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Enklaar RA, Schulten SFM, van Eijndhoven HWF, Weemhoff M, van Leijsen SAL, van der Weide MC, van Bavel J, Verkleij-Hagoort AC, Adang EMM, Kluivers KB. Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial. JAMA 2023; 330:626-635. [PMID: 37581670 PMCID: PMC10427949 DOI: 10.1001/jama.2023.13140] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 06/28/2023] [Indexed: 08/16/2023]
Abstract
Importance In many countries, sacrospinous hysteropexy is the most commonly practiced uterus-preserving technique in women undergoing a first operation for pelvic organ prolapse. However, there are no direct comparisons of outcomes after sacrospinous hysteropexy vs an older technique, the Manchester procedure. Objective To compare success of sacrospinous hysteropexy vs the Manchester procedure for the surgical treatment of uterine descent. Design, Setting, and Participants Multicenter, noninferiority randomized clinical trial conducted in 26 hospitals in the Netherlands among 434 adult patients undergoing a first surgical treatment for uterine descent that did not protrude beyond the hymen. Interventions Participants were randomly assigned to undergo sacrospinous hysteropexy (n = 217) or Manchester procedure (n = 217). Main Outcomes and Measures The primary outcome was a composite outcome of success, defined as absence of pelvic organ prolapse beyond the hymen in any compartment evaluated by a standardized vaginal support quantification system, absence of bothersome bulge symptoms, and absence of prolapse retreatment (pessary or surgery) within 2 years after the operation. The predefined noninferiority margin was 9%. Secondary outcomes were anatomical and patient-reported outcomes, perioperative parameters, and surgery-related complications. Results Among 393 participants included in the as-randomized analysis (mean age, 61.7 years [SD, 9.1 years]), 151 of 196 (77.0%) in the sacrospinous hysteropexy group and 172 of 197 (87.3%) in the Manchester procedure group achieved the composite outcome of success. Sacrospinous hysteropexy did not meet the noninferiority criterion of -9% for the lower limit of the CI (risk difference, -10.3%; 95% CI, -17.8% to -2.8%; P = .63 for noninferiority). At 2-year follow-up, perioperative outcomes and patient-reported outcomes did not differ between the 2 groups. Conclusions Based on the composite outcome of surgical success 2 years after primary uterus-sparing pelvic organ prolapse surgery for uterine descent, these results support a finding that sacrospinous hysteropexy is inferior to the Manchester procedure. Trial Registration TrialRegister.nl Identifier: NTR 6978.
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Affiliation(s)
- Rosa A. Enklaar
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Sascha F. M. Schulten
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Mirjam Weemhoff
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, the Netherlands
| | | | - Marijke C. van der Weide
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeroen van Bavel
- Department of Obstetrics and Gynecology, Amphia Hospital, Breda, the Netherlands
| | | | - Eddy M. M. Adang
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kirsten B. Kluivers
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
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Enklaar RA, Knapen FMFM, Schulten SFM, van Osch LADM, van Leijsen SAL, Gondrie ETCM, Weemhoff M. The modified Manchester Fothergill procedure compared with vaginal hysterectomy with low uterosacral ligament suspension in patients with pelvic organ prolapse: long-term outcome. Int Urogynecol J 2023; 34:155-164. [PMID: 35652948 PMCID: PMC9160845 DOI: 10.1007/s00192-022-05240-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/19/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to compare the long-term outcome between vaginal hysterectomy with low uterosacral ligament suspension (VH) and the modified Manchester Fothergill procedure (MF) as surgical treatment in patients with pelvic organ prolapse (POP). We hypothesize that MF is non-inferior to VH in the long term. METHODS In this single-center retrospective cohort study patients who underwent MF or VH for primary apical compartment prolapse between 2003 and 2009 were eligible for inclusion. The primary outcome was subjective recurrence of POP. Secondary outcomes included number and type of reinterventions, time to reintervention and the degree of complaints. RESULTS One hundred sixty of 398 patients (53 MF, 107 VH) returned the questionnaires (40%). The mean follow-up was 12.97 years for MF and 13.24 years for VH (p = 0.38). There were similar rates of subjective POP recurrence (51% in both groups). The reintervention rate in the MF group was higher but reached no statistical significance [19/53 (36%) versus 29/107 (27%), p = 0.26]. Kaplan-Meier curve showed no statistically significant difference in risk of reintervention after MF at the maximum follow-up of 16.5 years [HR 1.830 (95% CI 0.934-3.586), p = 0.08]. The mean time to reintervention was 3 years shorter in the MF group (p = 0.03). CONCLUSIONS The subjective recurrence after MF is similar to VH in treatment of POP at the long term. MF appears to be non-inferior to VH when comparing the risk of reintervention. However, the small sample size precludes a definitive conclusion of non-inferiority, and future studies are needed.
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Affiliation(s)
- Rosa A Enklaar
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands.
