Complications and objective outcomes of uterine preserving surgeries for the repair of pelvic organ prolapse versus procedures removing the Uterus, a systematic review

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Abstract

Background

Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data.

Methods

We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis.

Results

Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD =  − 0.159 days, 95% CI [−0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD =  − 0.339, 95% CI [−0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD =  − 1.191 h, 95% CI [−1.836, −0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]).

Conclusion

We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.

Introduction

Pelvic organ prolapse (POP) is defined as a descent of one or more of the pelvic organs, including the uterus, vaginal cuff, urinary bladder, urethra, bowel, and rectum down through the vagina canal [1]. It is a major gynecological health problem that affects negatively women's quality of life and sexual activity all over the world [2]. Approximately 50% of all women will develop POP, but not all of them will seek medical care for clinical evaluation, so the exact prevalence is difficult to estimate [3]. There is wide variation of how often POP is reported, however almost all authors agree that the incidence of POP is increasing, which is most likely due to increased life expectancies around the world, as aging is an important risk factor for POP. POP is found in approximately 31% of women aged 50–59 years and 50% of women aged 80 years or older [4], [5]. Other risk factors most commonly associated with POP are obesity, repeated vaginal childbirth, and high parity. Other less directly associated factors include the prolongation of the second stage of labor, repeatedly carrying heavy objects, forceps delivery, high infant birth weight, and early age of first delivery. These factors lead to weakness in the connective tissue of the pelvic floor, which eventually can lead to prolapse [4], [6], [7], [8].

The management options for POP include surgical intervention, pelvic floor exercises and physical therapy, and vaginal pessaries. Surgical interventions can further be divided into obliterative surgery (such as colpocleisis) and reconstructive surgeries which may or may not include mesh augmentation or hysterectomy as part of the procedure [9], [10]. About 11.1% of women with POP will eventually opt for surgical intervention to correct the POP or related stress urinary incontinence [11]. The decision will depend on patient symptomatology, desire for sexual function, impact on the quality of life, and medical comorbidities. The decision of whether to combine a reconstructive surgery with a hysterectomy is based on many factors. The desire to retain fertility is the main contraindication for hysterectomy. Hysterectomy is more appropriate with the presence of cervical dysplasia, abnormal uterine bleeding, large fibroids, or uterine anomalies [9], [10]. However, hysterectomy without a reconstructive procedure is associated with frequent apical prolapse rates as it does not address the apical support [12]. For many reasons, reconstructive procedures that include preservation options have become more popular and more sought after by women in recent years [13]. The superiority of uterine preservation for surgical repair of POP when compared to surgeries including vaginal hysterectomy is still unclear [14]. For this reason, we sought to perform a systematic review and meta analysis to compare the outcomes and safety of different surgical procedures to repair POP while sparing the uterus, compared with those same procedures that include hysterectomy.

Section snippets

Material and methods

We followed the PRISMA statement guidelines [1], [15] during the preparation of this systematic review and meta-analysis and performed all steps in a strict accordance to the Cochrane handbook of systematic reviews of intervention [2].

Search results and characteristics of included studies

Our search retrieved 1521 unique citations from searching electronic databases. Following title and abstract screening, 34 full-text articles were retrieved and screened for eligibility. Of them, 20 articles were excluded, and 14 studies (n = 1285 patients) were reviewed in detail and included in this meta-analysis (PRISMA flow diagram; Fig. 1). All of the included studies were conducted between 2004 and 2020. With regard to the surgical approach, six studies utilized the open abdominal or

Discussion

Our analysis found that uterine sparing surgical procedures for POP had a significantly shorter operative time when compared to procedures that included removal of the uterus. In the subgroups analyses, we found that the vaginal approach had significantly shorter operative time in the two groups, however, the abdominal and laparoscopic approach showed no significant difference whether or not the uterus was removed. Nevertheless, no significant difference was found between the two groups

Ethics approval and consent to participate

This Manuscript has been reviewed by the institutional IRB committee at Marchand Institute and was found to be exempt from IRB review. (January 2021). Data used was exempt from consent to participate or publish secondary to the nature of the study being a systematic review, retrospectively looking at previously published data.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

The Marchand Institute for Minimally Invasive Surgery would like to acknowledge the efforts of all of the students, researchers, residents and fellows at the institute who put their time and effort into these projects without compensation, only for the betterment of women’s health. We firmly assure them that the future of medicine belongs to them.

References (44)

  • A. Olsen et al.

    Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence

    Obstet Gynecol

    (1997)
  • N.B. Korbly et al.

    Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse

    Am J Obstet Gynecol

    (2013)
  • B.T. Haylen et al.

    An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP)

    Neurourol Urodyn.

    (2016)
  • Avcıbay Vurgeç B, Kızılkaya Beji N. İleri Evre Pelvik Organ Proplapsusu Olan Kadınlarda Yaşam Kalitesi Ve Cinsel Yaşam....
  • M.D. Barber et al.

    Epidemiology and outcome assessment of pelvic organ prolapse

    Int Urogynecol J Pelvic Floor Dysfunct.

    (2013)
  • A.Y. Weintraub et al.

    Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse

    Int Braz J Urol.

    (2020)
  • M.C.P. Slieker-ten Hove et al.

    The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population

    Int Urogynecol J.

    (2009)
  • G.J.A. Walker et al.

    Pelvic organ prolapse and incontinence in developing countries: review of prevalence and risk factors

    Int Urogynecol J.

    (2011)
  • G.G. Masenga et al.

    Prevalence and risk factors for pelvic organ prolapse in Kilimanjaro, Tanzania: a population based study in Tanzanian rural community

    PLoS One

    (2018)
  • T. Belayneh et al.

    Pelvic organ prolapse in Northwest Ethiopia: a population-based study

    Int Urogynecol J

    (2020)
  • H. Jefferis et al.

    Management of uterine prolapse: is hysterectomy necessary?

    Obstet Gynaecol

    (2016)
  • I. Kuncharapu et al.

    Pelvic organ prolapse

    Am Fam Physician

    (2010)
  • P. Dällenbach et al.

    Incidence rate and risk factors for vaginal vault prolapse repair after hysterectomy

    Int Urogynecol J

    (2008)
  • C. Maher et al.

    Surgery for women with apical vaginal prolapse (Review) SUMMARY OF FINDINGS FOR THE MAIN COMPARISON

    Cochrane Database Syst Rev

    (2016)
  • Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred Reporting Items for Systematic Reviews and...
  • Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions: Cochrane Book Series. Vol. Version 5.,...
  • Green S, Higgins P. Julian T, Alderson P, Clarke M, Mulrow D C, Oxman D A. Cochrane Handbook: Cochrane Reviews: Ch 8:...
  • X. Wan et al.

    Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range

    BMC Med Res Methodol

    (2014)
  • M. Egger et al.

    Bias in meta-analysis detected by a simple, graphical test

    BMJ

    (1997)
  • S. Carramão et al.

    A randomized comparison of two vaginal procedures for the treatment of uterine prolapse using polypropylene mesh: hysteropexy versus hysterectomy

    Revista do Colegio Brasileiro de Cirurgioes

    (2009)
  • E.B. de Castro et al.

    Vaginal hysterectomy with bilateral sacrospinous fixation plus an anterior mesh versus abdominal sacrocervicopexy for the treatment of primary apical prolapse in postmenopausal women: a randomized controlled study

    Int Urogynecol J

    (2020)
  • P. Rahmanou et al.

    Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study

    Int Urogynecol J.

    (2015)
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