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Alternatives to Hysterectomy in Patients With Uterovaginal Prolapse

Article in Journal of Clinical Gynecology and Obstetrics · September 2022

DOI: 10.14740/jcgo795

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 Review J Clin Gynecol Obstet. 2022;11(3):53-61

Alternatives to Hysterectomy in Patients With

Uterovaginal Prolapse
Baburam Dixit Thapaa, c, Tulasa Basneta, G. Willy Davilab,
Mohan Chandra Regmia

Abstract function, sexual dysfunction and mesh erosion, when mesh used.

Background: Uterovaginal prolapse is a common problem in wom- Conclusion: The evidence from currently available literature sug-
en. Hysterectomy has been considered as a standard procedure during gests the vaginal and abdominal uterus-preserving surgeries to be
surgical management of pelvic organ prolapse. However, in recent equally effective, and not inferior to surgical procedures including
years, interest has been growing in the use of uterus-preserving sur- hysterectomy. When surgeons are faced with a patient requesting
geries. Different options available for uterine preservation include the uterine preservation, counseling should be performed cautiously re-
Manchester Fothergill’s operation, sacral hysteropexy (abdominal, garding choosing one type of hysteropexy over another. However, the
laparoscopic or robotic with or without mesh), uterosacral ligament data on long-term follow-up and outcomes are lacking.
hysteropexy, sacrospinous hysteropexy (with or without mesh) and
Keywords: Hysterectomy; Sacrohysteropexy; Uterus-preserving
colpocleisis. The aim of this review was to analyze the different op-
surgeries; Uterine suspension; Uterovaginal prolapse; Vaginal hyster-
tions of uterus-preserving surgeries and compare their outcomes with
opexy
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 Introduction
controlled studies (nrPCSs) where different uterus-preserving surger-
ies for uterovaginal prolapse were compared with surgeries involving
Pelvic organ prolapse (POP) is a common condition that may
hysterectomy were included for the review.
affect up to 50-70% of women worldwide. On an average, a
Results: We identified 225 articles from the electronic search and 19 woman has an 11% risk of undergoing surgery for POP dur-
articles meeting the inclusion and exclusion criteria were reviewed. ing her lifetime [1]. Pelvic reconstructive surgery can be per-
Among them, 10 were RCTs and nine were nrPCSs. The review iden- formed through either abdominal (laparoscopy or laparotomy)
tified that objective prolapse recurrence, quality of life and adverse or vaginal routes.
events were similar between uterine preservation and hysterectomy Even though the uterus may not be culprit for develop-
groups. Abdominal routes were non-inferior to vaginal uterus-pre- ment of prolapse, hysterectomy is traditionally performed
serving surgeries. Need for repeat surgery after a hysteropexy proce- along with POP repairs [2]. Transvaginal hysterectomy (TVH)
dure ranged from 2% to 29%. The Manchester operation demonstrat- for POP typically is accompanied by vaginal vault suspension
ed good anatomical and symptomatic improvement as compared to by either uterosacral ligament suspension (USLS) or sacros-
hysterectomy. When comparing sacrohysteropexy routes, the laparo- pinous ligament fixation (SSLF). More recently, the role of
scopic approach had lower recurrent prolapse symptoms than open hysterectomy during POP repair has been under debate. While
sacrohysteropexy. Operating time and estimated blood loss were less some researchers believe that hysterectomy increases risk of
with uterus-preserving surgeries. The most common adverse events complications, others believe that uterine preservation increas-
in hysteropexy surgeries were urinary incontinence, voiding dys- es the risk of recurrence [3].
Currently, women are increasingly choosing apical POP
surgeries that preserve the uterus, a collection of procedures
Manuscript submitted January 31, 2022, accepted July 6, 2022 also known as hysteropexy. Preservation of the uterus may be
Published online September 30, 2022 desired for many reasons including future fertility, avoiding
higher complication rates during hysterectomy, beliefs regard-
aDepartment of Obstetrics and Gynecology, BP Koirala Institute of Health Sci-
ing impaired sexual function following hysterectomy, and
ences, Dharan, Nepal
bHoly Cross Medical Group, Fort Lauderdale, FL, USA personal choice. Uterine preservation surgeries include Man-
cCorresponding Author: Baburam Dixit Thapa, Department of Obstertrics and chester Fothergill’s operation, sacral hysteropexy (abdominal,
Gynecology, BPKIHS, Dharan, Nepal. Email: baburamdixit@yahoo.com laparoscopic or robotic with or without mesh), sacrospinous
hysteropexy (SSHP, with or without mesh), USLS and col-
doi: https://doi.org/10.14740/jcgo795 pocleisis. The available data show most approaches are equal-

Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org
This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits 53
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited
Alternatives to Hysterectomy for Prolapse J Clin Gynecol Obstet. 2022;11(3):53-61

Figure 1. Flowchart showing screening of studies.

ly effective [4]. sion were excluded.

