INTRODUCTION: Cervical elongation is often characterized by hypertrophy, hyperplasia, and elongation of cervical tissue. At times, it may be associated with descent of one or more pelvic organs or can be an isolated entity. Considering increasing numbers of sacral colpopexy (SCP) procedures performed, we highlight the need to consider alternative surgical options in the setting of cervical elongation, which may not improve with a SCP approach, especially in the setting of a supracervical hysterectomy. To date, there are no strict definitions for cervical elongation, and previous literature has defined it by cervical length between 5 cm and 8 cm. Given its unique presentation, surgical management can vary significantly. OBJECTIVE: The objective of this video is to review approaches to surgical management, specifically focusing on a case involving a trachelectomy with a sacrospinous ligament fixation. METHODS: We present the case of a 48-year-old female with cervical elongation and minimal apical descent at outpatient office evaluation. On physical exam, the patient’s POP-Q was significant for a C-point of +4 and a D-point of −5. This video shows a unique surgical approach and highlights key techniques to consider when managing cervical elongation. RESULTS: This video signifies the importance of a thorough exam under anesthesia and reviews treatment options for vaginal approaches to cervical elongation. Intraoperative findings revealed apical descent with a D-point of −2. Given the extent of pelvic organ prolapse, the decision was made to incorporate apical suspension into the surgical plan. A partial vaginal trachelectomy, sacrospinous ligament suspension, anterior colporrhaphy, posterior colporrhaphy, and perineorrhaphy were performed. Key surgical concepts shown in this video include (1) important preoperative and intraoperative considerations, (2) steps to a vaginal trachelectomy, and (3) importance of placement of the sacrospinous sutures. CONCLUSIONS: Cervical elongation can present a challenge for gynecologic surgeons, and it is important to tailor surgical approaches to individual patients. Isolated cervical elongation can often be surgically repaired with a simple vaginal trachelectomy or a Manchester procedure. Cervical elongation with apical descent requires further surgical intervention. It is paramount to consider the possibility for advanced prolapse under anesthesia when counseling and consenting patients about surgical management. As demonstrated in this video, a trachelectomy with a sacrospinous ligament fixation can be safely performed in these unique presentations.Figure 1Figure 2
Patel et al. (Fri,) studied this question.