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

Hysterectomy versus uterine preservation for pelvic organ prolapse surgery: a prospective cohort study

BACKGROUND

One in 5 females will have surgery to treat pelvic organ prolapse in their lifetime. Uterine-preserving surgery involving suspension of the uterus is an increasingly popular alternative to the traditional use of hysterectomy with vaginal vault suspension to treat pelvic organ prolapse; however, comparative evidence with native tissue repairs remains limited in scope and quality.

OBJECTIVE

To compare 1-year outcomes between hysterectomy-based and uterine-preserving native tissue prolapse surgeries performed through minimally invasive approaches.

STUDY DESIGN

We used a nonrandomized design with patients self-selecting their surgical group to integrate a pragmatic, patient-centered, and autonomy-focused approach. Participants chose between uterine-preserving surgery or hysterectomy-based surgery, guided by neutral evidence-based discussions and individualized decision-making, with support from fellowship-trained urogynecologists. Inverse probability of treatment weighting based on high-dimensional propensity scores was used to balance baseline differences across surgical groups in an effort to resemble a randomized clinical trial. A prospective cohort study of 321 participants with stage ≥2 prolapse involving the uterus who desired surgical treatment were recruited between 2020 and 2022 and followed to 1 year (retention >90%). Patients chose to receive uterine-preserving pelvic organ prolapse surgery through hysteropexy (n=151) or hysterectomy with vaginal vault suspension (n=170; reference group), with repair of anterior and/or posterior prolapse if indicated. The primary outcome was anatomic prolapse recurrence within 1 year, defined as apical descent ≥50% of the total vaginal length. Secondary outcomes were perioperative, functional, clinical, and healthcare outcomes measured at 6 weeks and 1 year. Inverse probability of treatment weighted linear regression and modified Poisson regression were used to estimate adjusted mean differences and relative risks, respectively.

RESULTS

Apical anatomic recurrence rates at 1 year were 17.2% following hysterectomy and 7.5% following uterine-preservation, resulting in an adjusted relative risk of 0.35 (95% CI 0.15, 0.83). Uterine-preserving surgery was associated with shorter length of surgery (adjusted mean difference -0.68 hours [-0.80, -0.55]) and hospitalization (adjusted mean difference -4.34 hours [-7.91, -0.77]), less use of any opioids within 24 hours (adjusted relative risk 0.79 [0.65, 0.97]), and fewer procedural complications (adjusted relative risk 0.19 [0.04, 0.83]) than hysterectomy. Up to 1 year, uterine-preserving surgery was associated with lower risk of composite recurrence (stage ≥2 prolapse in any compartment or retreatment; adjusted relative risk 0.47 [0.32, 0.69]) than hysterectomy, driven by anatomic outcomes. There were no clinically meaningful differences in functional or healthcare outcomes between surgical groups.

CONCLUSION

This study adds real-world evidence to the growing body of research supportive of uterine-preserving surgery as a safe, efficient, and effective alternative to hysterectomy during native tissue prolapse repair. Given mounting evidence on safety, efficiency, and effectiveness of uterine-preserving surgery and its alignment with the preferences of approximately half of patients to keep their uterus, the standard of care should include routine offering and patient choice between uterine-preserving and hysterectomy-based surgery for pelvic organ prolapse.

The Role of Uterine Preservation at the Time of Pelvic Organ Prolapse Surgery

OBJECTIVE

The aim of the study was to synthesize the current literature and provide surgeons with data to inform counseling of eligible patients for uterine-preserving prolapse surgery (UPPS).

METHODS

We compared UPPS to similar techniques incorporating hysterectomy, including native-tissue repairs by vaginal, laparoscopic, or open approach; mesh-reinforced repairs by vaginal, laparoscopic, or open approach; obliterative repairs; and the Manchester procedure. Reviewed outcomes include surgical and patient-reported outcomes, complications, uterine pathology, and sexual function. We conducted a structured literature search of English language articles published 1990-2023, combining MeSH terms for pelvic organ prolapse and UPPS. Data were categorized by procedure and approach, and evaluated to provide recommendations and strength of evidence based on group consensus.

RESULTS

Patient counseling on prolapse surgery should follow a benefit/risk assessment related to techniques that preserve the uterus. The discussion should include the benefits of hysterectomy for cancer detection and prevention and acknowledgment that patients should continue cervical cancer screening and evaluation of abnormal uterine bleeding following UPPS. The rate of hysterectomy after UPPS is low and most commonly for recurrent prolapse. If cervical elongation is present, trachelectomy should be considered at the time of UPPS. There is no difference in sexual function between UPPS and prolapse repair with hysterectomy. Data on pregnancy outcomes following UPPS are limited.

CONCLUSIONS

Uterine-preserving prolapse surgery should be a surgical option for all patients considering surgical treatment for symptomatic pelvic organ prolapse unless contraindications exist. Uterine-preserving prolapse surgery should be offered using an individualized benefit and risk discussion of both approaches to help patients make an informed decision based on their own values.

Comparison of sexual function between laparoscopic lateral suspension and laparoscopic sacrocervicopexy with the use of the PISQ-IR questionnaire

Introduction and hypothesis

We aimed to analyze the quality of sexual life of patients with apical vaginal wall prolapse who had undergone laparoscopic lateral suspension (LLS) and laparoscopic sacrocolpopexy (LSC).

