Trends in Hysteropexy and Apical Support for Uterovaginal Prolapse in the United States from 2002 to 2012:

Nationwide assessment of practice variability in the utilization of hysteropexy at laparoscopic apical suspension for uterine prolapse

BACKGROUND

Although hysteropexy has been used to preserve the uterus during uterine prolapse surgery for a long time, there is a scarcity of data that describe the nationwide patterns of use of this surgical procedure.

OBJECTIVE

This study aimed to examine the national-level use and characteristics of hysteropexy at the time of laparoscopic apical suspension surgery for uterine prolapse in the United States.

STUDY DESIGN

This cross-sectional study used data from the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population included 55,608 patients with a diagnosis of uterine prolapse who underwent laparoscopic apical suspension surgery from 2016 to 2019. Patients who had a hysterectomy were assigned to the hysterectomy group, and those who did not have a hysterectomy were assigned to the hysteropexy group. The main outcome was clinical characteristics associated with hysteropexy, assessed using a multivariable binary logistic regression model. A classification tree was further constructed to assess the use pattern of hysteropexy during laparoscopic apical suspension procedures. The secondary outcome was surgical morbidity, including urinary tract injury, intestinal injury, vascular injury, and hemorrhage.

RESULTS

A hysteropexy was performed in 6500 (11.7%) patients. In a multivariable analysis, characteristics associated with increased use of a hysteropexy included (1) patient factors, such as older age, Medicare coverage, private insurance, self-pay, and medical comorbidity; (2) pelvic floor dysfunction factor of complete uterine prolapse; and (3) hospital factors, including medium bed capacity center and location in the Southern United States (all P<.05). Conversely, (1) the patient factor of higher household income; (2) gynecologic factors such as uterine myoma, adenomyosis, and benign ovarian pathology; (3) pelvic floor dysfunction factor with stress urinary incontinence; and (4) hospital factors including Midwest and West United States regions and rural setting center were associated with decreased use of a hysteropexy (all P<.05). A classification tree identified a total of 14 use patterns for hysteropexies during laparoscopic apical suspension procedures. The strongest factor that dictated the use of a hysteropexy was the presence or absence of uterine myomas; the rate of hysteropexy use was decreased to 5.6% if myomas were present in comparison with 15% if there were no myomas (P<.001). Second layer factors were adenomyosis and hospital region. Patients who did not have uterine myomas or adenomyosis and who underwent surgery in the Southern United States had the highest rate of undergoing a hysteropexy (22.6%). Across the 14 use patterns, the percentage rate difference between the highest and lowest uptake patterns was 22.0%. Patients who underwent a hysteropexy were less likely to undergo anteroposterior colporrhaphy, posterior colporrhaphy, and sling procedures (all P<.05). Hysteropexy was associated with a decreased risk for measured surgical morbidity (3.0 vs 5.4 per 1000 procedures; adjusted odds ratio, 0.57; 95% confidence interval, 0.36-0.90).

CONCLUSION

The results of these current, real-world practice data suggest that hysteropexies are being performed at the time of ambulatory laparoscopic apical suspension surgery for uterine prolapse. There is substantial variability in the application of hysteropexy based on patient, gynecologic, pelvic floor dysfunction, and hospital factors. Developing clinical practice guidelines to address this emerging surgical practice may be of use.

Trends in Urogynecologic Surgery Among Obstetrics and Gynecology Residents From 2002 to 2022

IMPORTANCE

The number of American women with a pelvic floor disorder is projected to increase from 28.1 million in 2010 to 43.8 million in 2050.

OBJECTIVES

The objective of this study was to evaluate trends in the number of urogynecologic procedures performed by graduating obstetrics and gynecology residents and to compare variability in volume between residents in the 70th and 30th percentiles for logged cases.

STUDY DESIGN

National case log measures for residents who graduated between 2003 and 2022 were reviewed. Mean case numbers and variability in case numbers were analyzed over time.

RESULTS

Data were collected from a median of 1,216.5 residents (range, 1,090 to 1,427) annually. Mean number of vaginal hysterectomies logged per resident decreased by 46.4% from 2002/2003 to 2021/2022 ( P = 0.0007). Mean number of urogynecology procedures increased by 1,165.5% from 2002/2003 to 2007/2008 ( P = 0.0015). Mean number of incontinence and pelvic floor procedures (including cystoscopies) increased by 190.9% from 2002/2003 to 2011/2012 ( P = 0.0002). Mean number of incontinence and pelvic floor procedures (excluding cystoscopies) decreased by 39.7% from 2012/2013 to 2021/2022 ( P < 0.0001). Mean number of cystoscopies increased by 19.7% from 2012/2013 to 2021/2022 ( P < 0.0001). Ratios of cases logged by residents in the 70th percentile to those in the 30th percentile decreased for vaginal hysterectomies and cystoscopies ( P < 0.0001 and P = 0.0040, respectively). The ratio for incontinence and pelvic floor procedures (excluding cystoscopies) was 1.76 in 2012/2013 and 2.35 in 2021/2022 ( P = 0.2878).

CONCLUSION

Resident surgical training in urogynecology is decreasing nationally.

