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Xiao X, Yu X, Yin L, Zhang L, Feng D, Zhang L, Gong Z, Zhang Q, Lin Y, He L. Surgical outcomes of sacrospinous hysteropexy and hysteropreservation for pelvic organ prolapse: a systematic review of randomized controlled trials. Front Med (Lausanne) 2024; 11:1399247. [PMID: 39114831 PMCID: PMC11303157 DOI: 10.3389/fmed.2024.1399247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 07/11/2024] [Indexed: 08/10/2024] Open
Abstract
Objective In several randomized controlled trials (RCTs), sacrospinous hysteropexy and other forms of hysteropreservation have been compared. Nevertheless, there is no definitively best treatment. This study summarized RCT evidence for various uterine preservation surgical procedures. Methods From each database inception to August 2023, we searched PubMed, Embase, Cochrane Library, and Web of Science for eligible RCTs. A comparison was made between sacrospinous hysteropexy and other hysteropreservation, including vaginal and abdominal surgery. For categorical and continuous variables, relative risks (RRs) and mean differences (MDs) were calculated using random-effects models. Results We reviewed a total 1,398 studies and ultimately included five RCTs that met all inclusion criteria. These five studies included a total of 1,372 uterine POP cases all of whom received transvaginal surgery and had a follow-up period for assessment of recurrence from 12 months to 5 years. There were no significant differences between sacrospinous hysteropexy and other hysteropreservation for the incidences of recurrence (RR,1.24; 95% CI, 0.58 to 2.63; p = 0.58) or hematoma (RR,0.70; 95% CI, 0.17 to 2.92; p = 0.62). Moreover, neither sacrospinous hysteropexy nor hysteropreservation had any significant effect on the risk of mesh exposure (RR,0.34; 95% CI, 0.03 to 4.31; p = 0.41), dyspareunia (RR,0.45; 95% CI, 0.13 to1.6; p = 0.22), urinary tract infection (RR,0.66; 95% CI, 0.38 to 1.15; p = 0.15), bothersome bulge symptoms (RR,0.03; 95% CI, -0.02 to 0.08; p = 0.24), operative time (MD, -4.53; 95% CI, -12.08 to 3.01; p = 0.24), and blood loss (MD, -25.69; 95% CI, -62.28 to 10.91; p = 0.17). However, sacrospinous hysteropexy was associated with a lower probability of pain (RR,4.8; 95% CI, 0.79 to 29.26; p = 0.09) compared with other hysteropreservation. Conclusion There was no difference between sacrospinous hysteropexy and hysteropreservation in terms of recurrence, hematoma, mesh exposure, dyspareunia, urinary tract infection, bothersome bulge symptoms, operative time, pain, and blood loss. Systematic Review Registration PROSPERO [CRD42023470025].
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Affiliation(s)
- Xinyu Xiao
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xia Yu
- Department of Clinical Laboratory, Chengdu Women's and Children's Central Hospital, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Litong Yin
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ling Zhang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Dan Feng
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Lushuang Zhang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhaolin Gong
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qiang Zhang
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yonghong Lin
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Li He
- Department of Obstetrics and Gynecology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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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] [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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Ferrari A, Giannini A, Seghieri C, Simoncini T, Vainieri M. Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data. BMJ Open 2023; 13:e068145. [PMID: 36882257 PMCID: PMC10008403 DOI: 10.1136/bmjopen-2022-068145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
OBJECTIVES To explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP). DESIGN AND SETTING A retrospective cohort study employing administrative health data from the Tuscany region, Italy. PARTICIPANTS All women over 40 years hospitalised for apical/multicompartmental POP reconstructive surgery (excluding anterior/posterior colporrhaphy without concomitant hysterectomy) from January 2017 to December 2019. OUTCOMES We first computed treatment rates just for women residing in Tuscany (n=2819) and calculated the Systematic Component of Variation (SCV) to explore variation in access to care among health districts. Then, using the full cohort (n=2959), we ran multilevel models for the average length of stay and reoperations, readmissions and complications, and computed the intraclass correlation coefficient to assess the individual and hospital determinants of efficiency and quality of care provided by hospitals. RESULTS The 5.4-fold variation between the lowest-rate (56/100 000 inhabitants) and the highest-rate (302/100 000) districts and the SCV over 10% confirmed high systematic variation in the access to care. Higher treatment rates were driven by greater provisions of robotic and/or laparoscopic interventions, which showed highly variable usage rates. Both individual and hospital factors influenced quality and efficiency provided by hospitals, but just low proportions of variation were explained by hospital and patient characteristics. CONCLUSIONS We found high and systematic variation in the access to POP surgical care in Tuscany and in quality and efficiency provided by hospitals. Such a variation may be mainly explained by user and provider preferences, which should be further explored. Also, supply-side factors may be involved, suggesting that wider and more uniform dissemination of robotic/laparoscopic procedures may reduce variation.
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Affiliation(s)
- Amerigo Ferrari
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Andrea Giannini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Chiara Seghieri
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynaecology, University of Pisa, Pisa, Italy
| | - Milena Vainieri
- Institute of Management, MeS (Management and Health) Laboratory, Sant'Anna School of Advanced Studies, Pisa, Italy
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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] [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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Enklaar RA, van IJsselmuiden MN, IntHout J, Haan SJH, Rijssenbeek OGAM, Bremmer RH, van Eijndhoven HWF. Practice pattern variation: treatment of pelvic organ prolapse in The Netherlands. Int Urogynecol J 2021; 33:1973-1980. [PMID: 34487194 PMCID: PMC9270291 DOI: 10.1007/s00192-021-04968-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Great variety in clinical management of pelvic organ prolapse (POP) has been described over the last years. Practice pattern variation (PPV) reflects differences in care that cannot be explained by the underlying condition. We aim to explore whether PPV in management of POP in The Netherlands has changed between 2011 and 2017. METHODS We conducted a multicenter cohort study, using prospective routinely collected benchmark data from LOGEX, a healthcare analytics company (Amsterdam, The Netherlands). Data of patients with a diagnosis POP from 50 hospitals (16 teaching and 34 non-teaching hospitals) were collected for the years 2011 and 2017. All treatments were categorized into three groups: conservative treatment, uterus-preserving or uterus-removing surgery. Using meta-analysis, we evaluated whether the proportions of conducted treatments changed over time and estimated the between-center variation (Cochran's Q), reflecting the PPV in 2011 and 2017. This variation was analyzed using F-tests. RESULTS Compared to 2011, referral for POP in 2017 decreased by 16.2% (-4505 patients), and the percentage of hysterectomies decreased by 33.6% (p < 0.0001). The PPV of POP surgery decreased significantly by 47.2% (p = 0.0137) and of hysterectomies by 41.5% (p = 0.0316). CONCLUSIONS We found a decline in PPV for POP surgery between 2011 and 2017. Furthermore, the number of surgical interventions decreased, which was mostly due to a decline of hysterectomies. This indicates a shift toward more conservative therapy and uterus preservation. A further reduction of PPV would be beneficial for the quality of health care.
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Affiliation(s)
- Rosa A Enklaar
- Radboud Institute for Health Sciences, Department of Obstetrics and Gynecology, Radboud University Medical Center, Geert Groote plein Zuid 10, 6525, GA, Nijmegen, The Netherlands. .,Department of Obstetrics and Gynecology, Zuyderland Medical Center, Heerlen, The Netherlands.
| | | | - Joanna IntHout
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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