Uterus Preservation in Surgical Correction of Urogenital Prolapse

doi:10.1016/j.eururo.2005.04.022

European Urology

Volume 48, Issue 4, October 2005, Pages 642-649

https://doi.org/10.1016/j.eururo.2005.04.022 Get rights and content

Abstract

Objective:

This study aimed to evaluate the efficacy of colposacropexy with uterine preservation as therapy for uterovaginal prolapse. Surgical techniques, efficacy and overall results are described.

Methods:

In this prospective, controlled study, 34 of the 72 consecutive patients with symptomatic uterovaginal prolapse were treated with colposacropexy with uterus conservation (hysterocolposacropexy, HSP) and the other 38 with hysterectomy followed by sacropexy (CSP). Anchorage was achieved with two rectangular meshes in CSP and with one posterior rectangular and one anterior Y-shaped mesh in HSP. Check-ups were scheduled at 3, 6 and 12 months and then yearly. Pre-operative patient characteristics, operative and post-operative events and follow-up results were recorded. Mean follow-up was 51 months (range 12–115).

Results:

No significant differences emerged in demographic and clinical characteristics between the HSP and CSP groups. Mean operating times, intra-operative blood loss and hospital stay were significantly less after HSP (p < 0.001). At follow-up success rates were similar in the two groups in terms of uterine and upper vaginal support (100%). Recurrent low-grade cystoceles developed in 1/38 (2.6%) in the CSP group and in 5/34 (14.7%) in the HSP group (p = NS), recurrent low-grade rectocele developed in 6/38 (15.8%) and in 3/34 (8.8%) patients respectively (p = NS). No patient required surgery for recurrent vault or uterus prolapse. Urodynamic results showed that pressure/flow parameters improved significantly (p < 0.001) in both groups. Thirty-one of the 34 patients (91%) in the HSP group and 33/38 (86.8%) in the CSP group were satisfied and would repeat surgery again.

Conclusions:

Colposacropexy provides a secure anchorage, restoring an anatomical vaginal axis and a good vaginal length. HSP can be safely offered to women who request uterine preservation. Whether the uterus was preserved or not, patients had similar results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions. HSP has shorter operating times and less blood loss.

Introduction

For many years uterine prolapse has been an indication for hysterectomy [1], apart from the presence or absence of any uterine disease and independently of the patient's desires. Hysterectomy is still considered standard practice for correction of uterovaginal prolapse, even though descent of the uterus is a consequence, and not the cause, of prolapse [2]. In the past decades the lifestyles, beliefs and perspectives of women with regards to sexual function and pregnancy have undergone profound changes and many patients who undergo surgery for genital prolapse want to preserve the uterus. Uterine preservation during prolapse surgery is not new [2], [3] and three surgical options are available: Manchester repair [4], sacrospinous hysteropexy [2], [5], [6], [7] and sacral hysteropexy [8], [9], [10], [11], [12]. Few studies on uterus preservation have been reported and there are no clear indications for uterus sparing or removal in open or vaginal surgery for advanced prolapse.

We have performed colposacropexy in women with uterovaginal prolapse for many years with satisfactory results [8], [10]. This study was designed to determine whether, in the treatment of uterovaginal prolapse, sacropexy with uterus conservation is associated with less operative and post-operative morbidity and similar long-term outcomes as hysterectomy with sacropexy. We prospectively identified eligible patients and offered them the chance to avoid hysterectomy. In this first study on sacropexy with and without hysterectomy we describe the surgical techniques and compare efficacy and overall results.

Section snippets

Materials and methods

Institutional Research Committee approval was obtained.

We clearly outlined the surgical procedure, the risks associated with uterus preservation and the need for long-term check-ups. We acquainted fertile patients with pregnancy-related risks. Patients understood that the surgeon reserved the right to perform hysterectomy during surgery if necessary or advisable before providing informed consent.

Seventy-two consecutive patients with symptomatic grade III–IV uterovaginal prolapse were recruited

Results

Table 1 lists demographic details. There were no significant differences in age, parity, body mass index, incidence of previous surgery, constipation, sexual activity, menopausal status, urinary stress incontinence, degree of prolapse, voiding and irritative symptoms or length of follow-up, indicating that the two groups were matched.

All patients complained of vaginal heaviness and urinary dysfunction (obstructive and or irritative symptoms).

