The AAGL listserv has an ongoing discussion on techniques of cuff closure during hysterectomy. The main conclusion is that we have several opinions but no data

Below a comment written by the Gruppo Italo Belga.

Date: Mon, 17 Dec 2012 18:38:49 -0500
From: Philippe R Koninckx and Anastasia Ussia
Subject: Recurrent prolapse following LSH/cervicosacropexy Vaginal Cuff

This has been a nice discussion.

* We have to realize that we are discussing rare events of a few percent incidence, for which RCT are vitually impossible to perform. Indeed the rule of thumb that meaningful statistics need 30 cases, learns that to evaluate a 1% event a rct of 6000 (3000 cases and 3000 comparators) interventions would be necessary.

* Most comments therefore reflect opinions based on personal experience, meetings and ‘table’ discussions. These not only are the best we have, these opinions reflect honest experience and should be considered thoughtfully. In addition we should try to understand them based upon our growing knowledge of surgery. Let us try.

* What has emerged over the last decades for prolapse prevention/surgery is the importance of the support structures and of the vagina resting on the levator plate. This knowledge has not been the consequence of MIS but development was simultaneous. As an example, I did see for the first time the levator ani muscle at the Rome meeting in the early nineties during a lecture by Harry. It made me think and probably others too. My translation today is that repair/attachment of the pubo vesical fascia to the uterosacrals is important. When we realized the importance of the vagina resting on the levator plate, we started to pull the vaginal cuff backwards by shortening the uterosacrals. This got a name later, the high McCall procedure. This however introduced something new: first we sutured the uterosacrals much more posteriorly than we used to do before, and to do it well we often went more posteriorly introducing traction. “The better is the enemy of the good” also applies here and we soon realized that this could introduce kinking of the ureters. Some of us introduced systematic a small incision between ureter and uterosacrals (PK et all, JMIG 1996) others introduced systematic cystoscopy.

* A similar comment concerning ureters could be made for suturing the bladder and stent insertion after full thickness removal of a deep endometriosis nodule.

* The bottom line for us is that it needs a surgeon to do surgery, and that we continuously need to stay open minded in order to learn from each other.

This has been the hallmark of MIS development.

Philippe R. Koninckx and Anastasia Ussia

Date: Tue, 18 Dec 2012 20:14:15 -0500
From: Elliot Greenberg
Subject: Recurrent prolapse following LSH/cervicosacropexy Vaginal Cuff

It has been very gratifying to know that I began a subject thread on this listerv that might set a record for the longest continuous conversation as well one of the most diverse in opinion and international participation.

I want to thank Harry Reich and everyone for their comments. As always, this is an amazing forum for sharing ideas.

I very much appreciate the comments of Professors Koninckx and Ussia regarding the difficulty in obtaining hard, level 1, data when it comes to surgical outcomes in surgery. Also, being a Baystate Medical Center physician and a minimally invasive surgeon since the late 1980’s, I have admired Dr Reich for many years. I do agree with many of his comments regarding the use of high uterosacral suspension of the vaginal cuff and appreciate the fact that he references other studies and not just his vast experience.

That being said, IN MY OPINION, one of the problems we run into with recommendations regarding surgical procedures is the fact that the success of the procedure is directly related to the skill of the surgeon. By default, most series are performed by excellent surgeons who’s skill and numbers far exceed the average competent surgeon. In Dr Reich’s hands I suspect that a laparoscopic high uterosacral suspension gives consistently excellent results and is a low risk procedure. It is my humble opinion that a well done high McCalls procedure is not any easier, nor is it safer, than a colposacropexy. In fact, I think I could argue that a colposacropexy is a more reproducible procedure for the average pelvic support surgeon. A high McCall’s, done well, requires the proper identification of the uterosacrals, at the proper level, while avoiding kinking of the ureters or releasing them, and attaching the uterosacrals to the vagina without excessive tension and without creating an air knot which could risk an internal hernia and bowel strangulation. I have done many of these and continue to offer them to patients as a “native” tissue alternative. I think the LSH/cervicosacropexy patients heal faster, have less postoperative pain, and may have an equal or lower risk of complication.. At the moment I can’t quote the source, but I was taught many years ago to do a Modified McCalls procedure vaginally or abdominally by attaching the Uterosacrals to the vaginal cuff on the ipsilateral side, and not in the middle, to avoid kinking of the ureters and to avoid bowel dysfunction due to narrowing the cul de sac over the rectum. I suspect that most surgeons who do laparoscopic uterosacral suspensions don’t attach it high enough because they aren’t comfortable operating in that space, leading to a higher failure rate.

Certainly there are unique risks to mesh but the same can be said of TLH/High Uterosacral Suspension. I think that the LSH/Cervicosacropexy has a learning curve but, by and large, is a reproducible procedure with an excellent long term outcome and a complication rate comparable to a TLH/ High Uterosacral procedure if not lower.

With Warmest Regards,
Elliot

Elliot Greenberg MD, FACOG
Assistant Clinical Professor
Tufts University School of Medicine
Baystate Ob/Gyn Group Inc
50 Union St
West Springfield, MA 01089
Prof em KULeuven, Oxford, Rome and Gruppo Italo Belga