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Geron Y, From A, Peled Y, Zeevi G, Matot R, Nachshon S, Krissi H. Abnormal Pathology Following Vaginal Hysterectomy for Pelvic Organ Prolapse Repair. J Womens Health (Larchmt) 2024. [PMID: 38700374 DOI: 10.1089/jwh.2023.1019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
Objective: Uterine-sparing surgery for pelvic organ prolapse (POP) repair has shown good results, but the potential negative implications of leaving the uterus in place are yet to be fully defined. We aimed to assess the risk of unanticipated abnormal gynecological pathology at the time of reconstructive pelvic surgery. Methods: A retrospective consecutive case series including women who underwent vaginal hysterectomy for POP repair at a tertiary medical center in 2006-2020. All patients were offered a free Pap smear test at the age of 65 years as part of a national screening program. Transvaginal ultrasound was routinely performed preoperatively. Standard 3 pedicle hysterectomy was performed with/without bilateral salpingo-oophorectomy (BSO). Results: The study comprised 462 women of mean age 63 ± 9.3 years without previous known malignant or premalignant pathology. Benign pathology was observed in 286 patients (61.9%). Endometrial malignancy was found in three patients (0.7%) and significant premalignant pathology in 15 patients (3.2%), including cervical intraepithelial neoplasia stage 2-3 in seven patients (1.5%) and complex hyperplasia with atypia in eight patients (1.7%). All these pathologies were found in postmenopausal women. None had preoperative clinical symptoms or endometrial thickness of ≥5 mm on preoperative ultrasound. In the 35 patients after BSO, adnexal findings were normal (77.2%) or benign (22.8%). Conclusions: Premenopausal women with uterovaginal prolapse and normal preoperative evaluation have a minimal risk of significant abnormal uterine pathology. In postmenopausal women, the risk of unanticipated malignant uterine pathology is 0.7% and 3.2% for significant premalignancy.
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Affiliation(s)
- Yossi Geron
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Anat From
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Peled
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Gil Zeevi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ran Matot
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Sapir Nachshon
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Haim Krissi
- Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center - Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Porcari I, Zorzato PC, Bosco M, Garzon S, Magni F, Salvatore S, Franchi MP, Uccella S. Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis. Int J Gynaecol Obstet 2024. [PMID: 38269852 DOI: 10.1002/ijgo.15343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/26/2024]
Abstract
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.
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Affiliation(s)
- Irene Porcari
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Pier Carlo Zorzato
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Mariachiara Bosco
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Francesca Magni
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Salvatore
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy
| | - Massimo P Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Mao M, Fu H, Wang Q, Bai J, Zhang Y, Guo R. The effect of hysteropreservation versus hysterectomy on the outcome of laparoscopic uterosacral suspension in pelvic organ prolapse surgery. Maturitas 2023; 170:58-63. [PMID: 36773501 DOI: 10.1016/j.maturitas.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/14/2022] [Accepted: 01/06/2023] [Indexed: 01/19/2023]
Abstract
OBJECTIVES This study compares the recurrence rate, complication rate and subjective satisfaction with laparoscopic uterosacral suspension with or without hysterectomy. STUDY DESIGN This retrospective cohort study included 105 patients between June 2014 and December 2019. Recurrent pelvic organ prolapse was defined as any prolapse to or beyond the hymen with straining or needing retreatment. Student's t-test, the Mann-Whitney U test, the chi square test or Fisher's exact test, multivariate Cox proportional hazards regression and Kaplan-Meier survival analysis were used for the data analysis. MAIN OUTCOME MEASURES Whether the durability of laparoscopic uterosacral suspension surgery is affected by uterine preservation. RESULTS 60 patients underwent laparoscopic uterosacral suspension with concomitant hysterectomy (Hysterectomy group), and 45 underwent laparoscopic uterosacral hysteropexy (Hysteropexy group). The median (interquartile range) duration of follow-up for all 105 patients was 31 (22.5-47.5) months. The results of multivariate Cox proportional hazards regression showed that no difference was found in the risk of overall recurrence between the hysterectomy and hysteropexy groups (25 % vs. 22 %; HR, 0.37; 95 % CI, 0.14-1.00). Kaplan-Meier survival analysis also demonstrated that there were no significant differences in the overall rates of recurrent prolapse between the two groups (P = 0.30). In addition, the subjective success rates were high in both groups (82 %). CONCLUSIONS Our study demonstrated equally satisfactory objective and subjective long-term outcomes after laparoscopic uterosacral suspension with or without hysterectomy. Laparoscopic uterosacral hysteropexy can be safely and effectively offered to patients with pelvic organ prolapse who wish to preserve their uterus and do not have contraindications.
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Affiliation(s)
- Meng Mao
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hanlin Fu
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qian Wang
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jing Bai
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ye Zhang
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruixia Guo
- Department of Obstetrics and Gynaecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 29:469-478. [PMID: 36516026 DOI: 10.1097/spv.0000000000001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Gan ZS, Roberson DS, Smith AL. Role of Hysteropexy in the Management of Pelvic Organ Prolapse. Curr Urol Rep 2022; 23:175-183. [PMID: 35789456 DOI: 10.1007/s11934-022-01101-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Zoe S Gan
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, PCAM 3-334W, Philadelphia, PA, 19104, USA.
| | - Daniel S Roberson
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, PCAM 3-334W, Philadelphia, PA, 19104, USA
| | - Ariana L Smith
- Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, PCAM 3-334W, Philadelphia, PA, 19104, USA
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How and on whom to perform uterine-preserving surgery for uterine prolapse. Obstet Gynecol Sci 2022; 65:317-324. [PMID: 35754366 PMCID: PMC9304435 DOI: 10.5468/ogs.22003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/09/2022] [Indexed: 12/03/2022] Open
Abstract
The demand for uterine preservation in pelvic reconstructive surgery for uterovaginal prolapse is steadily increasing, and several procedures have been introduced, such as sacrospinous hysteropexy, uterosacral hysteropexy, sacrohysteropexy, and hysteropectopexy. However, the benefits and risks of uterine-preserving surgeries are not well understood. This review discusses the current evidence surrounding uterine-preserving surgery for uterovaginal prolapse repair. This may help surgeons and patients have a balanced discussion on how and on whom to perform uterine-preserving surgery.
