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Supracervical Hysterectomy at Sacrocolpopexy

When hysterectomy is performed concomitantly with sacrocolpopexy for symptomatic uterovaginal prolapse, supracervical (subtotal) hysterectomy preserves the cervix as the anchor for mesh fixation. The cervix is retained, the uterine corpus is amputated above the internal os, and the polypropylene Y-mesh is sutured to the cervical stump anteriorly and posteriorly before being secured to the sacral anterior longitudinal ligament. The principal rationale is lower mesh-exposure risk compared with total hysterectomy + sacrocolpopexy, achieved by avoiding a vaginal cuff suture line directly under the mesh.[1][2]

Indications​

  • Symptomatic uterovaginal prolapse with planned sacrocolpopexy in a patient willing to undergo concomitant hysterectomy.
  • Cervix free of dysplasia (current normal cytology / hrHPV negative; in-clinic counseling about ongoing cervical-cancer screening).
  • No history of cervical or endometrial neoplasia.
  • Patient acceptance of the residual cervical-cancer screening obligation and the ~5% risk of cyclic spotting from retained endocervical glands.

Contraindications​

  • Current or prior cervical, endometrial, or uterine malignancy or high-grade dysplasia.
  • Postmenopausal bleeding without endometrial workup.
  • Patient preference for definitive cervical removal (e.g., screening reluctance).

Technique​

The procedure is performed laparoscopically or robotically, typically through the same ports used for the sacrocolpopexy.

  1. Adnexal decision. Bilateral salpingectomy is recommended for ovarian-cancer risk reduction (see Opportunistic Adnexal Surgery). Oophorectomy is decided independently per age, menopause status, and risk profile.
  2. Round and broad ligament division. Round ligaments transected; anterior leaf of broad ligament opened to develop the bladder flap.
  3. Uterine artery control. Uterine vessels skeletonized at the level of the internal os and divided with sealing-device or stapler.
  4. Corpus amputation. The uterus is amputated transversely just above the internal cervical os using monopolar hook or harmonic. Monopolar coagulation of the endocervical canal (1–2 cm column) is performed to reduce post-supracervical cyclic bleeding.[3]
  5. Specimen retrieval. In-bag morcellation or extension of a port site for intact removal — power morcellation is no longer used given the FDA tissue-spread warning.
  6. Mesh attachment. The arms of the Y-mesh are sutured to the anterior and posterior cervical stump using non-absorbable monofilament suture, then routed retroperitoneally to the sacral promontory and secured to the anterior longitudinal ligament at S1.
  7. Peritonealization. Full peritoneal closure over the mesh prevents bowel adherence and reduces small-bowel obstruction risk.

Outcomes — Supracervical vs. Total Hysterectomy at Sacrocolpopexy​

OutcomeSupracervical + SCPTotal + SCPReference
Mesh exposure (any)~0–2%~5–9%Tan-Kim 2011[1]; Linder 2018[4]
Mesh erosion requiring reoperation~0.5%~3–5%Linder 2018[4]
Apical recurrence at 5 yr~5%~5% (no significant difference)Linder 2018[4]; Brubaker CARE long-term[5]
Operative timeComparableComparableTan-Kim 2011[1]
Blood lossComparableComparableLinder 2018[4]
Cyclic vaginal spotting (post-op)~5%0%Berner 2014[3]

The contemporary preference among urogynecologists in the U.S. is supracervical hysterectomy + sacrocolpopexy specifically because of the reduced mesh-exposure rate. A 2018 Mayo Clinic series of 814 patients demonstrated mesh-exposure rates of 0.5% for supracervical vs. 4.7% for total hysterectomy with sacrocolpopexy at a median 1.4-year follow-up.[4] Tan-Kim 2011 first reported this trade-off in a prospective cohort.[1]

Post-Operative Considerations​

  • Cervical-cancer screening must continue per population guidelines — see Cervical Cancer Screening.
  • Cyclic spotting (~5%) is typically self-limited; persistent bleeding warrants endocervical evaluation. Trachelectomy is occasionally required for refractory symptoms.
  • Sexual function is comparable to total hysterectomy in pooled data; no consistent advantage from cervix preservation has been demonstrated for orgasm or dyspareunia.[6]

Cross-references​

References​

1. Tan-Kim J, Menefee SA, Luber KM, Nager CW, Lukacz ES. "Robotic-Assisted and Laparoscopic Sacrocolpopexy: Comparing Operative Times, Costs and Outcomes." Female Pelvic Med Reconstr Surg. 2011;17(1):44-49. doi:10.1097/SPV.0b013e3182000a0d

2. Nygaard I, Brubaker L, Zyczynski HM, et al. "Long-Term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse." JAMA. 2013;309(19):2016-2024. doi:10.1001/jama.2013.4919

3. Berner E, Qvigstad E, Myrvold AK, Lieng M. "Pelvic Pain and Patient Satisfaction After Laparoscopic Supracervical Hysterectomy: Prospective Trial." J Minim Invasive Gynecol. 2014;21(3):406-411. doi:10.1016/j.jmig.2013.10.011

4. Linder BJ, Anand M, Klingele CJ, Trabuco EC, Gebhart JB, Occhino JA. "Outcomes of Robotic Sacrocolpopexy Using Only Absorbable Suture for Mesh Fixation." Female Pelvic Med Reconstr Surg. 2018;24(1):13-16. doi:10.1097/SPV.0000000000000451

5. Brubaker L, Nygaard I, Richter HE, et al. "Two-Year Outcomes After Sacrocolpopexy With and Without Burch to Prevent Stress Urinary Incontinence." Obstet Gynecol. 2008;112(1):49-55. doi:10.1097/AOG.0b013e3181778d2a

6. Lethaby A, Mukhopadhyay A, Naik R. "Total Versus Subtotal Hysterectomy for Benign Gynaecological Conditions." Cochrane Database Syst Rev. 2012;(4):CD004993. doi:10.1002/14651858.CD004993.pub3