopausal women with uterine descent are
cause LHUS might not be successful for women with uterine prolapse more likely to have a longer cervix than are older women with better
apical support [7].
Taken together, these observations prompted us to perform trache-
☆ Preliminary results presented at the 6th Gynecological Endoscopy and Mini-invasive lectomy combined with LHUS instead of LHUS alone when treating
Therapy Scientific Meeting of China; April 26–28, 2013; Luoyang, China. women with cervical elongation. The aim of the present study was to
⁎ Corresponding author at: Department of Obstetrics and Gynecology, Peking Union
Medical College Hospital, Chinese Academy of Medical Science, Beijing, China, 100730.
evaluate the medium-term anatomic and sexual function outcomes
Tel.: +86 10 65296784, +86 10 13911714696; fax: +86 10 65124875. among young women with severe uterine prolapse who were surgically
E-mail address: zhu_julie@sina.com (L. Zhu). treated by trachelectomy combined with LHUS.

http://dx.doi.org/10.1016/j.ijgo.2015.07.012
0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
 Z. Sun et al. / International Journal of Gynecology and Obstetrics 132 (2016) 224–228 225

2. Materials and methods To compare postoperative sexual function, a group of 39 age-

matched women who underwent health examinations at the Physical
The present prospective study included women with severe pelvic Examination Center, PUMCH, during the same period were recruited
organ prolapse, defined as stage III POP-Q or higher, attending as a control group and completed the PISQ-12 questionnaire. All the
PUMCH, Beijing, China, between November 1, 2007, and August 31, PISQ-12 questionnaires were self-administered by the patients in the
2011. All participants met the following six criteria: interactive POP-Q outpatient clinic.
stage III or IV [8]; POP-Q point D measurements above −3 cm, because Statistical analysis was performed with SPSS version 16.0 (SPSS Inc,
the cervical length can be explained by the descent of point D; age Chicago, IL, USA). The means of variables with normal or approximately
50 years or younger; parous; a history of regular menstrual cycles normal distributions (determined by Shapiro–Wilk test) were com-
with normal uterus body, fallopian tubes, and ovaries revealed by B- pared by paired t test. The Mann–Whitney test was used to compare
ultrasonography, and with cervical lesions (if present) less than cervical PISQ-12 scores between the surgical and control groups. Significance
intraepithelial neoplasia grade 3; and a desire for uterine preservation. was set at P b 0.05.
In addition, all participants had cervical elongation, defined as a cervical
length of 4 cm or more. Women who could not tolerate LHUS were 3. Results
excluded from the study. The study protocol was approved by the
ethical review board of PUMCH, and all participants provided written During the study period, 49 patients who had trachelectomy com-
informed consent. bined with LHUS were enrolled (Fig. 1). The mean age at the time of sur-
One researcher (L.Z.) performed the surgery, which combined trach- gery was 37.1 years (range 34–45 years). All the patients had various
electomy and LHUS and has been described in detail [9], for all patients. degrees of other site-specific defects, including cystocele and rectocele.
The procedure began with trachelectomy. First, the cervix was incised The characteristics of the 49 study women and 39 healthy control
circumferentially to the depth of the cervical stroma at the level of the women are given in Table 1. All 49 study participants were followed
bladder fold at the cervix with an electrosurgical generator to form a up for more than 3 years.
vaginal cuff. The cylinder of tissue over the cervix was then grasped The mean operating time for trachelectomy combined with LHUS
and retracted, and sharp dissection was used to separate the vagina (excluding other concurrent operations) was 51.0 ± 8.4 minutes, and
from adjacent structures. The bladder was pushed gently up to the the mean blood loss was 32.0 ± 17.5 mL. No intraoperative complica-
level of the internal os so that the descending vaginal could be located, tions such as injuries or pelvic hematoma occurred. Within 24 hours
divided, and then transected at the level of the internal os. Bipolar dia- of surgery, all the participants experienced similar mild buttock pain,
thermy was used for hemostasis. Last, the cervix was re-epithelialized which resolved gradually within 2 weeks. No pain relief medication
with Sturmdorf suturing. It was checked that the cervical canal was needed to help ease discomfort. Postoperatively, there were no
remained open and easily accessible. complications such as ureteric obstruction due to distal kinking, lower
