Intraoperative Uterine Descent After Uterosacral Ligament Stretching During Vaginal Hysterectomy for Apical Prolapse:...

Vaginal hysterectomy (VH) remains a common surgical approach for the treatment of apical pelvic organ prolapse. Stretching of the uterosacral ligaments (USL) before surgery may increase uterine descent during VH. This study aimed to assess the magnitude of uterine descent following USL stretching and transection and to examine its relationship with baseline prolapse severity and uterine characteristics.

This prospective study included women undergoing VH for stage II-IV uterine prolapse. Patients with a uterine size greater than 15 weeks of gestation and those with connective tissue or neurological disorders were excluded. POP-Q point C was measured at three predefined intraoperative stages: at baseline, after bilateral USL stretching, and after complete USL transection. The primary outcomes were the changes in point C from baseline to after bilateral USL stretching and from after stretching to after USL transection. Secondary outcomes included the associations between baseline point C and the magnitude of change following USL stretching and the additional change after USL transection; differences in intraoperative changes in point C according to apical prolapse stage; and associations between these changes and baseline uterine characteristics, including uterine weight, uterine volume, and cervical length.

Fifty-four women were enrolled. Bilateral USL stretching resulted in a mean additional uterine descent of 1.42 ± 0.61 cm, with no significant differences across included prolapse stages. Complete USL transection resulted in a further descent of 3.58 ± 1.25 cm. A weak positive correlation was observed between baseline point C and the magnitude of descent following USL stretching (Spearman's ρ = 0.273, 95% CI 0.006-0.504, p = 0.046). No association was observed between baseline point C and the additional descent following USL transection (ρ = 0.005, 95% CI -0.263 to 0.273, p = 0.969). The pattern of intraoperative change in point C did not differ significantly across prolapse stages. Changes in point C following USL stretching and transection were not associated with uterine weight, uterine volume, or cervical length.

This study quantitatively confirms and extends Cohen's historical observations by demonstrating increased apical descent following USL stretching in women with stage II-IV apical prolapse. These anatomical findings support further clinical evaluation of whether USL stretching facilitates vaginal hysterectomy.