Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial

A Retrospective Cohort Study of vNOTES Extraperitoneal Versus Laparoscopic Sacral Hysteropexy With Uterine Preserving Regarding Surgical Outcomes and 2 Year Follow-up Results

STUDY OBJECTIVE

To explore the effectiveness of transvaginal natural orifice transluminal endoscopic surgery extraperitoneal sacral hysteropexy (vNOTES-ESH) in women with symptomatic uterine prolapse over a 2 year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Gynecological minimally invasive center.

PATIENTS

Women undergoing sacral hysteropexy either by vNOTES (n = 25) or laparoscopic (n = 74) between November 2016 and December 2020.

INTERVENTIONS

Both vNOTES-ESH and laparoscopic sacral hysteropexy (LAP-SH) were used for uterine prolapse. Demographic data, operative characteristics, perioperative outcomes, and follow-up information 2 years postsurgery in the 2 groups were retrospectively evaluated.

RESULTS

Both procedures showed similar operation time, estimated blood loss, hospital stays, and pain scores (p >0.05). During a median follow-up of 59 (24-72) months, the surgical success rate was 96% for vNOTES-ESH and 97.3% for LAP-SH (p >0.05), with no differences in anatomical position or pelvic organ function after the operation. Women in the LAP-SH group experienced more bothersome symptoms of constipation compared to those in the vNOTES-ESH group (5.41% vs 0, p <0.05). Lastly, 1 case in the vNOTES-ESH group had a mesh exposed area of less than 1 cm2, and 1 patient in the LAP-SH group experienced stress incontinence.

CONCLUSIONS

In this retrospective study, vNOTES-ESH met our patients' preference for uterine preservation and was a successful and effective treatment for uterine prolapse, providing good functional improvement in our follow-up. This procedure should be considered as an option for patients with pelvic organ prolapse.

Vaginal hysteropexy compared with vaginal hysterectomy with apical suspension for the treatment of pelvic organ prolapse: A 5-year cost-effectiveness Markov model

OBJECTIVE

Our objective was to perform a 5-year cost-effectiveness analysis of transvaginal hysteropexy (HP) via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) versus vaginal hysterectomy (VH) with apical suspension via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) for the treatment of uterine prolapse.

DESIGN

A decision analytic model assessed the cost-effectiveness of the surgical intervention over a 5-year horizon.

SETTING

This model was constructed using TreeAge® software.

POPULATION OR SAMPLE

Healthy women undergoing surgery for uterine prolapse were modeled.

METHODS

A Markov model was constructed to simulate the possible recurrence of prolapse. Recurrence rates, repeat surgery for surgical failures and complication rates were modeled. Base case, sensitivity analyses and probabilistic modeling were performed.

MAIN OUTCOME MEASURES

The primary outcome was the incremental cost-effectiveness ratio (ICER) of <$100 000 per quality-adjusted life year (QALY).

RESULTS

Using the available prolapse recurrence rates and repeat surgery rates in the literature, both HP-SS and HP-US are cost-effective at a willingness-to-pay (WTP) threshold of <$100 000 per QALY. The incremental cost-effectiveness ratio (ICER) for HP-US compared to HP-SS is $90 738.14, while VH-US and VH-SS are both dominated strategies. HP-US is the optimal cost-effective strategy but decays exponentially with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. The cost-effectiveness acceptability curve (CEAC) favors sacrospinous hysteropexy until reaching a WTP threshold between $90 000 and $100 000.

CONCLUSION

Hysteropexy surgical strategies are cost-effective transvaginal surgical approaches for uterine prolapse. Vaginal hysterectomy with apical suspension becomes more cost-effective with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. Given the variability of prolapse recurrence rates in the literature, more comparative studies are needed to understand the cost-effectiveness relationship between these different 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.

Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis

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.

Effect of different surgical techniques on postoperative wound infection in patients with uterine prolapse: A meta-analysis

The assumption is that a number of controlled trials have been conducted to assess the impact of uterus retaining or hysterectomy on wound and haemorrhage, but there is no indication as to which method would be more beneficial for wound healing. This research is intended to provide a comprehensive overview of the availability of wound healing in case studies of both operative methods. From inception to October 2023, four databases were reviewed. The odds ratio (OR) and the mean difference (MD) for both groups were computed with a random effect model, as well as the corresponding 95% confidence intervals. A total of five studies were carried out in the overall design and enrolled 16 972 patients. No statistical significance was found in the rate of postoperative wound infection among the two treatments (OR,1.46; 95% CI,0.66,3.22 p = 0.35); The rates of bleeding after surgery did not differ significantly from one procedure to another (OR,1.41; 95% CI,0.91,2.17 p = 0.12); two studies demonstrated no statistical significance for the rate of incisional hernia after surgery (OR,2.58; 95% CI,0.37,18.05 p = 0.34). Our findings indicate that there is a similar risk between uterine preservation and hysterectomies for the incidence of wound infection, haemorrhage and protrusion of incision.

Surgical management practice of pelvic organ prolapse among Ethiopian gynecologists, 2021: a descriptive study

INTRODUCTION

Pelvic Organ Prolapse is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus, or the apex of the vagina. Surgical intervention addresses both anatomical defect and associated symptoms. The landscape of prolapse surgery has been evolving constantly over years. Emerging evidences either support or challenge existing surgical treatment options, making urogynecology a dynamic field. In Ethiopia, the surgical management of pelvic organ prolapse has transitioned from abdominal to vaginal hysterectomy, supplemented later by McCall's culdoplasty. Disparities exist in the national uniformity of surgical approaches, linked to the establishment of Urogynecology centers in certain institutions.

OBJECTIVES

This study was done to assess the surgical management practice of Ethiopian gynecologists on pelvic organ prolapse.

METHODS

A cross-sectional study encompassing all Gynecologists in Ethiopia took place between January to June 2021. Information was gathered through online Google forms crafted in English. Subsequently, the collected data underwent verification, coding, and entry into Epi info 7 before being exported to SPSS version 22 software for descriptive statistical analysis.

RESULTS

We reached 280 gynecologists out of the 450 practicing in the Ethiopia making 62% response rate. Anterior colporrhaphy (98.6%), vaginal hysterectomy with McCall's cul-do-plasty (51.8%), and Posterior colporrhaphy (97.5%) were the most commonly performed surgical procedures for anterior vaginal wall prolapse, apical prolapse (uterine/cervical), and posterior vaginal wall prolapse respectively. Only 3.2% and 0.7% of the gynecologists conducted abdominal and vaginal paravaginal repair for anterior vaginal wall prolapse. Sacrospinous ligament fixation and sacrocolpopexy for apical prolapse were carried out by 32.9% and 9.3% of the gynecologists respectively. Site-specific posterior repair for posterior vaginal wall prolapse was performed only by 23.9% of the gynecologists. The main reasons mentioned not to perform paravaginal repair, sacrocolpopexy, sacrospinous ligament fixation, and site-specific posterior repair were lack of skill and lack of appropriate materials.

