Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey)

Participants were hospital-based female specialist obstetricians and gynecologists who have completed their postgraduate training and working as generalists or subspecialists in obstetrics and gynecology.

We used a bespoke questionnaire based on previously published study exploring women’s perception of hysterectomy and attitudes towards uterine preservation at the time of POP reconstructive surgery [16]. The questionnaire was distributed in the native language of each of the participating countries (the questionnaires in the participating countries native languages are available on request, the questionnaire in English language—see in Additional file 1). Demographic details collected included participants’ age, country of residence, type of hospital they work at, sub-specialization or main area of special interest (materno-fetal medicine, oncogynecology, urogynecology, reproductive medicine, others, no sub-specialty). We also asked about future fertility plans using a 4-point Likert scale ranging from “not at all” to “I definitely will”.

Participants were asked to assume they are postmenopausal healthy women, with no prior major gynecological surgeries, suffering from a significant POP involving all compartments (i.e. anterior, apical, posterior), participants were then asked to respond to a set of questions and hypothetical scenarios to explore the following issues:

Of the 120 approached departments, questionnaires were returned from 81 (67.5%) of them. A total of 140 female gynecologists completed the questionnaire with a mean age of 38.7 years (range 28–67 years). Of these, 84 (60.0%), 31 (22.1%) and 25 (17.9%) were from the Czech Republic, Slovakia and Slovenia respectively. Participants were based at university or teaching hospitals (n = 82, 58.6%), regional hospitals (n = 39, 27.8%) and district hospitals (n = 19, 13.6%). All participants were fully specialized gynecologists, of these 23 (16.4%) were feto-maternal, 16 (11.4%) urogynecology and 4 (2.9%) oncogynecology subspecialists. With regard to future fertility plans, 49 participants (35.0%) stated that they completed their family while the remaining 91 (65.0%) either partially or not at all.

Based on the requested assumed scenario that participants were healthy, postmenopausal, with no prior gynecological surgeries and suffering with a significant POP involving all compartments, relying on a urogynecologist as a source of information was chosen by 130 (92.9%) of the participants as the main information resource. While searching the medical literature, consulting their partner or colleague was chosen by 54 (38.6%), 24 (17.1%) and 14 (10.0%) of the respondents respectively. Ten participants only have indicated that they would also seek assistance from online resources (n = 6, 4.3%), a female friend (n = 3, 2.1%) or an oncogynecologist (n = 1, 0.7%).

Using the same assumption above, participants were asked to rate their likelihood of choosing different management options for POP on a 4-point Likert scale which was later dichotomized to “yes”, for definitely and likely, and “no”, for not likely and not at all (Fig. 1). The options favored by respondents, when combining definitely and likely responses, were sacrocolpopexy and physiotherapy. While a Manchester repair, no treatment, colpocleisis, and the use of a pessary were the least favored amongst female gynecologists.

Participants were asked about their views regarding the importance of various factors on their decision to opt for or decline a hysterectomy, during POP reconstructive surgery, if both were feasible options. Professionals’ opinion and risk of surgical complications were considered important by 100% and 99% of respondents respectively. The list of factors assessed ranked in order of their importance based on participants’ responses are demonstrated in Fig. 2.

When participants were asked about choice of surgery if there was evidence to suggest that anatomical outcomes following POP surgery with uterine sparing were similar to concomitant hysterectomy, 82/125 (65.6%) still opted for a concomitant hysterectomy. When asked about their choice if there was evidence that uterine sparing is associated with slightly worse outcomes, 35/43 (81.4%) who initially opted for uterine sparing changed their mind to a concomitant hysterectomy (Fig. 3).

When information on actual background potential risk of uterine cancer in relation to other types of cancers in females was provided while still assuming equal effectiveness of uterine sparing and concomitant hysterectomy POP procedures, 5 (6.1%) women changed their decision from hysterectomy to uterus sparing surgery and 6 (13.9%) women from uterus sparing surgery to hysterectomy (Fig. 4). Additionally, 122 (87.1%) respondents stated that they would need to know the recent cervical screening result and 93 (66.4%) to have a transvaginal ultrasound assessment of their endometrial thickness preoperatively to enable them to make a well informed decision regarding hysterectomy or uterus sparing procedure. The choice of surgery depending on the different scenarios by country is presented in Table 1.

