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    The future of treating pelvic organ prolapse

     

    Uterus-sparing procedures

    A hysterectomy is traditionally performed at the time of POP repair in the United States, and more than 100,000 hysterectomies are performed annually in this country for POP.38 Uterus-sparing techniques date back to the late 1800s but fell out of favor in the United States in the twentieth century with improvement in surgical morbidity and mortality and due to efforts to reduce the risk of cervical and endometrial cancers.

    With the renewed interest and importance of patient preferences in POP procedures, the role of uterine-sparing prolapse procedures has resurged.39 Women report that a doctor’s opinion, surgical risk, and cancer risk were leading considerations. On a non-validated questionnaire that was mailed before they were seen for POP at a large academic urogynecology group, 60% of 100 women reported that they preferred to avoid hysterectomy at the time of surgery.40

    Geography may influence patient preference as well. The highest proportion of women preferring uterine preservation lived in the west (62%) and the lowest in the south (27%). In addition, women with at least some college education and those who believe that the uterus is important for their sense of self prefer uterine preservation.41

    Sacrospinous hysteropexy is a common uterine-sparing vaginal approach.39 The first non-randomized trial by Maher et al. compared sacrospinous hysteropexy and vaginal hysterectomy with SSLS.42 Operative time and estimated blood loss were lower in sacrospinous hysteropexy compared to hysterectomy with SSLS with no difference in short-term (26–33 months), subjective (86% vs 78%), or objective success rates (72% vs 74%) in the hysterectomy versus hysteropexy groups, respectively.42 However, data are mixed. In a RCT comparing sacrospinous hysteropexy to vaginal hysterectomy with suspension, the rate of objective success was higher in the hysterectomy group; 11% in the hysterectomy group versus 27% in the hysteropexy group had stage 2 or greater recurrent prolapse at 1-year follow up.43 Recent data have demonstrated that sacrospinous hysteropexy is not inferior to a vaginal hysterectomy with USLS at 1 year.44

    Mesh kits also are available that can be used for uterine-sparing POP repairs. Limited data regarding TVM hysteropexy report > 95% composite outcome success rates at 1 year using one of these kits, the Uphold (Boston Scientific). The mesh extrusion and reoperation rates were 6.52% and 7.53%, respectively.45

    Other uterine-preserving options include abdominal uterosacral hysteropexy or mesh-augmented sacrohysteropexy. A small comparative trial of abdominal sacrohysteropexy versus hysterectomy with sacrocolpopexy found no difference in anatomic outcomes at 51 months but mean operating times, intraoperative blood loss, and hospital stay were significantly less after hysteropexy.46 Additionally, Maher et al. reported on the largest prospective trial to date of laparoscopic uterosacral ligament hysteropexy.47 One-year success rates for laparoscopic uterosacral ligament hysteropexy were reported to be 81% for subjective and 79% for objective success rates; 16% of participants underwent additional surgery for symptomatic uterine prolapse.47 Hence, it appears that laparoscopic uterosacral ligament hysteropexy is relatively safe and effective, although more data are needed.39

    Although long-term comparative data are largely lacking, there is evidence that uterine-preserving prolapse surgeries can be successful and in alignment with patient preference, because uterine preservation is important to some women. These procedures may play an increasingly important role in the future of prolapse repair.

     

    Cara Ninivaggio, MD, FACOG
    Dr Ninivaggio is a fellow in the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, ...
    Gena Dunivan, MD, FACOG
    Dr Dunivan is an Associate Professor and Fellowship Program Director in the Division of Female Pelvic Medicine & Reconstructive Surgery, ...

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