Methods

We performed a secondary analysis of sexual outcomes of a previous randomized control trial comparing LLS and LSC in 89 women with symptomatic POP stage ≥ II. We evaluated sexually active (SA) and non-sexually active women (NSA) using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA-Revised (PISQ-IR). Women were reviewed over a period of 1 year post-surgery.

Results

Analysis of the entire PISQ-IR questionnaire indicates that surgical treatment of POP resulted in an improvement of the quality of sexual life in 21 (80.76%) in the group of sexually active women after LSC and in 20 (83.33%) in the group of SA patients after LLS. In both groups of patients, dyspareunia was not observed.

Conclusion

In conclusion, the quality of sexual life in SA group of patients improved significantly after both surgical procedures. The quality of sexual life of surveyed women significantly improved after curing POP symptoms.

Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy

STUDY OBJECTIVE

To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair.

DESIGN

A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome.

SETTING

Tertiary center for urogynecology.

PATIENTS

Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse.

INTERVENTIONS

Comparison analysis of estimated long-term costs was performed.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse.

CONCLUSION

The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

Safety of an anchor-based device for sacrospinous ligament fixation: A pilot case-control study

INTRODUCTION AND HYPOTHESIS

Sacrospinous ligament fixation (SSLF) is a popular surgical technique for treating apical prolapse. The use of suture-capturing devices (SCD), or the more recently introduced anchor-based device (ABD), is useful for a posterior approach but essential for an anterior one. The aim of our study was to assess the safety of the ABD, which was recently introduced to our unit, compared to the traditionally used SCD.

METHODS

This was a pilot case-control study of 40 patients who had a SSLF, 20 of these represented all the patients who had the procedure with the aid of the ABD and 20 patients who had the procedure using the SCD over approximately the same duration. The main safety endpoints of this pilot study were patient reported postoperative pain scores and perioperative complications rate.

RESULTS

The population characteristics were similar. The mean postoperative pain scores differed significantly only on postoperative day 1 in favor of the suture capturing device (3.40 [2.60] vs 1.60 [1.64], p = 0.013). The mean highest pain score was similar in both groups. Peri-operative complications rates were low and comparable between both groups. According to POPQ at 6 weeks follow-up the median Ba point was higher in the ABD group and this difference was significant (-3.00 [-3.00; -2.25] vs. -2.00 [-3.00; -1.50]; p = 0.03).

CONCLUSION

The anchor-based device for sacrospinal ligament fixation seems to have comparable safety profile to the traditionally used suture capturing devices.

Restriction of Surgical Options for Pelvic Floor Disorders

ABSTRACT

The purpose of this document is to update the 2013 AUGS Position Statement based on subsequent decisions made by the U.S. Food and Drug Administration, published clinical data, and relevant society and national guidelines related to the use of surgical mesh. Urogynecologists specialize in treating pelvic floor disorders, such as pelvic organ prolapse (POP) and urinary incontinence, and have been actively involved and engaged in the national and international discussions and research on the use of surgical mesh in the treatment of POP and stress urinary incontinence. In 2019, the U.S. Food and Drug Administration ordered manufacturers of transvaginally placed mesh kits for prolapse to stop selling and distributing their devices, stating that the data submitted did not provide a reasonable assurance of safety and effectiveness. Evidence supports the use of mesh in synthetic midurethral sling and abdominal sacrocolpopexy. The American Urogynecologic Society (AUGS) remains opposed to any restrictions that ban currently available surgical options performed by qualified and credentialed surgeons on appropriately informed patients with pelvic floor disorders. The AUGS supports the U.S. Food and Drug Administration's recommendations that surgeons thoroughly inform patients seeking treatment for POP about the risks and benefits of all potential treatment options, including nonsurgical options, native tissue vaginal repairs, or abdominally placed mesh. There are certain clinical situations where surgeons may assert that the use and potential benefit of transvaginal mesh for prolapse outweighs the risk of other routes/types of surgery or of not using mesh. The AUGS recommends that surgeons utilize a shared decision-making model in the decision-making process regarding surgical options, including use of transvaginally placed mesh.

Trends in Urogynecology-Transvaginal Mesh Surgery in Germany

BACKGROUND

Pelvic organ prolapse constitutes a prevalent condition associated with a considerable impact on the quality of life. The utilization of transvaginal mesh surgery for managing POP has been a subject of extensive debate. Globally, trends in TVM surgery experienced significant shifts subsequent to warnings issued by the FDA.

METHODS

This study aims to explore temporal patterns in transvaginal mesh surgery in the German healthcare system. A comprehensive analysis was conducted on in-patient data from the German Federal Statistical Office spanning 2006 to 2021. A total of 1,150,811 operations, each associated with specific codes, were incorporated into the study. Linear regression analysis was employed to delineate discernible trends.

RESULTS

The trends in transvaginal mesh surgery within the anterior compartment exhibited relative stability (p = 0.147); however, a significant decline was noted in all other compartments (posterior: p < 0.001, enterocele surgery: p < 0.001). A subtle increasing trend was observed for uterine-preserving transvaginal mesh surgery (p = 0.045).

CONCLUSION

Surgical trends over the specified timeframe demonstrate how POP management has evolved globally. Notably, despite observed fluctuations, transvaginal mesh surgery remains a viable option, particularly for specific cases with a high risk of relapse and contraindications to alternative surgical approaches.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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