Recurrent surgery in uterine prolapse: A nationwide register study

Treatment outcomes of Manchester procedure versus vaginal hysterectomy for mid-compartment prolapse: A systematic review and meta-analysis

INTRODUCTION

To compare the effectiveness and safety of Manchester procedure versus vaginal hysterectomy in the treatment of mid-compartment prolapse in women.

MATERIAL AND METHODS

We searched PubMed, Web of Science, Google Scholar, and the Cochrane Library for randomized controlled trials (RCTs), prospective, or retrospective studies comparing the Manchester procedure and vaginal hysterectomy up to July 2024. Primary outcomes included anatomical recurrence, subjective recurrence, overall complication rate, and reoperation. Secondary outcomes included estimated blood loss, operative time, and relevant subgroup analyses. This study has been registered in PROSPERO with the registration number CRD42024575874.

RESULTS

A total of 11 783 cases from 1 RCT, 1 prospective study, and 9 retrospective studies were included. For the primary outcomes, the Manchester procedure demonstrated significantly lower subjective recurrence rates (risk ratio [RR] = 0.85; 95% confidence interval [CI]: 0.73-0.98; I2 = 0%; p = 0.03) and reoperation rates (RR = 0.62; 95% CI: 0.43-0.89; I2 = 64%; p = 0.009) compared with vaginal hysterectomy, with no significant difference in anatomical recurrence rates (RR = 0.84; 95% CI: 0.58-1.21; I2 = 54%; p = 0.34) and overall complication rates (RR = 0.89; 95% CI: 0.79-1.00; I2 = 0%; p = 0.06) between the two groups. Secondary outcomes indicated that the Manchester procedure had a significantly shorter operative time and less estimated blood loss (p < 0.05). Subgroup analysis indicated that the Manchester procedure was associated with lower short-term (1-3 years) subjective recurrence rates (RR = 0.87; 95% CI: 0.78-0.98; I2 = 0%; p = 0.02) and reoperation rates (RR = 0.71; 95% CI: 0.55-0.92; I2 = 0%; p = 0.008). No significant differences were found between the two groups in terms of short-term anatomical recurrence rates or in mid- to long-term (>3 years) subjective recurrence rates, anatomical recurrence rates, and reoperation rates (p > 0.05).

CONCLUSIONS

Overall, the rates of anatomical recurrence and overall complications for Manchester procedure and vaginal hysterectomy are similar. Manchester procedure appears to have a lower subjective recurrence and reoperation rate in the short term, but this advantage was not observed in mid- to long-term follow-up. Further high-quality prospective studies are needed to confirm these findings.

Recurrent pelvic organ prolapse after hysterectomy; a 10-year national follow-up study

PURPOSE

Hysterectomy may be a risk factor for pelvic organ prolapse (POP). We assessed the risk of recurrent POP (operations and visits) after hysterectomy among women with previous POP. We also studied patient and operation related risk factors for POP recurrence.

METHODS

This retrospective cohort study included 1697 women having previous POP diagnosis or POP at the time of hysterectomy (FINHYST 2006 cohort). Follow-up was until the end of 2016. The data was derived from the Finnish National Care register linked to the cohort. Hysterectomy approaches and other demographics were compared to the risk of a prolapse diagnosis and/or surgery. Cox regression model was used to identify hazard ratios.

RESULTS

Following hysterectomy, a total of 280 women (16.5%) had a POP reoperation and 359 (21.2%) had an outpatient visit due to POP. Vaginal vault prolapse repair was the most common POP reoperation (n = 181, 10.7%), followed by anterior wall repair (n = 120, 7.1%). Median time to POP reoperation was 3.7 years. Hysterectomy approach did not affect reoperations or visits. Previous cesarean section and anterior repair during hysterectomy were associated with decreased risk, whereas concomitant sacrospinous fixation and uterus prolapse as the main indication led to increased risk of anterior/vault prolapse reoperations. Concomitant posterior repair decreased posterior reoperations and visits, but uterus weight over 500 g caused a fivefold increased risk of posterior prolapse visit. Residential status was associated with elevated risk of any POP reoperations and visits.

CONCLUSIONS

Approximately one out of five women suffering from POP ensue POP reoperation or visit after hysterectomy. These high rates are independent on hysterectomy approach, but probably indicate that hysterectomy may worsen previous pelvic floor dysfunction.

Surgical outcomes of sacrospinous hysteropexy and hysteropreservation for pelvic organ prolapse: a systematic review of randomized controlled trials

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].

Old meets new: vNOTES retroperitoneal promontory fixation in conjunction with the uterus preserving Manchester procedure✰,✰✰

INTRODUCTION AND HYPOTHESIS

The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.

Long-term outcomes and quality of life after Manchester procedure for pelvic reconstructive surgery in women with cervical elongation

OBJECTIVE

Native-tissue techniques for Pelvic Organ Prolapse (POP) repairs, such as the Manchester Procedure (MP), have recently been revitalized. However, there are conflicting opinions regarding correcting cervical elongation support by the MP, and the risk of possible poor outcomes and postoperative complications. Therefore, this study aimed to investigate anatomical and patient-reported outcomes during one year after MP.

DESIGN

Prospective cohort study.

SETTING

This study was conducted on women who underwent the MP for cervical elongation between 2010 and 2020.

PATIENTS

Women with apical compartment prolapse up to stage 3 due to cervical elongation.

INTERVENTIONS

Manchester Procedure.

MEASUREMENTS

Pre and postoperative evaluations by POP Quantification (POP-Q) system were performed, and patients filled out the quality-of-life questionnaires including Pelvic Floor Distress Inventory Short Form 20 (PFDI-20), and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12) before and 12 months after the procedure. Anatomical outcomes were measured by POP-Q and the changes in POP-related symptoms were evaluated and reported.

MAIN RESULTS

33 participants were recruited in the study. Significant anatomical improvements were obtained in all compartments after the surgery. After 12 months in POP-Q examination, the mean (±SD) of Ba was changed from +1.82 (±1.71) to -1.18 (±1.50), C was changed from -1.25 (±2.81) to -6 (±1.82), and D from -6.30 (±1.42) to -7.1 (±1.25) respectively (P < 0.001). POP-Q stage 0-1 was obtained inof7% in the apical compartment (C <  -1), but only in 45.4% in the anterior compartment (Ba <  -1). A significant reduction in symptom scores was obtained for PFDI-20 (P < 0.01) and PISQ-12 (P = 0.011).

CONCLUSIONS

Our findings suggest that the MP provides adequate apical support with improvement in anatomic and subjective findings for patients with cervical elongation.

Cervical cancer after the Manchester procedure: a nationwide cohort study

INTRODUCTION AND HYPOTHESIS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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