CONCLUSION AND RECOMMENDATION

Most gynecologists in Ethiopian continue to perform vaginal hysterectomy and colporrhaphy procedures for treatment of pelvic organ prolapse due primarily to lack of skill and appropriate materials to perform the alternative procedures. Implementing short term training on alternative surgical treatment options of pelvic organ prolapse with provision of suitable materials and increasing the number of urogynecologists in the country in the long run holds the potential to enhance the standard of care of women with the condition.

Gynecologists' perspectives on surgical treatment for apical prolapse: a qualitative study

INTRODUCTION AND HYPOTHESIS

Vaginal sacrospinous fixation (VSF) without mesh and sacrocolpopexy (SCP) with mesh are the most frequently performed surgical procedures for apical prolapse in the Netherlands. There is no long-term evidence suggesting the optimal technique, however. The aim was to identify which factors play a role in the choice between these surgical treatment options.

METHODS

A qualitative study using semi-structured interviews amongst Dutch gynecologists was carried out. An inductive content analysis was performed with Atlas.ti.

RESULTS

Ten interviews were analyzed. All gynecologists performed vaginal surgeries for apical prolapse, six gynecologists perform SCP themselves. Six gynecologists would perform VSF for a primary vaginal vault prolapse (VVP); three gynecologists preferred a SCP. All participants prefer a SCP for recurrent VVP. All participants have stated that multiple comorbidities could be a reason for choosing VSF, as this procedure is considered less invasive. Most participants choose a VSF in the case of older age (6 out of 10) or higher body mass index (7 out of 10). All treat primary uterine prolapse with vaginal, uterine-preserving surgery.

CONCLUSIONS

Recurrent apical prolapse is the most important factor in advising patients which treatment they should undergo for VVP or uterine descent. Also, the patient's health status and the patient's own preference are important factors. Gynecologists who do not perform the SCP in their own clinic are more likely to perform a VSF and find more reasons not to advise a SCP. All participants prefer a vaginal surgery for a primary uterine prolapse.

A new technique for uterine-preserving pelvic organ prolapse surgery: Laparoscopic rectus abdominis hysteropexy for uterine prolapse by comparing with traditional techniques

Contemporary understanding of the dynamic anatomy of pelvic floor support has led us to new conservative surgery for uterine prolapse (UP). In this study, we comprehensively evaluate the safety and feasibility of a new technique for uterine-preserving pelvic organ prolapse surgery: laparoscopic rectus abdominis hysteropexy for uterine prolapse (LRAHUP). A retrospective study was conducted between 2006 and 2016. Sixty-five women diagnosed with advanced prolapsed uterus were eligible and grouped into traditional vaginal surgery (TVS, n = 30) group and new laparoscopic surgery (NLS, n = 35) group. Evaluated items of 65 cases included surgery-related parameters and postoperative outcomes. Surgical safety evaluating indicators, including operation time, blood loss, postoperative hospitalized day, and operation complications, also showed great significant difference between two groups (P < 0.05). The subjective index of post-operative Pelvic Floor Distress Inventory-short form 20 scores and some objective anatomic outcomes all showed great difference between pre- and post-operation (P < 0.05). Although the TVL showed no difference between pre- and post-operation in the same group, the TVL displayed a remarkable elongation. And a remarkable tendency was a higher cumulative recurrence ratio in the TVS group and a shorter follow-up period in the NLS group. LRAHUP may be a good procedure to manage women with advanced prolapsed uterus.

Effectiveness of Laparoscopic Pectopexy for Pelvic Organ Prolapse Compared with Laparoscopic Sacrocolpopexy

STUDY OBJECTIVE

To evaluate the clinical benefits of laparoscopic pectopexy vs laparoscopic sacrocolpopexy in women with pelvic organ prolapse (POP).

DESIGN

Prospective cohort study.

SETTING

A tertiary hospital.

PATIENTS

We included 203 patients with POP.

INTERVENTIONS

Laparoscopic pectopexy or laparoscopic sacrocolpopexy.

MEASUREMENTS AND MAIN RESULTS

Anatomic effectiveness was measured using the POP Quantification system, both before and after operation. Functional recovery effectiveness was evaluated using complications and recurrence rates within 1 year. Quality of life was assessed by the Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life questionnaires at enrollment and postoperative months 3, 6, and 12. Comparisons between groups were performed using t test, chi-square test, and mixed-effects model with repeated measures. The analysis included 203 eligible patients (sacrocolpopexy, 101; pectopexy, 102). The proportion of robotic-assisted surgeries was lower in the pectopexy group than in the sacrocolpopexy group (15.7% vs 41.6%, p <.001). The average operation time of pectopexy was shorter than that of sacrocolpopexy (174.2 vs 187.7 minutes) with a mean difference of 13.5 minutes (95% confidence interval, 3.9-23.0; p = .006). Differences of intraoperative blood loss, length of hospital stay, and postoperative 7-day complications between groups were not significant. Anatomic successes were obtained in both groups with similar improvement in POP Quantification scores. The rate of urinary symptoms recurrence was higher in the pectopexy group (13.7%) than in the sacrocolpopexy group (5.0%) at the 1-year follow-up (odds ratio, 3.1; 95% confidence interval, 1.1-8.8, p = .032). The Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life scores were better improved at postoperative months 3, 6, and 12 for laparoscopic pectopexy than for sacrocolpopexy.

CONCLUSION

Laparoscopic pectopexy revealed comparable anatomic success, shorter operation time, and better improvement in quality of life scores of prolapse, colorectal-anal, and urinary symptoms at 1-year follow-up, possibly being an alternative when sacrocolpopexy is not practicable. However, clinicians should pay more attention to the recurrence of urinary symptoms after pectopexy.

Manchester Procedure vs Sacrospinous Hysteropexy for Treatment of Uterine Descent: A Randomized Clinical Trial

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.

Surgery for women with apical vaginal prolapse

BACKGROUND

Apical vaginal prolapse is the descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available, but there are no guidelines to recommend which is the best.

OBJECTIVES

To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings and ClinicalTrials.gov (searched 14 March 2022).

SELECTION CRITERIA

We included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site).

