Extreme cervical elongation after sacrohysteropexy

A systematic review of uterine cervical elongation and meta-analysis of Manchester repair

OBJECTIVE

This review aims to consolidate current research on cervical elongation, a common but often overlooked complication in pelvic organ prolapse and hysteropexy procedures. It seeks to define, diagnose, and manage cervical elongation, aiming to establish standardized criteria and strategies to enhance clinical outcomes for this condition.

DATA SOURCES

A comprehensive search of the PubMed/MEDLINE, Cochrane Library, and Web of Science databases was executed utilizing the keywords: "cervical elongation," "long cervix uteri," "Manchester," and "cervical amputation". Data were gathered and organized in an Excel spreadsheet, with the analysis conducted according to each category, methodology, or reference range.

STUDY ELIGIBILITY CRITERIA

All types of study designs with full-text availability, including randomized controlled trials, cohort studies, case-control studies, case reports, and systematic reviews, were considered for inclusion. Included studies were fully accessible in English and focused on the topic of interest. Exclusions were made for studies addressing cervical elongation not pertinent to pelvic organ prolapse, and publications such as secondary analyses, case reports, literature reviews, and opinion papers.

RESULTS

Out of 108 relevant studies, only 63 defined their inclusion criteria; of these, 57 were utilized for the narrative review and 8 were used in a meta-analysis comparing the Manchester operation with vaginal hysterectomy. Magnetic Resonance Imaging offers the highest sensitivity in measuring cervical elongation, its practical limitations and high cost necessitate the use of the more feasible Pelvic Organ Prolapse Quantification System (POP-Q), particularly effective for stage 2 and 3 prolapse cases. The POP-Q point C emerges as a pivotal marker for identifying cervical elongation, with specific measurements indicating the condition's presence. The Manchester-Fothergill procedure presents a viable management option for isolated cervical elongation, showing fewer complications and comparable recurrence rates to vaginal hysterectomy.

CONCLUSION

This review highlights the diagnostic and definitional diversity of cervical elongation within populations experiencing pelvic organ prolapse. It emphasizes the critical role of preoperative cervical evaluation, particularly in patients with uterine descensus for selecting the most appropriate surgical intervention.

A novel technique for the measurement of cervical length in non-pregnant women

Introduction

Cervical elongation is considered a risk factor for pelvic organ prolapse treatment failure in uterine preservation surgery. Consensus has not been reached regarding what is considered a normal cervical length, or how to measure it. Our primary aim was to test a new technique for measuring cervical length.

Materials and Methods

We enrolled women undergoing hysterectomy, with or without pelvic organ prolapse (for all indications except cervical tumours/history of cervical operations). Their cervical lengths were measured both by ultrasound and anatomical measurement. The external length of the cervix was measured using Doppler location of the uterine artery near the cervical-uterine junction as the proximal point and compared to the ultrasound measurement of the cervical canal. The uterine specimen was used to record anatomical cervical measurements as well as uterine corpus length. Baseline characteristics such as age, body mass index and pelvic organ prolapse quantification were also collected.

Results

Twenty women were eligible for evaluation. We found the average anatomical cervical canal length was (ccAN) 33.95 mm (range ±  9.23) and by external measurement (ceAN) 36.80 mm (range ± 7.54). We found a significant, high-powered correlation between our ultrasound and anatomical measurements in both techniques, as well as between the two ultrasound techniques. We also found a negative correlation between cervical length and women's age (rp = -0.443, P = 0.05).

Conclusion

Transvaginal ultrasound measurement of cervical length using the location of the uterine artery was found to have a strong correlation to the anatomical cervical length and can be used for the measurement of normal cervical length.

