Alternatives to Hysterectomy in Patients With Uterovaginal Prolapse

Abstract

Background: Uterovaginal prolapse is a common problem in women. Hysterectomy has been considered as a standard procedure during surgical management of pelvic organ prolapse. However, in recent years, interest has been growing in the use of uterus-preserving surgeries. Different options available for uterine preservation include the Manchester Fothergills operation, sacral hysteropexy (abdominal, laparoscopic or robotic with or without mesh), uterosacral ligament hysteropexy, sacrospinous hysteropexy (with or without mesh) and colpocleisis. The aim of this review was to analyze the different options of uterus-preserving surgeries and compare their outcomes with prolapse surgeries including hysterectomy.

Methods: PubMed, MEDLINE, Clinical trials.gov and the Hinari database were reviewed through 2020 by two of the authors. Only randomized controlled trials (RCTs) or non-randomized prospective controlled studies (nrPCSs) where different uterus-preserving surgeries for uterovaginal prolapse were compared with surgeries involving hysterectomy were included for the review.

Results: We identified 225 articles from the electronic search and 19 articles meeting the inclusion and exclusion criteria were reviewed. Among them, 10 were RCTs and nine were nrPCSs. The review identified that objective prolapse recurrence, quality of life and adverse events were similar between uterine preservation and hysterectomy groups. Abdominal routes were non-inferior to vaginal uterus-preserving surgeries. Need for repeat surgery after a hysteropexy procedure ranged from 2% to 29%. The Manchester operation demonstrated good anatomical and symptomatic improvement as compared to hysterectomy. When comparing sacrohysteropexy routes, the laparoscopic approach had lower recurrent prolapse symptoms than open sacrohysteropexy. Operating time and estimated blood loss were less with uterus-preserving surgeries. The most common adverse events in hysteropexy surgeries were urinary incontinence, voiding dysfunction, sexual dysfunction and mesh erosion, when mesh used.

Conclusion: The evidence from currently available literature suggests the vaginal and abdominal uterus-preserving surgeries to be equally effective, and not inferior to surgical procedures including hysterectomy. When surgeons are faced with a patient requesting uterine preservation, counseling should be performed cautiously regarding choosing one type of hysteropexy over another. However, the data on long-term follow-up and outcomes are lacking.

J Clin Gynecol Obstet. 2022;11(3):53-61
doi: https://doi.org/10.14740/jcgo795