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Schulten SF, Detollenaere RJ, IntHout J, Kluivers KB, Van Eijndhoven HW. Risk factors for pelvic organ prolapse recurrence after sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. Am J Obstet Gynecol 2022; 227:252.e1-252.e9. [PMID: 35439530 DOI: 10.1016/j.ajog.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/17/2022] [Accepted: 04/05/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given that the number of surgeries for pelvic organ prolapse is expected to increase worldwide, knowledge on risk factors for prolapse recurrence is of importance for developing preventive strategies and shared decision-making. OBJECTIVE To identify risk factors for subjective and objective failure after either sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension over a period of 5 years after surgery. STUDY DESIGN This was a secondary analysis of the 5-year follow-up of the SAVE-U trial. The SAVE-U trial was conducted in 4 Dutch hospitals. A total of 208 women with uterine prolapse stage ≥2 were randomized to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. For the current analysis, available annual 5-year follow-up data of 207 women were analyzed. Without missing values this analysis would have included 1035 measurements in total over the 5-year follow-up. Recurrences were analyzed as "events" using generalized linear mixed models because recurrences of anatomic failure and bothersome vaginal bulge symptoms fluctuated over time. The primary outcome was the composite outcome of failure defined as prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse. Secondary outcome measures were bothersome vaginal bulge symptoms, overall anatomic failure (Pelvic Organ Prolapse Quantification stage ≥2 in any compartment), apical compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2), anterior compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2), and posterior compartment recurrence (Pelvic Organ Prolapse Quantification stage ≥2). RESULTS For the composite outcome of failure (164 events in 66 different women), statistically significant risk factors were: body mass index (odds ratio, 1.10 [per 1 kg/m2]; 95% confidence interval, 1.02-1.19; P=.02), smoking (odds ratio, 2.88; 95% confidence interval, 1.12-7.40; P=.03), and preoperative Pelvic Organ Prolapse Quantification point Ba (odds ratio, 1.23 [per 1 cm]; 95% confidence interval, 1.01-1.50; P=.04). When analyzing each surgical outcome measure separately, body mass index and Pelvic Organ Prolapse Quantification point Ba were risk factors for overall anatomic failure (462 events in 147 women; odds ratio, 1.15; 95% confidence interval, 1.07-1.25; P<.01 and odds ratio, 1.14; 95% confidence interval, 1.00-1.30; P=.05, respectively) and anterior compartment recurrence (385 events in 128 women; odds ratio, 1.11; 95% confidence interval, 1.02-1.22; P=.02 and odds ratio, 1.17; 95% confidence interval, 1.02-1.34; P=.02, respectively). Vaginal hysterectomy was a risk factor for posterior compartment recurrence when compared with sacrospinous hysteropexy (93 events in 40 women; odds ratio, 5.21; 95% confidence interval, 2.05-13.27; P<.01). Smoking was a risk factor for bothersome vaginal bulge symptoms (70 events in 41 women; odds ratio, 3.80; 95% confidence interval, 1.48-9.75; P=.01), and preoperative Pelvic Organ Prolapse Quantification stage 3 or 4 was significantly protective against bothersome bulge symptoms (odds ratio, 0.32; 95% confidence interval, 0.11-0.89; P=.03). CONCLUSION Body mass index, smoking, and Pelvic Organ Prolapse Quantification point Ba were statistically significant risk factors for the composite outcome of failure (prolapse beyond the hymen, bothersome bulge symptoms, repeated surgery, or pessary use for recurrent prolapse) in the period of 5 years after surgery.
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Affiliation(s)
- Sascha F Schulten
- Department of Obstetrics and Gynaecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | - Joanna IntHout
- Department for Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Kirsten B Kluivers
- Department of Obstetrics and Gynaecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Hickman LC, Tran MC, Paraiso MFR, Walters MD, Ferrando CA. Intermediate term outcomes after transvaginal uterine-preserving surgery in women with uterovaginal prolapse. Int Urogynecol J 2021; 33:2005-2012. [PMID: 34586437 PMCID: PMC8479721 DOI: 10.1007/s00192-021-04987-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/24/2021] [Indexed: 12/02/2022]
Abstract
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
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Affiliation(s)
- Lisa C Hickman
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. .,Division of Female Pelvic Medicine and Reconstructive Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Room 504, OH, 43210, Columbus, USA.