Gynecologists' perspectives on surgical treatment for apical prolapse: a qualitative study

INTRODUCTION AND HYPOTHESIS

Vaginal sacrospinous fixation (VSF) without mesh and sacrocolpopexy (SCP) with mesh are the most frequently performed surgical procedures for apical prolapse in the Netherlands. There is no long-term evidence suggesting the optimal technique, however. The aim was to identify which factors play a role in the choice between these surgical treatment options.

METHODS

A qualitative study using semi-structured interviews amongst Dutch gynecologists was carried out. An inductive content analysis was performed with Atlas.ti.

RESULTS

Ten interviews were analyzed. All gynecologists performed vaginal surgeries for apical prolapse, six gynecologists perform SCP themselves. Six gynecologists would perform VSF for a primary vaginal vault prolapse (VVP); three gynecologists preferred a SCP. All participants prefer a SCP for recurrent VVP. All participants have stated that multiple comorbidities could be a reason for choosing VSF, as this procedure is considered less invasive. Most participants choose a VSF in the case of older age (6 out of 10) or higher body mass index (7 out of 10). All treat primary uterine prolapse with vaginal, uterine-preserving surgery.

CONCLUSIONS

Recurrent apical prolapse is the most important factor in advising patients which treatment they should undergo for VVP or uterine descent. Also, the patient's health status and the patient's own preference are important factors. Gynecologists who do not perform the SCP in their own clinic are more likely to perform a VSF and find more reasons not to advise a SCP. All participants prefer a vaginal surgery for a primary uterine prolapse.

Colpocleisis: reoperation risk and risk of uterine and vaginal cancer: A nationwide cohort study

INTRODUCTION AND HYPOTHESIS

We aimed to evaluate the risk of reoperation and uterine (myometrial, endometrial, and cervical) and vaginal cancer after colpocleisis performed during the years 1977-2018. Furthermore, we also aimed to assess the development in colpocleisis procedures performed during the study period.

METHODS

Danish nationwide registers covering operations, diagnoses, and life events can be linked on an individual level owing to the unique personal numbers of all Danish residents. We performed a nationwide historical cohort study including women born before year 2000 who underwent colpocleisis between 1977 and 2018 (N = 2,228) using the Danish National Patient Registry (DNPR). We followed the cohort until death/emigration/31 December 2018, whichever came first. Primary outcomes were number of pelvic organ prolapse (POP) operations performed after colpocleisis and uterine and vaginal cancer diagnosed after colpocleisis in a subgroup of women with the uterus in situ. This was assessed with cumulative incidences.

RESULTS

During follow-up (median 5.6 years) 6.5% and 8.2% underwent POP surgery within 2 and 10 years after colpocleisis respectively. Within 10 years after colpocleisis 0.5% (N = 8) were diagnosed with uterine or vaginal cancer in the subgroup of women with their uterus (N = 1,970). During the study time 37-80 women underwent colpocleisis yearly and the mean age increased (77.1 to 81.4 years).

CONCLUSION

Despite smaller studies showing no recurrence after colpocleisis, we found that 6.5% underwent reoperation within 2 years. Few women were diagnosed with uterine or vaginal cancer after colpocleisis. The increased age at the time of colpocleisis indicates changed attitudes regarding surgical treatment for elderly women with comorbidities.

Cervical cancer after the Manchester procedure: a nationwide cohort study

INTRODUCTION AND HYPOTHESIS

The Manchester procedure is a successful operation to treat uterine prolapse. However, the influence on cervical cancer remains unknown. We hypothesized a lower risk of cervical cancer after the Manchester procedure.

METHODS

We included all Danish women undergoing the Manchester procedure during 1977-2018 (N = 23,935). Women undergoing anterior colporrhaphy (N = 51,008) were included as references due to comparable health-seeking behaviors. The study cohort is as previously described. We assessed the risk of cervical cancer mortality after the Manchester procedure versus anterior colporrhaphy using cumulated incidence plots and Cox hazard regressions. We applied Fisher's exact test to compare the distribution of histological subtypes after the operations.

RESULTS

Generally, few women were diagnosed with cervical cancer (0.1% after Manchester procedure and 0.2% after anterior colporrhaphy). After the Manchester procedure, the risk of cervical cancer was reduced (HR 0.60 [95% CI 0.39-0.94]). Furthermore, we found a slightly reduced risk of overall death (HR 0.96 [95% 0.94-0.99]), but no association regarding death due to cervical cancer (HR 0.66 [95% 0.34-1.25]). The distribution of histological subtypes was not changed.

CONCLUSIONS

Women undergoing the Manchester procedure are at lower risk of being diagnosed with cervical cancer, while the risk of cancer specific mortality is unchanged compared to women undergoing anterior colporrhaphy. Based on this study, we cannot recommend that women exit ordinary screening programs for human papillomavirus/cervical dysplasia after a Manchester procedure.

Anatomic Criterion for Clinically Relevant Apical Prolapse in Urogynecology Populations

IMPORTANCE

Despite recognition of the critical role of the apex in vaginal support, there is no consensus on the anatomic criteria for clinically relevant apical prolapse.

OBJECTIVE

The aim of this study was to define an optimal anatomic criterion for clinically relevant apical prolapse.

STUDY DESIGN

This retrospective cohort study included 3,690 patients who had visited a tertiary hospital for ambulatory urogynecologic care. Vaginal bulge symptom was defined as a response of "somewhat," "moderately," or "quite a bit" to Question 3 on the Pelvic Floor Distress Inventory-20. Receiver operating characteristic curves were generated for a vaginal bulge symptom and apical support (Pelvic Organ Prolapse Quantification point C and C/total vaginal length [TVL]).