Clinical Risk Factors for Uterine Cervical Elongation among Women with Pelvic Organ Prolapse

Background: Cervical elongation is commonly associated with pelvic organ prolapse (POP). It was an identified risk for recurrent prolapse after hysteropexy, requiring additional surgeries. The aim of the study is to investigate the risk factors for uterine cervical elongation among women with POP. Methods: In this single-center retrospective cohort study, women who underwent vaginal total hysterectomy for POP between 2014 and 2016 were collected. The cervical and total uterine lengths were measured by pathologists, while the ratio of cervical length to total uterine length were calculated. The cervical elongation is defined as corpus/cervix ratio ≤ 1.5. Results: A total of 133 patients were enrolled in this study. Among these patients, 43 women had cervical elongation and 90 women had normal length of uterine cervix. We found that age > 65 years old (67.4% vs. 42.2%, p = 0.007), total vaginal length ≥ 9.5 cm (65.1% vs. 45.6%, p = 0.035), uterine weight < 51 gm (72.1% vs. 52.2%, p = 0.03), and Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6) ≥ 12 (30.2% vs. 14.4%, p = 0.032) were associated with the risk of cervical elongation. There were no significant differences on preoperative urodynamic parameters in the two groups. Conclusion: The patient age > 65 years old, the total vaginal length of POP-Q system ≥ 9.5 cm, uterine weight < 51 g, and POPDI-6 ≥ 12 are independent risk factors of cervical elongation in women with POP. For women scheduled for pelvic reconstructive hysteropexy, concomitant cervical amputation should be considered.

Hegde's Modification of Fothergill Surgery for Cervical Elongation: A 7-Year Retrospective Review

OBJECTIVE

This study aimed to evaluate the efficacy of Hegde's modification of Fothergill surgery, an innovative procedure for cervical elongation (CE), and to report perioperative challenges and follow-up.

METHODS

This is a retrospective review of data from 12 patients who underwent successful repair of CE by Hegde's modification of Fothergill surgery from June 2012 to May 2019. Primary outcomes were cervical viability and stenosis. Secondary outcomes were perioperative complications, Pelvic Organ Prolapse Quantification system (POP-Q) measurement and staging, recurrence, conception rates, and World Health Organization Quality of Life (QOL) BREF (WHOQOL-BREF) scores.

RESULTS

All women had a viable, patent cervix at 1-month follow-up. Perioperative complications included total intraoperative blood loss (>50 mL) and febrile morbidity (both 16.7%) and urinary tract infections (8.3%). The mean reduction of point C was 5.78 cm (2.87 ± 0.13 cm to -2.91 ± 1.55 cm). Recurrence was noted in 1 patient (8.3%) who had POP-Q stage 2 prolapse at 6 and 12 months of follow-up. The conception rate was 8.3% at 12 months. All women conceived spontaneously. Mean preoperative WHOQOL-BREF scores improved in all 4 domains, with major improvement seen in the physical domain, from 24.66 ± 8.18 to 70.91 ± 11.01, 19.0 ± 6.48 to 54.92 ± 8.21, 9.33 ± 7.46 to 59.33 ± 14.33, and 19.0 ± 4.89 to 47.07 ± 7.14, for the physical, psychological, social, and environmental domains, respectively.

CONCLUSION

Hegde's modification of Fothergill surgery can be considered as a surgical option for the repair of isolated CE with a healthy cervix in women who desire uterine preservation with the major advantage of preventing cervical stenosis.

Diagnostic value of preoperative ultrasonography, cervical length measurement, and POP-Q examination in cervical elongation estimation

INTRODUCTION AND HYPOTHESIS

Cervical elongation (CE) has not been clearly defined and has similar symptoms to pelvic organ prolapse. We aimed to evaluate the diagnostic value of preoperative POP-Q examinations, ultrasonographic measurements, and direct cervical length measurement with a Foley catheter in predicting CE on postoperative hysterectomy specimens.

METHODS

Fifty-six patients who underwent vaginal hysterectomy for apical pelvic organ prolapse were included. The patients were divided into two groups based on the hysterectomy specimens' corpus/cervix ratio (CCR) as follows: the non-CE group, CCR > 1; the CE group, CCR < 1. The preoperative direct cervical length measurement was performed using 10-French Foley catheters. The recommended cutoff values and sensitivity/specificity analysis of the cervical measurements with Foley, ultrasound, and C-D measurements according to POP-Q were determined by the receiver-operating characteristic analysis.