MAIN RESULTS

We included 59 RCTs (6705 women) comparing surgical procedures for apical vaginal prolapse. Evidence certainty ranged from very low to moderate. Limitations included imprecision, poor methodology, and inconsistency. Vaginal procedures compared to sacral colpopexy for vault prolapse (seven RCTs, n=613; six months to f four-year review) Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.27 to 4.21, 4 RCTs, n = 346, I2 = 0%, moderate-certainty evidence). If 8% of women are aware of prolapse after sacral colpopexy, 18% (10% to 32%) are likely to be aware after vaginal procedures. Surgery for recurrent prolapse was more common after vaginal procedures (RR 2.33, 95% CI 1.34 to 4.04; 6 RCTs, n = 497, I2 = 0%, moderate-certainty evidence). The confidence interval suggests that if 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 25%) are likely to require it after vaginal procedures. Prolapse on examination is probably more common after vaginal procedures (RR 1.87, 95% CI 1.32 to 2.65; 5 RCTs, n = 422; I2 = 24%, moderate-certainty evidence). If 18% of women have recurrent prolapse after sacral colpopexy, between 23% and 47% are likely to do so after vaginal procedures. Other outcomes: Stress urinary incontinence (SUI) was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-certainty evidence). The effect of vaginal procedures on dyspareunia was uncertain (RR 3.44, 95% CI 0.61 to 19.53; 3 RCTs, n = 106, I2 = 65%, low-certainty evidence). Vaginal hysterectomy compared to sacral hysteropexy/cervicopexy (six RCTS, 554 women, one to seven year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.01 95% CI 0.10 to 9.98; 2 RCTs, n = 200, very low-certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 0.85, 95% CI 0.47 to 1.54; 5 RCTs, n = 403; I2 = 9%, low-certainty evidence). Prolapse on examination- there was little or no difference between the groups for this outcome (RR 0.78, 95% CI 0.54 to 1.11; 2 RCTs n = 230; I2 = 9%, moderate-certainty evidence). Vaginal hysteropexy compared to sacral hysteropexy/cervicopexy (two RCTs, n = 388, 1-four-year review) Awareness of prolapse - No difference between the groups for this outcome (RR 0.55 95% CI 0.21 to 1.44; 1 RCT n = 257, low-certainty evidence). Surgery for recurrent prolapse - No difference between the groups for this outcome (RR 1.34, 95% CI 0.52 to 3.44; 2 RCTs, n = 345; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 0.99, 95% CI 0.83 to 1.19; 2 RCTs n =367; I2 =9%, moderate-certainty evidence). Vaginal hysterectomy compared to vaginal hysteropexy (four RCTs, n = 620, 6 months to five-year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.0 95% CI 0.44 to 2.24; 2 RCTs, n = 365, I2 = 0% moderate-quality certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 1.32, 95% CI 0.67 to 2.60; 3 RCTs, n = 443; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 1.44, 95% CI 0.79 to 2.61; 2 RCTs n =361; I2 =74%, low-certainty evidence). Other outcomes: Total vaginal length (TVL) was shorter after vaginal hysterectomy (mean difference (MD) 0.89cm 95% CI 0.49 to 1.28cm shorter; 3 RCTs, n=413, low-certainty evidence). There is probably little or no difference between the groups in terms of operating time, dyspareunia and stress urinary incontinence. Other analyses There were no differences identified for any of our primary review outcomes between different types of vaginal native tissue repair (4 RCTs), comparisons of graft materials for vaginal support (3 RCTs), pectopexy versus other apical suspensions (5 RCTs), continuous versus interrupted sutures at sacral colpopexy (2 RCTs), absorbable versus permanent sutures at apical suspensions (5 RCTs) or different routes of sacral colpopexy. Laparoscopic sacral colpopexy is associated with shorter admission time than open approach (3 RCTs) and quicker operating time than robotic approach (3 RCTs). Transvaginal mesh does not confer any advantage over native tissue repair, however is associated with a 17.5% rate of mesh exposure (7 RCTs).

AUTHORS' CONCLUSIONS

Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative SUI than a variety of vaginal interventions. The limited evidence does not support the use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. There were no differences in primary outcomes for different routes of sacral colpopexy. However, the laparoscopic approach is associated with a shorter operating time than robotic approach, and shorter admission than open approach. There were no significant differences between vaginal hysteropexy and vaginal hysterectomy for uterine prolapse nor between vaginal hysteropexy and abdominal hysteropexy/cervicopexy. There were no differences detected between absorbable and non absorbable sutures however, the certainty of evidence for mesh exposure and dyspareunia was low.

A novel anchoring system for pelvic organ prolapse repair: an observational study

INTRODUCTION AND HYPOTHESIS

Sacrospinous ligament (SSL) fixation is an effective and widely used vaginal procedure for correcting apical prolapse. The Saffron Fixation System (Coloplast Corp., Minneapolis, MN, USA) is a new anchoring device aimed at facilitating a durable, easy, and short procedure for SSL fixation with the goal of minimizing operative complications. The objective was to demonstrate the efficacy and safety of anchor deployment and suture fixation for pelvic organ prolapse repair using the Saffron Fixation System.

METHODS

An observational human cadaver study was conducted to measure the distance between anchor location and anatomical landmarks in the pelvis, and the holding force of the fixated anchors. Anchors were placed in four human cadavers by different implanters. The pull-out force of these anchors was measured to assess efficacy (three cadavers by three implanters) and the distance between anchors and primal vessels and nerves was measured to assess safety (one cadaver by one implanter).

RESULTS

Nineteen out of 20 anchors (95%) were correctly placed as judged by independent assessment performed by non-implanting surgeons. Distance between anchors and surrounding nerves and vessels exceeded 10 mm. Mean (SD) pull out-force was 17.9 (5.6) N.

CONCLUSION

The innovative anchoring device that was developed appeared to enable precise and solid anchor placement in the SSL. Future clinical studies are needed to explore if the theoretical advantages of this device translate to improved clinical outcomes in comparison with available suturing and anchoring devices.

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

INTRODUCTION AND HYPOTHESIS

This systematic review (PROSPERO:CRD42022275789) is aimed at comparing qualitatively the success, recurrence, and complication rates of sacrocolpopexy with concomitant hysterectomy, hysteropexy, sacrospinous fixation (SSF) with and without vaginal hysterectomy (VH) and uterosacral fixation (USF) with and without VH.

METHODS

A systematic search was performed using Embase, PubMed, Scopus, and Cochrane databases for studies published from 2011, on women with apical pelvic organ prolapse requiring surgical interventions. Risk of bias was assessed via the National Institutes of Health study quality assessment tool. The primary outcomes are the success and recurrence rate of each technique, for ≥12 months' follow-up. Findings were summarised qualitatively.

RESULTS

A total of 21 studies were included. Overall significant findings for a high success and low recurrence rate are summarised as: minimally invasive sacrocolpopexy (MISC) is superior to abdominal sacrocolpopexy (ASC); sacrospinous hysteropexy (SSHP) is superior to USF + VH, which is superior to uterosacral hysteropexy and mesh hysteropexy (MHP). Significant findings related to complications include: MISC recorded a lower overall complication rate than ASC except in mesh exposure; USF + VH tends to perform better than SSHP and SSF, with SSHP performing better than MHP in faecal incontinence and overactive bladder rates.

CONCLUSION

There is no evidence to conclude that hysterectomy is superior to uterine-sparing approaches. MISC should be considered over ASC given similar efficacy and reduced complications. Superiority of MHP is unproven against native tissue hysteropexy. Further studies under standardised settings are required for direct comparisons between the surgical management methods.

