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
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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.
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