Laparoscopic sacral hysteropexy versus laparoscopic sacral colpopexy plus supracervical hysterectomy in patients with pelvic organ prolapse

Laparoscopic sacrocolpopexy with concurrent hysterectomy or uterine preservation: A metanalysis and systematic review

BACKGROUND

Literature is lacking strong evidence about comparisons of efficacy and quality of life-related outcomes between laparoscopic total and/or supracervical hysterectomy (LTH/LSCH) with laparoscopic sacrocolpopexy (LSC) and minimally invasive sacrohysteropexy (LSH).

OBJECTIVE

To summarize and compare available data on this topic providing a useful clinical tool in the treatment decision process.

SEARCH STRATEGY

We performed a systematic research of PubMed (MEDLINE), Web of Science, and Gooogle Scholar.

SELECTION CRITERIA

We included studies that compared at least one efficacy outcome (objective or subjective outcome) between LTH/LSCH with LSC and LSH. Data on surgery-related morbidities were also extracted where available.

DATA COLLECTION AND ANALYSIS

A random-effect meta-analysis was conducted reporting pooled mean differences and odds ratios (OR) between groups using Review Manager V.7.9.0.

MAIN RESULTS

We included a total of nine observational studies. LTH/LSCH with LSH was associated with a significantly higher objective success (apical compartment OR 7.95; 95% confidence interval [CI] 2.23-28.33; I2 = 0%; P = 0.001; anterior compartment OR 2.23; 95% CI 1.26-4.30; I2 = 12%; P = 0.007) and subjective success (OR 3.19; 95% CI 1.42-7.17; I2 = 39%; P = 0.005). No differences were found regarding intraoperative and postoperative complications, sexual dysfunction, and stress urinary incontinence rate after surgery. Hysteropexy showed shorter operative time and shorter hospital length with a pool mean difference of 27.37 min (95% CI 18.04-32.71; I2 = 0%; P < 0.001) and 0.7 days (95% CI 0.24-1.17; I2 = 75%; P = 0.003), respectively. Concurrent hysterectomy was not associated with a higher rate of mesh-related complications (P = 0.53). No major differences were found regarding recurrence and reoperation rate (P = 0.10 and P = 0.93, respectively).

CONCLUSIONS

LTH/LSCH with LSC has better objective and subjective outcomes in pelvic organ prolapse surgery than LSH alone, especially for apical and anterior compartments, and is not associated with higher postoperative sexual dysfunction and mesh-related complications. Adequate preoperative counseling is highly recommended in patients who desire uterine preservation.

PROSPERO REGISTRATION NUMBER

CRD42024537270.

Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis

BACKGROUND

Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned.

OBJECTIVES

To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair.

SEARCH STRATEGY

MEDLINE and Embase databases were searched from inception to January 2023.

SELECTION CRITERIA

We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded.

DATA COLLECTION AND ANALYSIS

A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI).

MAIN RESULTS

Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups.

CONCLUSIONS

No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors.

Pilsner Modification of Mesh Sacrohysterocolpopexy (PiMMS): An Initial Report on Safety and Efficacy

INTRODUCTION AND HYPOTHESIS

It is reported that up to 60% of women would prefer to spare their uterus during pelvic organ prolapse (POP) repair surgery. A reliable hysteropexy technique is therefore crucial. We aimed to describe the safety profile and initial core patient-reported and clinical outcomes of the Pilsner modification of laparoscopic mesh sacrohysterocolpopexy (PiMMS) in comparison with the laparoscopic sacrohysterocolpopexy technique (standard laparoscopic sacrohysterocolpopexy [sLSH]) previously used in our unit.

METHODS

This was a retrospective cohort study conducted in a single tertiary referral urogynecological center. All patients who underwent laparoscopic mesh sacrohysterocolpopexy between 1 January 2015, and 31 January 2022 were included in the study. Follow-up clinical, patient-reported, and imaging outcomes at the 12-month follow-up time point are presented.

RESULTS

A total of 87 patients were included. Of these, 49 (56.3%) and 38 (43.7%) underwent sLSH and PiMMS respectively. Low numbers of perioperative complications were found in both groups with no mesh-related complications reported following PiMMS up to 12 months postoperatively. There were no apical compartment failures in either group. There were 8 (17.0%) vs 1 (2.7%) anterior compartment failures (Ba ≤ -1) in the sLSH and PiMMS groups respectively (p = 0.07) at 12 months. At the 1-year follow-up, 42 (89.4%) patients reported a Patient Global Impression of Improvement score of ≤ 2 in the sLSH groups compared with 35 (94.6%) patients following PiMMS.