The median operating time in the CSP group was 115 min

Discussion

The goals of pelvic floor and reconstructive genital surgery are to maintain the natural cranio-posterior course of the vagina, reinforce the vaginal septa and correctly suspend the top of the vagina (including the cervix). In a retrospective study (34 sacrospinous hysteropexy and 36 vaginal hysterectomy and sacrospinous fixation) Maher et al. [3] concluded that sacrospinous hysteropexy could safely be offered to women with symptomatic uterovaginal prolapse who request uterine preservation.

Conclusions

As a result of changing attitudes in our Western society to sexuality and the psychological and emotional value of the sexual organs, surgeons must consider the wishes and feelings of the patient who wants to preserve vaginal function and the uterus.

Colposacropexy with or without hysterectomy provides secure proximal and distal anchorage without tension so the pelvic statics remain as close as possible to the physiological with normal vaginal axis and good vaginal length.

HSP can safely be

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Cited by (95)

Directive clinique n<sup>o</sup> 413: Traitement chirurgical du prolapsus génital apical chez les femmes
2021, Journal of Obstetrics and Gynaecology Canada
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.
Les femmes présentant un prolapsus symptomatique de l'utérus ou du dôme vaginal qui souhaitent obtenir un traitement chirurgical.
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.
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).
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.
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.
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).
Gynécologues, urologues, urogynécologues et autres fournisseurs de soins de santé qui évaluent, conseillent et soignent des femmes ayant un prolapsus génital.
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.
- 1
  La suspension vaginale par suture à divers ligaments pelviens était inférieure à la colposacropexie par voie abdominale (toutes voies d'abord confondues) avec treillis synthétique pour ce qui est des résultats cliniques suivants :
  •
  échec global objectif (moyenne);
  •
  échec apical objectif (moyenne).
- 2
  La suspension vaginale par suture à divers ligaments pelviens était comparable à la colposacropexie par voie abdominale (toutes voies d'abord confondues) avec treillis synthétique pour ce qui est des résultats cliniques suivants :
  •
  échec antérieur objectif (moyenne);
  •
  échec postérieur objectif (moyenne);
  •
  sensation subjective d'un prolapsus génital récidivé (moyenne);
  •
  réopération pour un prolapsus génital récidivé (moyenne);
  •
  lésions vésicales et urétérales peropératoires (faible);
  •
  troubles mictionnels postopératoires (faible).
- 3
  La suspension vaginale par suture à divers ligaments pelviens n’était pas associée au risque d'exposition du treillis comparativement à la colposacropexie abdominale (toutes voies d'abord confondues) avec treillis synthétique, qui est associée à un risque d'exposition du treillis de 2,7 % à 3,4 % (moyenne).
- 4
  La colposacropexie par voie abdominale ouverte était inférieure à la colposacropexie minimalement invasive (laparoscopique ou robotisée) pour ce qui est des résultats cliniques suivants :
  •
  échec global objectif (faible);
  •
  échec postérieur objectif (faible).
- 5
  La colposacropexie par voie abdominale ouverte était comparable à la colposacropexie minimalement invasive (laparoscopique ou robotisée) pour ce qui est des résultats cliniques suivants :
  •
  échec objectif antérieur (faible);
  •
  sensation subjective d'un prolapsus génital récidivé (moyenne);
  •
  réopération pour un prolapsus génital récidivé (moyenne);
  •
  lésions vésicales peropératoires (moyenne);
  •
  réopération pour incontinence urinaire d'effort (faible);
  •
  exposition du treillis (moyenne).
- 6
  Les diverses voies d'abord minimalement invasives de la colposacropexie (laparoscopique ou robotisée) se sont révélées comparables pour ce qui est des risques suivants :
  •
  sensation subjective d'un prolapsus génital récidivé (très faible);
  •
  lésions vésicales peropératoires (moyenne);
  •
  incontinence urinaire d'effort postopératoire (très faible);
  •
  exposition du treillis (moyenne).
- 7
  Il n'y a pas suffisamment de données comparant l'incontinence urinaire par urgenturie et le risque de dysfonction mictionnelle après une colposacropexie par voie abdominale ouverte et minimalement invasive ni entre les différentes méthodes de colposacropexie minimalement invasive (très faible).