There are no clear guidelines on alternatives to hysterec- Studies were graded as good (A), fair (B) and poor (C)
tomy in the repair of POP [5, 6]. Given that the number of dif- depending on the quality of study, risk of biases and complete-
ferent studies comparing hysteropexy procedures in different ness of report based on outcomes according to the Cochrane
reviews is limited, it is difficult to recommend any specific risk of bias tool [7] and relevant questions from Newcastle-
alternative to hysterectomy. We conducted a review of recent Ottawa scale [8].
randomized controlled trials (RCTs) and prospective compara- Alternatives to hysterectomy were categorized as Man-
tive studies, comparing POP surgery with hysterectomy and chester procedure (MP), modified Manchester (MM), SSHP,
alternatives to hysterectomy (hysteropexy). vaginal uterosacral hysteropexy, vaginal mesh sacrospinous
hysteropexy (VMSSHP), laparoscopic or robotic sacrohyster-
opexy (LRSHP), laparoscopic uterosacral hysteropexy (Lap
Materials and Methods USHP) and abdominal sacrohysteropexy (Abd SHP).

We performed a systematic search of articles published in

peer-reviewed, open-access, indexed journals. An electronic
Results
search was conducted on PubMed, MEDLINE,Clinical trials.
gov and the Hinari database until through December 2020. Eighty full text articles were identified from the search of da-
Search terms included hysteropexy, uterine prolapse, pel- tabases. Nineteen articles met the inclusion and exclusion cri-
vic organ prolapse, uterine preservation, and hysterectomy. teria at the end of the review process. Among them, 10 were
Studies were selected according to population, intervention, RCTs and nine were prospective controlled studies (Fig. 1).
comparator, outcome and study design (PICOS) criteria. To The RCTs compared hysterectomy to hystero-preserva-
be included in the review, the study population had to have tion with different fixation types, or different routes or types of
POP with a uterus, undergoing surgery (uterine preserving or uterus-preserving surgeries in the management of uterovaginal
hysterectomy) and the study design had to be either an RCT or prolapse. Of these, 17 studies compared hysterectomy with
non-randomized prospective controlled study (nrPCS) where hystero-preservation with 14 studies that included vaginal hys-
uterine preservation was compared with hysterectomy. Stud- terectomy. Three studies compared Manchester operation with
ies needed to include assessment of one or more POP out- vaginal hysterectomy. Six RCTs and three prospective con-
comes, perioperative or postoperative adverse events, sexual trolled studies compared SSHP with other surgeries. One RCT
health or quality of life (QoL). Prospective single arm studies, and one nrPCS used vaginal mesh during SSHP. Abdominal
retrospective studies, studies with obliterative surgery (col- route surgeries were compared in six studies (three RCTs and
pocleisis), and studies with only abstract published were not three nrPCS). Among them, two studies used a laparoscopic
included. Studies that included hysterectomy for non-prolapse approach, whereas four used an open approach.
benign (fibroid uterus, cervical dysplasia, and adenomysosis) Vaginal hysterectomy technique and any performed asso-
or malignant diseases and POP surgery without apical suspen- ciated POP repairs (vault, anterior or posterior) were not uni-

54 Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org
Dixit Thapa et al J Clin Gynecol Obstet. 2022;11(3):53-61

Table 1. Characteristics of Studies Comparing Manchester Procedure With TVH

Study Design Surgery Follow-up Outcomes

Thys et al [12] nrPCS Manchester vs. 6 weeks 1) Operating time: 67 vs. 101 min (P = 0.01)
TVH with USLS 2) Blood loss: 250 vs. 358 mL (P = 0.01)
3) Repeat surgery: 4% vs. 9% (P = 0.15)
Tolstrup et al [13] Prospective Manchester vs. 24 months 1) Apical recurrence: 0.3% vs. 5.1% (P = 0.004)
cohort study TVH with USLS 2) Overall recurrence: 7.8% vs. 18.3% (P = 0.002)
3) Repeat surgery: 2% vs. 8.5% (P ≤ 0.05)
Unlubilgin et al [14] RCT Manchester vs. 5 years 1) Operating time: 62 vs. 77 min (P = 0.003)
TVH with USLS 2) Postop point C: -6.3 vs. -6 cm (P = 0.132)
3) Postop TVL: 8.3 vs. 6 cm (P = 0.016)
nrPCS: non-randomized prospective controlled study; RCT: randomized controlled trial; TVH: transvaginal hysterectomy; TVL: total vaginal length;
USLS: uterosacral ligament suspension.

