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Uterine-preserving POP surgery

  • POP Surgery Review
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

Introduction and hypothesis

To review the safety and efficacy of uterine preservation surgery.

Methods

Every four years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

Results

A wide variety of surgical options remain for women presenting with uterine prolapse without contraindications to uterine preservation. However, long-term data are limited and the need for subsequent hysterectomy unknown (grade C). Sacrospinous hysteropexy is as effective as vaginal hysterectomy and repair in retrospective comparative studies and in a meta-analysis with reduced operating time, blood loss and recovery time. However, in a single RCT there was a higher recurrence rate associated with sacrospinous hysteropexy compared with vaginal hysterectomy (grade D). Severe prolapse increases the risk of recurrent prolapse after sacrospinous hysteropexy. In consistent level 2 evidence sacrospinous hysteropexy with mesh augmentation of the anterior compartment was as effective as hysterectomy and mesh augmentation with no significant difference in the rate of mesh exposure between the groups (grade B). Level 1 evidence from a single RCT suggests that vaginal hysterectomy and uterosacral suspension were superior to sacral hysteropexy based on reoperation rates, despite similar anatomical and symptomatic improvement (grade C). Consistent level 2 and 3 evidence suggests that sacral hysteropexy (open or laparoscopic) was as effective as sacral colpopexy and hysterectomy in anatomical outcomes; however, the sacral colpopexy and hysterectomy were associated with a five times higher rate of mesh exposure compared with sacral hysteropexy (grade B). Performing hysterectomy at sacral colpopexy was associated with a four times higher risk of mesh exposure compared with sacral colpopexy without hysterectomy (grade B).

Conclusion

While uterine preservation is a viable option for the surgical management of uterine prolapse the evidence on safety and efficacy is currently lacking.

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Acknowledgements

This publication results from the work of the Committee on Pelvic Organ Prolapse Surgery, part of the 5th International Consultation on Incontinence, held in Paris in February 2012, under the auspices of the International Consultation on Urological Diseases, and enabled by the support of the European Association of Urology.

The authors wish to acknowledge the fine work of previous consultations led by Professor Linda Brubaker.

Conflicts of interest

None.

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Authors and Affiliations

  1. MedStar Washington Hospital Center, Washington, DC, USA

    Robert Gutman

  2. University of Queensland, Royal Brisbane and Wesley Urogynaecology, 30 Chaseley Street, Auchenflower, 4067, Brisbane, Australia

    Christopher Maher

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  1. Robert Gutman
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Correspondence to Christopher Maher.

Additional information

On behalf of Committee 15 “Surgical Management of Pelvic Organ Prolapse” from the 5th International Consultation on Incontinence held in Paris, February 2012

This work has been previously published as: Maher C, Baessler K, Barber M, Cheon C, Deitz V, DeTayrac R, Gutman R, Karram M, Sentilhes L (2013) Surgical management of pelvic organ prolapse. In: Abrams, Cardozo, Khoury, Wein, (eds) 5th International Consultation on Incontinence. Health Publication Ltd, Paris, Chapter 15 and modified for publication in International Urogynaecology Journal.

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Gutman, R., Maher, C. Uterine-preserving POP surgery. Int Urogynecol J 24, 1803–1813 (2013). https://doi.org/10.1007/s00192-013-2171-2

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