| | - Misha C Tran
- University of Chicago School of Medicine, Chicago, IL, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark D Walters
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cecile A Ferrando
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Hemming C, Constable L, Goulao B, Kilonzo M, Boyers D, Elders A, Cooper K, Smith A, Freeman R, Breeman S, McDonald A, Hagen S, Montgomery I, Norrie J, Glazener C. Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs. Health Technol Assess 2021; 24:1-220. [PMID: 32138809 DOI: 10.3310/hta24130] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND New surgical approaches for apical prolapse have gradually been introduced, with few prospective randomised controlled trial data to evaluate their safety and efficacy compared with traditional methods. OBJECTIVE To compare surgical uterine preservation with vaginal hysterectomy in women with uterine prolapse and abdominal procedures with vaginal procedures in women with vault prolapse in terms of clinical effectiveness, adverse events, quality of life and cost-effectiveness. DESIGN Two parallel randomised controlled trials (i.e. Uterine and Vault). Allocation was by remote web-based randomisation (1 : 1 ratio), minimised on the need for concomitant anterior and/or posterior procedure, concomitant incontinence procedure, age and surgeon. SETTING UK hospitals. PARTICIPANTS Uterine trial - 563 out of 565 randomised women had uterine prolapse surgery. Vault trial - 208 out of 209 randomised women had vault prolapse surgery. INTERVENTIONS Uterine trial - uterine preservation or vaginal hysterectomy. Vault trial - abdominal or vaginal vault suspension. MAIN OUTCOME MEASURES The primary outcome measures were women's prolapse symptoms (as measured using the Pelvic Organ Prolapse Symptom Score), prolapse-specific quality of life and cost-effectiveness (as assessed by incremental cost per quality-adjusted life-year). RESULTS Uterine trial - adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for uterine preservation was 4.2 (standard deviation 4.9) versus vaginal hysterectomy with a Pelvic Organ Prolapse Symptom Score of 4.2 (standard deviation 5.3) (mean difference -0.05, 95% confidence interval -0.91 to 0.81). Serious adverse event rates were similar between the groups (uterine preservation 5.4% vs. vaginal hysterectomy 5.9%; risk ratio 0.82, 95% confidence interval 0.38 to 1.75). There was no difference in overall prolapse stage. Significantly more women would recommend vaginal hysterectomy to a friend (odds ratio 0.39, 95% confidence interval 0.18 to 0.83). Uterine preservation was £235 (95% confidence interval £6 to £464) more expensive than vaginal hysterectomy and generated non-significantly fewer quality-adjusted life-years (mean difference -0.004, 95% confidence interval -0.026 to 0.019). Vault trial - adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for an abdominal procedure was 5.6 (standard deviation 5.4) versus vaginal procedure with a Pelvic Organ Prolapse Symptom Score of 5.9 (standard deviation 5.4) (mean difference -0.61, 95% confidence interval -2.08 to 0.86). The serious adverse event rates were similar between the groups (abdominal 5.9% vs. vaginal 6.0%; risk ratio 0.97, 95% confidence interval 0.27 to 3.44). The objective anterior prolapse stage 2b or more was higher in the vaginal group than in the abdominal group (odds ratio 0.38, 95% confidence interval 0.18 to 0.79). There was no difference in the overall prolapse stage. An abdominal procedure was £570 (95% confidence interval £459 to £682) more expensive than a vaginal procedure and generated non-significantly more quality-adjusted life-years (mean difference 0.004, 95% confidence interval -0.031 to 0.041). CONCLUSIONS Uterine trial - in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between uterine preservation and vaginal hysterectomy. Vault trial - in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between an abdominal and a vaginal approach. FUTURE WORK Long-term follow-up for at least 6 years is ongoing to identify recurrence rates, need for further prolapse surgery, adverse events and cost-effectiveness. TRIAL REGISTRATION Current Controlled Trials ISRCTN86784244. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 13. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
| | - Lynda Constable
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mary Kilonzo
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professionals Research Unit (NMAHP RU), Glasgow Caledonian University, Glasgow, UK
| | - Kevin Cooper
- Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Anthony Smith
- St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | | | - Suzanne Breeman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison McDonald
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professionals Research Unit (NMAHP RU), Glasgow Caledonian University, Glasgow, UK
| | - Isobel Montgomery
- Independent patient representative, c/o Health Services Research Unit, Aberdeen, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, Edinburgh BioQuarter, University of Edinburgh, Edinburgh, UK
| | - Cathryn Glazener
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Donaldson K, Huntington A, De Vita R. Mechanics of Uterosacral Ligaments: Current Knowledge, Existing Gaps, and Future Directions. Ann Biomed Eng 2021; 49:1788-1804. [PMID: 33754254 DOI: 10.1007/s10439-021-02755-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/17/2021] [Indexed: 12/11/2022]
Abstract
The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and apical vagina within the pelvis. As these structures are over-stretched, become weak, and exhibit laxity, pelvic floor disorders such as pelvic organ prolapse occur. Although several surgical procedures to treat pelvic floor disorders are directed toward the USLs, there is still a lot that is unknown about their function. This manuscript presents a review of the current knowledge on the mechanical properties of the USLs. The anatomy, microstructure, and clinical significance of the USLs are first reviewed. Then, the results of published experimental studies on the in vivo and ex vivo, uniaxial and biaxial tensile tests are compiled. Based on the existing findings, research gaps are identified and future research directions are discussed. The purpose of this exhaustive review is to help new researchers navigate scientific literature on the mechanical properties of the USLs. The use of these structures remains very popular in reconstructive surgeries that restore and augment the support of pelvic organs, especially as synthetic surgical mesh implants continue to be highly controversial.
