Hysterectomy has historically been a mainstay in the surgical treatment of uterovaginal prolapse, even in cases in which the removal of the uterus is not indicated. However, uterine-sparing procedures have a long history and are now becoming more popular. Whereas research on these operations is underway, hysteropexy for the treatment of prolapse is not as well studied as hysterectomy-based repairs. Compared with hysterectomy and prolapse repair, hysteropexy is associated with a shorter operative time, less blood loss, and a faster return to work. Other advantages include maintenance of fertility, natural timing of menopause, and patient preference. Disadvantages include the lack of long-term prolapse repair outcomes and the need to continue surveillance for gynecological cancers. Although the rate of unanticipated abnormal pathology in this population is low, women who have uterine abnormalities or postmenopausal bleeding are not good candidates for uterine-sparing procedures. The most studied approaches to hysteropexy are the vaginal sacrospinous ligament hysteropexy and the abdominal sacrohysteropexy, which have similar objective and subjective prolapse outcomes compared with hysterectomy and apical suspension. Pregnancy and delivery have been documented after vaginal and abdominal hysteropexy approaches, although very little is known about outcomes following parturition. Uterine-sparing procedures require more research but remain an acceptable option for most patients with uterovaginal prolapse after a balanced and unbiased discussion reviewing the advantages and disadvantages of this approach.
In 2015, hysterectomy is a controversial topic. Should it be performed vaginally or abdominally? Should the robot be used? How will tissue be removed? And the biggest question of all: should it be done in the first place?
Hysterectomy is no longer a topic reserved for medical journals; headlines in lay publications such as the Wall Street Journal and Reader’s Digest address the controversy surrounding hysterectomy. In fact, hysterectomy has been cited as the number 1 surgery to avoid by Health Magazine , beating out episiotomy and heartburn surgery, and Dr Mehmet Oz has named it the number 1 surgery women do not need.
Feelings about hysterectomy are dependent on several factors: age, sex, race, cultural beliefs, completion of child-bearing, and whether one is the patient or the surgeon. Despite the controversy surrounding hysterectomy, more than 430,000 inpatient hysterectomies are performed in the United States annually with uterovaginal prolapse cited as the indication for approximately 74,000 cases.
Traditionally, operations to treat uterine and uterovaginal prolapse include hysterectomy, even when uterine disease is not present or suspected. However, it remains unknown whether concomitant hysterectomy at the time of prolapse surgery is integral to the effective cure of this condition, and few randomized clinical trials of hysterectomy vs no hysterectomy have been done.
The surgical treatment of uterovaginal prolapse using uterine-sparing techniques dates back to the late 1800s when hysterectomy was intentionally avoided as a means to decrease surgical morbidity. With the advent of antibiotics and improved surgical techniques, the morbidity and mortality related to hysterectomy were greatly reduced. This led to increased hysterectomy rates in the latter part of the 20th century, during which hysterectomy was considered favorable, given its potential to reduce the risk of endometrial and cervical cancer.
Vaginal hysterectomy at the time of prolapse repair is also perceived as advantageous because it creates access to the peritoneal cavity for high vaginal vault suspensions and reduces the risk of cervical elongation causing recurrent prolapse symptoms or dyspareunia. More recently, improvements in the conservative treatment for abnormal bleeding and symptomatic leiomyoma, as well as effective strategies for cervical cancer screening, the human papilloma virus (HPV) vaccine, and an emphasis on quality of life have led physicians to modify their thoughts on the role of hysterectomy when treating pelvic organ prolapse.
Advantages of uterine-sparing procedures
There is a renewed interest in uterine conservation among patients. Two independent studies investigated patient preferences toward hysterectomy in women undergoing evaluation for uterovaginal prolapse. Patients completed questionnaires delineating their perceptions and preferences of hysterectomy. Frick et al found that 60% of women indicated they would decline a hysterectomy if presented with an equally efficacious alternative to a hysterectomy-based prolapse repair. Those patients who were considered active decision makers and those who had family or friends who had negative experiences with hysterectomy were more likely to decline hysterectomy.
Similarly, Korbly et al found that 36% of women preferred uterine preservation when presented with equally efficacious surgical options. Interestingly, 21% of women in this study continued to prefer uterine preservation, even when the uterine-sparing prolapse procedure was associated with worse efficacy. Patient preferences were associated with geographic region, with more patients in the West and Northeast favoring uterine conservation.