RESULTS

Both point C and the C-to-TVL ratio (C/TVL) had excellent performance for predicting vaginal bulge symptoms (area under the curve, 0.917 and 0.927, respectively). The optimal cutoffs were -3.0 for C and -0.50 for C/TVL. When we analyzed the data set according to the TVL, there was a significant difference in the cutoffs for C, whereas those for C/TVL had little difference. There was no difference in the cutoffs of C and C/TVL according to hysterectomy status.

CONCLUSIONS

The C/TVL is more appropriate than point C as a measure to define an anatomic criterion for clinically relevant apical prolapse. Descent of the vaginal apex beyond the halfway point of the vagina could be considered as an anatomic threshold for clinically relevant apical prolapse. This finding needs to be validated in nonurogynecology populations.

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.

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.

Pelvic organ prolapse recurrence after pregnancy following uterine-sparing prolapse repair: a systematic review and meta-analysis

INTRODUCTION

We sought to determine rates of pelvic organ prolapse (POP) recurrence following pregnancy and delivery in reproductive-age women with prior hysteropexy.

METHODS

Scopus, MEDLine, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to May 2020 for combinations of any of the keywords: "pregnancy", "delivery", "fertility", or "cesarean" with a comprehensive list of uterine-sparing surgical procedures for POP repair. Using approach, 1,817 articles were identified describing surgical, uterine-sparing POP repair techniques and subsequent pregnancy and delivery outcomes in reproductive-age women.   RESULTS: Twenty-seven studies describing 218 pregnancies, including 215 deliveries and 3 abortions, were summarized using narrative review and descriptive statistics. Successful pregnancies were reported following a diverse range of uterine-sparing prolapse repairs, both native tissue and mesh-augmented, that utilized vaginal, open abdominal, and laparoscopic approaches. We observed shifts from native tissue repairs to mesh-augmented laparoscopic repairs over time. POP recurrence occurred in 12% of subjects overall, 15% after vaginal and 10% after abdominal prolapse repairs. While meta-analysis identified higher recurrence rates after vaginal delivery (15%) than cesarean section (10%), due to small study numbers, multiple confounders, and heterogeneity between studies, no significant differences in recurrence rates could be identified between vaginal and abdominal surgical approaches, utilization of mesh augmentation, or mode of delivery.

CONCLUSION

Although literature on pregnancy following uterine-sparing POP repair is limited, available data suggest that prolapse recurrence after pregnancy and delivery remains similar to that after prolapse repair without subsequent pregnancies with few documented perinatal complications.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021247722.

Who Places High Value on the Uterus? A Cross-sectional Survey Study Evaluating Predictors for Uterine Preservation

STUDY OBJECTIVE

To determine predictors for placing high value on the uterus in patients who no longer desire fertility. The secondary objective was to identify reasons for placing high value on the uterus.

DESIGN

Cross-sectional survey study.

SETTING

Three hospitals within a large healthcare system in the United States.

PATIENTS

New patients ≥45 years old seeking care for benign gynecologic conditions, including abnormal uterine bleeding, uterine myomas, pelvic organ prolapse, endometriosis, or pelvic pain.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the summative score of the validated Value of Uterus (VALUS) instrument for measuring value placed on the uterus and the validated visual analog scale with the question "how important is it to you to keep your uterus when you have a gynecologic condition?" A total of 163 surveys were returned for analysis (79.2%). Using the VALUS cutoff, 64 patients (45.7%) were considered to have low value for their uterus (VALUS score <14), whereas 76 patients (54.3%) were considered to have high value for their uterus (VALUS score ≥14). The adjusted odds of placing high value for the uterus was 5.06 times higher among those who wanted to be sexually active in the future than those who do not desire to be sexually active (95% confidence interval, 1.55-16.52, p = .01). Patients who are sexually active have 3.94 higher adjusted odds of placing high value on the uterus than those who are not sexually active and do not desire to be (95% confidence interval, 1.36-11.43; p = .01). Race, religion, and personal history of cancer were not statistically significant.

CONCLUSION

Patients who highly value the uterus were highly motivated by the desire to be sexually active. Nonwhite race, religion, and personal history of cancer were not predictors for placing high value on uterine preservation.

Comparison of Different Laparoscopic Sacropexy Procedures for Advanced Uterine Prolapse: A Retrospective Analysis

STUDY OBJECTIVE

To compare the long-term outcomes and complications of 3 different variants of laparoscopic sacropexy.

DESIGN

Single-center retrospective cohort study.

SETTING

A tertiary university hospital.

PATIENTS

A total of 483 patients with advanced uterine prolapse who underwent laparoscopic sacrohysteropexy (LSH), laparoscopic supracervical hysterectomy with concomitant laparoscopic sacrocervicopexy (LSCH + LSC), or total laparoscopic hysterectomy with concomitant laparoscopic sacrocolpopexy (TLH + LSC).

INTERVENTIONS

Demographic data, Pelvic Organ Prolapse Quantification scores, questionnaire results, surgical conditions, postoperative outcomes, and complications were all extracted from medical and follow-up records.