- 8
  La suspension aux ligaments utéro-sacrés et la sacrospinofixation se sont révélées comparables pour ce qui est des risques suivants :
  •
  taux d’échec objectif (global et par compartiment) (moyenne);
  •
  sensation subjective d'un prolapsus génital récidivé (moyenne);
  •
  réopération pour un prolapsus génital récidivé (moyenne);
  •
  lésions vésicales peropératoires (moyenne);
  •
  réopération pour incontinence urinaire d'effort (faible).
- 9
  La suspension aux ligaments utéro-sacrés s'est révélée avoir un risque plus élevé comparativement à la sacrospinofixation pour ce qui est du risque suivant :
  •
  lésions urétérales peropératoires (moyenne).
- 10
  L'hystérectomie avec suspension était comparable à l'hystéropexie (toutes voies d'abord confondues) pour ce qui est des résultats cliniques suivants :
  •
  échec global objectif (faible);
  •
  échec antérieur objectif (faible);
  •
  échec apical objectif (faible);
  •
  sensation subjective d'un prolapsus génital récidivé (faible);
  •
  réopération pour un prolapsus génital récidivé (faible);
  •
  troubles mictionnels (faible);
  •
  lésions vésicales et urétérales peropératoires (faible).
- 11
  L'hystérectomie avec suspension s'est révélée inférieure à l'hystéropexie (toutes voies d'abord confondues) pour ce qui est du résultat clinique suivant :
  •
  échec postérieur objectif (faible).
- 12
  L'hystérectomie avec colposacropexie s'est révélée avoir un risque supérieur comparativement à l'hystérosacropexie (par voie abdominale, laparoscopique ou robotisée) pour ce qui est du risque suivant :
  •
  exposition du treillis (faible).
- 13
  L'hystérectomie vaginale avec suspension et l'hystéropexie par voie vaginale se sont montrées comparables pour ce qui est des risques suivants :
  •
  échec objectif (global et par compartiment) (faible);
  •
  réopération pour un prolapsus génital récidivé (très faible);
  •
  lésions urétérales peropératoires (très faible).
- 14
  À court terme (1 an), la correction du prolapsus apical de stade avancé (stade 3 ou 4) au moyen de la suspension vaginale par suture à divers ligaments pelviens est comparable au colpocléisis pour ce qui est des résultats cliniques d’échec global objectif, de lésions peropératoires des voies urinaires et d'amélioration spécifique de la qualité de vie (très faible).
- 15
  La suspension aux ligaments utéro-sacrés s'est révélée avoir un risque plus faible comparativement à la sacrospinofixation pour ce qui est du risque suivant :
  •
  douleur aux fesses transitoire ou à court terme (faible).
- 16
  Les données actuelles ne sont pas concluantes pour ce qui est des résultats cliniques relatifs à la douleur pelvienne persistante ou à la fonction sexuelle postopératoire, notamment la dyspareunie de novo, lorsque l'on compare la suspension apicale par voie vaginale par rapport à la voie abdominale, la suspension apicale minimalement invasive à la voie ouverte, les différentes méthodes de suspension apicale du dôme vaginal entre elles et l'hystérectomie avec suspension par rapport à l'hystéropexie (très faible).
- 1
  Il y a lieu d'informer les femmes souhaitant obtenir une correction chirurgicale pour un prolapsus apical que la suspension vaginale par suture, par comparaison à la colposacropexie par voie abdominale (toutes voies d'abord confondues), présente un risque accru d’échec objectif, mais un taux comparable pour ce qui est (1) de l’échec subjectif, (2) de la réopération pour un prolapsus génital récidivé et (3) des complications. Il importe donc de prendre ces risques en compte au regard du risque permanent d'exposition du treillis après une colposacropexie, complication qui peut exiger une réopération (conditionnelle, moyenne).
- 2
  Il est recommandé pour les chirurgiens dûment formés de privilégier la colposacropexie minimalement invasive par voie laparoscopique ou robotisée (si l’équipement chirurgical est disponible), plutôt que la colposacropexie par chirurgie ouverte, étant donné l'amélioration objective globale des résultats cliniques et l’équivalence des résultats cliniques subjectifs à court et à moyen terme (conditionnelle, faible).
- 3
  Il est possible d'offrir la suspension vaginale aux ligaments utéro-sacrés et la sacrospinofixation aux femmes ayant un prolapsus génital apical en fonction des préférences du chirurgien et de la patiente. Les deux méthodes semblent avoir des résultats cliniques objectifs et subjectifs comparables jusqu’à 5 ans post-intervention, à l'exception d'une augmentation du risque de lésion urétérale peropératoire dans le cas de la suspension aux ligaments utéro-sacrés et du risque de douleur aux fesses transitoire ou à court terme après une sacrospinofixation (forte, modérée).
