Hypothesis / aims of study
Pelvic organ prolapse (POP) is common in postmenopausal women, with a lifetime risk of 11%. The etiology of POP is multifactorial. Neuromuscular dysfunction and fascial defect were included. Uterine prolapse may be caused by the weakness of the ligament complex. Surgery with native tissue repair such as anterior or posterior colporrhaphy showed a high recurrence rate (1).
The choice of surgery for POP was including vaginal hysterectomy and transvaginal mesh (TVM). However, vaginal hysterectomy was associated with a high recurrence rate of apical prolapse due to cut all ligament attached to the uterus. Transvaginal mesh repair provided a high success rate but also increased complications such as mesh exposure, dyspareunia, and hematoma etc. FDA announced the mesh repair is in high risk.
During the last decade, laparoscopic sacropexy had became popular due to most TVM were off-market and good results of POP correction. Both laparoscopic and abdominal sacropexy were recommended for POP treatment and yield good results. Uterine sparing surgery for POP was one of the choices due to effectively easy the prolapse symptoms, sexual function and psychological well being. This kind of surgery also preserve the ligaments around the cervix and can be strengthened by non-absorbable materials.
The aim of this study is to compare the surgical outcome of laparoscopic hysteropexy (LH) versus supracervical hysterectomy (SH) plus cervicopexy for the treatment of POP.
Study design, materials and methods
In this study, we retrospectively included patients who underwent laparoscopic sacral hysteropexy or cervicopexy between January 2015 and September 2017 at Hualien Tzu Chi Hospital. Data were extracted from the medical charts: age at the time of surgery, body mass index at the time of admission, an initial stage of genital prolapse, operative and postoperative data, and anatomical results. Genital prolapse stage was classified according to the International Continence Society Pelvic Organ Prolapse Quantification (POP-Q).
Laparoscopic sacral cervicopexy was performed by a single trained surgeon in all cases. A non-absorbable polypropylene mesh (Alyte™ Y-mesh, JUNE Medical, Buckinghamshire, London, UK) was sutured to the anterior and posterior wall of the cervix. A supracervical hysterectomy (SH) was associated if a uterine abnormality was diagnosed (menorrhagia or enlarged uterus).
When Y-mesh using in hysteropexy (uterus sparing surgery), we cut both leaves of mesh into the same width with posterior leaf. We left 5cm in length in both leaves to be able to circle the cervix. We adapted the previous published hysteropexy method.
Postoperatively (at six months of follow-up), clinical results were assessed objectively using the POP-Q. Surgery was considered successful if the POP score (according to the POP-Q) was below stage 2 for all compartments.
Statistical analyses of the data were performed using SPSS 20.0 (IBM, Armonk, NY, USA). The Mann-Whitney U test was used to compare continuous variables. A P value of less than 0.05 is considered to be significant.
Totally, 16 patients received laparoscopic hysteropexy (n=7) or SH plus cervicopexy (n=9). The mean ages of the patients were 60 and 58 years in hysteropexy and SH plus cervicopexy, respectively. Their mean BMI were 24.1 and 23.7 in hysteropexy and SH plus cervicopexy, respectively. Their mean parities were 3 and 2.5 in hysteropexy and SH plus cervicopexy, respectively (Table 1).
Surgical outcome showed the mean surgical time in hysteropexy was shorter than SH plus cervicopexy (124 and 182 minutes, respectively, p=0.002). Postoperative VAS pain scores were 1.29 and 0 in hysteropexy and SH plus cervicopexy, respectively. The mean blood loss amount was 52.8 and 55.5 ml in hysteropexy and SH plus cervicopexy, respectively. The mean hospital stay was 3.2 and 4.1 days in hysteropexy and SH plus cervicopexy, respectively (Table 1).
All the women were available for follow-up in the clinic at 6 months after their operations. In 16 out of 16 women (100%) the procedure was successful, with no objective evidence of uterine prolapse on examination at follow-up (Table 2).
Interpretation of results
Our findings suggest that both LH group and SH plus cervicopexy group result in objective improvement without evidence of uterine prolapse at the 6-month follow-up. LH was significantly associated with shorter operation time. Age, parity, BMI, operation blood loss, and hospital stay were similar in both groups. In this condition, our findings provide support for the clinical practice of women who need fertility conservation that laparoscopic hysteropexy is feasible with satisfactory outcome. A recent systematic review including 94 studies by Meriwether et al. suggests that uterine-preserving prolapse surgeries decrease operating time, blood loss and morbidities without worsening short-term prolapse outcomes (2).
Vaginal hysterectomy has been considered as a traditional surgical treatment of uterine prolapse, even in the absence of uterine disease. Nowadays, surgeons may offer several management options to women with symptomatic pelvic organ prolapse, including vaginal, abdominal and laparoscopic or robotic procedures. Growing studies suggest that hysterectomy has been associated with hypertension, hyperlipidemia, coronary artery disease, obesity, and lower urinary tract symptoms (3). Uterine conservation is also important for women who want to preserve fertility, improve sexual function, retain self-confidence, self-esteem, or a sense of femininity. Therefore, recently there has been increased popularity in preserving the uterus during prolapse surgery. Laparoscopic uterine preservation surgery for POP has developed rapidly, as it is a minimally invasive surgical approach with better visualization, reduced blood loss, shorter hospital stay and decreased postoperative pain. Our study indicates future trends of operations for managing POP.