MEASUREMENTS AND MAIN RESULTS

Between April 2012 and December 2020, 277 women underwent LSH, 95 women underwent LSCH + LSC, and 111 women underwent TLH + LSC. LSH procedures were associated with statistically significantly least blood loss and least postoperative hospital days and catheterization days (all p <.001). During the median follow-up of 32 months (13-117 months), analysis of the data revealed notable anatomic correction in all groups regarding Pelvic Organ Prolapse Quantification measurements (p <.001), and the anatomic cure rate showed no significant difference among these 3 groups (p = .273). No statistically significant differences were detected for prolapse recurrence (p = .171) and functional improvements among these groups. Neither intraoperative injuries (p = .098) nor total postoperative complications (p = .218) differed considerably, whereas the rate of severe postoperative complications (p <.001) including mesh exposure (p = .004) was significantly higher in the TLH + LSC group than that in the other groups.

CONCLUSIONS

LSH is the appropriate choice for women with uterine prolapse without contraindications for uterine preservation. For patients with benign uterine lesions and a normal cervix, LSCH + LSC is a safer approach that provides similar anatomic results and improved quality of life scores that are similar to those of TLH + LSC. For patients with lesions in the uterus and cervix, TLH + LSC should be selected.

Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery

IMPORTANCE

Vaginal hysteropexy can be performed via the uterosacral or the sacrospinous ligament(s), but little data exist comparing these routes.

OBJECTIVE

The aim of the study was to compare prolapse recurrence, retreatment, and symptoms along with the incidence of adverse events between patients undergoing vaginal uterosacral hysteropexy and sacrospinous hysteropexy.

STUDY DESIGN

This was a multicenter retrospective cohort study of patients who underwent vaginal uterosacral or sacrospinous hysteropexy (SSHP) between 2015 and 2019. Anatomic failure was the primary outcome, defined as prolapse beyond the hymen. Composite failure was defined as anatomic failure, bulge symptoms, and/or retreatment for prolapse.

RESULTS

At 4 geographically diverse referral centers, 147 patients underwent SSHP and 114 underwent uterosacral hysteropexy. The 1-year follow-up rate was 32% (83/261) with no difference between groups. There were 10 (3.8%) anatomic failures: 3 (2%) sacrospinous and 7 (6.1%) uterosacral (P = 0.109). There was no difference in bulge symptoms (9.9%), composite failure (13%), or median prolapse stage (2).The overall incidence of complications was low (7%; 95% confidence interval, 4.12%-10.43%) with a higher rate of ureteral kinking in the uterosacral group (7% vs 1.4%, P = 0.023). With a median follow-up of 17 months, 4.6% underwent subsequent hysterectomy and 6.5% had treatment for uterine/cervical pathology.

CONCLUSIONS

One year after hysteropexy, 1 in 3 patients were available for follow-up, and there were no differences in prolapse recurrence between patients who underwent uterosacral hysteropexy versus SSHP. The incidence of adverse events was low, and less than 5% of patients underwent subsequent hysterectomy for prolapse.

Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus

BACKGROUND

Currently, there are no clear frameworks or tools to objectively or subjectively evaluate patient attitudes toward uterine preservation and how they influence the decision to proceed with hysterectomy vs uterine preservation when undergoing prolapse surgery.

OBJECTIVE

This study aimed to develop a reliable and valid instrument to measure patients' valuation of their uterus.

STUDY DESIGN

The Value of Uterus instrument was developed on the basis of existing literature and created with structured patient-reported outcome measurement development methodology. An initial 14-question instrument was administered to 152 patients, and the instrument was revised on the basis of an analysis of internal consistency. The resulting Value of Uterus instrument has 6 items and includes a visual analog scale for the question "How important is it to you to keep your uterus when you have a gynecologic condition?" To validate the instrument, we recruited 51 patients aged >45 years with uterovaginal prolapse who presented to the urogynecology department and were scheduled to undergo vaginal surgery with or without hysterectomy. Internal reliability of the instrument was measured with Cronbach alpha. For known-groups validity, Value of Uterus summary scores were compared between women who underwent hysteropexy and those who underwent hysterectomy using the t test. Intraclass correlation coefficient was used to assess test-retest reliability with Value of Uterus administered to women twice. Lastly, a receiver-operating characteristic curve analysis was conducted to identify a cutoff Value of Uterus and visual analog scale score for predicting whether a woman would undergo hysteropexy (vs hysterectomy).

RESULTS

A total of 51 patients were recruited (26 patients in the hysterectomy and 25 in the hysteropexy group), with a mean age of 64±10 years; 87.8% of patients self-identified as White. There were no differences in demographics between the groups. Cronbach's alpha was 0.94, suggesting excellent internal consistency of the items in the Value of Uterus instrument. The Value of Uterus instrument was highly correlated with the visual analog scale question, with r=0.82 (95% confidence interval, 0.69-0.89; P<.001). Patients in the hysteropexy group had significantly higher Value of Uterus scores (indicating greater value placed on the uterus) than women who underwent hysterectomy (20.8 vs 12.2; P<.001). Receiver-operating characteristic curve analysis identified a Value of Uterus cutoff score ≥14, with good accuracy for predicting hysteropexy (area under the curve, 0.87; sensitivity, 92.0%; specificity, 68%).