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Surgical Management of Symptomatic Apical Pelvic Organ Prolapse: A Systematic Review and Meta-analysis. Obstet Gynecol 2021; 137:1061-1073. [PMID: 33957652 DOI: 10.1097/aog.0000000000004393] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/24/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To systematically review objective and subjective success and complications of apical suspensions for symptomatic uterine or vaginal vault pelvic organ prolapse (POP). DATA SOURCES MEDLINE, CENTRAL, ClinicalTrials.gov, and EMBASE (2002-2019) were searched using multiple terms for apical POP surgeries, including comparative studies in French and English. METHODS OF STUDY SELECTION From 2,665 records, we included randomized controlled trials and comparative studies of interventions with or without hysterectomy, including abdominal apical reconstruction through open, laparoscopic, or robotic approaches and vaginal apical reconstructions. Repairs using transvaginal mesh, off-the-market products, procedures without apical suspension, and follow-up less than 6 months were excluded. TABULATION, INTEGRATION, AND RESULTS Relative risk (RR) was used to estimate the effect of surgical procedure on each outcome. For each outcome and comparison, a meta-analysis was conducted to pool the RRs when possible. Meta-regression and bias tests were performed when appropriate. The GRADE (Grades for Recommendation, Assessment, Development and Evaluation) system for quality rating and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting were used. Sixty-two articles were included in the review (N=22,792) and 50 studies in the meta-analyses. There was heterogeneity in study quality, techniques used, and outcomes reported. Median follow-up was 1-5 years. Vaginal suspensions showed higher risk of overall and apical anatomic recurrence compared with sacrocolpopexy (RR 1.82, 95% CI 1.22-2.74 and RR 2.70, 95% CI 1.33-5.50) (moderate), whereas minimally invasive sacrocolpopexy showed less overall and posterior anatomic recurrence compared with open sacrocolpopexy (RR 0.59, 95% CI 0.47-0.75 and RR 0.59, 95% CI 0.44-0.80, respectively) (low). Different vaginal approaches, and hysterectomy and suspension compared with hysteropexy had similar anatomic success. Subjective POP recurrence, reintervention for POP recurrence and complications were similar between most procedures. CONCLUSION Despite variations in anatomic outcomes, subjective outcomes and complications were similar for apical POP procedures at 1-5 years. Standardization of outcome reporting and comparative studies with longer follow-up are urgently needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42019133869.
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Eckhardt S, Bermudez A, Rosenman A. Uterosacral Ligament Hysteropexy for Uterine Didelphys: A Case Report. J Minim Invasive Gynecol 2021; 28:1425-1428. [PMID: 33962025 DOI: 10.1016/j.jmig.2021.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/10/2021] [Accepted: 04/24/2021] [Indexed: 10/21/2022]
Abstract
Surgical approach to pelvic organ prolapse has traditionally included hysterectomy; however, in the past decade, uterine sparing prolapse surgery (hysteropexy) has become increasingly popular within female pelvic medicine and reconstructive surgery. The current literature demonstrates comparable outcomes for hysteropexy and traditional approach. As these procedures become more common, it is important to consider how to approach patients with unique anatomy such as uterine anomalies who desire uterine sparing surgery. In our case, we describe a woman aged 77 years with uterine didelphys who underwent a successful vaginal uterosacral ligament hysteropexy for stage 2 pelvic organ prolapse and was followed for 12 months postoperatively. Our case demonstrates that vaginal uterosacral ligament hysteropexy is feasible in a patient with uterine didelphys.
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Affiliation(s)
- Sarah Eckhardt
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Harbor-UCLA Medical Center, Torrance (Dr. Eckhardt).
| | - Ana Bermudez
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, UCLA Medical Center, Los Angeles (Drs. Bermudez and Rosenman) California
| | - Amy Rosenman
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, UCLA Medical Center, Los Angeles (Drs. Bermudez and Rosenman) California
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Geoffrion R, Larouche M. Directive clinique n o 413 : Traitement chirurgical du prolapsus génital apical chez les femmes. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:524-538.e1. [PMID: 33548502 DOI: 10.1016/j.jogc.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIF Comparer les taux de réussite et de complications des interventions de suspension apicale pour le traitement du prolapsus symptomatique de l'utérus ou du dôme vaginal. POPULATION CIBLE Les femmes présentant un prolapsus symptomatique de l'utérus ou du dôme vaginal qui souhaitent obtenir un traitement chirurgical. OPTIONS Les interventions abordées sont les méthodes reconstructives apicales par voie abdominale (colposacropexie, hystérosacropexie ou hystéropexie avec suspension aux ligaments utéro-sacrés) par chirurgie ouverte, laparoscopique ou robotisée; les méthodes reconstructives apicales par voie vaginale (suspension du dôme vaginal ou hystéropexie, sacrospinofixation, suspension aux ligaments utéro-sacrés, suspension au muscle ilio-coccygien, culdoplastie de McCall ou amputation du col [technique de Manchester]); et les interventions vaginales oblitérantes (avec ou sans utérus in situ). Les interventions individuelles ou les grandes catégories d'interventions ont été comparées : (1) reconstruction par voie vaginale versus abdominale, (2) interventions reconstructives par voie abdominale, (3) interventions reconstructives par voie vaginale, (4) reconstruction par hystérectomie avec suspension par comparaison à la reconstruction par hystéropexie et (5) options reconstructives versus oblitérantes. RéSULTATS: Le comité d'urogynécologie a sélectionné les résultats cliniques suivants : échec objectif (obtenu par des systèmes validés de quantification du prolapsus génital et défini comme un échec global objectif et un taux d'échec par compartiment); échec subjectif (réapparition de la sensation de protubérance déterminée subjectivement, avec ou sans l'utilisation d'un questionnaire validé); réopération pour un prolapsus génital récidivé; complications postopératoires de troubles mictionnels (incontinence urinaire d'effort de novo ou postopératoire; réopération d'une incontinence urinaire d'effort de novo, persistante ou récidivée; incontinence urinaire par urgenturie; et dysfonction mictionnelle); lésion des voies urinaires détectée en périopératoire (vessie ou uretère); autres complications (exposition prothétique, définie comme un treillis visible et exposé dans le vagin et une douleur pelvienne non sexuelle); et fonction sexuelle (dyspareunie de novo et score de la fonction sexuelle d'après un questionnaire validé). BéNéFICES, RISQUES ET COûTS: Cette directive clinique sera bénéfique pour les patientes qui souhaitent obtenir une correction chirurgicale du prolapsus génital apical en améliorant les conseils sur les options de traitement chirurgical et les résultats cliniques possibles. La directive sera également utile pour les fournisseurs de soins chirurgicaux en améliorant leurs connaissances sur diverses méthodes chirurgicales. Les données présentées pourraient servir à élaborer des cadres et des outils pour la prise de décision partagée. DONNéES PROBANTES: Nous avons effectué des recherches dans les bases de données Medline, Cochrane Central Register of Controlled Trials (CENTRAL) et Embase pour des articles publiés entre 2002 et 2019. Les termes de recherche étaient nombreux et portaient sur les interventions de correction du prolapsus génital apical, les voies d'abord et les complications. Nous avons exclu les reconstructions par treillis transvaginal et les études comparant les interventions sans suspension apicale. Nous avons inclus des essais cliniques randomisés et des études comparatives prospectives ou rétrospectives. Nous avons limité nos recherches aux articles publiés en anglais ou en français dont le texte intégral était accessible. Une revue systématique des articles avec méta-analyse a ensuite été effectuée. MéTHODES DE VALIDATION: Les auteures ont évalué la qualité des données probantes et la force des recommandations en utilisant lecadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CIBLES Gynécologues, urologues, urogynécologues et autres fournisseurs de soins de santé qui évaluent, conseillent et soignent des femmes ayant un prolapsus génital. DÉCLARATIONS SOMMAIRES: Toutes les déclarations font référence à la correction du prolapsus génital apical à court et à moyen terme (jusqu'à 5 ans), sauf indication contraire. RECOMMANDATIONS.