formly detailed in the reviewed papers. The same can be said In contrast to previous studies that showed similar ana-
about the uterine preservation papers reviewed, as most did not tomical and symptomatic improvement after both the pro-
detail additional POP repairs performed, or their techniques cedures, Tolstrup et al in 2017 [13] found that the risk of
used. We thus did not analyze the possible impact of these vari- recurrent or de novo POP in any compartment was higher
ables on the reported outcomes. We also did not include that after TVH (18.3%) compared to MP (7.8%) and there were
information in the summary tables. more perioperative complications (2.7% vs. 0%, P = 0.007)
Since there are different alternatives to hysterectomy in after TVH. The authors concluded that MP should be recom-
terms of type or route of sugery, we reviewed them based on mended over TVH for surgical treatment of POP in the apical
chosen route: either vaginal or abdominal (open/laparoscopic/ compartment if there are no additional indications for hys-
robotic) hysteropexy. terectomy. With 2- to 5-year follow-up, the recurrence rate
of uterine prolapse ranged from 2.04% to 7.8% and repeat
surgery was 1.1-5.4%.
Vaginal route surgeries

This includes MP, vaginal SSHP and vaginal mesh hyster- SSHP with or without mesh
opexy.
The most researched vaginal approach for uterine preservation
prolapse surgery is SSHP, which was first described by Rich-
The Manchester operation
ardson [15]. It suspends the cervix with permanent or delayed
absorbable sutures by employing the sacrospinous ligaments.
MP is considered as one of the earliest uterus-preserving sur- The comparison of transvaginal SSHP with other opera-
geries. Cervical elongation (hypertrophy) is the most common tions was explored in nine studies (Table 2) (six RCTs and
reason for the procedure. The cervix is removed and the stump three nrPCSs). Six studies compared SSHP versus TVH (four
reattached to the cardinal and/or utero-sacral ligaments. The RCTs [16-19] and two nrPCSs [20, 21]). One RCT [22] com-
uterosacral and cardinal ligaments are plicated posteriorly and pared SSHP with Lap SHP and two (one RCT [23] and one nr-
anteriorly, respectively in modified Manchester operations PCS [24]) compared mesh augmented SSHP with TVH. In one
(Sturmdorf sutures) [9, 10]. Most of the research on MP are study, TVH was compared to a combination of uterine preser-
retrospective [11] or prospective controlled trials (Table 1) vation surgical techniques [25]. Two cohort studies compar-
[12-14] and demonstrated significant anatomical and symp- ing SSHP with vaginal hysterectomy found no difference in
tomatic improvement as a result of the surgery. We included anatomical or symptomatic improvement, but the vaginal hys-
two nrPCSs and one RCT in this review [9-11]. A retrospec- terectomy group had a three-fold increase in overactive blad-
tive study done in the Netherlands showed significantly less der complaints. SSHP is advantageous in terms of blood loss,
operating time and blood loss in the Manchester group than operational time, and recovery time. However, SSHP had the
in the hysterectomy group [8]. The only RCT done in Turkey same rates of recurrence and reoperation as the hysterectomy
[11] found that the Manchester group had significantly shorter group [20, 21].
surgical time (62 vs. 77 min) and significantly shorter hospi- A study done by Dietz et al [18] showed that SSHP had a
tal stay (P = 0.042) than the vaginal hysterectomy group. Five shorter operative time and less blood loss. The hysterectomy
years after the surgery, there was no statistically significant group had 17% (95% CI: 2-30) decrease in recurrent prolapse
difference in the postoperative mean C point level between the compared to SSHP. There were no differences in QoL and uro-
groups (P = 0.132). Thys et al [12] discovered no differences in genital symptoms between the groups.
functional results or POP recurrence rates between the groups In 2012, SSHP and vaginal hysterectomy with USLS
in a similar study. were compared in a randomized controlled experiment. The

Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org 55
Alternatives to Hysterectomy for Prolapse J Clin Gynecol Obstet. 2022;11(3):53-61

Table 2. Characteristics of Studies Comparing SSHP With Surgeries Involving Hysterectomy

Study Design Surgeries compared Follow-up Outcomes

Detollenaere RCT SSHP vs. TVH 12 months 1) Apical failure: 2% vs. 7% (CI: -11.1 to 1.2)
et al [16] 2) Anterior failure: 8% vs. 6% (CI: -0.5 to 26.4)
3) Repeat surgery: 1% vs. 4% (CI: -7.8 to 2)
4) Blood loss: 202 vs. 209 mL (CI: -32.8 to 20)
5) Operating time: 59 vs. 72 min (CI: -18.5 to -8.6)
Schulten et al [17] RCT SSHP vs. TVH 5 years 1) Apical failure: 3% vs. 7% (CI: -10.2 to 2.5)
2) Anterior failure: 40% vs. 36% (CI: -8.9 to 17.8)
3) Repeat surgery: 3% vs. 9% (CI: -10.2 to 2.5)
Dietz et al [18] RCT SSHP vs. TVH 12 months 1) Apical failure: 21% vs. 3%
2) Anterior failure: 50% vs. 35% (P = 0.2)
3) Repeat surgery: 11.6% vs. 6% (CI: -9 to 19)
Jeng et al [19] RCT SSHP vs. TVH 6 months 1) Decrease sexual interest: 13% vs. 5.1%
2) Less frequent orgasm: 20% vs. 21%
Hefni et al [20] nrPCS SSHP vs. TVH 18 months 1) Apical failure: 4.9% vs. 4.1% (P = NS)
2) Anterior failure: 11.4% vs. 10.4% (P = NS)
3) Repeat surgery: 5% vs. 4% (P = NS)
4) Blood loss: 46 vs. 135 mL (P < 0.01)
5) Operating time: 51 vs. 77 min (P < 0.01)
van Brummen nrPCS SSHP vs. TVH 1) UI: 38.6% vs. 50% (P = 0.23)
et al [21] 2) SUI: 47.7% vs. 46.7% (P =1.00)
3) Recurrence of POP: 11.4% vs. 6.7% (P = 0.45)
van Ijsselmuiden RCT SSHP vs. Lap SHP 12 months 1) Surgical failure: 3.3% vs. 1.6%
et al [22] 2) Apical failure: 3.4% vs. 3.6% (CI: -6.6 to 7)
3) Anterior failure: 56.9% vs. 50.9% (-24.3 to 12.4)
Nager et al [23] RCT VMSSHP vs. TVH 3 years 1) Failure rate: 31% vs. 41% (-25 to 4)
2) POP-Q: Ba: -1.2 vs. -0.7 cm (P = 0.05)
C: -5.7 vs. -5.8 cm (P = 0.74)
TVL: 8.5 vs. 7.7 cm (P < 0.01)
3) Operating time: 111 vs. 156 min (P < 0.01)
Chu et al [24] nrPCS VMSSHP vs. TVH 9 months 1) Postoperative POP-Q values (P > 0.05)
2) Operating time: 97.2 vs. 129 min (P < 0.01)
3) Blood loss: 77.4 vs. 179 mL (P < 0.01)
4) Mesh extrusion: 3.8% vs. 12.8% (P = 0.134)
nrPCS: non-randomized prospective controlled study; RCT: randomized controlled trial; SHP: sacrohysteropexy; SSHP: sacrospinous hysteropexy;
SUI: stress urinary incontinence; TVH: transvaginal hysterectomy; TVL: total vaginal length; UI: urgency incontinence; VMSSHP: vaginal mesh sac-
rospinous hysteropexy; CI: confidence interval.