Next, the LHUS was performed. After video-laparoscopy was extremity sensory nerve symptoms that might be related to LHUS, or
established, blunt dissection was used to visualize the ureters, and cervical stenosis that might be related to trachelectomy.
hydro-dissection was performed by injecting 20–30 mL of physiologic Over the mean follow-up time of 54 months (range 36–82 months),
saline and 1:200 000 angiotensin into the retroperitoneal space be- the anatomic success rate was 100%. Preoperative and postoperative
tween the ureter and uterosacral ligament. The ureter was pushed out- POP-Q measurements demonstrated significant improvements after
side, and the peritoneum was opened upward from the level of the surgery, as measured by POP-Q points Aa, Ba, C, D, Ap, Bp, GH (genital
internal os. Subsequently, the two uterosacral ligaments, both approxi- hiatus), and PB (perineal body; all P b 0.01) (Table 2). In particular,
mately 4-cm long, were respectively grasped with forceps and ligated the POP-Q scores for points C and D were significantly higher after the
with non-absorbable sutures (Ethibond, Ethicon, Somerville, NJ, USA). operation than before surgery (both P b 0.001). The total vaginal length
Tie knots were used to shorten the two uterosacral ligaments and to remained unchanged. In a subjective assessment, 100% of the study pa-
unite them across the midline. Last, the pouch of Douglas was closed tients felt “very satisfied” or “satisfied” after surgery.
to end the surgical procedure. At the end of the surgery, the POP-Q Preoperatively, 48 of the 49 patients had engaged in sexual inter-
point C should be located at the level of the ischial spine or above. course within the past few years. One patient was widowed and had
Postoperative assessments were conducted by examiners in the not engaged in sexual intercourse for several years. Among the 48 pa-
Department of Obstetrics and Gynecology, PUMCH, who were masked tients who had had sexual intercourse recently, 17 were sexually active
to other study data. Anatomic results were assessed by a clinical exam- (defined as having sexual intercourse at least 2–3 times a week) at the
ination at 6 weeks (when wound healing was also evaluated), 6 months, time of the study. Postoperatively, the 48 patients returned to sexual ac-
12 months, and then yearly after surgery. For each patient, the most re- tivity and became sexually active within 6 months. No de novo
cent measurements were evaluated in the present study. For both the dyspareunia was reported.
anterior and posterior segments, surgical success was defined as POP- Among the 48 sexually active patients, 39 (81%) answered the PISQ-
Q stage I or lower in accordance with the NIH Standardization Work- 12 questionnaire completely. The other nine patients received the PISQ-
shop [10]. If the wound had healed well, the patient was encouraged 12 questionnaire but did not complete it: several participants replied
to become sexually active 3 months after surgery. that the subject was too intimate to be discussed. When asked during
Patient satisfaction was evaluated by the question “How satisfied the clinical follow-up whether they were satisfied with their postoper-
are you with the results of your surgery?” at 6 months and 12 months ative sexual intercourse, they all responded that their sex life was
after surgery and then annually thereafter. The response options “much better” than before surgery.
included “very satisfied,” “satisfied,” “neutral,” “unsatisfied,” and “very For the 39 patients who were sexually active after surgery and com-
unsatisfied” [11]. pleted the pre- and postoperative PISQ-12 questionnaires, significant
Sexual outcomes were assessed at 6 months after surgery using the improvements were observed both in the total score and in all three
Short-Form Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ- subscale domains at 6 months (Table 3). The percentage improvements
12) [12], which is easy to understand and has been validated for from baseline for individual item scores of the questionnaire,
Chinese-speaking populations [13]. Twelve items are used to assess sex- representing various aspects of sexual function, are presented in Fig. 2.
ual function and feelings over the previous 6 months in three areas: be- The mean PISQ-12 score for 39 age-matched (34.7 ± 2.4 years vs
havioral/emotive (score range 0–16); physical (0–20); and partner- 37.1 ± 5.3 years, P = 0.46) healthy women was not significantly differ-
related (0–12). These scores yield a composite total score of 0–48. ent from that of patients 6 months after LHUS (Table 3). Considering the
Higher scores indicate better sexual function. mean score of each domain, the study women who underwent surgery
226 Z. Sun et al. / International Journal of Gynecology and Obstetrics 132 (2016) 224–228

Fig. 1. Flow of patients through the study.