- 4
  Il est possible d'offrir différentes voies d'abord et techniques d'hystéropexie comme solution de rechange à l'hystérectomie et à la suspension pour les femmes atteintes d'un prolapsus génital apical qui souhaitent préserver leur utérus; ces techniques et voies d'abord sont associées à des résultats cliniques objectifs et subjectifs comparables pour les 5 premières années post-intervention (conditionnelle, faible).
- 5
  En dépit du manque de données probantes comparatives, il y a lieu d'aborder le colpocléisis comme option thérapeutique avec les femmes qui ne souhaitent plus être sexuellement actives; il semble s'agir d'une intervention réussie pour laquelle on signale peu de complications (fortes, faibles).
- 6
  Il y a lieu d'informer les femmes qui se soumettent au traitement chirurgical du prolapsus apical symptomatique qu'il existe peu de données comparatives sur la douleur pelvienne et la fonction sexuelle postopératoires pour diverses interventions. Dans l'ensemble, le risque de douleur pelvienne postopératoire semble faible, et la fonction sexuelle semble s'améliorer chez les femmes sexuellement actives qui se soumettent au traitement chirurgical reconstructif du prolapsus génital apical (conditionnelle, très faible).
Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women
2021, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Women considering hysteropexy should be made aware that a hysterectomy may be required in the future for these conditions. All routes for hysterectomy and suspension versus hysteropexy were compared in this analysis (Table 4).25,26,45,48,49,51-58 Types of procedures included vaginal or laparoscopic ligament suspensions, as well as sacrocolpopexies or sacrohysteropexies.
To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse.
Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction.
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.
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).
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.
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.
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).
Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP.
All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified.
- 1
  Vaginal suture suspension to various pelvic ligaments was inferior to abdominal sacrocolpopexy (any route) with synthetic mesh for the outcomes of
  •
  overall objective failure (moderate)
  •
  objective apical failure (moderate)
- 2
  Vaginal suture suspension to various pelvic ligaments was similar to abdominal sacrocolpopexy (any route) with synthetic mesh for the outcomes of
  •
  objective anterior failure (moderate)
  •
  objective posterior failure (moderate)
  •
  subjective awareness of pelvic organ prolapse recurrence (moderate)
  •
  reoperation for pelvic organ prolapse recurrence (moderate)
  •
  intraoperative bladder and ureteric injuries (low)
  •
  postoperative lower urinary tract symptoms (low)
- 3
  Vaginal suture suspension to various pelvic ligaments was not associated with a risk of mesh exposure compared with abdominal sacrocolpopexy (any route) with synthetic mesh, which is associated with a 2.7% to 3.4% risk of mesh exposure (moderate).
- 4
  Open abdominal sacrocolpopexy was inferior to minimally invasive (laparoscopic or robotic) sacrocolpopexy for the outcomes of
  •
  overall objective failure (low)
  •
  objective posterior failure (low)
- 5
  Open abdominal sacrocolpopexy was similar to minimally invasive (laparoscopic or robotic) sacrocolpopexy for the outcomes of
  •
  objective anterior failure (low)
  •
  subjective awareness of pelvic organ prolapse recurrence (moderate)
  •
  reoperation for pelvic organ prolapse recurrence (moderate)
  •
  intraoperative bladder injuries (moderate)
  •
  reoperation for stress urinary incontinence (low)
  •
  mesh exposure (moderate)
- 6
  Various minimally invasive sacrocolpopexy approaches (laparoscopic or robotic) showed similar risk of
  •
  subjective awareness of pelvic organ prolapse recurrence (very low)
  •
  intraoperative bladder injury (moderate)
  •
  postoperative stress urinary incontinence (very low)
  •
  mesh exposure (moderate)
- 7
  There are insufficient data comparing urge urinary incontinence and voiding dysfunction risk after open abdominal and minimally invasive sacrocolpopexy and among various approaches to minimally invasive sacrocolpopexy (very low).
- 8
  Uterosacral ligament suspension and sacrospinous fixation showed similar risk of
  •
  objective failure rates (overall and by compartment) (moderate)