follow-up after the procedure was scheduled at 1 and 5 years. Table 3 compares the primary and secondary findings of
At 12 months, SSHP was non-inferior to vaginal hysterectomy SSHP studies. The majority of the studies found that uterine
in terms of structural apical compartment recurrence with un- preservation resulted in reduced blood loss, shorter operative
pleasant bulge symptoms or repeat operation. There were no time, and a higher rate of anterior compartment failure. Apical
differences in functional results, QoL, complications, hospi- failure occurred at a variable rate. In contrast to the Dietz et al
tal stays, or sexual functioning between the two groups. Ana- study, there was an increased apical failure rate after hysterec-
tomical recurrence of the apical compartment with unpleasant tomy [18].
bulge symptoms or repeat surgery was substantially higher in Use of transvaginal mesh is an option during uterine pres-
the hysterectomy group than in the SSHP group 5 years fol- ervation surgery. Mesh is frequently utilized to make a repair
lowing surgery (7.8% vs. 1%) [16]. However, there was no more durable. Recent systematic reviews and meta-analyses
difference between the two in terms of functional results, QoL, [26, 27] found that mesh uterine preservation (VMSSHP) sur-
problems, hospital stays, or sexual functioning [17]. Jeng et gery resulted in decreased blood loss and operating time, and
al [19] evaluated sexual function in patients undergoing TVH that recurrence of POP ranged from 2-33% to 3-29%. De novo
versus SSHP and discovered that TVH patients had lessened urinary incontinence, mesh exposure, sexual dysfunction, and
sexual interest and orgasms than uterine preservation patients urinary retention were all common complications linked with
(5.1% vs. 13%). vaginal mesh surgery. When POP surgery included uterine

56 Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org
Dixit Thapa et al J Clin Gynecol Obstet. 2022;11(3):53-61

Table 3. Study Comparing SHP Through Various Routes With TVH

Study Study design Surgeries compared Follow-up Outcomes

Hemming et al [25] RCT 1) SSHP vs. TVH 12 months Uterine preservation vs. hysterectomy:
2) VMSSHP vs. TVH 1) Overall stage II or more: 18 vs. 15 (P > 0.05)
3) Abd SHP vs. TVH 2) Further surgery needed: 7.4% vs. 4.5% (P = 0.182)
4) Lap SHP vs. TVH
RCT: randomized controlled trial; SHP: sacrohysteropexy; SSHP: sacrospinous hysteropexy; TVH: transvaginal hysterectomy; VMSSHP: vaginal
mesh sacrospinous hysteropexy.

preservation instead of vaginal hysterectomy, both mesh ex- Abdominal uterus-preserving surgeries (abdominal/lapa-
posure and mesh exposure repeat operation were reduced [24, roscopic/robotic hysteropexy)
26, 28]. Jirschele et al studied mesh augmented SSHP for uter-
ovaginal prolapse and concluded that mesh augmented SSHP
was an effective and safe procedure for treating uterovaginal Open, laparoscopic, and robotic sacrohysteropexy are three
prolapse [29]. procedures for uterine preservation that use the sacral promon-
One RCT [20] and one nrPCS [21] comparing VMSSHP tory as a fixation point with or without mesh. Arthure et al [30]
with TVH were included in this review. The failure rates of described the open procedure initially but Addison et al [31]
POP in both groups were comparable. Mesh exposure was less described the mesh sacrohysteropexy first. Cutner et al were
prevalent, blood loss and operative time were reduced, and the first to create a laparoscopic uterine sling suspension [32].
the total vaginal length was longer in the uterine preservation In this review, we identified four RCTs [19, 22, 33, 34] and
group relative to the hysterectomy group. Mesh exposure was four nrPCSs [35-38] (Table 4).
seen in 8% of patients in the TVH RCT. In addition, ureteral Roovers et al [33] compared open Abd SHP with TVH
kinking and suture exposure were shown to be more common with anterior and posterior repairs in 2004. Recurrent prolapse
in the hysterectomy group. As a result, the controversy over symptoms (39% vs. 12%) and repeated prolapse surgery (22%
vaginal mesh’s usefulness and safety continues, and further vs. 2%) were substantially greater in the abdominal group than
study is needed [23]. in the vaginal group 1 year after the first surgery. In terms of
Table 4. Studies Comparing Abdominal Uterus-Preserving Surgeries With Surgeries Involving Hysterectomy