and completed the PISQ-12 questionnaire might be considered finding an anatomic success rate of approximately 80% [4–6,15,16].
“normal” in terms of the behavioral/emotive, physical, and partner- For patients with cervical elongation, however, LHUS is generally
related aspects of sexual function (all P N 0.30). not feasible.
The results of the present study indicate that a combination of trach-
electomy and LHUS is effective for the treatment of these young women
4. Discussion with POP-Q III or IV uterine prolapse, yielding excellent medium-term
outcomes. The anatomic success and patient satisfaction rates were
LHUS is an operation that appends the vaginal apex to the remnants of both 100% during a mean follow-up of at least 3 years, which is consid-
the uterosacral ligaments at the level of the ischial spines without erably higher than the reported 80% anatomic success rate of the
significantly distorting the vaginal axis [5,14]. Previous studies have eval- Manchester procedure [17] and that of LHUS alone. There are some pos-
uated large numbers of women with POP who underwent LHUS alone, sible reasons for this result. First, a combination of trachelectomy and
uterosacral suspension was performed, which reduced both the cervical
elongation rate and the symptomatic bulge after surgery. Second, the
POP-Q point C was elevated by at least 2 cm, which helped to maintain
Table 1 the total vaginal length. Third, the entire uterosacral ligaments were in-
Baseline characteristics.a dependently plicated and shortened to less than 4 cm, reaching a posi-
Characteristic Women undergoing Healthy control tion near the level of the sacrospinous ligaments. This was done so that
trachelectomy women (n = 39) point D would be positioned above −3 cm and thereby ensure that the
and LHUS (n = 49)b operation was effective.
Age, y 37.1 ± 5.3 34.7 ± 2.4 There are few data regarding sexual function outcomes (on the basis
BMI 21.8 ± 1.9 22.9 ± 2.4 of sexual function questionnaires) after LHUS. Doumouchtsis et al. [18]
Gravidity 2.6 (1–5) 2.1 (1–4)
Parity 1.1 (1–2) 1.3 (1–2)
Stage of other site-specific defects
Cystocele
Stage1 31 (63) 2 (5) Table 2
Stage2 15 (31) 0 Preoperative and postoperative POP-Q measurements of women undergoing trachelecto-
Stage3 3 (6) 0 my and laparoscopic high uterosacral ligament suspension.
Rectocele
Stage1 26 (53) 1 (3) POP-Q Pre-operative measurement, Postoperative measurement, P valuea
Stage2 18 (37) 0 point cm (n = 49) cm (n = 49)
Stage3 5 (10) 0
Mean ± SD Mean ± SD
Concurrent surgical procedures
Anterior colporrhaphy 3 (6) 0 Aa −0.1 ± 1.1 −2.3 ± 0.5 b0.001
Posterior colporrhaphy 5 (10) 0 Ba −0.2 ± 2.0 −3.0 ± 0.0 0.001
Intrauterine devices removal 3 (6) 0 C +2.2 ± 0.8 −5.5 ± 0.5 b0.001
TVT-O 2 (4) 0 GH +6.2 ± 0.6 +5.4 ± 0.9 b0.012
Ovarian cyst resection 2 (4) 0 PB +2.5 ± 0.5 +3.3 ± 0.9 0.011
Diagnostic curettage 1 (2) 0 TVL +8.0 ± 0.4 +8.0 ± 0.4 N0.99
Ap −1.4 ± 0.8 −2.8 ± 0.4 b0.001
Abbreviations: LHUS, laparoscopic high uterosacral ligament suspension; BMI (body mass
Bp −2.3 ± 0.6 −3.0 ± 0.0 b0.004
index, calculated as weight in kilograms divided by the square of height in meters); TVT-O,
D −4.1 ± 0.7 −6.9 ± 0.3 b0.001
tension-free vaginal tape obturator; POP-Q, Pelvic Organ Prolapse Quantification.
a
Values are given as mean ± SD, median (range), or number (percentage). Abbreviations: POP-Q, Pelvic Organ Prolapse Quantification; GH, genital hiatus; PB, perine-
b
All 49 women had POP-Q point D measurements above − 3 cm and POP-Q stage III al body; TVL, total vaginal length.
a
uterine prolapse. Paired t test comparing preoperative and postoperative POP-Q measurement.
 Z. Sun et al. / International Journal of Gynecology and Obstetrics 132 (2016) 224–228 227

Table 3
PISQ-12 values of sexually active study women and healthy controls.

