Traction on the cervix in theatre before anterior repair: Does it tell us when to perform a concomitant hysterectomy?

OBJECTIVE: To evaluate the surgical outcome of uterine preservation during anterior colporrhaphy, in women with apparent uterine descent, after the application of validated cervical traction under anaesthesia.

STUDY DESIGN: This study was conducted at a tertiary referral hospital in the United Kingdom. Thirty five patients with symptomatic anterior compartment prolapse (stage 2 or more) with the cervix, pelvic organ prolapse quantification (POPQ) point C, at or higher than -3 cm (stage 1), who had requested surgical repair, were recruited. In all patients there was no evidence of apical descent, with point D at -8 cm or above. All patients had a validated 'cervical traction' force applied intra-operatively to the cervix, and if the cervix, point C, did not come down further than 'stage 2' (+1cm) the uterus was conserved. These patients had an anterior repair, without a vaginal hysterectomy or apical support procedure, and were reviewed 3 months postoperatively. International Consultation on Incontinence Questionnaire-vaginal symptoms (ICIQ-VS) and POP-Q scores were completed pre- and post-operatively, with another POPQ performed intraoperatively during validated cervical traction. The Wilcoxon test was used to look at differences in vaginal descent and also to compare specific items of the ICIQ.

RESULTS: In all 35 women, there was cervical descent below -1cm (stage 2) when a validated amount of cervical traction was applied. When examined at follow up, however, the cervix (point C) had returned to its preoperative, asymptomatic level (stage 1) in all except one patient. There was no significant change in the position of point C pre- and 3 months post- operatively. Only one of the 35 women required a subsequent vaginal hysterectomy for prolapse (2.86%, 95% CI 0.07-14.91%). Significant improvements in ICIQ-VS scores were observed following anterior repair with uterine conservation.

CONCLUSION: The degree of uterine descent with cervical traction under anaesthesia has not been shown to be helpful in assessing the need for vaginal hysterectomy at the time of vaginal repair. The 'cervical traction' test is therefore unnecessary, and the decision as to whether to perform a concomitant vaginal hysterectomy should be based on the clinical findings on examination in the clinic.