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Geoffrion R, Larouche M. Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:511-523.e1. [PMID: 33548503 DOI: 10.1016/j.jogc.2021.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse. TARGET POPULATION Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction. OPTIONS Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ). Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options. OUTCOMES The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire). BENEFITS, HARMS, AND COSTS This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. EVIDENCE We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The search included multiple terms for apical POP surgical procedures, approaches, and complications. We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension. We included randomized controlled trials and prospective or retrospective comparative studies. We limited language of publication to English and French and accessibility to full text. A systematic review and meta-analysis was performed. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED USERS Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP. SUMMARY STATEMENTS All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified. RECOMMENDATIONS
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Perioperative Adverse Events in Women Undergoing Vaginal Prolapse Repair With Uterine Preservation Versus Concurrent Hysterectomy: A Matched Cohort Study. Female Pelvic Med Reconstr Surg 2021; 27:621-626. [PMID: 33476105 DOI: 10.1097/spv.0000000000001011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Barba M, Schivardi G, Manodoro S, Frigerio M. Obstetric outcomes after uterus-sparing surgery for uterine prolapse: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 256:333-338. [PMID: 33271407 DOI: 10.1016/j.ejogrb.2020.11.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/18/2020] [Indexed: 11/18/2022]
Abstract
Up-to-date there are no guidelines about uterus-sparing prolapse repair procedures for women desiring childbearing. This systematic review and meta-analysis aims to evaluate obstetrical outcomes after uterus-sparing apical prolapse repair in terms of pregnancy rate, obstetrical adverse outcomes and delivery mode according to the type of procedure. To identify potentially eligible studies, we searched PubMed, Scopus, Cochrane Library and ISI Web of Science (up to April 15, 2020). Case reports, reviews, letters to Editor, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded. Twenty-four studies met inclusion criteria and were incorporated into the final assessment, which included 1518 surgical procedures. In total 151 patients got pregnant after prolapse surgical repair, for a resulting pregnancy raw rate of 9.9 %. Overall, adverse obstetric outcomes resulted low, rating 4.6 %. Manchester procedure resulted associated with the highest risk of adverse obstetrical outcomes and preterm premature rupture of membranes (p < 0.0001). After exclusion of Manchester procedure, sacrohysteropexy was found to be associated with higher risk of obstetrical adverse outcomes compared to native-tissue procedures (p = 0.04). Native-tissue surgery might represent the most cautious option for women wishing for pregnancy.
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Manodoro S, Braga A, Barba M, Caccia G, Serati M, Frigerio M. Update in fertility-sparing native-tissue procedures for pelvic organ prolapse. Int Urogynecol J 2020; 31:2225-2231. [PMID: 32809111 DOI: 10.1007/s00192-020-04474-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
Uterine-sparing prolapse surgery has been gaining back popularity with clinicians and patients. Although both prosthetic and native-tissue surgery procedures are described, the latter is progressively regaining a central role in pelvic reconstructive surgery, owing to a lack of mesh-related complications. Available native-tissue procedures have different advantages and pitfalls, as well as different evidence profiles. Most of them offer anatomical and subjective outcomes comparable with those of hysterectomy-based procedures. Moreover, native-tissue procedures in young women desiring childbearing allow to avoid synthetic material implantation, which may lead to potentially serious complications during pregnancy. As a consequence, we do think that offering a reconstructive native-tissue procedure for uterine preservation (with the exception of the Manchester procedure) is the safest option in women wishing for pregnancy. Sacrospinous ligament hysteropexy and high uterosacral ligament hysteropexy may be considered first-line options in consideration of the higher level of evidence and lack of adverse obstetrical outcomes.
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Affiliation(s)
| | - Andrea Braga
- EOC-Beata Vergine Hospital, Mendrisio, Switzerland
| | | | | | | | - Matteo Frigerio
- San Gerardo University Hospital, Via Pergolesi 33, 20900, Monza, Italy.
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Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy. J Minim Invasive Gynecol 2020; 28:100-106. [PMID: 32387566 DOI: 10.1016/j.jmig.2020.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/21/2020] [Accepted: 04/26/2020] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING Teaching hospital. PATIENTS Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS TULH. MEASUREMENTS AND MAIN RESULTS A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.