PISQ-12 domain Women undergoing trachelectomy and laparoscopic high uterosacral ligament Healthy women (n = 39)
suspension (n = 39)

Baseline Month 6 Changea P valueb Baseline P valuec

Behavioral/ emotive 4.7 ± 1.7 10.5 ± 3.1 5.8 ± 2.9 b0.001 10.3 ± 2.0 0.71
Physical 13.4 ± 2.3 18.6 ± 1.8 5.2 ± 2.4 b0.001 18.2 ± 1.0 0.30
Partner related 8.3 ± 1.9 9.0 ± 2.6 0.7 ± 1.3 0.001 9.0 ± 1.0 0.90
Total score 26.4 ± 3.9 38.1 ± 5.5 11.7 ± 5.1 b0.001 37.5 ± 3.0d 0.52

Abbreviation: PISQ-12, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire.

a
Calculated as 6-month score minus baseline score.
b
Paired t-test comparing response at baseline and month 6.
c
Paired t-test comparing response at month 6 and healthy controls.
d
The 95% bilateral confidence interval for the mean summary score difference comparing study group response at month 6 and healthy control response was −1.42 to 2.62.

200

180
Improvement from baseline, %

160

140

120

100

80

60

40

20

Fig. 2. Improvements in individual item scores of the Short-Form Prolapse/Urinary Incontinence Sexual Questionnaire at 6 months after after surgery among women with severe uterine
prolapse. Abbreviations: Incon fear, fear of incontinence; Prem ejacln, premature ejaculation.

assessed 42 women with POP who underwent vaginal hysterectomy numbness after surgery, indicating that there were no nerve injuries.
combined with LHUS. At 5 years after surgery, 18 of 20 women who The reason why the present patients did not experience nerve injuries
were sexually active completed the PISQ-31. The mean total score for is not clear. It might be due to the surgical approach, whereby the entire
all domains was 91/125 (which is equivalent to a mean total score of uterosacral ligaments were plicated and shortened to less than 4 cm
35/48 in the PISQ-12 [12]. In the present study, the mean PISQ-12 after the knots were tied.
total score for the 39 sexually active women was 38.1 points at 6 One of the strengths of the study is that the examiners who per-
months after surgery, which was 11.7 points higher than the preopera- formed all of the sexual function assessments (Z.X.S. and H.Y.H.) were
tive score (P b 0.001). There was no significant difference in PISQ-12 different from the surgeon who performed the surgery (L.Z.) to avoid
score between the postoperative group and the age-matched control the risk of positive outcome bias. However, the study has some major
group. These results indicate that the present approach protected the limitations. First, owing to the relatively low success rate (~ 80%) of
sexual function of the young women who had severe uterine prolapse, the Manchester procedure [17], it was not appropriate to include two
at least within a short-term follow-up period. As compared with the study groups to compare trachelectomy only with trachelectomy and
study of Doumouchtsis et al. [18], there were more sexually active pa- LHUS. Second, the present study design included a healthy control
tients with a higher equivalent PISQ-12 score in the present cohort. A group; however, whether the PISQ-12 questionnaire was appropriate
possible explanation might lie in the better anatomic outcomes of the for these healthy volunteers and whether the sample was sufficiently
present study (100% vs 88% success rate). powered for a comparison between women with uterine prolapse and
Symptoms affecting lower extremity sensory nerves can be one of healthy women require further investigation.
the most common late complications of LHUS. Flynn et al. [19] retro- In summary, a combination of trachelectomy and LHUS is a simple
spectively evaluated 182 LHUS procedures, finding that seven women and effective procedure that has been found to provide satisfactory
had severe postoperative pain and numbness in a S2–4 distribution medium-term anatomic and sexual function outcomes for young
within 24 hours. These symptoms seemed to be related to placement women with severe uterine prolapse. A trial with a more appropriate
of the uterosacral ligament sutures. Three of the women experienced control group is needed to confirm the present results.
symptom relief after prompt removal of the ipsilateral uterosacral liga-
ment suture. The remaining four women were treated with gabapentin
and narcotics, which partially reduced their symptoms. By contrast, no Conflict of interest
intraoperative or postoperative complications occurred in the present
study. The patients experienced no more than moderate pain and no The authors have no conflicts of interest.
228 Z. Sun et al. / International Journal of Gynecology and Obstetrics 132 (2016) 224–228

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