  •
  subjective awareness of pelvic organ prolapse recurrence (moderate)
  •
  reoperation for pelvic organ prolapse recurrence (moderate)
  •
  intraoperative bladder injury (moderate)
  •
  reoperation for stress urinary incontinence (moderate)
- 9
  Uterosacral ligament suspension compared with sacrospinous fixation showed a higher risk of
  •
  intraoperative ureteric injury (moderate)
- 10
  Hysterectomy and suspension versus hysteropexy (by any route) were similar for the outcomes of
  •
  overall objective failure (low)
  •
  objective anterior failure (low)
  •
  objective apical failure (low)
  •
  subjective awareness of pelvic organ prolapse recurrence (low)
  •
  reoperation for pelvic organ prolapse recurrence (low)
  •
  lower urinary tract symptoms (low)
  •
  intraoperative bladder or ureteric injury (low)
- 11
  Hysterectomy and suspension compared with hysteropexy (by any route) were inferior for the outcome of
  •
  objective posterior failure (low)
- 12
  Hysterectomy and sacrocolpopexy compared with sacrohysteropexy (abdominal, laparoscopic, or robotic) showed a higher risk of
  •
  mesh exposure (low)
- 13
  Vaginal hysterectomy with suspension and vaginal hysteropexy showed similar risk of
  •
  objective failure (overall and by compartment) (low)
  •
  risk of reoperation for pelvic organ prolapse recurrence (very low)
  •
  intraoperative ureteric injury (very low)
- 14
  In the short-term (1-year) correction of advanced apical vaginal prolapse (stage 3 or 4), vaginal suture suspension to various pelvic ligaments is similar to colpocleisis for the outcomes of overall objective failure, intraoperative urinary tract injury, and condition-specific improvement in quality of life (very low).
- 15
  Uterosacral ligament suspension compared with sacrospinous fixation showed a lower risk of
  •
  short-term/transient buttock pain (low)
- 16
  Current data are inconclusive for the outcomes of persistent pelvic pain or postoperative sexual function, including de novo dyspareunia, when comparing vaginal with abdominal apical suspensions, open with minimally invasive apical suspensions, various vaginal apical suspensions, and hysterectomy and suspension with hysteropexy (very low).
- 1
  Women seeking surgical correction of apical pelvic organ prolapse should be counselled about the higher risk of objective failure but similar rate of (1) subjective failure, (2) reoperation for pelvic organ prolapse recurrence, and (3) complications after vaginal suture suspensions compared with abdominal sacrocolpopexy (any approach). This is balanced against the ongoing risk of mesh exposure after sacrocolpopexy, possibly requiring reintervention (conditional, moderate).
- 2
  Appropriately trained surgeons should favour minimally invasive laparoscopic or robotic approaches to sacrocolpopexy (if surgical equipment is available) over open sacrocolpopexy, considering the improved overall objective outcomes and similar subjective outcomes in the short and medium term (conditional, low).
- 3
  Both vaginal uterosacral ligament suspension and sacrospinous fixation can be offered to women with apical pelvic organ prolapse, based on surgeon and patient preference; they appear to have similar objective and subjective outcomes at up to 5 years, apart from an increased risk of intraoperative ureteric injury with uterosacral ligament suspension and a higher risk of short-term/transient buttock pain after sacrospinous fixation (strong, moderate).
- 4
  Various hysteropexy routes and techniques can be offered as an alternative to hysterectomy and suspension for women with apical pelvic organ prolapse who wish to conserve their uterus; they are associated with similar objective and subjective outcomes in the first 5 years (conditional, low).
- 5
  Colpocleisis should be discussed as a treatment option for women who do not wish to be sexually active in the future, despite the paucity of comparative evidence; it appears to be a successful procedure with few reported complications (strong, low).
- 6
  Women undergoing surgery for symptomatic apical pelvic organ prolapse should receive counselling about the lack of comparative data on postoperative pelvic pain and sexual function for various procedures. Overall, the risk of postoperative pelvic pain appears to be low, and sexual function seems to improve among sexually active women with pelvic organ prolapse who undergo reconstructive surgery (conditional, very low).
Uterine preservation or not during prolapse surgery: Review of the literature
2019, Progres en Urologie
