Preservation of the uterus in vaginal prolapse surgery: the sacrospinous hysteropexy

Abstract

With the enormous growth of the world population in the last decades and the higher life expectancy, pelvic organ prolapse has become a world wide health problem. In the Netherlands, in case of a uterine descent, a vaginal hysterectomy is a popular procedure to perform. However, from current literature, more evidence is gained suggesting that removing the uterus in prolapse surgery might be unnecessary. Moreover, preserving the uterus was associated with less morbidity and a shorter recovery time. The sacrospinous hysteropexy, a procedure in which the uterus is preserved and fixed to the sacrospinous ligament in case of a uterine descent, has been performed since 1989. The few studies published describing this procedure focus on anatomical outcomes, not on functional outcomes and quality of life. We first performed a retrospective study in which the sacrospinous hysteropexy was found to be an efficient procedure with a low complication rate. 84% of women was (highly) satisfied with the procedure and 91% would recommend the procedure to other women. Recurrent surgery because of prolapse symptoms was performed in 2.3% of women. Recurrent cystocele stage 2 or more was found in 38% of women, however these women did not experience more functional symptoms compared to women without a recurrent cystocele. A second study showed that functional outcomes and quality of life, measured with validated questionnaires before and after surgery, improved significantly after a sacrospinous hysteropexy. To answer the question if the sacrospinous hysteropexy is a better procedure compared to the more common vaginal hysterectomy in terms of morbidity, anatomical outcomes, functional outcomes and quality of life, a randomized study was performed. Compared with a vaginal hysterectomy, hospitalization was 1 day shorter (P = 0.03) and women were able to return to work 23 days earlier (P = 0.02). Although urogenital symptoms and quality of life scores after both procedures were comparable a year after surgery, anatomical outcomes differed. At 1-year follow-up, the recurrence rates for the anterior and posterior compartment were comparable. Of all women with a stage 2-4 prolapse pre operative, a lower recurrence rate was found of the apical compartment after vaginal hysterectomy compared to women who had a sacrospinous hysteropexy. The difference in risk for recurrent apical descent was 17% (95% CI, 2 to 30) in favour of the vaginal hysterectomy. Especially high recurrence was noted in the preoperative high stage prolapse patients who underwent a sacrospinous hysteropexy. However, recurrent surgery was not significantly higher after a sacrospinous hysteropexy. Surgery for prolapse after a sacrospinous hysteropexy was performed in 11% (4/35) of patients. Surgery for prolapse after a vaginal hysterectomy occurred in 7% (2/31) of patients (Risk difference: 5%, 95% CI = -9 - 19). We can conclude that the sacrospinous hysteropexy is a good alternative for women who wish to preserve their uterus. This seems most appropriate for patients with a prolapse stage 2 and 3 pre operative.