CONCLUSION

Value of Uterus is a reliable and valid 6-item instrument that measures patients' valuation of the uterus and preferences for uterine preservation when undergoing surgery for pelvic organ prolapse. Value of Uterus and visual analog scale were shown to reliably predict whether a patient undergoes uterine-preserving prolapse surgery. The Value of Uterus instrument and visual analog scale tool can be useful tools to ensure that the patient's preferences are included in the medical decision-making. Value of Uterus may be useful for future research in other gynecologic conditions where uterine preservation is an option.

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.

Endometrial cancer after the Manchester procedure: a nationwide cohort study

INTRODUCTION AND HYPOTHESIS

We aimed to investigate whether the Manchester procedure affects the risk and prognosis of endometrial cancer.

METHODS

All Danish residents have a personal number permitting linkage of nationwide registers on the individual level enabling epidemiological studies with lifelong follow-up. We performed a nationwide historical cohort study including Danish women born before 2000 undergoing the Manchester procedure (N = 23,935) during 1977-2018. We included women undergoing anterior colporrhaphy as a reference group (N = 51,008) because of comparable inclination to consult a doctor and clinical similarities. Main outcomes were the number of women diagnosed with endometrial cancer, the stage of endometrial cancer at time of diagnosis, and cancer-specific and overall mortality. We followed the cohort until endometrial cancer/death/emigration/hysterectomy/31 December 2018. We performed chi-square test for trend to compare the diagnostic stage and Cox regressions to analyze the risk of endometrial cancer and mortality. The models were adjusted for age, calendar year, income level, and parity.

RESULTS

During follow-up (median 13 years), 271 (1.13%) women were diagnosed with endometrial cancer after the Manchester procedure and 520 (1.05%) after anterior colporrhaphy. The adjusted hazard ratio (HR) for endometrial cancer was 1.00 [95% confidence interval (CI) 0.86-1.16]. No difference in stage of cancer was found (p = 0.18) nor when stratifying for calendar year. The HR for cancer-specific mortality and overall mortality after the Manchester procedure was 0.87 (95% CI 0.65-1.16) and 0.93 (95% CI 0.77-1.12), respectively.

CONCLUSIONS

The Manchester procedure does not affect the risk or prognosis of endometrial cancer.

How does colpocleisis for pelvic organ prolapse in older women affect quality of life, body image, and sexuality? A critical review of the literature

Colpocleisis is a surgical treatment for pelvic organ prolapse that results in vaginal obliteration. This review aims to systematically evaluate the quality of life, changes in body image, regret, and impact on sexual activity in women after colpocleisis. A review was conducted using the PubMed and Scopus databases with search criteria specifying pelvic organ prolapse, colpocleisis, quality of life, body image, regret, sexuality, and their synonyms. For the selection of the eligible articles, we used the PRISMA reporting system. A total of 1285 articles were found. After removing duplicates and applying the inclusion and exclusion criteria, 30 articles were reviewed in full length. Quality of life after colpocleisis was evaluated in 22 articles, and 20 authors used validated questionnaires. All concluded that quality of life improved after surgical treatment. Twenty-one articles studied regret after obliterative treatment for pelvic organ prolapse. Most of the patients reported no regret. Regret was often due to bowel and bladder symptoms. A few patients reported regret because of loss of coital function. Body image was highlighted in six studies. Three articles assessed body image using the modified Body Image scale. The body image scores demonstrated a significant improvement after surgery. Women tended to remain sexually active and some also regained sexual activities after surgery. Colpocleisis remains a viable option for pelvic organ prolapse, without compromising quality of life, body image, or sexuality, but diligent patient selection is needed. Particular concern should be given to bladder and bowel symptoms since these are the main reason for dissatisfaction after colpocleisis.

Intermediate term outcomes after transvaginal uterine-preserving surgery in women with uterovaginal prolapse

Introduction and hypothesis

There is growing interest in and performance of uterine-preserving prolapse repairs. We hypothesized that there would be no difference in pelvic organ prolapse (POP) recurrence 2 years following transvaginal uterosacral ligament hysteropexy (USLH) and sacrospinous ligament hysteropexy (SSLH).

Methods

This is a retrospective cohort study with a cross-sectional survey of women who underwent transvaginal uterine-preserving POP surgery from May 2016 to December 2017. Patients were included if they underwent either USLH or SSLH. POP recurrence was defined as a composite of subjective symptoms and/or retreatment. A cross-sectional survey was used to assess pelvic floor symptoms and patient satisfaction.

Results

A total of 47 women met the criteria. Mean age was 52.8 ± 12.5 years, and all had a preoperative POP-Q stage of 2 (55.3%) or 3 (44.7%). Thirty (63.8%) underwent SSLH and 17 (36.2%) underwent USLH. There were no differences in patient characteristics or perioperative data. There was no difference in composite recurrence (26.7% [8] vs 23.5% [4]) and retreatment (6.7% [2] vs 0%) retrospectively between SSLH and USLH groups at 22.6 months. Survey response rate was 80.9% (38) with a response time of 30.7 (28.0–36.6) months. The majority of patients (84.2%) reported POP symptom improvement, and both groups reported great satisfaction (89.5%). In respondents, 13.2% (5) reported subjective recurrence and 5.3% (2) underwent retreatment, with no differences between hysteropexy types. There were no differences in other pelvic floor symptoms.