The American Congress of Obstetricians and Gynecologists acknowledges the importance of patient autonomy and the increased patient access to information in a Committee Opinion published in 2013. They urge that decision making should be guided by patient autonomy, avoiding harm, cost-effectiveness, and the effects of choice on the health care system. They note that the importance of uncovering and incorporating, where possible, patients’ own priorities and values in their medical care is widely endorsed, especially when the preferences are informed and deeply held.
The need for hysterectomy at the time of prolapse repair has never been proven. Removing the uterus fails to address the underlying deficiency causing prolapse. Additionally, removal of the uterus disrupts the uterosacral-cardinal ligament complex (pericervical endopelvic fascia), which may further weaken support. This is not a novel concept because Bonney in the 1930s stated that the uterus has only a passive role in prolapse. Furthermore, uterine preservation at the time of prolapse repair avoids an unnecessary procedure and has been associated with faster operative times and less blood loss.
There may be additional benefits to avoiding hysterectomy, including preservation of ovarian and sexual function. Even in women who undergo ovarian-sparing hysterectomies, ovarian function is affected. Two studies have compared ovarian function after ovarian-sparing hysterectomies with a nonsurgical control group. In these studies, menopause was defined as follicle-stimulating hormone levels of ≥40 IU/L or higher. In these cohorts, approximately twice as many women who underwent hysterectomy became menopausal during the 4-5 year study period.
Sexual function is also often cited as a reason to avoid hysterectomy. However, 2 studies comparing sexual function after a hysterectomy-based or uterine-sparing prolapse repair have reported conflicting results. Jeng et al compared sexual function after randomizing women with uterovaginal prolapse to either transvaginal hysterectomy or transvaginal sacrospinous uterine suspension. The authors found no significant differences between groups in sexual scores, sexual interest, and orgasm frequency between the groups.
Costantini et al compared women who underwent hysterectomy and sacrocolpopexy with those who underwent a uterine-sparing procedure, noting that although both groups had improved scores on a validated questionnaire, the uterine-sparing group was associated with a greater improvement.
Studying sexual function in women is difficult, given the complex nature of sexual desire and sexual function. Furthermore, in a cohort of women with prolapse, preexisting sexual dysfunction, dyspareunia related to atrophy, low libido, and partner sexual dysfunction add additional challenges. To date, most published studies evaluating sexual function after uterine-sparing procedures include bias and confounding factors that may influence outcomes.
Please see Table 1 for perceived and studied advantages and disadvantages of uterine-preservation at the time of prolapse surgery.
| Advantages | Disadvantages |
|---|---|
| Reduction in surgical time and blood loss | Fewer surgical outcome data available |
| Maintenance of fertility | Maintenance of fertility |
| Natural menopausal timing | Small, ongoing risk for cervical or endometrial cancer |
| Avoidance of an unnecessary procedure | Subsequent hysterectomy may be difficult |
| Perceived role of the uterus and cervix in pelvic stability and sexual satisfaction | Continuation of menses |
| Less invasive | Ongoing surveillance of cervix and endometrium |
| Association with a quicker recovery | Colpopexy may be easier for surgeon after hysterectomy |
| Decreased risk of mesh exposure | |
| Similar short-term outcomes | |
| Patient preference |
Risk of unanticipated uterine pathology
One concern about uterine-sparing procedures is that by not removing the uterus, one avoids the opportunity to reduce the risk of gynecological cancers. The risk of cervical carcinoma has not been studied in hysteropexy, but data from studies evaluating supracervical hysterectomy can be extrapolated to uterine-sparing surgery. Even in studies that predated modern cytological and viral screening techniques, the rate of cervical carcinoma was low (below 0.3%). With improved cytological and viral screening and the HPV vaccine, the true rate is likely to be even lower.
Studies evaluating uterine pathology also demonstrate low risks for endometrial hyperplasia and cancer. Renganathan et al studied pathological specimens from 517 women who underwent vaginal hysterectomy for prolapse and found the rate of endometrial cancer to be 0.8%. Frick et al also evaluated the risk of unanticipated pathology at the time of hysterectomy for uterovaginal prolapse. Of 681 pathological specimens, 2.6% had unanticipated premalignant or malignant uterine pathology, including 0.3% with low-grade cervical dysplasia, 0.8% with simple hyperplasia, 0.5% with complex hyperplasia, 1.1% with complex hyperplasia with atypia, and 0.3% with endometrial carcinoma. Interestingly, none of the premenopausal women (even those with preoperative bleeding concerns) had premalignant or malignant pathology. In contrast, postmenopausal women with abnormal bleeding had a very high rate (13.3%) of unanticipated endometrial pathology despite negative preoperative diagnostic evaluations.
