Pelvic organ prolapse is one of the most common indications for hysterectomy in the United States, although the uterus is a passive structure in the development of prolapse.¹,²,³ In recent years, there has been a growing acknowledgment of the desire of many patients for uterine preservation, or hysteropexy, at the time of prolapse surgery. Patient surveys have demonstrated that, assuming equal surgical outcomes, 36% to 60% of women undergoing prolapse surgery in the United States would choose uterine preservation.⁴,⁵ International patient surveys show similar rates of interest in uterine preservation.⁶,⁷ Patient demographics are associated with preference for hysteropexy, with college-educated women 3 times more likely to choose uterine preservation, whereas women living in the Southern United States were less likely to request hysteropexy (odds ratio 0.7).⁵

There are a variety of reasons that patients are interested in uterine preservation including concerns about decreased libido, weight gain, hormonal changes, sense of feminine identity, cultural importance, and increased risk for hysterectomy complications. Interestingly, many reasons that patients report interest in uterine preservation are more closely related to ovarian function and conservation.⁴ Proven benefits of uterine preserving surgery compared to hysterectomy include decreased blood loss, shorter operating room time, and a decreased risk of early menopause.²,⁸,⁹ Consequently, it is important to fully elicit patient goals and their understanding of the surgical risks, benefits, and alternatives to provide patient-centered counseling during the informed consent process.

Uterine conservation may not be the best surgical options for many patients, and strict selection criteria should be maintained. Given the limited outcomes data, we prefer to avoid hysteropexy procedures for patients who desire future fertility. Instead, we encourage conservative management with observation, physical therapy, or a pessary until childbearing is complete. Additionally, uterine preservation is not recommended when there is an increased risk of subsequent cervical, uterine, or endometrial pathology, given the potential technical challenges of a subsequent hysterectomy. Women with recent or current cervical dysplasia should not be considered hysteropexy candidates, and patients undergoing hysteropexy should be up-to-date on cervical screening. Those with increased risks for endometrial cancer due to obesity, genetic syndromes such as Lynch syndrome, endometrial hyperplasia, or current tamoxifen use are also poor candidates for uterine preservation. Even with a negative workup, uterine preservation in patients with postmenopausal bleeding is discouraged because there remains a 13% lifetime risk of endometrial pathology, which may impact subsequent treatment.¹⁰ Current estimates of overall rates of endometrial cancer in patients who have undergone uterine preservation during prolapse surgery is 0.3% to 0.8%.¹⁰,¹¹ Additionally, there is limited to no access to adnexal structures during the majority of hysteropexy procedures; thus, women who have BRCA1 or BRCA2 mutations or a history of estrogen receptor-positive breast cancer should be offered hysterectomy and bilateral salpingo-oophorectomy. Patients should also be counseled on the inability to perform opportunistic salpingectomy at the time of most hysteropexy procedures, which decreases ovarian cancer risk up to 20%.¹² Lastly, there are anatomic factors to consider; women with abnormal uterine bleeding, fibroids, or adenomyosis are at a higher potential risk for future interventions, whereas women with cervical elongation may experience worse outcomes in uterine preserving prolapse procedures unless a partial trachelectomy is performed.¹³

As hysteropexy procedures and patient desire for uterine preservation increases, it is important to determine patient goals and expectations while maintaining strict selection criteria to limit potential surgical risks, uterine or cervical pathology, and recurrent prolapse.