Conclusions

Although 1 in 4 women experienced subjective POP recurrence after transvaginal uterine-preserving prolapse repair and <5% underwent retreatment at 2 years, our results must be interpreted with caution given our small sample size. No differences in outcomes were identified between hysteropexy types; however, additional studies should be performed to confirm these findings. Both hysteropexy approaches were associated with great patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04987-5

Laparoscopic sacrohysteropexy versus vaginal hysterectomy and apical suspension: 7-year follow-up of a randomized controlled trial

Introduction and hypothesis

Laparoscopic mesh sacrohysteropexy offers a uterine-sparing alternative to vaginal hysterectomy with apical suspension, although randomised comparative data are lacking. This study was aimed at comparing the long-term efficacy of laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse.

Methods

A randomised controlled trial comparing laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse was performed, with a minimum follow-up of 7 years. The primary outcome was reoperation for apical prolapse. Secondary outcomes included patient-reported mesh complications, Pelvic Organ Prolapse Quantification, Patient Global Impression of Improvement in prolapse symptoms and the International Consultation on Incontinence Questionnaire Vaginal Symptoms, Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and PISQ-12 questionnaires.

Results

A total of 101 women were randomised and 62 women attended for follow-up at a mean of 100 months postoperatively (range 84–119 months). None reported a mesh-associated complication. The risk of reoperation for apical prolapse was 17.2% following vaginal hysterectomy (VH) and 6.1% following laparoscopic mesh sacrohysteropexy (LSH; relative risk 0.34, 95% CI 0.07–1.68, p = 0.17). Laparoscopic sacrohysteropexy was associated with a statistically significantly higher apical suspension (POP-Q point C −5 vs −4.25, p = 0.02) and longer total vaginal length (9 cm vs 6 cm, p < 0.001). There was no difference in the change in ICIQ-VS scores between the two groups (ICIQ-VS change −22 vs −25, p = 0.59).

Conclusion

Laparoscopic sacrohysteropexy and vaginal hysterectomy with apical suspension have comparable reoperation rates and subjective outcomes. Potential advantages of laparoscopic sacrohysteropexy include a lower risk of apical reoperation, greater apical support and increased total vaginal length.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-021-04932-6

Effect of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with uterovaginal prolapse: 5-year results of a randomized clinical trial

BACKGROUND

Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Sacrospinous hysteropexy with graft (vaginal mesh hysteropexy) is an alternative, although in 2019 the Food and Drug Administration removed this mesh product from the United States market.

OBJECTIVE

Our objective was to compare the efficacy and adverse events of these 2 procedures.

STUDY DESIGN

At 9 clinical sites in the United States National Institutes of Health and National Institute of Child Health and Human Development Pelvic Floor Disorders Network, 183 postmenopausal women requesting vaginal surgery for symptomatic uterovaginal prolapse were enrolled in a multisite randomized superiority clinical trial, comparing a sacrospinous hysteropexy with graft (hysteropexy) with a vaginal hysterectomy with uterosacral ligament suspension (hysterectomy). Participants consented to remain masked to treatment assignment for the study duration. Study visits were conducted at 6-month intervals through 60 months. The primary treatment failure composite outcome (retreatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival modeling. Secondary outcomes included complications or adverse events, individual anatomic measures of the pelvic organ prolapse quantification examination, and presence, severity, and impact and bother of prolapse, urinary, bowel, and pain symptoms as measured by validated questionnaires. The 3-year published results suggested better primary outcomes with sacrospinous hysteropexy with graft, but the differences were not statistically significant (P=.06). This study reports the 5-year outcomes.

RESULTS

A total of 183 women with a mean age of 66 years were randomized between April 2013 and February 2015; 93 were randomized to hysteropexy and 90 were randomized to hysterectomy. Notably, 175 were included in the trial, and 156 (89%) completed the 5-year follow-up. The primary outcome showed fewer failures for hysteropexy than hysterectomy through 5 years (adjusted hazard ratio, 0.58; 95% confidence interval, 0.36-0.94; P=.03), with failure rates of 37% vs 54%, respectively, resulting in a difference of -18% (95% confidence interval, -33% to -3%) at 5 years. With the exception of the Urogenital Distress Inventory, no group differences were demonstrated in patient-reported pelvic floor symptoms, prolapse symptoms, bowel function symptoms, general quality of life, body image, or pelvic pain. At their last visit through 5 years, 70% of participants (129 of 183) reported they remained masked to their treatment with no difference in masking between groups. Adverse events for hysteropexy vs hysterectomy included mesh exposure (8% vs 0%), granulation tissue after 12 weeks (1% vs 12%), and suture exposure after 12 weeks (3% vs 21%), respectively.

CONCLUSION

Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, sacrospinous hysteropexy with graft resulted in a lower composite failure rate than vaginal hysterectomy through 5 years. There were no meaningful differences in patient-reported outcomes between groups. Our results suggest that this vaginal mesh hysteropexy procedure should be made available to patients.

Perioperative Adverse Events in Women Undergoing Vaginal Prolapse Repair With Uterine Preservation Versus Concurrent Hysterectomy: A Matched Cohort Study

OBJECTIVE

The objective of this study is to compare the incidence of perioperative adverse events (AEs) in women undergoing vaginal prolapse repair with uterine preservation (hysteropexy) versus concurrent hysterectomy.