Currently, a noninvasive, cost-effective screening strategy does not exist for asymptomatic women desiring uterine-sparing surgery. Beyond a careful history, physical examination, Papanicolaou smear, and HPV screening, there are not sufficient data to recommend routine screening for endometrial pathology.
Most transvaginal ultrasound measurement data are described for women with postmenopausal bleeding and cannot be directly applied to asymptomatic women. In women without postmenopausal bleeding, using an endometrial thickness of ≥5 mm has a sensitivity of 83% and a specificity of 72% for detecting endometrial carcinoma, which are much lower than in women with postmenopausal bleeding. Office endometrial biopsy is associated with a high false-negative rate, and tests with better sensitivity and specificity are invasive. Furthermore, uterine-sparing prolapse procedures should not increase the risk of endometrial cancer nor do they mask the early symptoms.
Contraindications to uterine-sparing prolapse procedures are listed in Table 2 .
| Contraindications |
|---|
| Postmenopausal bleeding |
| Current or recent cervical dysplasia |
| Familial cancer syndrome, BRCA 1 and 2 |
| Hereditary nonpolyposis colonic cancer syndrome |
| Tamoxifen therapy |
| Uterine abnormalities |
| Fibroids, adenomyosis, abnormal endometrial sampling |
| Abnormal uterine bleeding |
| Inability to comply with routine gynecological surveillance |
| Cervical elongation (relative contraindication) |
Risk of unanticipated uterine pathology
One concern about uterine-sparing procedures is that by not removing the uterus, one avoids the opportunity to reduce the risk of gynecological cancers. The risk of cervical carcinoma has not been studied in hysteropexy, but data from studies evaluating supracervical hysterectomy can be extrapolated to uterine-sparing surgery. Even in studies that predated modern cytological and viral screening techniques, the rate of cervical carcinoma was low (below 0.3%). With improved cytological and viral screening and the HPV vaccine, the true rate is likely to be even lower.
Studies evaluating uterine pathology also demonstrate low risks for endometrial hyperplasia and cancer. Renganathan et al studied pathological specimens from 517 women who underwent vaginal hysterectomy for prolapse and found the rate of endometrial cancer to be 0.8%. Frick et al also evaluated the risk of unanticipated pathology at the time of hysterectomy for uterovaginal prolapse. Of 681 pathological specimens, 2.6% had unanticipated premalignant or malignant uterine pathology, including 0.3% with low-grade cervical dysplasia, 0.8% with simple hyperplasia, 0.5% with complex hyperplasia, 1.1% with complex hyperplasia with atypia, and 0.3% with endometrial carcinoma. Interestingly, none of the premenopausal women (even those with preoperative bleeding concerns) had premalignant or malignant pathology. In contrast, postmenopausal women with abnormal bleeding had a very high rate (13.3%) of unanticipated endometrial pathology despite negative preoperative diagnostic evaluations.
Currently, a noninvasive, cost-effective screening strategy does not exist for asymptomatic women desiring uterine-sparing surgery. Beyond a careful history, physical examination, Papanicolaou smear, and HPV screening, there are not sufficient data to recommend routine screening for endometrial pathology.
Most transvaginal ultrasound measurement data are described for women with postmenopausal bleeding and cannot be directly applied to asymptomatic women. In women without postmenopausal bleeding, using an endometrial thickness of ≥5 mm has a sensitivity of 83% and a specificity of 72% for detecting endometrial carcinoma, which are much lower than in women with postmenopausal bleeding. Office endometrial biopsy is associated with a high false-negative rate, and tests with better sensitivity and specificity are invasive. Furthermore, uterine-sparing prolapse procedures should not increase the risk of endometrial cancer nor do they mask the early symptoms.
Contraindications to uterine-sparing prolapse procedures are listed in Table 2 .
| Contraindications |
|---|
| Postmenopausal bleeding |
| Current or recent cervical dysplasia |
| Familial cancer syndrome, BRCA 1 and 2 |
| Hereditary nonpolyposis colonic cancer syndrome |
| Tamoxifen therapy |
| Uterine abnormalities |
| Fibroids, adenomyosis, abnormal endometrial sampling |
| Abnormal uterine bleeding |
| Inability to comply with routine gynecological surveillance |
| Cervical elongation (relative contraindication) |
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