Hakim

𝗣𝗲𝗹𝘃𝗶𝗰 𝗢𝗿𝗴𝗮𝗻 𝗣𝗿𝗼𝗹𝗮𝗽𝘀𝗲: 𝗜𝘀 𝗛𝘆𝘀𝘁𝗲𝗿𝗲𝗰𝘁𝗼𝗺𝘆 𝗔𝗹𝗼𝗻𝗲 𝗮 𝗧𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁?

One of the most common misconceptions in pelvic organ prolapse surgery is the belief that removal of the uterus automatically cures prolapse.

The evidence tells a different story.

Pelvic organ prolapse is primarily a defect of pelvic support structures -the ligaments, fascia, and muscles that suspend the uterus and va**na. The uterus is often the victim of support failure, not the cause of the disease.

Therefore, removing the uterus alone does not correct the underlying support defect.

The American College of Obstetricians and Gynecologists (ACOG) states:

"Hysterectomy alone is not an acceptable treatment for uterova**nal prolapse because removal of the uterus does not correct inadequate apical support."

Similarly, the International Continence Society (ICS) emphasizes that restoration of apical va**nal support is a critical component of prolapse repair. Failure to address apical support is associated with recurrent prolapse and post-hysterectomy va**nal vault prolapse.

Scientific studies consistently demonstrate that women undergoing hysterectomy with concomitant apical suspension have significantly lower rates of recurrent prolapse and repeat surgery compared with hysterectomy alone.

Current evidence-based prolapse surgery focuses on restoring support through procedures such as:

✔ Uterosacral Ligament Suspension (USLS)

✔ Sacrospinous Ligament Fixation (SSLF)

✔ Sacrocolpopexy

✔ Uterine-preserving procedures (Hysteropexy)

The modern question is no longer:

"Should the uterus be removed?"

The real question is:

"How will apical support be restored?"

𝗞𝗲𝘆 𝗠𝗲𝘀𝘀𝗮𝗴𝗲 For Gynecologists

Pelvic organ prolapse is a support defect, not simply a uterine problem. Hysterectomy without apical suspension is not definitive prolapse surgery. Every prolapse procedure should include careful assessment and restoration of apical support to achieve durable long-term outcomes.

“Removing the uterus without restoring support is like replacing the roof of a house while ignoring its collapsing foundation. Successful prolapse surgery depends on restoring support, not simply removing an organ."

References

1. Pelvic Organ Prolapse. ACOG Practice Bulletin No. 214. Obstetrics & Gynecology. 2019;134(5):e126-e142

2. DeLancey JOL. Anatomic aspects of va**nal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166(6 Pt 1):1717-1728

3. Cruikshank SH, Kovac SR. Randomized comparison of three surgical methods used at the time of va**nal hysterectomy. J Pelvic Surg. 1999;5:197-203.

4. Maher C, Feiner B, Baessler K, Schmid C, et al. Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse. Journal of Clinical Medicine. 2022;11(20):6106. doi:10.3390/jcm11206106.

5. Haylen BT, Maher CF, Barber MD, Camargo SFM, Dandolu V, Digesu A, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse. International Urogynecology Journal. 2016;27(2):165-194

Dr. Finot Gashu: Obstetrician and Gynecologist, Urogynecology and RPS sub specialist

Telegram: t.me/HakimEthio