METHODS

This was a retrospective matched cohort study between 2012 and 2019. Patients who received a sacrospinous or uterosacral hysteropexy or colpopexy with hysterectomy were matched by surgeon, surgical year, and age. The electronic medical record was queried for demographic and perioperative data. Strict definitions were used for all clinically relevant AEs.

RESULTS

One hundred and thirty hysteropexy (89 sacrospinous, 41 uterosacral) patients were matched to 260 concurrent hysterectomy (6 sacrospinous, 253 uterosacral, 1 both) patients. Mean age and body mass index were 58 years (±13 years) and 27.9 kg/m2 (±6 kg/m2). Compared with hysteropexy, cases with hysterectomy were longer, had higher blood loss, and a longer hospital stay. The overall incidence of AEs was 29.0% for concurrent hysterectomy versus 10.5% in hysteropexy cases (P = 0.02); on logistic regression, concurrent hysterectomy remained a statistically significant predictor of AEs, with an adjusted odds ratio of 4.03 (95% confidence interval, 1.48-11.01). There was no difference in Dindo grade 3 complications between concurrent hysterectomy and hysteropexy procedures (0.8% vs 1.3%, P = 0.12). In a subanalysis examining the 2 hysteropexy types, there were no significant differences in AEs.

CONCLUSIONS

The overall incidence of serious AEs is low in women with uterovaginal prolapse undergoing vaginal native tissue repair with or without hysterectomy. Vaginal hysteropexy is associated with lower odds of experiencing AEs, shorter operating times, a shorter length of stay, and less blood loss.

Unanticipated Uterine and Cervical Malignancy in Women Undergoing Hysterectomy for Uterovaginal Prolapse

OBJECTIVE

This study aimed to determine the prevalence of unanticipated uterine cancer and cervical cancer in women undergoing hysterectomy for uterovaginal prolapse.

METHODS

Using data from the 2015-2018 American College of Surgeons National Surgical Quality Improvement Program, we identified adult women who underwent a hysterectomy with a concurrent procedure for uterovaginal prolapse. Patients who underwent a radical hysterectomy or had other procedures or diagnoses suggestive of preoperatively suspected or known gynecologic cancer were excluded. Our outcome measures were pathology-confirmed diagnoses of uterine cancer and cervical cancer. Bivariate statistical tests and multivariable logistic regression were used to identify patient characteristics associated with the likelihood of having unanticipated uterine cancer.

RESULTS

Among 9,687 patients meeting the sample eligibility criteria (median age, 60 years), 51 (0.53%; 95% confidence interval, 0.39%-0.69%) had a diagnosis of uterine cancer. Forty-three (84.3%) were stage I-IB. Multivariable logistic regression showed that older age (adjusted odds ratio, 2.75; 95% confidence interval, 1.47-5.51, for age >60 vs 41-60 years) and uterine weight greater than 250 g (adjusted odds ratio, 4.34; 95% confidence interval, 1.48-10.79) were associated with a significantly higher likelihood of having unexpected uterine malignancy. In addition, in a subsample of 7,908 patients who underwent a total hysterectomy, 7 (0.09%; 95% confidence interval, 0.04%-0.18%) had a diagnosis of cervical cancer.

CONCLUSIONS

The risk of unexpected uterine cancer and cervical cancer in women undergoing hysterectomy for uterovaginal prolapse was relatively low but should be appropriately considered when counseling patients desiring uterine- or cervix-sparing procedures.

Dynamic magnetic resonance imaging to quantify pelvic organ mobility after treatment for uterine descent: differences between surgical procedures

INTRODUCTION AND HYPOTHESIS

Pelvic organ mobility is defined as the displacement of pelvic organs between rest and maximal straining. We hypothesized that pelvic organ mobility after vaginal sacrospinous hysteropexy (SSHP) might be increased compared with other surgeries for uterine descent, which may contribute to the high occurrence of postoperative cystocele after this surgery. Pelvic organ mobility and the vaginal axes after SSHP are compared with other surgical procedures for uterine descent: vaginal hysterectomy with uterosacral suspension (VH) and laparoscopic sacrohysteropexy (LSH).

METHODS

In this prospective pilot study, 15 women were included (5 for each procedure). Six months postoperatively, POP-Q examination and dynamic MRI were performed and questionnaires were filled out regarding prolapse complaints. Pelvic organ mobility on MRI was defined as vertical displacement of pelvic organs at rest and maximal straining. The displacements and angles were measured using an image registration method. Furthermore, the angle of displacement of cervix/vaginal vault and vaginal axes were assessed.

RESULTS

No anatomical recurrences of pelvic organ prolapse were found. No difference in pelvic organ mobility was demonstrated. After VH, a more posterior position of the upper vagina was found compared with SSHP and LSH.

CONCLUSIONS

Based on these data, the higher recurrence risk in the anterior compartment after SSHP cannot be explained. Larger sample sizes, studying women with recurrence or de novo cystocele after SSHP or using an upright MRI scanner would be of interest to further assess the relationship between pelvic organ mobility and the occurrence of anterior vaginal wall prolapse.

Evidence-Based Review of Vaginal Native Tissue Hysteropexy for Uterovaginal Prolapse

Importance

As surgical techniques evolve in the treatment of pelvic organ prolapse and patient preferences are better understood, more studies are investigating uterine-sparing procedures for efficacy, safety, and potentially improved quality of life. Much of the literature reflects the use of mesh material in uterine-sparing procedures, and there is a paucity of data regarding the safety and efficacy of native tissue uterine-sparing procedures for the treatment of pelvic organ prolapse.