Study Design Surgeries compared Follow-up Outcomes

Roovers et al [33] RCT Abd SHP vs. TVH 12 months 1) Apical failure: 5% vs. 5%
2) Anterior failure: 36% vs. 39%
3) Repeat surgery: 22% vs. 2%
3) Operating time: 97 vs. 107 min (CI: -2 to 22)
4) Blood loss: 244 vs. 248 mL (CI: -119 to 127)
Rahmanou et al [34] RCT Lap SHP vs. TVH 12 months 1) Operating time: 39.5 vs. 28.1 min (P < 0.001)
2) Blood loss: 19.6 vs. 82.1 mL (P < 0.001)
3) Repeat surgery: 2% vs. 8% (P = 0.185)
Rosen et al [35] nrPCS Lap USLS with uterus 24 months 1) Operating time: 115 vs. 150 min (P ≤ 0.001)
vs. TLH with USLS 2) Blood loss: 100 vs. 110 mL (P = 0.0295)
3) Failure rate: 20% vs. 20%
Paek et al [36] nrPCS RLSHP vs. Abd SHP 12 months 1) Operating time: 120 vs. 187 min (P < 0.001)
2) Blood loss: 50 vs. 150 mL (P < 0.001)
3) Repeat surgery: 4.7% vs. 1.8% (P = 0.611)
4 ) Success rate: 94.4% vs. 91.2% (P = 0.717)
5) Mesh erosion: 0 vs. 5.3% (P = 0.244)
Constantini et al [37] nrPCS Abd hysterectomy and 12 months 1) FSFI score: 22.4 vs. 24.3 (P ≤ 0.05)
CSP vs. Abd SHP 2) TVL: 6.5 vs. 8 cm (P = 0.828)
Constantini et al [38] nrPCS Abd hysterectomy and 51 months 1) Operating time: 115 vs. 89 min (P ≤ 0.05)
CSP vs. Abd SHP 2) Blood loss: 325 vs. 200 mL (P ≤ 0.001)
3) Mesh erosion: 3 vs. 0
4) TVL: 6.5 vs. 8 cm (P = 0.813)
5) Success rate: 92% vs. 91% (P ≥ 0.05)
CSP: colposacropexy; FSFI: female sexual function index; nrPCS: non-randomized prospective controlled study; RCT: randomized controlled trial;
LRSHP: laparoscopic/robotic sacrohysteropexy; SHP: sacrohysteropexy; TLH: total laparoscopic hysterectomy; TVH: transvaginal hysterectomy;
TVL: total vaginal length; USLS: uterosacral ligament suspension.

Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org 57
Alternatives to Hysterectomy for Prolapse J Clin Gynecol Obstet. 2022;11(3):53-61

