Level I Difference between Women with and without Prior Hysterectomy: Findings in Prolapse and Normal Support

Objectives: Compare Level I apical support structures with and without prior hysterectomy in women with 1) anterior prolapse, 2) posterior prolapse and 3) normal support.

Methods: We performed a secondary analysis of resting MRIs from women in the following groups: anterior prolapse (AW) with prior hysterectomy (h) and with a uterus (u), n=12h/15u; posterior prolapse (PW), n=14h/19u; normal support controls (CTR), n=18h/22u. Women with supracervical hysterectomy or hysterectomy for prolapse were excluded. Cardinal ligament (CL) (Figure 1) and uterosacral ligament (USL) insertion into cervix and vagina were marked and measured in women with normal support. The S3 to vaginal cuff/cervico-vaginal junction distance was measured to reflect the uterosacral ligament line-of-action (Figure 2). The angle between sacrum-apex line and horizontal (Pelvic Inclination Correction System [PICS] line) was measured. Left and right sides were similar so averaged. CL lengths from origin to cervical and vaginal insertion were marked and measured (Figure 1).

Results: Age, height, and BMI are similar between the six groups. Among patients with anterior vaginal prolapse, women without a uterus have larger prolapse size (Ba: 3±2 vs 1±1, p=.005; C: -2±4 vs -6±1, p=.002) and genital hiatus at Valsalva (6±2 vs 5±1, p=.029) on POP-Q. For women with a uterus and normal support, CL attachment length was 21+5 mm to the cervix (36%), and 38±6 mm to the vagina (64%). With prior hysterectomy, vaginal CLs attachment was 34±6 mm. For women with a uterus, USLs attached to the cervix for 12±5 mm (44%), and 15±7 mm (56%) to the vagina. With prior hysterectomy, the USLs attachment length to the vagina was 12±4 mm. The sacrum-apex distances are 26%, 35% and 29% longer in women with history of hysterectomy than those with a uterus in AW (p=.021), PW (p=.000) and CTR (p=.000) groups respectively (Figure 2). The angles between the sacrum-apex line and horizontal were more vertical in women with a uterus in PW 18% (p=.013) groups, but similar in AW and CTR groups. Cardinal ligament lengths at the lowest location (CL4) were 11% and 9% longer in women without a uterus compared to women with a uterus in PW (p=.024) and CTR (p=.008) groups. Other lengths were similar (Figure 1).

Conclusions: Apical support changes after hysterectomy. Apex location is 29% further from the sacrum in women who have had hysterectomy for non-prolapse indication in women with normal support. One third to half of the apical supports attach to the cervix and are lost with hysterectomy while the portion attached to the vagina is similar in women with or without a uterus. Comment: These observations are relevant to discussions of ligament re-attachment or culdoplasty at the time of hysterectomy.