Objective

To summarize existing evidence regarding objective and subjective outcomes of uterine-preserving procedures including the Manchester procedure (MP) as well as native tissue uterovaginal hysteropexy with repairs, namely, uterosacral hysteropexy (USH) and sacrospinous hysteropexy (SSH), compared with outcomes of total vaginal hysterectomy (TVH) with repairs for the management of uterovaginal prolapse.

Evidence Acquisition

A review of the literature included MEDLINE, Cochrane, and clinicaltrials.gov databases.

Results

Few level 1 data exist comparing outcomes of native tissue hysteropexy to vaginal hysterectomy for management of uterovaginal prolapse. In general, outcomes of the MP for the management of uterovaginal prolapse revealed that compared with TVH it is associated with shorter operative times, lower estimated blood loss and risk of blood transfusion with no difference in hospital stay, and similar quality of life and sexual function outcomes. Retrospective data suggest no difference with respect to recurrent prolapse of any compartment between USH and TVH with repairs. Level 1 data reveal that SSH has been shown to have similar 1-year outcomes and safety compared with TVH with native tissue suspension. Women with stage 4 prolapse who undergo an SSH may be at higher risk of recurrence and may benefit from an alternative method of apical prolapse repair.

Conclusions and Relevance

More level 1 data are needed in order to robustly understand long-term differences in outcomes between native tissue uterine-conserving versus vaginal hysterectomy surgical approaches in women with uterovaginal prolapse.

Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial

IMPORTANCE

Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Transvaginal mesh hysteropexy is an alternative option.

OBJECTIVE

To compare the efficacy and adverse events of vaginal hysterectomy with suture apical suspension and transvaginal mesh hysteropexy.

DESIGN, SETTING, PARTICIPANTS

At 9 clinical sites in the US Pelvic Floor Disorders Network, 183 postmenopausal women with symptomatic uterovaginal prolapse were enrolled in a randomized superiority clinical trial between April 2013 and February 2015. The study was designed for primary analysis when the last randomized participant reached 3 years of follow-up in February 2018.

INTERVENTIONS

Ninety-three women were randomized to undergo vaginal mesh hysteropexy and 90 were randomized to undergo vaginal hysterectomy with uterosacral ligament suspension.

MAIN OUTCOMES AND MEASURES

The primary treatment failure composite outcome (re-treatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival models. Secondary outcomes included operative outcomes and adverse events, and were evaluated with longitudinal models or contingency tables as appropriate.

RESULTS

A total of 183 participants (mean age, 66 years) were randomized, 175 were included in the trial, and 169 (97%) completed the 3-year follow-up. The primary outcome was not significantly different among women who underwent hysteropexy vs hysterectomy through 48 months (adjusted hazard ratio, 0.62 [95% CI, 0.38-1.02]; P = .06; 36-month adjusted failure incidence, 26% vs 38%). Mean (SD) operative time was lower in the hysteropexy group vs the hysterectomy group (111.5 [39.7] min vs 156.7 [43.9] min; difference, -45.2 [95% CI, -57.7 to -32.7]; P = <.001). Adverse events in the hysteropexy vs hysterectomy groups included mesh exposure (8% vs 0%), ureteral kinking managed intraoperatively (0% vs 7%), granulation tissue after 12 weeks (1% vs 11%), and suture exposure after 12 weeks (3% vs 21%).

CONCLUSIONS AND RELEVANCE

Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, vaginal mesh hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension did not result in a significantly lower rate of the composite prolapse outcome after 3 years. However, imprecision in study results precludes a definitive conclusion, and further research is needed to assess whether vaginal mesh hysteropexy is more effective than vaginal hysterectomy with uterosacral ligament suspension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01802281.

Trends in apical prolapse surgery between 2010 and 2016 in Denmark

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is a common diagnosis. Today there is no consensus on the ideal operation technique for apical prolapse. Vaginal hysterectomy with suspension of the vaginal cuff is the most frequently used, but the popularity of uterus-preserving techniques is increasing. The aim of this study was to describe trends in surgical techniques used to treat primary apical prolapse in Danish hospitals.

METHODS

Data were obtained from the Danish Urogynecological Database and included women with primary prolapse surgery in the apical compartment operated in Denmark 2010-2016. Public hospital departments were divided into three categories according to degree of urogynecological specialization: high level, moderate level, and no specialization.

RESULTS

The number of vaginal hysterectomies decreased and the number of uterus-preserving operations increased from 2010 to 2016. The proportion of uterus-preserving techniques versus vaginal hysterectomy differed substantially between different hospital types. At departments with high and moderate levels of specialization, uterus-preserving techniques increased during the period, accounting for nearly 90% and 40%, respectively, in 2016, while decreasing to < 35% for departments with no specialization. Three of the four departments with high-level specialization preferred the Manchester-Fothergill procedure, while one preferred sacrospinous hysteropexy. Only 2.3% of all procedures were performed at private hospitals.

CONCLUSIONS

The proportion of uterus-preserving techniques to treat apical prolapse increased from 2010 to 2016. However, there is a wide variation in practice at the different hospitals. An agreement on uterus-preserving techniques has not been reached.