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Hoke TP, Tan-Kim J, Richter HE. Evidence-Based Review of Vaginal Native Tissue Hysteropexy for Uterovaginal Prolapse. Obstet Gynecol Surv 2020; 74:429-435. [PMID: 31343708 DOI: 10.1097/ogx.0000000000000686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Tanya P Hoke
- Clinical Instructor/Fellow, Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Jasmine Tan-Kim
- Voluntary Assistant Clinical Professor, Department of Reproductive Medicine, University of California, San Diego, La Jolla; Attending Physician, Division of Female Pelvic Medicine and Reconstructive Surgery Kaiser Permanente, San Diego, San Diego, CA
| | - Holly E Richter
- Professor and Research Director, Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
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Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2020; 26:173-201. [PMID: 32079837 DOI: 10.1097/spv.0000000000000846] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Surgeries for pelvic organ prolapse (POP) are common, but standardization of surgical terms is needed to improve the quality of investigation and clinical care around these procedures. The American Urogynecologic Society and the International Urogynecologic Association convened a joint writing group consisting of 5 designees from each society to standardize terminology around common surgical terms in POP repair including the following: sacrocolpopexy (including sacral colpoperineopexy), sacrocervicopexy, uterosacral ligament suspension, sacrospinous ligament fixation, iliococcygeus fixation, uterine preservation prolapse procedures or hysteropexy (including sacrohysteropexy, uterosacral hysteropexy, sacrospinous hysteropexy, anterior abdominal wall hysteropexy, Manchester procedure), anterior prolapse procedures (including anterior vaginal repair, anterior vaginal repair with graft, and paravaginal repair), posterior prolapse procedures (including posterior vaginal repair, posterior vaginal repair with graft, levator plication, and perineal repair), and obliterative prolapse repairs (including colpocleisis with hysterectomy, colpocleisis without hysterectomy, and colpocleisis of the vaginal vault). Each of these terms is clearly defined in this document including the required steps of the procedure, surgical variations, and recommendations for procedural terminology.
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Joint report on terminology for surgical procedures to treat pelvic organ prolapse. Int Urogynecol J 2020; 31:429-463. [DOI: 10.1007/s00192-020-04236-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Milani R, Manodoro S, Cola A, Bellante N, Palmieri S, Frigerio M. Transvaginal uterosacral ligament hysteropexy versus hysterectomy plus uterosacral ligament suspension: a matched cohort study. Int Urogynecol J 2019; 31:1867-1872. [DOI: 10.1007/s00192-019-04206-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/03/2019] [Indexed: 11/25/2022]
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Palmerola R, Rosenblum N. Prolapse Repair Using Non-synthetic Material: What is the Current Standard? Curr Urol Rep 2019; 20:70. [PMID: 31612341 DOI: 10.1007/s11934-019-0939-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Due to recent concerns over the use of synthetic mesh in pelvic floor reconstructive surgery, there has been a renewed interest in the utilization of non-synthetic repairs for pelvic organ prolapse. The purpose of this review is to review the current literature regarding pelvic organ prolapse repairs performed without the utilization of synthetic mesh. RECENT FINDINGS Native tissue repairs provide a durable surgical option for pelvic organ prolapse. Based on recent findings of recently performed randomized clinical trials with long-term follow-up, transvaginal native tissue repair continues to play a role in the management of pelvic organ prolapse without the added risk associated with synthetic mesh. In 2019, the FDA called for manufacturers of synthetic mesh for transvaginal mesh to stop selling and distributing their products in the USA. Native tissue and non-synthetic pelvic organ prolapse repairs provide an efficacious alternative without the added risk inherent to the utilization of transvaginal mesh. A recent, multicenter, randomized clinical trial demonstrated no clear advantage to the utilization of synthetic mesh. Furthermore, transvaginal native tissue repairs have demonstrated good long-term efficacy, particularly when anatomic success is not the sole metric used to define surgical success.
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Affiliation(s)
- Ricardo Palmerola
- Departments of Urology and Obstetrics & Gynecology, New York University School of Medicine, 222 East 41st Street, 11th Floor, New York, NY, 10017, USA.
| | - Nirit Rosenblum
- Departments of Urology and Obstetrics & Gynecology, New York University School of Medicine, 222 East 41st Street, 11th Floor, New York, NY, 10017, USA
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Joueidi Y, Gueudry P, Cardaillac C, Vaucel E, Lopes P, Winer N, Dochez V, Thubert T. [Uterine preservation or not during prolapse surgery: Review of the literature]. Prog Urol 2019; 29:1021-1034. [PMID: 31130408 DOI: 10.1016/j.purol.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation. MATERIAL AND METHODS We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer. RESULTS Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR=2.21 [95% CI: 0.33-14.67]) or vaginal surgery (OR=1.07 [95% CI: 0.38-2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3-11). CONCLUSION In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.
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Affiliation(s)
- Y Joueidi
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - P Gueudry
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - C Cardaillac
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; CIC, centre d'investigation clinique de Nantes, 5, allée de l'Ile Gloriette, 44093 Nantes cedex 01, France
| | - E Vaucel
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - P Lopes
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France
| | - N Winer
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; CIC, centre d'investigation clinique de Nantes, 5, allée de l'Ile Gloriette, 44093 Nantes cedex 01, France
| | - V Dochez
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; CIC, centre d'investigation clinique de Nantes, 5, allée de l'Ile Gloriette, 44093 Nantes cedex 01, France
| | - T Thubert
- Service de gynécologie, CHU de Nantes, CHU Hôtel-Dieu, 38, boulevard Jean-Monnet, 44000 Nantes, France; CIC, centre d'investigation clinique de Nantes, 5, allée de l'Ile Gloriette, 44093 Nantes cedex 01, France; GREEN, groupe de recherche clinique en neuro-urologie, GRCUPMC01, 75020 Paris, France.