CONCLUSIONS

The PiMMS technique seems to have comparable safety profile and patient-reported outcomes with the sLSH technique. However, there is a trend toward reduced anterior compartment failures with this modification. The findings of this preliminary report need to be re-evaluated in a well-powered prospective study.

Sacrocolpopexy after sub-total hysterectomy vs. sacral hysteropexy for advanced urogenital prolapse: A propensity-matched study

OBJECTIVE

To compare objective and subjective outcomes of laparoscopic sacral colpopexy with supracervical hysterectomy (L-SCP) and robotic sacral hysteropexy (R-SHP).

METHODS

This is a multicenter retrospective propensity score matched study. In the period between January 2014 and December 2018, we enrolled 161 patients with apical prolapse stage 2 or above, alone or with multicompartment descensus.

RESULTS

After propensity-match analysis, there were 44 women for each group. Patients of the two groups had similar preoperative characteristics. No difference was found in terms of estimated blood loss, hospital stay, operative time, and intraoperative or postoperative complications. Subjective success rate, 12 months after surgery, was statistically better in the L-SCP group (P = 0.034): 81.8% and 97.8% women had Patient Global Impression of Improvement scores less than 3, in R-SHP and L-SCP, respectively. The objective cure rate was high in both groups without any significant differences in recurrence rate (P = 0.266).

CONCLUSION

Both procedures are safe and effective in pelvic organ prolapse treatment. Patients who no longer desire uterine preservation could be encouraged to consider L-SCP. R-SHP is an alternative in women who are strongly motivated to preserve their uterus in the absence of abnormal uterine findings.

Laparoscopic sacrocolpopexy in the management of recurrent pelvic organ prolapse

OBJECTIVES

We set out to assess long-term anatomical and functional outcomes in women after laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse.

METHODS

All women with a history of pelvic organ prolapse surgery operated between 2005 and 2022 were enrolled in this retrospective observational study. The indication for recurrent POP surgery was a symptomatic stage II and above pelvic organ prolapse. The data from objective urogynecologic examination and subjective patient assessment using validated questionnaires were collected. The last follow-up information was evaluated. The outcomes were compared with preoperative state using Student t-test and Wilcoxon test, p<0.05 was considered significant.

RESULTS

39 women were enrolled in the study. The rate of perioperative complications was very low; no significant hemorrhage, ureteral damage or conversion to laparotomy were observed. The mean follow-up was 40 ± 26.8 months. The postoperative course was not complicated by bowel incarceration, pelvic infection or mesh exposure. We observed a statistically significant elevation of all POP-Q points and decrease in all mean scores of PFDI, PFIQ, Wexner and VAS prolapse bother postoperatively. Improvement in stress urinary incontinence, anal incontinence and constipation was found.

CONCLUSIONS

Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse is a safe and effective surgery regardless of the type of the original repair performed. It provides good subjective and anatomical outcomes with a lasting effect on the quality of life in a long-term follow-up.

The Pros and Cons of Hystero-preservation on Pelvic Reconstructive Surgery

In the "boat at the dock" theory, pelvic organ prolapse (POP) may happen when the ropes (uterine supportive ligaments) break and/or the water level drops (pelvic floor muscles). Thus, it causes the boat (uterus and other pelvic organs) to slip from normal position and protrude out of the vagina. Surgical intervention with or without hysterectomy (hystero-preservation) is the most effective treatment for POP. Both hysterectomy and hystero-preservation for POP had a high anatomic and clinical cure rate. There is an increasing trend of hystero-preservation for POP during the past decades. The choices of either hysterectomy or hystero-preservation depend on the surgical factors, psychosocial factors, self-esteem and sexuality factors, and surgeon factors. Pelvic reconstructive surgery, either hysterectomy or hystero-preservation, can be performed via different approaches, including abdominal, laparoscopic, and vaginal routes, with native tissue or with mesh. This review will elucidate their related pros and cons, with further discussion and comparison of hystero-preservation via different routes.