Bilateral medial sacrospinous ligament suture for apical suspension through natural spaces: A single-center study with low perioperative complications

Sacrospinous ligament fixation (SSLF) is one of the most used native tissue approaches for apical suspension with a high rate of perioperative complications. This study aimed to review cases undergoing a modified SSLF and assess its perioperative adverse events. It was a retrospective study of 168 consecutive patients undergoing modified transvaginal SSLF at a single tertiary center from 2017 to 2021. The sutures were placed on the sacrospinous ligament (SSL) approaching the sacrum through natural spaces under direct vision. Moreover, it was performed bilaterally. Patient demographics and perioperative complications were reviewed. The median age was 65 years, and 85.7% (144/168) had stage III-IV prolapse. Among the 168 patients undergoing this modified SSLF, 161 were for uterovaginal prolapse, and seven were for posthysterectomy vaginal vault prolapse. 83.9% (135/161) patients were concomitant with hysterectomy, and 70.2% (118/168) were with anteroposterior colporrhaphy. The median operation time was 82 min (interquartile range [IQR], 61-100 min), and the median intraoperative blood loss was 50 ml (IQR, 30-50 ml). Two cases had pelvic hematoma, and both were cured after expectant treatment. No patient required a homologous blood transfusion, and none complained about buttock or lower limb pain 2 weeks postoperatively. Nor did injury of the ureters, bladder, or rectum occur intraoperatively. This modified transvaginal SSLF procedure was safe and had no severe perioperative complications.

Hysteropexy and Anterior Vaginal Native Tissue Repair in Women with Anterior and Central Compartment Prolapse: A Long Term Follow-Up

Although it is known that hysterectomy (HY) alone cannot resolve apical prolapse, vaginal hysterectomy (VH) remains the most common surgical procedure for this issue. In recent years, various procedures for uterine conservation have been proposed to avoid the surgical risks of HY. Furthermore, most women with symptomatic pelvic organ prolapse (POP) prefer uterine conservation in the absence of considerable benefit in uterine removal. In 2017, we proposed a new technique for hysteropexy and anterior vaginal native tissue repair (NTR) in women with cystocele and apical prolapse. The objective of this study is to assess the efficacy and safety of this new procedure after at least 5 years of follow-up. We included only patients with stage II or greater prolapse of the anterior vaginal wall and a concomitant stage II uterine prolapse in accordance with Pelvic Organ Prolapse Quantification (POP-Q) system. A Patient Global Impression of Improvement (PGI-I) score ≤ 2 in addition with the absence of POP symptoms was defined as subjective success. A descensus with a maximum point of less than −1 in any compartment was considered objective cure. A total of 102 patients who fulfilled the inclusion criteria were enrolled. At 60 months follow-up, 90 out of 102 patients (88%) were subjectively cured, whereas 88 out of the 102 (86%) patients were objectively cured. Subjective and objective cure rates persisted during the entire study period. Uni- and multivariate analysis of possible predictive factors associated with recurrence of prolapse showed that only a preoperative point C > 0 cm and BMI ≥ 25 kg/m2 were risk factors for failure. In conclusion, our study showed that hysteropexy with anterior vaginal native tissue repair may be an effective and safe option for the treatment of anterior vaginal prolapse and concomitant stage II uterine prolapse by at least 5 years of follow-up.

Sacrospinous Hysteropexy Versus Prolapse Hysterectomy with Apical Fixation: A Retrospective Comparison over an 18 Year Period

Background. Pelvic organ prolapse (POP) is a common health problem, with a high lifetime risk for prolapse surgery. Uterine-preserving procedures such as vaginal sacrospinous hysteropexy (SSH) have become an increasingly utilized surgical option for the primary treatment of POP. We wanted to evaluate peri- and postoperative outcome parameters of SSH as an alternative to vaginal hysterectomy with apical fixation. Methods. A retrospective cohort study was conducted (2003–2021). All patients who underwent primary SSH (study group) for symptomatic POP were matched 1:1 by age and BMI with patients who underwent primary prolapse hysterectomy with apical fixation (control group). Results. A total of 192 patients were included with 96 patients in the each of the SSH and hysterectomy groups. There were no statistically significant differences in baseline characteristics. The SSH group show a significantly shorter mean surgery time (p < 0.001), significantly fewer hospitalization days (p < 0.001), and significantly less intraoperative blood loss (p = 0.033) in comparison to the control group. Neither group had any intraoperative complication, or an intraoperative conversion to other surgical management options. No statistically significant difference was found in postoperative complications as categorized by the Clavien–Dindo classification or in postoperative urogynecological issues (UTI, de-novo, incontinence, residual urine, voiding disorders). Through log regression, none of the confounding factors such as age, BMI, or preoperative POP-Q stage could be identified as independent risk factors for the occurrence of postoperative complications. Conclusions. Our results confirm that a uterus-preserving technique has many benefits and, thus, should be considered as an additional intermediate step in a long-term treatment plan of pelvic organ prolapse.

Urinary Incontinence and Pelvic Organ Prolapse in Women

BACKGROUND

Pelvic floor disorders are common, especially in pregnancy and after delivery, in the postmenopausal period, and old age, and they can significantly impact on the patient's quality of life.

METHODS

This narrative review is based on publications retrieved by a selective search of the literature, with special consideration to original articles and AWMF guidelines.

RESULTS

Pelvic floor physiotherapy (evidence level [EL] 1), the use of pessaries (EL2), and local estrogen therapy can help alleviate stress/urge urinary incontinence and other symptoms of urogenital prolapse. Physiotherapy can reduce urinary incontinence by 62% during pregnancy and by 29% 3-6 months post partum. Anticholinergic and β-sympathomimetic drugs are indicated for the treatment of an overactive bladder with or without urinary urge incontinence (EL1). For patients with stress urinary incontinence, selective serotonin-noradrenaline reuptake inhibitors can be prescribed (EL1). The tension-free tape is the current standard of surgical treatment (EL1); in an observational follow-up study, 87.2% of patients were satisfied with the outcome 17 years after surgery. Fascial reconstruction techniques are indicated for the treatment of primary pelvic organ prolapse, and mesh-based surgical procedures for recurrences and severe prolapse (EL1).

CONCLUSION

Urogynecological symptoms should be specifically asked about by physicians of all relevant specialties; if present, they should be treated conservatively at first. Structured surgical techniques with and without mesh are available for the treatment of urinary incontinence and pelvic organ prolapse. Preventive measures against pelvic floor dysfunction should be offered during pregnancy and post partum.

Laparoscopic sacrohysteropexy versus vaginal sacrospinous hysteropexy as treatment for uterine descent: comparison of long-term outcomes

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a frequent occurring health issue, especially concerning elderly women. The objective of this study is to examine the long-term outcomes of laparoscopic sacrohysteropexy (LSH) and vaginal sacrospinous hysteropexy (SSHP) for treatment of uterine prolapse.