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Meriwether KV, Balk EM, Antosh DD, Olivera CK, Kim-Fine S, Murphy M, Grimes CL, Sleemi A, Singh R, Dieter AA, Crisp CC, Rahn DD. Uterine-preserving surgeries for the repair of pelvic organ prolapse: a systematic review with meta-analysis and clinical practice guidelines. Int Urogynecol J 2019; 30:505-522. [DOI: 10.1007/s00192-019-03876-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 01/09/2019] [Indexed: 12/29/2022]
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Meriwether KV, Antosh DD, Olivera CK, Kim-Fine S, Balk EM, Murphy M, Grimes CL, Sleemi A, Singh R, Dieter AA, Crisp CC, Rahn DD. Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol 2018; 219:129-146.e2. [PMID: 29353031 DOI: 10.1016/j.ajog.2018.01.018] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/03/2018] [Accepted: 01/10/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines. DATA SOURCES The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017. STUDY ELIGIBILITY CRITERIA We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy. STUDY APPRAISAL AND SYNTHESIS METHODS Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed. RESULTS We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation. CONCLUSION Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.
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Affiliation(s)
- Kate V Meriwether
- Department of Obstetrics and Gynecology, University of Louisville, Louisville, KY.
| | - Danielle D Antosh
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX
| | - Cedric K Olivera
- Department of Obstetrics and Gynecology, New York University, New York, NY
| | - Shunaha Kim-Fine
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Ethan M Balk
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI
| | - Miles Murphy
- The Institute for Female Pelvic Medicine and Reconstructive Surgery, North Wales, PA
| | - Cara L Grimes
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY
| | | | - Ruchira Singh
- Department of Obstetrics and Gynecology, University of Florida Health, Jacksonville, FL
| | - Alexis A Dieter
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | | | - David D Rahn
- Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, TX
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Bradley S, Gutman RE, Richter LA. Hysteropexy: an Option for the Repair of Pelvic Organ Prolapse. Curr Urol Rep 2018; 19:15. [DOI: 10.1007/s11934-018-0765-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW Owing to growing interest in uterine preservation, this evidence-based review compares hysteropexy with hysterectomy during surgery for uterovaginal prolapse. RECENT FINDINGS LeFort colpocleisis is preferred over vaginal hysterectomy and total colpocleisis. The majority of studies show no differences in outcomes comparing sacrospinous hysteropexy with vaginal hysterectomy native tissue prolapse repair except for a single randomized controlled trial showing increased apical recurrences with advanced prolapse. Results comparing uterosacral hysteropexy and sacral hysteropexy with hysterectomy native tissue repairs are inconclusive. Potentially better outcomes are reported when laparoscopic hysterectomy (total or supracervical) is performed with sacral colpopexy compared with laparoscopic sacral hysteropexy, but mesh and morcellation risks should be considered. Data comparing vaginal mesh hysteropexy with currently available products with hysterectomy prolapse repairs are lacking but a high-quality study is underway. SUMMARY High satisfaction and low reoperation rates can be accomplished using a variety of hysteropexy techniques. The advantages and disadvantages of uterine conservation must be considered when planning uterovaginal prolapse surgery. The type of hysteropexy and possible graft configuration may impact reoperation rates for recurrent prolapse. Vaginal mesh risks must be considered and laparoscopic mesh risks must be balanced with potential difficulty of future hysterectomy if needed.
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Hysteropreservation versus hysterectomy in the surgical treatment of uterine prolapse: systematic review and meta-analysis. Int Urogynecol J 2017; 28:1617-1630. [PMID: 28780651 DOI: 10.1007/s00192-017-3433-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/13/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The efficacy and safety of removing or preserving the uterus during reconstructive pelvic surgery is a matter of debate. METHODS We performed a systematic review and meta-analysis of studies that compared hysteropreservation and hysterectomy in the management of uterine prolapse. PubMed, Medline, SciELO and LILACS databases were searched from inception until January 2017. We selected only randomized controlled trials and observational cohort prospective comparative studies. Primary outcomes were recurrence and reoperation rates. Secondary outcomes were: operative time, blood loss, visceral injury, voiding dysfunction, duration of catheterization, length of hospital stay, mesh exposure, dyspareunia, malignant neoplasia and quality of life. RESULTS Eleven studies (six randomized and five non-randomized) were included involving 910 patients (462 in the hysteropreservation group and 448 in the hysterectomy group). Pooled data including all surgical techniques showed no difference between the groups regarding recurrence of uterine prolapse (RR 1.65, 95% CI 0.88-3.10; p = 0.12), but the risk of recurrence following hysterectomy was lower when the vaginal route was used with native tissue repair (RR 10.61; 95% CI 1.26-88.94; p = 0.03). Hysterectomy was associated with a lower reoperation rate for any prolapse compartment than hysteropreservation (RR 2.05; 95% CI 1.13-3.74; p = 0.02). Hysteropreservation was associated with a shorter operative time (mean difference -12.43 min; 95% CI -14.11 to -10.74 ; p < 0.00001) and less blood loss (mean difference -60.42 ml; 95% CI -71.31 to -49.53 ml; p < 0.00001). Other variables were similar between the groups. CONCLUSIONS Overall, the rate of recurrence of uterine prolapse was not lower but the rate of reoperation for prolapse was lower following hysterectomy, while operative time was shorter and blood loss was less with hysteropreservation. The limitations of this analysis were the inclusion of nonrandomized studies and the variety of surgical techniques. The results should be interpreted with caution due to potential biases.