Comparison of outcomes of laparoscopic sacrocolpopexy with concomitant supracervical hysterectomy or uterine preservation

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy was traditionally performed for post-hysterectomy prolapse or during concurrent hysterectomy. Sacrocolpopexy outcome with uterine preservation is poorly investigated. This study compared outcomes of laparoscopic sacrocolpopexy with concurrent supracervical hysterectomy or uterine preservation.

METHODS

This retrospective study compared data of patients with pelvic organ prolapse who underwent laparoscopic sacrocolpopexy with uterine preservation with the data of controls who underwent laparoscopic sacrocolpopexy with supracervical hysterectomy. We analyzed composite failure in uterine preservation versus concurrent supracervical hysterectomy (primary objective) and evaluated factors associated with the primary outcome of composite failure after laparoscopic sacrocolpopexy with preservation or supracervical hysterectomy (secondary objective). Composite failure was defined as subjective bulge symptoms, reoperation, or anatomical prolapse. Cox models indicated time to composite failure as an endpoint.

RESULTS

Of 274 patients, 232 underwent laparoscopic sacrocolpopexy with supracervical hysterectomy and 42 underwent laparoscopic uterine preservation. After propensity score matching (ratio: 2, for the laparoscopic sacrocolpopexy with supracervical hysterectomy group), 56 patients (24.1%) were in the supracervical hysterectomy group and 28 (66.7%) in the uterine preservation group. All patients underwent 24 months of follow-up. The composite failure rates were 10.7% for supracervical hysterectomy and 3.6% for preservation (p=0.87). The mean estimated blood loss was 10 ml (preservation, 10.0 ml [5.0-10.0] versus supracervical hysterectomy, 10.0 ml [10.0-15.0]; p=0.007). In the Cox proportional hazards model, higher preoperative body mass index and the point Ba increased composite failure risk.

CONCLUSIONS

Although not statistically significant, composite failure in the two techniques is likely clinically meaningful.

Modified Oxford technique of colpopexy for the treatment of uterine and vaginal vault prolapse: a retrospective pilot cohort study

Introduction

Pelvic organ prolapse is a common health issue that affects 30.8% of women. Laparoscopic sacrocolpopexy and colpopectopexy are two of the most common procedures to restore the pelvic anatomy. Mesh application on the other hand carries an increased complications risk over the short and long terms. The aim of this study is to provide a basis for meshless sacrocolpopexy and colpopectopexy.

Methods

This study is a retrospective cohort pilot study that analyzed the data of patients with a pelvic organ prolapse according to the pelvic organ prolapse quantification system and underwent the modified technique for sacrocolpopexy and colpopectopexy. Descriptive statistics were used to express the different variables.

Results

A total of 36 patients met the inclusion criteria and provided consent for the participation in this study. The majority of patients were postmenopausal. 22 out of 36 patients received a previous prolapse surgery. All patients presented with reducible vaginal lump. Dyspareunia and sexual dysfunction were the most commonly reported symptoms. The intraoperative complications rate was 0%. Only one patient had a postoperative persistent urinary retention that was managed medically.

Discussion

Sacrocolpopexy and colpopectopexy seems to be a safe alternative to the mesh-based pelvic surgeries with a very low rate of intraoperative complications and favorable follow up outcomes.

A systematic review of the surgical management of apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This systematic review (PROSPERO:CRD42022275789) is aimed at comparing qualitatively the success, recurrence, and complication rates of sacrocolpopexy with concomitant hysterectomy, hysteropexy, sacrospinous fixation (SSF) with and without vaginal hysterectomy (VH) and uterosacral fixation (USF) with and without VH.

METHODS

A systematic search was performed using Embase, PubMed, Scopus, and Cochrane databases for studies published from 2011, on women with apical pelvic organ prolapse requiring surgical interventions. Risk of bias was assessed via the National Institutes of Health study quality assessment tool. The primary outcomes are the success and recurrence rate of each technique, for ≥12 months' follow-up. Findings were summarised qualitatively.

RESULTS

A total of 21 studies were included. Overall significant findings for a high success and low recurrence rate are summarised as: minimally invasive sacrocolpopexy (MISC) is superior to abdominal sacrocolpopexy (ASC); sacrospinous hysteropexy (SSHP) is superior to USF + VH, which is superior to uterosacral hysteropexy and mesh hysteropexy (MHP). Significant findings related to complications include: MISC recorded a lower overall complication rate than ASC except in mesh exposure; USF + VH tends to perform better than SSHP and SSF, with SSHP performing better than MHP in faecal incontinence and overactive bladder rates.