METHODS

A retrospective study of patients who underwent a LSH or SSHP. Validated questionnaires and an outpatient examination visit were used to investigate the effects of both surgical treatments. The primary outcome was the composite outcome of success for the apical compartment, defined as no recurrence of uterine prolapse (POP-Q measurement C ≤ 0), no subjective recurrence of POP, and/or not requiring therapy for recurrent prolapse. Secondary outcomes were peri- and postoperative data, anatomical failure, prolapse beyond hymen, subjective outcomes, and disease-specific quality of life.

RESULTS

We included 105 patients, 53 in the LSH group and 52 in the SSHP group. The overall response rate of the questionnaires was 83% (n = 87) after a mean follow-up time of 4.5 years (54.2 months; 95% CI 44.8-64.2 months) in the LSH group and 2.5 years (30.1 months; 95% CI 29.3-31.5 months) in the SSHP group. There were no clinically relevant differences between the study groups in composite outcome of success (p = 0.073), anatomical failure of the apical compartment (p = 0.711), vaginal bulge symptoms for which patients consulted professionals (p = 0.126), and patient satisfaction (p = 0.741). The operative time was longer in the LSH group (117 min; interquartile range (IQR) 110-123) compared to the SSHP group (67 minutes; IQR 60-73) (p < 0.001). The duration of hospital stay was also longer in the LSH group (4 days) than in the SSHP group (3 days) (p = 0.006).

CONCLUSIONS

LSH and SSHP seem to be equally effective after long-term follow-up in treating uterine prolapse in terms of objective and subjective recurrence.

Reoperation for prolapse recurrence after sacrospinous mesh hysteropexy: characteristics of women choosing retreatment

INTRODUCTION AND HYPOTHESIS

Factors that contribute to reoperation and surgical approaches for the management of recurrent uterovaginal prolapse after vaginal mesh hysteropexy (mesh hysteropexy) are unknown. We aimed to describe surgical management of pelvic organ prolapse recurrence after vaginal mesh hysteropexy, and patient characteristics in those who chose reoperation.

METHODS

This is a descriptive analysis of women who experienced treatment failure within 5 years of mesh hysteropexy in a multi-site randomized trial. The composite definition of treatment failure included retreatment (pessary or reoperation), prolapse beyond the hymen, or bothersome prolapse symptoms. Characteristics of those pursuing and not pursuing repeat prolapse surgery, measures of prolapse, and symptom severity are described.

RESULTS

Over 5-year follow up, 31/91 (34%) of the hysteropexy group met treatment failure criteria. All seven women who pursued reoperation reported bothersome prolapse symptoms; six were anatomic failures. Most seeking reoperation were early treatment failures; six (86%) by the 12-month visit and all by the 18-month visit. Compared to those electing expectant management, those pursuing reoperation had more apical prolapse, POP-Q point C median (IQR) -5.5 (-6.0, -4.0) cm versus +1.0 (-1.0, 3.0) cm respectively. Hysterectomy was performed in 6/7 reoperations (three vaginal, three endoscopic), with apical suspension in 5/6 hysterectomies. One participant with posterior compartment prolapse underwent transvaginal enterocele plication, uterosacral ligament suspension with posterior colpoperineorrhaphy. At a mean surgical follow-up of 34.3 (15.8) months, all women remained without anatomic or symptomatic failure.

CONCLUSIONS

When recurrent prolapse after mesh hysteropexy occurred, most women did not choose reoperation. Those who pursued surgery experienced more significant apical prolapse and were universally symptomatic.

CLINICAL TRIAL IDENTIFICATION NUMBER

NCT01802281.

Clinical outcomes and complications of laparoscopic sacrocolpopexy with versus without concomitant hysterectomy for pelvic organ prolapse in Hong Kong Chinese patients after median follow-up of 7 years

INTRODUCTION AND HYPOTHESIS

This retrospective cohort study is aimed at comparing outcomes and complications of laparoscopic sacrocolpopexy (LSC) with or without concomitant hysterectomy in the Hong Kong Chinese population.

METHODS

Women with stage II or above uterine or apical vault prolapse who underwent LSC with or without concomitant hysterectomy in a regional referral unit from 2007 to 2019 were included. The primary objectives were to compare the anatomical outcomes by pelvic organ prolapse quantification system (POP-Q) and recurrence of apical vault prolapse (≥stage II). The secondary objective was to compare the functional outcomes and complications. Anatomical recurrence and incidence of mesh exposure were analyzed using the Kaplan-Meier method. Cox proportional hazard regression was performed to identify risk factors of anatomical recurrence.

RESULTS

Seventy-six women were included for analysis. The recurrence rate of apical vault prolapse was 3.9% after a median follow-up time of 83 months (20-190 months). A significant reduction of POP-Q scores of three compartments in both groups of women were demonstrated (p<0.001). There was no difference between the two groups in terms of functional outcomes and complications. 6.6% of women developed mesh exposure. The time to recurrence of apical vault prolapse was shorter in women who had LSC with prior hysterectomy (p =0.019). No risk factors were identified for recurrence of apical vault prolapse.

CONCLUSIONS

Laparoscopic sacrocolpopexy with concomitant hysterectomy is comparable with LSC alone. The recurrence and complication rates are low. We suggest that LSC with concomitant hysterectomy might be offered to women with pelvic organ prolapse, with women's preference taken into account.

The modified Manchester Fothergill procedure compared with vaginal hysterectomy with low uterosacral ligament suspension in patients with pelvic organ prolapse: long-term outcome

INTRODUCTION AND HYPOTHESIS

The objective of this study was to compare the long-term outcome between vaginal hysterectomy with low uterosacral ligament suspension (VH) and the modified Manchester Fothergill procedure (MF) as surgical treatment in patients with pelvic organ prolapse (POP). We hypothesize that MF is non-inferior to VH in the long term.

METHODS

In this single-center retrospective cohort study patients who underwent MF or VH for primary apical compartment prolapse between 2003 and 2009 were eligible for inclusion. The primary outcome was subjective recurrence of POP. Secondary outcomes included number and type of reinterventions, time to reintervention and the degree of complaints.

RESULTS

One hundred sixty of 398 patients (53 MF, 107 VH) returned the questionnaires (40%). The mean follow-up was 12.97 years for MF and 13.24 years for VH (p = 0.38). There were similar rates of subjective POP recurrence (51% in both groups). The reintervention rate in the MF group was higher but reached no statistical significance [19/53 (36%) versus 29/107 (27%), p = 0.26]. Kaplan-Meier curve showed no statistically significant difference in risk of reintervention after MF at the maximum follow-up of 16.5 years [HR 1.830 (95% CI 0.934-3.586), p = 0.08]. The mean time to reintervention was 3 years shorter in the MF group (p = 0.03).

CONCLUSIONS

The subjective recurrence after MF is similar to VH in treatment of POP at the long term. MF appears to be non-inferior to VH when comparing the risk of reintervention. However, the small sample size precludes a definitive conclusion of non-inferiority, and future studies are needed.