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Abstract
Uterovaginal prolapse may be treated with or without concomitant hysterectomy. Many patients express interest in uterine-sparing prolapse procedures, for which there are increasing evidence available regarding techniques and outcomes. Uterine-sparing procedures to treat uterovaginal prolapse require a unique set of surgical considerations including uterine abnormalities, possibility of occult malignancy, and future pregnancy. Data, including randomized controlled trials, support the use of sacrospinous hysteropexy. Other prospective trials detailing outcomes following uterosacral hysteropexy, mesh augmented sacrospinous hysteropexy, and sacrohysteropexy are also encouraging.
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Milani R, Frigerio M, Spelzini F, Manodoro S. Transvaginal uterosacral ligament hysteropexy: a video tutorial. Int Urogynecol J 2016; 28:789-791. [DOI: 10.1007/s00192-016-3222-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/21/2016] [Indexed: 02/04/2023]
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Cayrac M, Warembourg S, Le Normand L, Fatton B. L’hystérectomie modifie-t-elle les résultats anatomiques et fonctionnels de la cure de prolapsus ? : Recommandations pour la pratique clinique. Prog Urol 2016; 26 Suppl 1:S73-88. [DOI: 10.1016/s1166-7087(16)30430-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Uterine Conservation at the Time of Pelvic Organ Prolapse Treatment: the Options for Patients and Providers. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0146-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Milani R, Frigerio M, Manodoro S, Cola A, Spelzini F. Transvaginal uterosacral ligament hysteropexy: a retrospective feasibility study. Int Urogynecol J 2016; 28:73-76. [DOI: 10.1007/s00192-016-3036-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
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Ridgeway BM. Does prolapse equal hysterectomy? The role of uterine conservation in women with uterovaginal prolapse. Am J Obstet Gynecol 2015; 213:802-9. [PMID: 26226554 DOI: 10.1016/j.ajog.2015.07.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/19/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
Hysterectomy has historically been a mainstay in the surgical treatment of uterovaginal prolapse, even in cases in which the removal of the uterus is not indicated. However, uterine-sparing procedures have a long history and are now becoming more popular. Whereas research on these operations is underway, hysteropexy for the treatment of prolapse is not as well studied as hysterectomy-based repairs. Compared with hysterectomy and prolapse repair, hysteropexy is associated with a shorter operative time, less blood loss, and a faster return to work. Other advantages include maintenance of fertility, natural timing of menopause, and patient preference. Disadvantages include the lack of long-term prolapse repair outcomes and the need to continue surveillance for gynecological cancers. Although the rate of unanticipated abnormal pathology in this population is low, women who have uterine abnormalities or postmenopausal bleeding are not good candidates for uterine-sparing procedures. The most studied approaches to hysteropexy are the vaginal sacrospinous ligament hysteropexy and the abdominal sacrohysteropexy, which have similar objective and subjective prolapse outcomes compared with hysterectomy and apical suspension. Pregnancy and delivery have been documented after vaginal and abdominal hysteropexy approaches, although very little is known about outcomes following parturition. Uterine-sparing procedures require more research but remain an acceptable option for most patients with uterovaginal prolapse after a balanced and unbiased discussion reviewing the advantages and disadvantages of this approach.
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AL-BADR A, PERVEEN K, AL-SHAIKH G. Evaluation of Sacrospinous Hysteropexy vs. Uterosacral Suspension for the Treatment of Uterine Prolapse: A Retrospective Assessment. Low Urin Tract Symptoms 2015; 9:33-37. [DOI: 10.1111/luts.12104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 04/08/2015] [Accepted: 04/26/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Ahmed AL-BADR
- Department of Urogynecology and Pelvic Reconstructive Surgery; Women's Specialized Hospital, King Fahad Medical City; Riyadh Saudi Arabia
| | - Kauser PERVEEN
- Department of Urogynecology and Pelvic Reconstructive Surgery; Women's Specialized Hospital, King Fahad Medical City; Riyadh Saudi Arabia
| | - Ghadeer AL-SHAIKH
- Department of Urogynecology and Pelvic Reconstructive Surgery; Women's Specialized Hospital, King Fahad Medical City; Riyadh Saudi Arabia
- Department of Obstetrics and Gynecology; King Khalid University Hospital, King Saud University; Riyadh Saudi Arabia
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Wan OYK, Cheung RYK, Chan SSC, Chung TKH. Risk of malignancy in women who underwent hysterectomy for uterine prolapse. Aust N Z J Obstet Gynaecol 2013; 53:190-6. [DOI: 10.1111/ajo.12033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 11/07/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Osanna Y. K. Wan
- Department of Obstetrics and Gynaecology, Faculty of Medicine; The Chinese University of Hong Kong; Hong Kong; Hong Kong
| | - Rachel Y. K. Cheung
- Department of Obstetrics and Gynaecology, Faculty of Medicine; The Chinese University of Hong Kong; Hong Kong; Hong Kong
| | - Symphorosa S. C. Chan
- Department of Obstetrics and Gynaecology, Faculty of Medicine; The Chinese University of Hong Kong; Hong Kong; Hong Kong
| | - Tony K. H. Chung
- Department of Obstetrics and Gynaecology, Faculty of Medicine; The Chinese University of Hong Kong; Hong Kong; Hong Kong
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Where to for pelvic organ prolapse treatment after the FDA pronouncements? A systematic review of the recent literature. Int Urogynecol J 2013; 24:707-18. [PMID: 23306770 DOI: 10.1007/s00192-012-2025-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/08/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management. METHODS A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance. RESULTS Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient's lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥ 10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery. CONCLUSION Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.
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