- Radboud Institute for Health Sciences, Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Femke M F M Knapen
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Sascha F M Schulten
- Radboud Institute for Health Sciences, Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Liesbeth A D M van Osch
- Department of Health Promotion/CAPHRI, Maastricht University, Maastricht, the Netherlands
- Department of Clinical Genetics, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Sanne A L van Leijsen
- Department of Obstetrics & Gynecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Ed T C M Gondrie
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mirjam Weemhoff
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands
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Schulten SFM, Essers B, Notten KJB, Enklaar RA, van Leijsen SAL, van Eijndhoven HWF, Kluivers KB, Weemhoff M. Patient’s preference for sacrospinous hysteropexy or modified Manchester operation: a discrete choice experiment. BJOG 2022; 130:99-106. [PMID: 36043332 PMCID: PMC10087824 DOI: 10.1111/1471-0528.17280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 06/19/2022] [Accepted: 07/05/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate women's preference for modified Manchester (MM) or sacrospinous hysteropexy (SH) as surgery for uterine prolapse. DESIGN Labelled discrete choice experiment (DCE). SETTING Eight Dutch hospitals. POPULATION Women with uterine prolapse, eligible for primary surgery and preference for uterus preservation. METHODS DCEs are attribute-based surveys. The two treatment options were labelled as MM and SH. Attributes in this survey were treatment success ( levels SH: 84%, 89%, 94%; levels MM: 89%, 93%, 96%), dyspareunia (levels: 0%, 5%, 10%), cervical stenosis (levels: 1%, 6%, 11%) and severe buttock pain (levels: 0%, 1%). A different combination of attribute levels was used in each choice set. Women completed nine choice sets, making a choice based on attribute levels. Data were analysed in multinomial logit models. MAIN OUTCOME MEASURES Women's preference for MM or SH. RESULTS 137 DCEs were completed (1233 choice sets). SH was chosen in 49% of the choice sets, MM in 51%. Of all women, 39 (28%) always chose the same surgery. After exclusion of this group, 882 choice sets were analysed, in which women preferred MM, likely associated with a labelling effect, i.e. description of the procedure, rather than the tested attributes. In that group, MM was chosen in 53% of the choice sets and SH in 47%. When choosing MM, next to the label, dyspareunia was relevant for decision-making. For SH, all attributes were relevant for decision-making. CONCLUSIONS The preference of women for MM or SH seems almost equally divided. The variety in preference supports the importance of individualised healthcare.
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Affiliation(s)
- Sascha F. M. Schulten
- Radboud university medical center Radboud Institute for Health Sciences, department of Obstetrics and Gynaecology, Geert Grooteplein Zuid 10 GA Nijmegen The Netherlands
- Department of Obstetrics and Gynaecology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem The Netherlands
| | - Brigitte Essers
- Department of clinical epidemiology and medical technology assessment, P. Debyelaan 25, 6202 AZ Maastricht university medical centre+ The Netherlands
| | - Kim J. B. Notten
- Department of Obstetrics and Gynaecology Radboud university medical center GA Nijmegen The Netherlands
| | - Rosa A. Enklaar
- Radboud university medical center Radboud Institute for Health Sciences, department of Obstetrics and Gynaecology, Geert Grooteplein Zuid 10 GA Nijmegen The Netherlands
- Department of Obstetrics and Gynaecology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen The Netherlands
| | - Sanne A. L. van Leijsen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre Veldhoven, De Run 4600, 5500 MB Veldhoven The Netherlands
| | - Hugo W. F. van Eijndhoven
- Department of Gynaecology and Obstetrics, Isala Zwolle, Dokter van Heesweg 2, 8025 AB Zwolle The Netherlands
| | - Kirsten B. Kluivers
- Department of Obstetrics and Gynaecology Radboud university medical center GA Nijmegen The Netherlands
| | - Mirjam Weemhoff
- Department of Obstetrics and Gynaecology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen The Netherlands
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Schulten SFM, Detollenaere RJ, Stekelenburg J, IntHout J, Kluivers KB, van Eijndhoven HWF. Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial. BMJ 2019; 366:l5149. [PMID: 31506252 PMCID: PMC6734519 DOI: 10.1136/bmj.l5149] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in the surgical treatment of uterine prolapse five years after surgery. DESIGN Observational follow-up of SAVE U (sacrospinous fixation versus vaginal hysterectomy in treatment of uterine prolapse ≥2) randomised controlled trial. SETTING Four non-university teaching hospitals, the Netherlands. PARTICIPANTS 204 of 208 healthy women in the initial trial (2009-12) with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery who had been randomised to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. The women were followed annually for five years after surgery. This extended trial reports the results at five years. MAIN OUTCOME MEASURES Prespecified primary outcome evaluated at five year follow-up was recurrent prolapse of the uterus or vaginal vault (apical compartment) stage 2 or higher evaluated by pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. Secondary outcomes were overall anatomical failure (recurrent prolapse stage 2 or higher in apical, anterior, or posterior compartment), composite outcome of success (defined as no prolapse beyond the hymen, no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse), functional outcome, quality of life, repeat surgery, and sexual functioning. RESULTS At five years, surgical failure of the apical compartment with bothersome bulge symptoms or repeat surgery occurred in one woman (1%) after sacrospinous hysteropexy compared with eight women (7.8%) after vaginal hysterectomy with uterosacral ligament suspension (difference-6.7%, 95% confidence interval -12.8% to-0.7%). A statistically significant difference was found in composite outcome of success between sacrospinous hysteropexy and vaginal hysterectomy (89/102 (87%) v 77/102 (76%). The other secondary outcomes did not differ. Time-to-event analysis at five years showed no differences between the interventions. CONCLUSIONS At five year follow-up significantly less anatomical recurrences of the apical compartment with bothersome bulge symptoms or repeat surgery were found after sacrospinous hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension. After hysteropexy a higher proportion of women had a composite outcome of success. Time-to-event analysis showed no differences in outcomes between the procedures. TRIAL REGISTRATION trialregister.nl NTR1866.