Review of Vaginal Approaches to Apical Prolapse Repair

PURPOSE OF REVIEW

To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery.

RECENT FINDINGS

Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.

Robotic sacrohysteropexy: an instructional video for uterovaginal prolapse repair in patients with desired uterine preservation

INTRODUCTION

Minimally invasive sacrohysteropexy is a feasible and safe option for the treatment of uterovaginal prolapse in patients with prior sacrorectopexy. This video demonstrates an approach to robotic sacrohysteropexy while also adapting for a patient's prior sacrorectopexy. Sacrohysteropexy has been shown to be a viable option in women undergoing pelvic reconstructive surgery for the repair of uterovaginal prolapse.

METHODS

This video demonstrates key steps in performing a robotic sacrohysteropexy without compromising the integrity of the patient's prior sacrorectopexy. First, incision and dissection of the anterior and posterior peritoneum overlying the cervical stroma is carried out. Tunnels are made through the avascular plane of the broad ligament lateral to the uterine vessels, so as not to compromise uterine blood supply. The anterior and posterior arms of the mesh are attached with interrupted sutures to the cervical stroma. The presacral space is entered and dissected such that the anterior longitudinal ligament is exposed. Care is taken not to disrupt the sutures from the prior sacrorectopexy as the sacral arm of the mesh is secured with two interrupted stitches.

CONCLUSION

At completion of the procedure the patient had a well-supported apical compartment.

Sacrospinous Fixation and Vaginal Uterosacral Suspension—Evaluation in Uterine Preservation Surgery

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.

Development and validation of the Value of Uterus instrument and visual analog scale to measure patients' valuation of their uterus

BACKGROUND

Currently, there are no clear frameworks or tools to objectively or subjectively evaluate patient attitudes toward uterine preservation and how they influence the decision to proceed with hysterectomy vs uterine preservation when undergoing prolapse surgery.

OBJECTIVE

This study aimed to develop a reliable and valid instrument to measure patients' valuation of their uterus.

STUDY DESIGN

The Value of Uterus instrument was developed on the basis of existing literature and created with structured patient-reported outcome measurement development methodology. An initial 14-question instrument was administered to 152 patients, and the instrument was revised on the basis of an analysis of internal consistency. The resulting Value of Uterus instrument has 6 items and includes a visual analog scale for the question "How important is it to you to keep your uterus when you have a gynecologic condition?" To validate the instrument, we recruited 51 patients aged >45 years with uterovaginal prolapse who presented to the urogynecology department and were scheduled to undergo vaginal surgery with or without hysterectomy. Internal reliability of the instrument was measured with Cronbach alpha. For known-groups validity, Value of Uterus summary scores were compared between women who underwent hysteropexy and those who underwent hysterectomy using the t test. Intraclass correlation coefficient was used to assess test-retest reliability with Value of Uterus administered to women twice. Lastly, a receiver-operating characteristic curve analysis was conducted to identify a cutoff Value of Uterus and visual analog scale score for predicting whether a woman would undergo hysteropexy (vs hysterectomy).

RESULTS

A total of 51 patients were recruited (26 patients in the hysterectomy and 25 in the hysteropexy group), with a mean age of 64±10 years; 87.8% of patients self-identified as White. There were no differences in demographics between the groups. Cronbach's alpha was 0.94, suggesting excellent internal consistency of the items in the Value of Uterus instrument. The Value of Uterus instrument was highly correlated with the visual analog scale question, with r=0.82 (95% confidence interval, 0.69-0.89; P<.001). Patients in the hysteropexy group had significantly higher Value of Uterus scores (indicating greater value placed on the uterus) than women who underwent hysterectomy (20.8 vs 12.2; P<.001). Receiver-operating characteristic curve analysis identified a Value of Uterus cutoff score ≥14, with good accuracy for predicting hysteropexy (area under the curve, 0.87; sensitivity, 92.0%; specificity, 68%).

CONCLUSION

Value of Uterus is a reliable and valid 6-item instrument that measures patients' valuation of the uterus and preferences for uterine preservation when undergoing surgery for pelvic organ prolapse. Value of Uterus and visual analog scale were shown to reliably predict whether a patient undergoes uterine-preserving prolapse surgery. The Value of Uterus instrument and visual analog scale tool can be useful tools to ensure that the patient's preferences are included in the medical decision-making. Value of Uterus may be useful for future research in other gynecologic conditions where uterine preservation is an option.

Bilateral Sacrospinous Hysteropexy Versus Bilateral Sacrospinous Ligament Fixation with Vaginal Hysterectomy for Apical Uterovaginal Prolapse

Purpose

The aim of this retrospective study was to compare the anatomical and functional outcomes between bilateral sacrospinous hysteropexy (BSHP) and bilateral sacrospinous ligament fixation with vaginal hysterectomy (BSLF/VH) in women with apical-predominant uterovaginal prolapse.

Methods

Clinical data from patients with symptomatic Pelvic Organ Prolapse-Quantification (POP-Q) stage 2 or higher uterovaginal prolapse who underwent either BSHP (48 patients) or BSLF/VH (69 patients) between January 2014 and December 2018 were reviewed retrospectively. The primary outcome was the subjective satisfaction rate evaluated by Patient Global Impression of Improvement, and the secondary outcomes included objective anatomical success rates, impact on disease-specific quality of life evaluated by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, Pelvic Floor Distress Inventory-Short Form 20, and Pelvic Floor Impact Questionnaire 7, and surgical complications.

Results

After a median follow-up of 35 months (range, 25–58 months), all patients in both groups demonstrated significant postoperative improvements in anatomical and functional outcomes (P<0.001). There were no significant differences in postoperative subjective and objective results, sexual satisfaction outcomes, or disease-specific quality of life between the BSHP and BSLF/VH groups, and similar incidence rates of intraoperative and postoperative complications were also recorded.

Conclusions

The uterus-sparing BSHP procedure yielded noninferior anatomical and functional outcomes compared to the BSLF/VH procedure and could be adopted as an alternative to conventional hysterectomy-based native-tissue repair modalities for symptomatic apical-predominant uterovaginal prolapse.

Patient’s preference for sacrospinous hysteropexy or modified Manchester operation: a discrete choice experiment

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.

A preliminary clinical report of transvaginal natural orifice transluminal endoscopic Sacrospinous Ligament Fixation in the treatment of moderate and severe pelvic organ prolapse

Objective

To study the efficacy and safety of transvaginal natural orifice transluminal endoscopic Sacrospinous Ligament Fixation in the treatment of moderate and severe pelvic organ prolapse.

Design

Patients were selected into this study on a voluntary basis to evaluate the short-term efficacy of this surgery by comparing the OP-Q scores before the operation, three months after the operation, and six months after the operation.

Setting and Patients

Evaluate the clinical efficacy and safety by a retrospective analysis of the clinical data of the 18 patients with POP-Q grade III–IV pelvic organ prolapse treated by the Department of Gynecology of Nanjing Medical University Affiliated Changzhou No.2 People's Hospital from April 2020 to November 2020, and their post-operation follow-ups.