CONCLUSION

There is no evidence to conclude that hysterectomy is superior to uterine-sparing approaches. MISC should be considered over ASC given similar efficacy and reduced complications. Superiority of MHP is unproven against native tissue hysteropexy. Further studies under standardised settings are required for direct comparisons between the surgical management methods.

Robot-assisted sacrohysteropexy vs robot-assisted sacrocolpopexy in women with primary advanced apical prolapse: A retrospective cohort study

BACKGROUND

This study aimed to evaluate the anatomic and clinical outcomes of robot-assisted sacrohysteropexy (RASH) against robot-assisted sacrocolpopexy (RASC) for the treatment of primary advanced apical prolapse.

METHODS

We conducted a retrospective cohort study of all robot-assisted pelvic organ prolapse surgeries for primary advanced apical prolapse (stage ≥II) between January 2011 and May 2021 at an academic tertiary hospital. Surgical outcomes and pelvic organ function were evaluated using the Pelvic Organ Prolapse Quantitative (POP-Q) stage and validated questionnaires (POPDI-6) during preoperative and postoperative 12-month follow-up evaluations. All data were obtained from electronic medical records.

RESULTS

A total of 2368 women underwent surgery for apical prolapse repair, and 18 women underwent either RASH (n = 11) or RASC (n = 7). Compared to the RASC group, the RASH group was significantly younger, premenopausal, and less parous. Preoperative prolapse stage, operative time, estimated blood loss, and hospitalization length was comparable between the groups. No intraoperative complications were observed. All women had a median follow-up duration of 24 months (range: 12-108 months). During the 12-month follow-up period, women in the RASH group reported higher satisfaction with the surgery than those in the RASC group (100% vs. 71.4%, p = 0.137). The mesh exposure rate was significantly higher in the RASC group (3/7, 42.9%) than in the RASH group (0/11, 0%) ( p = 0.043), which was found at 12 to 36 months postoperatively and was successfully managed with vaginal estrogen cream. In the RASH group, one woman required reoperation with anterior colporrhaphy for recurrent anterior prolapse at 60 months postoperatively. The apical success rate was 100% at one year postoperatively, without apical recurrence in either group during the follow-up period.

CONCLUSION

RASH represents an effective and feasible option for the surgical treatment of advanced primary apical prolapse in women who desire uterine preservation and have a significantly lower risk of mesh erosion than RASC.

Long-term development of surgical outcome of laparoscopic sacrohysteropexy with anterior and posterior mesh extension

INTRODUCTION AND HYPOTHESIS

Long-term durability and functional outcome of laparoscopic sacrohysteropexy (LSH) remains to be confirmed. We set out to assess the development of surgical outcome in women with increasing minimal follow-up.

METHODS

All women after LSH with anterior and posterior mesh extension operated for advanced apical uterine prolapse at Geoffroy Saint-Hilaire clinic from July 2005 to June 2020 were enrolled in this retrospective study. Last known follow-up information was used for the analysis and allocation into groups. The surgical success was defined as no prolapse beyond hymen, no symptomatic recurrence or no retreatment. Functional outcome was evaluated from validated questionnaires and presence of pelvic floor disorders. The outcomes were compared with preoperative state using chi-square and Fisher's test; p < 0.05 was considered significant.

RESULTS

In total, 270 patients after LSH with a follow-up of up to 14.5 years were enrolled and divided into groups according to their last follow-up length: ≥ 1 year 242, ≥ 3 years 112, ≥ 5 years 76, ≥ 7 years 45 and ≥ 10 years 18 women. Increase of minimal follow-up was associated with gradual decrease in surgical success. Rates of stress urinary incontinence were unchanged by the surgery, while anal incontinence and constipation rates decreased significantly; 14.5% of women were operated on for SUI in the follow-up. The PFDI-20, PFIQ-7 and VAS bother scores decreased significantly regardless of minimal follow-up length.

CONCLUSIONS

LSH with anterior and posterior mesh extension is a safe, effective and durable surgery with a positive long-term effect on quality of life. Although the surgical success gradually decreases, LSH remains a surgical success in most women.

Role of Hysteropexy in the Management of Pelvic Organ Prolapse

PURPOSE OF REVIEW

To discuss considerations for hysteropexy for apical pelvic organ prolapse (POP) and summarize available literature comparing various hysteropexy techniques to analogous procedures involving hysterectomy.

