Hypothesis / aims of study
The choice between hysterectomy or uterus preservation in patients with pelvic organ prolapse (POP) > stage II is still a controversial matter, depending on several factors and different surgical approach can make the difference. Aim of this study is to compare objective and subjective outcomes in women who underwent sacrocolpopexy with or without hysterectomy
Study design, materials and methods
This study is a single center prospective study performed in a tertiary urogynaecological center and included all the patients with symptomatic II to IV stage POP according to the POP-Q classification who performed sacrocolpopexy with total hysterectomy (HYSP) or with uterus preservation (HSP) by abdominal or laparoscopic route.The choice between HYSP or HSP included a detailed counseling.The exclusion criteria were: post-menopausal bleeding, previous CIN, abnormal cervical smears, uterine disease including uterine enlargement or cervical ulceration, and a family history of adnexal or uterine cancer.
The preoperative evaluation included: history, clinical examination, urodynamic test. All women completed the short form of Incontinence Impact Questionnaire (IIQ-7), Urinary Distress Inventory (UDI-6) and the Female Sexual Function Index Questionnaire (FSFI).All surgical procedures were performed by one senior surgeon. Preoperative assessments were repeated at regular follow-up visits, scheduled for 1, 3, 6 and 12 months postoperatively and then annually. Perioperative as well as late complications were recorded according to the Clavien–Dindo classification. The patient’s satisfaction with the operation was assessed with the Patient Global Impression of Improvement (PGI-I) questionnaire. The Mann-Whitney and Wilcoxon tests for unpaired and paired data, respectively, were used to compare ordinal and non-normally distributed continuous variables. Categorical data were analyzed by the McNemar, chi-square or Fisher exact test. Two-tailed p <0.05 was considered significant. All calculations were performed with IBM-SPSS®, version 23.0, (IBM Corp., Armonk, NY, USA, 2015).
Between December 2013 to December 2018 139 patients, with symptomatic stage >II urogenital POP underwent SC in our tertiary urogynaecological center ( 85 HYSP and 55 HSP). Three patients (2 in the HYSP group and 1 in the HSP group) were lost at the last follow-up so 136 patients were included in the study. At a median follow-up of 49.2 months (range 12 to 61 months) clinical evaluation showed a good anatomical correction in both groups with no differences between the HYSP and HSP group (Table I). No patients had apical recurrence and there was a 100% cure rate for both groups. In HSP group there were four and three cases of asymptomatic stage II persistence in anterior and posterior compartments respectively; while in HYSP three and two out of 83 patients had asymptomatic anterior and posterior persistence (stage II) respectively. None of these patients underwent reoperation. In both groups no woman had recurrent of anterior or posterior prolapse. Table II showed functional results that demonstrated a significant improvement in all the symptom post-operatively without any difference between the two groups. Furthermore IIQ-7, UDI-6 and FSFI scores were significantly improved, in both groups. The patient’s satisfaction (PGI-I scores) was high in both group. The 95% in HYSP group and 96% in HSP group reported that they are “very much better” or “much better” satisfied with the operation. According to the Clavien Dindo in both groups there were 2 cases of complications of grade I, 6 cases of grade II in HYSP group, and 3 in HSP group. In HYSP and in HSP groups there were 9 and 4 complications grade III respectively.Six cases of mesh exposures were recorded in HYSP group and 2 in HSP group. All mesh exposures were treated by vaginal revision. No anatomical and functional differences there were between abdominal and laparoscopic approach.
Interpretation of results
The preservation of the uterus does not lead to a worsening of long-term outcomes. It is probably due to the surgical technique of affixing the mesh that is able to correct all three compartments at the same time and to bring the uterus back to its original angle