Interventions

Patients with postoperative follow-ups found no obvious relapse without intervention measures.

Measurements and Main Results

The transvaginal natural orifice transluminal endoscopic Sacrospinous Ligament Fixation was performed successfully, and the anterior and posterior walls of vagina and/or trans-vaginal hysterectomy were repaired as appropriate. Except the total vaginal length (TVL), the P values of numerical analysis for all points before, three months after, and six months after the operation were all <0.05, being statistically significant.

Conclusion

This method is effective in the treatment of moderate and severe pelvic organ prolapse with few complications, but more cases and longer-term follow-up data are needed to determine the long-term effect of this procedure. For the selection of puncture sites, more anatomical data are needed to get more accurate result.

Role of Hysteropexy in the Management of Pelvic Organ Prolapse

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.

Recurrent surgery in uterine prolapse: A nationwide register study

INTRODUCTION

One in three women with pelvic organ prolapse (POP) undergoing surgery have a relapse. Currently, no optimal surgical treatment has been identified for correcting a uterine prolapse. This population-based register study aims to compare the relapse rate in patients with uterine prolapse undergoing hysterectomy with suspension or uterine-sparing surgical procedures.

MATERIAL AND METHODS

All women with uterine prolapse undergoing prolapse surgery in Sweden from January 1, 2015 to December 31, 2018, were identified from the Gynecological Operation Register (GynOp). The primary outcome was the number of recurrent POP surgeries up to December 31, 2020.

RESULTS

Sacrospinous hysteropexy (SSHP) without graft and sacrohysteropexy (SHP) were associated with a significantly higher rate of recurrent POP surgery (SSHP without graft: adjusted odds ratio [aOR] 2.6, 95% CI 2.0-3.5; SHP aOR 2.6, 95% CI 1.8-3.7) and patients describing a sense of globe (SSHP without graft, aOR 2.0, 95% CI 1.6-2.6; SHP, aOR 1.8, 95% CI 1.1-3.1) compared with cervical amputation with uterosacral ligament fixation (Manchester procedure). There was no difference in the reoperation rate or sense of a globe between SSHP with graft and Manchester procedure. Patients undergoing SSHP without graft had a higher frequency of 1-year postoperative complications compared with Manchester procedure (aOR 2.0, 95% CI 1.6-2.6) and SHP (aOR 2.4, 95% CI 1.4-3.9). Moreover, the frequency of 1-year postoperative complications was higher in SSHP with graft (aOR 1.6, 95% CI 1.1-2.2) than in Manchester procedure.

CONCLUSIONS

The Manchester procedure was associated with a low rate of recurrent POP surgery, symptomatic recurrence and low surgical morbidity compared with other surgical methods in women with uterine prolapse.

Sacrospinous ligament fixation vs uterosacral ligaments suspension for pelvic organ prolapse: a systematic review and meta-analysis

OBJECTIVE

To compare the effectiveness and safety of sacrospinous ligament fixation (SSLF) and uterosacral ligaments suspension (ULS) for surgical correction of pelvic organ prolapse (POP).

METHODS

Comparative studies were identified in PubMed, EMBASE, MEDLINE, Cochrane library, Medicine and clinicaltrials.gov databases. Randomized controlled trials, prospective and retrospective cohort studies were included. Primary outcomes were collected including anatomical success rate (Defined as anterior or posterior vaginal wall beyond the hymen), surgical success rate, recurrence and total complication rate, while secondary outcomes were specific complications rates. Data were analyzed using Revman (Version 5.4).

RESULTS

After searching databases and removing the duplicate studies, a total of 57 articles had entered the screening stage. Finally, nine moderate and high quality studies (4 randomized controlled trials and 5 retrospective studies) with 4516 participants were included. For primary outcomes, there was no statistical difference between the two groups regarding surgical success rate (RR=1.00; 95% CI: 0.91-1.01; I²= 0%; P=0.98), anatomical success (RR=0.90; 95% CI: 0.78-1.05; I²= 61%; P=0.19), recurrence rate (RR=1.26; 95% CI: 0.85-1.87; I²= 75%; P=0.24) and total complication rate (RR=1.07; 95% CI: 0.89-1.28; I²= 33%; P=0.47). Subgroup analysis regarding different follow-up times (1,2 and 5 years) and stages (Stage 2 and stage 3-4) found similar results in primary outcomes.

CONCLUSIONS

In conclusion, SSLF and ULS have the same efficacy and safety for patients. However, SSLF seems to have lower complication rates of vaginal granulation tissue and urethral injury and is gradually favored by surgeons because of its short operation time and simple operation. We still need more high-quality research, especially in terms of the incidence of complications.

Vaginal mesh hysteropexy: a review

PURPOSE OF REVIEW

Pelvic organ prolapse surgery is performed via native tissue or graft augmented repair. Graft augmentation with synthetic mesh was introduced to improve long-term surgical outcomes compared with vaginal native tissue repairs. Vaginal hysteropexy has recently become increasingly popular due to patient preference and an improved morbidity profile over hysterectomy, while maintaining comparable efficacy. As long-term outcomes remain unanswered, mesh augmentation to vaginal hysteropexy has sought to improve efficacy while minimizing complications.

RECENT FINDINGS

Recent studies have demonstrated superiority of vaginal mesh hysteropexy to vaginal hysterectomy with native tissue vault suspension. Short-term follow-up of vaginal mesh hysteropexy has also demonstrated lower blood loss and operative time with improved vaginal length compared with hysterectomy. Mesh exposure rates across studies were low and comparable to those of abdominally placed prolapse mesh.

SUMMARY

Vaginal mesh hysteropexy is a comparably well tolerated and effective surgical treatment option for women with uterovaginal prolapse. Although vaginal mesh kits are not commercially available, this procedure may be a viable treatment option in select patients.

Complications and objective outcomes of uterine preserving surgeries for the repair of pelvic organ prolapse versus procedures removing the Uterus, a systematic review

BACKGROUND

Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data.

METHODS

We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis.

RESULTS

Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD =  - 0.159 days, 95% CI [-0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD =  - 0.339, 95% CI [-0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD =  - 1.191 h, 95% CI [-1.836, -0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]).

CONCLUSION

We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.

Practice pattern variation: treatment of pelvic organ prolapse in The Netherlands

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.

Pelvic Organ Prolapse: Controversies in Surgical Treatment

This article discusses a few of the most prominent controversies currently confronting providers and patients when planning for surgical repair of pelvic organ prolapse including preoperative counseling and patient preparedness, preoperative urodynamics and concomitant anti-incontinence procedures, uterine preservation, total versus supracervical hysterectomy at the time of sacrocolpopexy, same-day discharge, and use of telemedicine for routine postoperative care. These current controversies reflect some of the larger questions and themes confronting the field at this time, and this discussion serves to highlight opportunities for further research and stimulate the constructive debate that moves the field forward.