This study presents personal views of female gynecologists on the issue of POP management with a particular focus on their choice of whether to preserve the uterus or not in response to different hypothetical clinical scenarios. The vast majority of our study participants stated they would rely on a urogynecologist as the main source of information to aid them with their choice of POP management options while, 4.3% and 0.7% only, would use online resources or seek the advice of an oncogynecologist, respectively, to help them make a decision.

The majority (65.6%) of female gynecologists would opt for hysterectomy if they were postmenopausal at the time of POP surgery, a proportion higher than that reported from previous women surveys whose participants were not recruited because of a particular professional background [16, 17].

Limited research exists that assesses patient knowledge of POP treatment options and attitudes regarding hysterectomy and its association with their perception of sexuality, femininity and womanhood [18, 22‐24]. Nevertheless, it is the general opinion that the two crucial determinants of the patients’ choice of POP surgical technique are the woman’s personal views about uterine preservation and the surgeon’s procedure preference based on their training and expertise [25, 26]. It is interesting to see that the majority of specialist female gynecologists seem to prefer a hysterectomy even when quoted similar anatomical success or when highlighting the proximity in life-time uterine cancer risk to other organs. The impact of this issue is more relevant when considering that our respondents are clinicians who can be counseling patients rather than as a woman considering her own options.

Our findings concur with other groups, [14, 27, 28], where we demonstrated that the issues of the impact of a hysterectomy on femininity, sex drive and sexual satisfaction, either for the woman or her partner, did not seem to be a priority in the decision-making process regarding hysterectomy at time of POP surgery. However, the impact of hysterectomy on clinical outcomes seemed to be an important factor when choosing the optimal procedure. Similar to those of Korbly et al. [14] and van IJsselmuiden et al. [17] the number of women opting for uterine sparing surgery in our study significantly reduced if this was associated with slightly inferior anatomical outcomes (34.4–8.8%; OR 11.6, p < 0.001). A large RCT comparing uterine preservation surgery versus vaginal hysterectomy for POP repair reported similar anatomical and functional outcomes at 12-months [29]. In our survey sacrocolpopexy was the most preferred surgical procedure amongst female gynecologists. This is not surprising given the high-level evidence indicating that abdominal and laparoscopic sacrocolpopexy achieve better anatomical outcomes compared to other surgical options [30]. Several studies compared laparoscopic hysteropexy against total or subtotal hysterectomy with sacrocolpopexy with conflicting results [31‐34]. Nonetheless, randomized comparisons of outcomes following sacrocolpopexy with or without uterine preservation are needed. Furthermore, it would also be prudent to explore alternative techniques and modifications that can overcome any variation in outcome [35]. This will ensure that women have two realistic and equal options to choose from. It is also important that women have access to specialized multidisciplinary expertise and validated instruments to help them evaluate their needs and hence make an individualized informed choice about their management [24].

We appreciate that our study has some limitations including the inability to know the exact number of specialists who received the questionnaire to be able to calculate an accurate response rate. Therefore, it is difficult to assess the risk of selection bias in this survey. However, the fact that our participants are specialized professionals working in different types of units from 3 different countries is reassuring that our sample is representative of the views of female gynecologists currently working in Central Europe. Moreover, the mean age of our participants was 38.7 years and several of them have not completed their families, yet they were asked to base their responses on the hypothetical assumption that they were postmenopausal. It could be argued that the views presented in this study might not be a true reflection of what postmenopausal female gynecologist would do. Nonetheless, it still reflects, to a large extent, what their perception is about the optimal modality of management for a postmenopausal healthy woman. This is of particular importance because of the potential impact this might have on others if we consider their roles as clinicians and trainers. In contrast, the fact that this is the first survey exploring views of female gynecologists about POP management and their preferences about uterine sparing or not is a major strength to our work.