RESULTS

There were 13 patients (23%) in the non-CE group and 43 patients (76%) in the CE group. The mean cervical measurements with Foley catheter and ultrasound, C-D diameter, and postoperative cervix measurements were 49.4 ± 12.6 mm, 42.14 ± 9.4 mm, 41.4 ± 17.2 mm, and 49.5 ± 13 mm, respectively. Cervical measurement with a Foley catheter had 65% sensitivity and 62.5% specificity with a 47.5-mm cutoff value. Among these preoperative measurements, Foley catheter measurements were the most compatible with postoperative cervical measurements. There was no significant association between CE and age, body mass index, menopause duration, point C, and point D.

CONCLUSION

Cervical length measurement with a Foley catheter may be preferred for estimation of CE.

Study of Prolapse-Induced Cervical Elongation

OBJECTIVE

The cervix often appears to be elongated in women with pelvic organ prolapse (POP). This can pose surgical challenges. MRI evidence has suggested that prolapsed cervices are significantly longer than those in normal controls. Our objective was to compare cervical length in surgical hysterectomy specimens from women with symptomatic POP with the length in specimens from women with other benign gynaecological conditions.

METHODS

In this pilot, prospective, case-control study, hysterectomy specimens were collected at St. Paul's Hospital, Vancouver, BC, between 2013 and 2015. Recorded patient demographics were age at the time of hysterectomy, any prior history of cervical dysplasia, and reason for hysterectomy. Specimens from women in whom the indication for hysterectomy was POP were compared with the specimens from women with other benign gynaecological conditions. Specimens were excluded if there was a history of cervical dysplasia because we could not verify whether women had undergone previous procedures resulting in cervical shortening. After bivalving each uterus, cervical and total uterine lengths were measured by staff pathologists, and the ratios of cervical length to total uterine length were calculated. Measurements in the two hysterectomy groups were compared using linear regression.

RESULTS

Seventy-seven specimens were collected, 52 from women with POP and 25 from women without POP. The most common indication for hysterectomy in women without POP was uterine fibroids. Women with POP were on average older than women without POP (mean 58.5 years vs. 47.8 years, P < 0.001). The ratio of cervical length to total uterine length in women with POP was 0.10 higher (95% CI 0.03, 0.16; P = 0.005) than in women without POP.

CONCLUSION

Women with symptomatic POP have significantly higher ratios of cervical length to total uterine length than women without POP.

Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse

OBJECTIVE

To define and classify cervical elongation, to compare uterine measurements after prolapse hysterectomy with a non-prolapse control group, and to associate stage of prolapse and degree of cervical elongation.

STUDY DESIGN

This was a single-centre retrospective case-control study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. Data were collected from patients with and without pelvic organ prolapse (POP) who underwent laparoscopically assisted vaginal hysterectomy. Post-hysterectomy uterine cervical elongation was examined using the corpus/cervix ratio (CCR), calculated from measurements taken on photographs. Cervical elongation was classified as physiological (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5).

RESULTS

Cervical elongation was detected in 288/295 (97.6%) patients in the prolapse group (grade I, 44/288 [15.2%]; grade II, 212 [73.6%]; grade III, 32 [11.1%]). Mean CCR was greater among those with stage II/III than among those with stage IV prolapse (1.0±0.4 vs. 0.8±0.2; p<0.001). Grades of cervical elongation and prolapse stages were associated (p<0.001). Grade I cervical elongation was detected in 26/69 (37.6%), grade II in 5/69, and grade III in 0/69 patients of the control group. Cervical elongation was found more often in the prolapse group compared to the control group (p<0.001). Mean total uterine length did not differ between the prolapse and control groups (8.0±1.6 vs. 8.2±1.3cm), but mean calculated cervical length was greater in the prolapse group than in the control group (4.4±1.1 vs. 3.1+0.8cm; p<0.001).

CONCLUSIONS

Uterine cervical elongation is found in patients undergoing hysterectomy for pelvic organ prolapse. Cervical elongation grades and prolapse stages are correlated. Defining uterine cervical elongation based on corpus/cervix ratio with grades I-III could be a valuable basic tool for further research.