Évaluer l’impact de la réalisation d’une hystérectomie en cas de cure de prolapsus sur les résultats anatomiques, fonctionnels, les complications per et postopératoires par rapport à la conservation utérine.
Nous avons réalisé une revue de la littérature sur Pubmed, Medline, Embase et Cochrane en utilisant les termes et MeSH (Medical Subject Headings of the National Library of Medicine) suivants : uterine prolapse ; genital prolapse ; prolapse surgery ; vaginal prolapse surgery ; abdominal prolapse surgery ; hysterectomy ; hysteropexy ; sacrocolpopexy ; surgical meshes ; complications ; sexuality ; neoplasia ; urinary ; incontinence ; cancer.
Parmi les 168 résumés étudiés, nous avons retenu 63 articles. Il n’existait pas de différence significative en termes de résultats anatomiques et fonctionnels en cas de promontofixation (OR = 2,21 [IC95 % : 0,33–14,67[) et en cas de chirurgie vaginale sans pose de prothèse (OR = 1,07 [IC95 % : 0,38–2,99]). Il n’y avait pas non plus de différence en termes de symptomatologie urinaire ou de sexualité au décours quel que soit la voie d’abord. L’hystérectomie était associée à une morbidité plus importante (saignements, allongement du temps opératoire, allongement de la durée d’hospitalisation), un risque augmenté d’exposition prothétique en cas d’hystérectomie totale (8,6 % IC95 % : 6,3–11).
En l’absence de preuve de supériorité en termes de résultats anatomiques et fonctionnels, avec une augmentation du taux de complications, l’hystérectomie concomitante en cas de cure de prolapsus ne doit probablement pas être réalisée de manière systématique.
To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation.
We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer.
Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR = 2.21 [95% CI: 0.33–14.67]) or vaginal surgery (OR = 1.07 [95% CI: 0.38–2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3–11).
In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.
Laparoscopic promontofixation: Where to stop the anterior dissection?
2019, Medical Hypotheses
Laparoscopic promontofixation is the gold standard to treat apical defects but the dissection of the anterior compartment is variable since based on surgical judgment only. We therefore evaluate the placement of the anterior mesh using an ultrasonographic measurement after promontofixation.
A prospective cohort study (Canadian Task Force Classification II-1) was conducted between January 2015 and September 2015. 63 women that underwent a promontofixation for prolapse were included. Pelvic floor descent was evaluated with POP-Q. The distance between the bladder neck, and the anterior mesh was measured by ultrasound at the end of surgery. The placement of the mesh was subsequently correlated to the anatomical repair 1 month after surgery, and the occurrence of de novo symptoms as stress urinary incontinence.
Ultrasound permitted to measure the distance between bladder neck and Mesh (BMD = Bladder neck-Mesh Distance) in all patients with variation between repeated measurements ranging for 0.6 to 1.2 mm. The BMD was highly variable from 0 to 13 mm (mean ± SD; 5.3 ± 3.1 mm). The BMD inversely correlated with the difference between C (P = 0.01) and Bp (P = 0.04) after and before surgery respectively, with the complication rate (P = 0.01) but not with the difference of Ba. A BMD of more than 6 mm predicted the absence of postoperative de novo symptoms. De novo“ stress urinary incontinence occurred in 23.8%.
BMD can be accurately measured by ultrasound. BMD predicts the apical repair but not the anterior repair. A short BMD predicted postoperative de novo stress urinary incontinence.
Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines
2018, American Journal of Obstetrics and Gynecology
Citation Excerpt :
A summary of surgical comparisons reviewed, overall level of evidence for the comparison, the number of women in studies with these comparisons, and main results of the review are summarized in Table 1. There were 9 studies (all nRCs) that compared mesh sacrohysteropexy with hysterectomy with mesh sacrocolpopexy via a laparoscopic or open abdominal approach.8,44-51 The nature of these studies is reviewed in Table 2.
We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.
The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.
We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.
Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.
We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.
Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.
Effect of different surgical techniques on postoperative wound infection in patients with uterine prolapse: A meta-analysis
2024, International Wound Journal

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