RECENT FINDINGS

Hysteropexy for apical POP has increased in popularity in recent years, although anatomic factors and gynecologic cancer risk must be taken into account. Native tissue hysteropexy options include the LeFort colpocleisis, sacrospinous hysteropexy, and uterosacral hysteropexy. Although vaginal mesh was banned by the Food and Drug Administration in 2019, abdominal mesh sacrohysteropexy done either open or laparoscopically remains an option in the USA. Overall, short-term prolapse outcomes appear to be comparable between uterus-sparing approaches and hysterectomy, with less blood loss and shorter operating room time observed with the uterine-sparing approaches, although long-term outcome data remains variable and limited. Uterine-sparing apical POP repair may be offered to appropriate patients without certain risk factors, although longer-term data will be required to evaluate durability.

Robot-assisted sacro(hystero)colpopexy with anterior and posterior mesh placement: impact on lower bowel tract function and clinical outcomes at mid-term follow-up

Background:

Robotic sacrocolpopexy (RSCP) is an established option for the treatment of apical, anterior, and proximal posterior compartment pelvic organ prolapses (POP). However, there is lack of evidence investigating how lower bowel tract symptoms (LBTS) may change after RSCP.

Methods:

Data from consecutive patients treated with RSCP for stage 3 or higher POP from 2012 to 2019 at a single tertiary referral center with at least 1 year of follow-up were prospectively collected and retrospectively analyzed. RSCP was performed following a standardized technique which always employed both anterior and posterior hand-shaped meshes. Outcomes were collected at follow-up and analyzed. LBTS were evaluated through the Wexner questionnaire.

Results:

Overall, 114 women underwent RSCP. Eleven were excluded for missing data, whereas 12 had insufficient follow-up. Thus, 91 (79.8%) patients were included in this cohort. Median follow-up was 42 [interquartile range (IQR), 19–62] months. Mean age was 65 ± 10 years. In our series, RSCP was mainly performed for anterior and apical/medium stage 3 POP (in 95.6% of patients). Anatomic success rate of RSCP was 97.8%, with 89 patients with POP stage 0–1 at 12-month follow-up. Two patients (2.2%) experienced POP recurrence and were treated with redo-SCP. No patient experienced clinically significant posterior vaginal wall prolapse after RSCP. When analyzing LBTS, there was no significant change in postoperative total Wexner’s score as compared to the preoperative value ( p > 0.05). However, the manual assistance subscore was statistically significantly lower within the first-year follow-up ( p = 0.04), but it spontaneously improved during the follow-up ( p = 0.12).

Conclusion:

RSCP with simultaneous placement of both anterior and posterior mesh is safe and successful to treat high-stage POP in carefully selected patients. Of note, LBTS appear unaffected by posterior mesh placement, supporting its routine use to prevent posterior POP recurrence. Larger prospective studies are needed to confirm our results.

Laparoscopic sacral hysteropexy for pelvic organ prolapse in a patient affected by marfan syndrome: a case report

Background: Marfan Syndrome (MS) is a dominantly inherited connective tissue disorder with consequences on the strength and resilience of connective tissues that may predispose to Pelvic Organ Prolapse (POP). Literature lacks studies investigating POP surgery in patients affected by MS that might help surgical management decisions. Objective: The objective of this paper is to describe the surgical procedure of laparoscopic sacral hysteropexy (LSHP) in a 37 years old woman affected by MS with symptomatic POP. Materials and Methods and main outcome measures: We performed a nerve-sparing laparoscopic sacral hysteropexy without complications and looked for anatomical and subjective outcomes. The patient completed The Female Sexual Distress Scale (FSDS), Pelvic Floor Disability Index (PFDI-20), and Wexner questionnaires preoperatively and postoperatively. Results: The patient stated a complete resolution of all POP related symptoms and there was a total correction of the descensus. Furthermore, no perioperative and postoperative complications were noted. Conclusions: LSHP could be an effective and safe procedure for the treatment of POP in women affected by MS and this case report is the first to describe a reconstructive procedure in this category of patients. What is new? The literature lacks studies investigating POP surgery in women with MS, that might help surgeons, thus we present this case to describe surgical and functional outcomes in this patient category, underlying the higher risk of complications and relapses related to the weakness of connective tissue. This case report may represent the basis of future studies to confirm the safety, efficacy and feasibility of LSHP and sacral colpopexy in patients with MS.