Surgical Management of Symptomatic Apical Pelvic Organ Prolapse: A Systematic Review and Meta-analysis

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.

Long-term outcomes of primary cystocele repair by transvaginal mesh surgery versus laparoscopic mesh sacropexy: extended follow up of the PROSPERE multicentre randomised trial

OBJECTIVE

To compare the effectiveness and safety of laparoscopic sacropexy (LS) and transvaginal mesh (TVM) at 4 years.

DESIGN

Extended follow up of a randomised trial.

SETTING

Eleven centres.

POPULATION

Women with cystocele stage ≥2 (pelvic organ prolapse quantification [POP-Q], aged 45-75 years without previous prolapse surgery.

METHODS

Synthetic non-absorbable mesh placed in the vesicovaginal space and sutured to the promontory (LS) or maintained by arms through pelvic ligaments and/or muscles (TVM).

MAIN OUTCOME MEASURES

Functional outcomes (pelvic floor distress inventory [PFDI-20] as primary outcome); anatomical assessment (POP-Q), composite outcome of success; re-interventions for complications.

RESULTS

A total of 220 out of 262 randomised patients have been followed at 4 years. PFDI-20 significantly improved in both groups and was better (but below the minimal clinically important difference) after LS (mean difference -7.2 points; 95% CI -14.0 to -0.05; P = 0.029). The improvement in quality of life and the success rate (LS 70%, 61-81% versus TVM 71%, 62-81%; hazard ratio 0.92, 95% CI 0.55-1.54; P = 0.75) were similar. POP-Q measurements did not differ, except for point C (LS -57 mm versus TVM -48 mm, P = 0.0093). The grade III or higher complication rate was lower after LS (2%, 0-4.7%) than after TVM (8.7%, 3.4-13.7%; hazard ratio 4.6, 95% CI 1.007-21.0, P = 0.049)).

CONCLUSIONS

Both techniques provided improvement and similar success rates. LS had a better benefit-harm balance with fewer re-interventions due to complications. TVM remains an option when LS is not feasible.

TWEETABLE ABSTRACT

At 4 years, Laparoscopic Sacropexy (LS) had a better benefit-harm balance with fewer re-interventions due to complications than Trans-Vaginal Mesh (TVM).

Current Role of Hysterectomy in Pelvic Floor Surgery: Time for Reappraisal? A Review of Current Literature and Expert Discussion

Since hysterectomy could be performed with low risk, it has been part of the standard of surgical prolapse therapy for decades. This has not been scrutinized for a long time. In this review, we describe the development of this issue in recent years. The current literature suggests that hysterectomy requires its own indication. The article describes the various options for a uterine-preserving surgical technique and the available data.

Uterosacral Ligament Hysteropexy for Uterine Didelphys: A Case Report

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.

Timing of recurrence after surgery in pelvic organ prolapse

OBJECTIVES

The aim of this study was to determine when women are at risk for recurrent pelvic organ prolapse (POP).

METHODS

From 2010 to 2018, all women with symptomatic prolapse, Pelvic Organ Prolapse Quantification (pop-Q) stage 2 in at least one compartment and prolapse surgery were included. The primary outcome measure was POP recurrence. Kaplan-Meier estimates were calculated, survival curves were created, and differences in survival curves were tested with log-rank test. Cox proportional hazard regression was used to investigate associations between recurrence and the number and type of involved compartment(s) and type of surgery.

RESULTS

Forty-six (16.8%) out of 274 patients had POP recurrence during a mean follow-up time of 55 ± 32 months. The mean age was 64 ± 12 years. The hazard of recurrence increased the most in the first 2 years after POP surgery, flattened in years 3 and 4 and remained almost stable in the years thereafter, regardless of the site and number of involved compartment(s). The hazard of recurrence over time seemed the largest when all three compartments were involved. However, there was no statistically significant difference in recurrence between the numbers of (p = 0.65) or in the combination of involved compartments (p = 0.19). There was no difference in POP recurrence over time between prolapse repair with either sacrospinous ligament fixation or vaginal hysterectomy (p = 0.48).

CONCLUSIONS

Women are at the highest risk of POP recurrence in the first 2 years after POP surgery independent of the number or combination of involved compartment(s).

Directive clinique no 413 : Traitement chirurgical du prolapsus génital apical chez les femmes

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.

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women

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

Quo Vadis Urogynecology 2020 - Innovative Treatment Concepts for Urinary Incontinence and Pelvic Organ Prolapse

The current treatment for urinary incontinence and pelvic organ prolapse includes a wide range of innovative options for conservative and surgical therapies. Initial treatment for pelvic floor dysfunction consists of individualized topical estrogen therapy and professional training in passive and active pelvic floor exercises with biofeedback, vibration plates, and a number of vaginal devices. The method of choice for the surgical repair of stress urinary incontinence consists of placement of a suburethral sling. A number of different methods are available for the surgical treatment of pelvic organ prolapse using either a vaginal or an abdominal/endoscopic approach and autologous tissue or alloplastic materials for reconstruction. This makes it possible to achieve optimal reconstruction both in younger women, many of them affected by postpartum trauma, and in older women later in their lives. Treatment includes assessing the patient's state of health and anesthetic risk profile. It is important to determine a realistically achievable patient preference after explaining the individualized concept and presenting the alternative surgical options.

Short-term outcomes of sacrospinous hysteropexy through an anterior approach

INTRODUCTION AND HYPOTHESIS

The posterior approach to sacrospinous hysteropexy has been well studied but little is known about the anterior approach. This study assessed the efficacy and complications of an anterior approach to sacrospinous hysteropexy compared to hysterectomy with apical repair. We hypothesized that anterior sacrospinous hysteropexy has similar efficacy and fewer complications.

METHODS

This retrospective cohort study compared patients who underwent native-tissue anterior sacrospinous hysteropexy (cases) with those who underwent hysterectomy with apical repair (controls). Composite success was defined as (1) leading edge of prolapse not beyond the hymen and apex not descended > 1/3 total vaginal length; (2) no vaginal bulge symptoms; (3) no prolapse retreatment. Descriptive and bivariate statistics were performed as well as a Cox regression analysis for time to failure.

RESULTS

Fifty cases and 97 controls were compared. The median follow-up time was 7.6 months. Operative time was shorter in the hysteropexy group (110.7 vs. 155.9 min, p < 0.001). The composite success was 92% for both cases and controls (p = 1.000) with no difference in time to surgical failure (p = 0.183). There were no serious intraoperative complications in the hysteropexy group and six in the control group (3 transfusions, 1 conversion to laparotomy, 1 ureteral injury, 1 cystotomy; p = 0.101). There was no difference in the number of postoperative complications (22.0% vs. 30.9%, p = 0.203).

CONCLUSIONS

For primary uterine prolapse, anterior sacrospinous hysteropexy has similar short-term efficacy compared to hysterectomy with apical repair with shorter operative time and a trend towards fewer serious complications.