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Affiliation(s)
- Sascha F M Schulten
- Department of Obstetrics and Gynaecology, Isala Clinics, PO Box 10400, 8000 GK Zwolle, Netherlands
- Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Renée J Detollenaere
- Department of Obstetrics and Gynaecology, Isala Clinics, PO Box 10400, 8000 GK Zwolle, Netherlands
| | - Jelle Stekelenburg
- Department of Obstetrics and Gynaecology, Medical Centre Leeuwarden, Leeuwarden, Netherlands
- Department of Health sciences, University Medical Center Groningen, Global health, Groningen, Netherlands
| | - Joanna IntHout
- Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Hugo W F van Eijndhoven
- Department of Obstetrics and Gynaecology, Isala Clinics, PO Box 10400, 8000 GK Zwolle, Netherlands
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Schulten SFM, Enklaar RA, Kluivers KB, van Leijsen SAL, Jansen-van der Weide MC, Adang EMM, van Bavel J, van Dongen H, Gerritse MBE, van Gestel I, Malmberg GGA, Mouw RJC, van Rumpt-van de Geest DA, Spaans WA, van der Steen A, Stekelenburg J, Tiersma ESM, Verkleij-Hagoort AC, Vollebregt A, Wingen CBM, Weemhoff M, van Eijndhoven HWF. Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study). BMC Womens Health 2019; 19:49. [PMID: 30940171 PMCID: PMC6444578 DOI: 10.1186/s12905-019-0749-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/22/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed. METHODS The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%. DISCUSSION This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed. TRIAL REGISTRATION Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.
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Affiliation(s)
- Sascha F M Schulten
- Department of Obstetrics and Gynaecology, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Department of Obstetrics and Gynaecology, Isala Zwolle, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands. .,Radboud university medical center, Department of Obstetrics and Gynaecology, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Rosa A Enklaar
- Department of Obstetrics and Gynaecology, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Department of Obstetrics and Gynecology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419, PC, Heerlen, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Sanne A L van Leijsen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre Veldhoven, De Run, 4600 5500, MB, Veldhoven, The Netherlands
| | - Marijke C Jansen-van der Weide
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Eddy M M Adang
- Department for Health Evidence, Radboud university medical center, Geert Grooteplein 27, 6525 EZ, Nijmegen, The Netherlands
| | - Jeroen van Bavel
- Department of Obstetrics and Gynaecology Amphia Hospital, Molengracht 21, 4818 CK, Breda, The Netherlands
| | - Heleen van Dongen
- Department of Obstetrics and Gynaecology Groene Hart Hospital, Bleulandweg 10, 2803 HH, Gouda, The Netherlands
| | - Maaike B E Gerritse
- Department of Obstetrics and Gynaecology Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
| | - Iris van Gestel
- Department of Obstetrics and Gynaecology, Viecuri Hospital, Tegelseweg 210, 5912 BL, Venlo, The Netherlands
| | - G G Alec Malmberg
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Ronald J C Mouw
- Department of Obstetrics and Gynaecology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands
| | | | - Wilbert A Spaans
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Annemarie van der Steen
- Department of Obstetrics and Gynaecology, Ziekenhuisgroep Twente, Zilvermeeuw 1, 7609 PP, Almelo, The Netherlands.,Department of obstetrics and Gynaeology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ, Enschede, The Netherlands
| | - Jelle Stekelenburg
- Department of Obstetrics and Gynaecology, Medical Centre Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - E Stella M Tiersma
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Anneke C Verkleij-Hagoort
- Department of Obstetrics and Gynaecology, st. Antonius hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
| | - Astrid Vollebregt
- Department of Obstetrics and Gynaecology, Spaarne Gasthuis, Spaarnepoort 1, 2134 TM, Hoofddorp, The Netherlands
| | - Chantal B M Wingen
- Department of Obstetrics and Gynaecology, Laurentius Hospital, Monseigneur Driessenstraat 6, 6043 CV, Roermond, The Netherlands
| | - Mirjam Weemhoff
- Department of Obstetrics and Gynecology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419, PC, Heerlen, The Netherlands
| | - Hugo W F van Eijndhoven
- Department of Obstetrics and Gynaecology, Isala Zwolle, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
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