blood loss, hospital stay, and complications, there was no sta- to follow up these patients for the next 12 years. As a result, we
tistical difference between the two groups. Rahmanou et al may be able to better understand the most clinically effective,
[34] conducted a similar study in which they evaluated Lap safe, and cost-efficient options.
SHP vs. TVH with anterior and posterior repairs. In this study, The level/depth of dissection, mesh type, and mesh ten-
Lap SHP had better apical support, longer total vaginal length, sion used in the reported Lap SHP procedures vary. These dif-
a shorter hospital stay, and an earlier return to work postop- ferences, as well as others, may influence anatomical and func-
eratively. The findings were challenged by Alay et al [39] who tional outcomes. As a result, more clinical trials are needed to
remarked that the USLS technique used at the time of vagi- determine optimal surgical techniques, especially when mesh
nal hysterectomy may not have been the strongest for apical is used [40].
suspension. They recommended that, because the uterosacral In other hysteropexy techniques, the uterine corpus was
ligaments may be weak in cases of uterovaginal prolapse, Mc- previously suture-fixed with sacral promomtary. This surgery
Call culdoplasty or sacrospinous ligament suspension be uti- has been linked to severe cervical elongation [41].
lized for apical stabilization, as these procedures may be more Mesh has the potential to strengthen and extend apical
equivalent to Lap SHP. Rosen et al [35] examined USLS with support by supplementing deficient connective tissue. It may
uterus or hysterectomy and found that the hysterectomy group reduce the risk of sexual dysfunction and dyspareunia by pre-
had longer operating times with no difference in periopera- venting vaginal shortening. Clinical trials have yet to back up
tive or postoperative complications or recurrent prolapse 24 this claim.
months later.
In a prospective observational research, Alshiek et al [3]
compared all types of uterus-conserving operations and dis- Discussion
covered that the risk of prolapse recurrence was equal in all
surgical methods (abdominal 13.3%, vaginal 14.7%, laparo- Our analysis found that uterus-conserving operations are just
scopic 11.6%, robotic 3.6%; P = 0.39). All groups had equal as beneficial as hysterectomy in the treatment of POP. When
rates of intraoperative, postoperative, and long-term complica- compared to hysterectomy, the MP takes less time, results in
tions. Paek et al [36] compared open Abd SHP to LRSHP and less blood loss, and requires less time in the hospital. There
reported similar results. They found that objective prolapse is no difference in POP recurrence. In short-term follow-up,
recurrence was similar between the groups, but that recurrent SSHP was equivalent to hysterectomy for POP recurrence,
prolapse symptoms and repeat prolapse surgery were less com-
but it was associated with less operative time and blood loss.
mon in the LRSHP group. In terms of adverse events, both
The use of transvaginal mesh is still debatable, and the re-
groups experienced de novo urinary incontinence, but the Abd
sults are contradictory in terms of increased mesh exposure
SHP experienced higher voiding dysfunction and sexual dys-
risk. When compared to the vaginal hysterectomy group,
function rates.
Abd SHP had a greater rate of prolapse symptoms and re-
Colposacropexy with or without hysterectomy was com-
pared by Constantini et al [37]. They demonstrated that hys- peat prolapse surgery. However, it resulted in longer overall
terosacrocolpopexy could be safely performed on women who vaginal length. LRSHP, on the other hand, had greater apical
desired uterine preervation. In terms of prolapse recurrence support and a lower risk of repeat apical surgery than the
and improvement in voiding and sexual dysfunction, both sur- other two groups.
geries produced identical results. In another study, the same Jeffris et al [42] examined whether hysterectomy is re-
author found that POP has a role in female sexual dysfunction quired for POP management and concluded that, despite the
and that uterine preservation operations are linked to better growing popularity of uterus-conserving operations, there is
sexual function outcomes [38]. no strong evidence that they are superior to hysterectomy. The
In the LAVA study, Lap SHP was compared to SSHP [22]. only putative benefits were improved apical support, reduced
In terms of surgical failure, anatomical recurrence, and QoL 1 vaginal dysfunction, and improved psychological well-being.
year after surgery, they determined that Lap SHP was not infe- The results of a review and meta-analysis of SSHP re-
rior to SSHP. SSHP had a greater rate of de novo dyspareunia, vealed that the apical failure rate was not significantly differ-
although it was not statistically significant. They came to the ent from that of vaginal hysterectomy, indicating that SSHP
conclusion that while the alternatives for uterine preservation was a safe and successful surgery for POP [43].
are limited, Lap SHP could be a viable alternative to SSHP. The review done in 2013 by Gutman and Maher [2] found
Recently, two multicenter RCTs comparing various uter- that SSHP is equally effective as vaginal hysterectomy while
ine preservation operations to hysterectomy were initiated with being associated with lessened operative time, blood loss, and
planned long-term follow-up [25]. They have reported that recovery time. Sacral colpopexy and hysterectomy were as
objective prolapse recurrence, QoL, and adverse events were successful as SHP (open/laparoscopic), although sacral col-
similar in the uterine preservation and hysterectomy groups popexy had a five-fold higher rate of mesh erosion than SHP.
in early data comparison. Increased blood loss and hematoma According to systematic reviews with meta-analysis and
were the most common major adverse events in both groups. clinical practice guidelines on uterus-preserving surgeries for
They found no clinical evidence that abdominal uterine pres- POP, LRSHP, rather than open SHP, should be considered
ervation surgeries are more effective than vaginal procedures a for women who desire uterine preservation and have no con-
year following surgery. Abdominal surgeries are more expen- traindications, to minimize estimated blood loss and urinary
sive, and the long-term consequences are unknown. They plan retention while reducing mesh exposure and the risk of repeat

58 Articles © The authors | Journal compilation © J Clin Gynecol Obstet and Elmer Press Inc™ | www.jcgo.org
Dixit Thapa et al J Clin Gynecol Obstet. 2022;11(3):53-61

prolapse surgery. Mesh exposure, urine retention, and sexual Conflict of Interest
dysfunction were the most prevalent adverse effects [27].
None to declare.
Strengths and limitations
Author Contributions
A strength of this review is that only RCTs and prospective
controlled studies were included. Single technique trials and
retrospective reports were excluded. With the exception of Dr. Baburam Dixit Thapa: study design, article search and syn-
colpocleisis, this review included all commonly used uterine thesis, report writing, and final manuscript preparation. Dr. Tu-
preservation operations. lasa Basnet: article search and synthesis and final manuscript
One limitation of this review is that it included a wide preparation. Dr. G. Wily Davila and Dr. Mohan Ch Regmi:
range of uterine preservation surgery procedures, resulting in a study design and final manuscript preparation.
heterogeneous comparison of results. There are not any rand-
omized trials comparing one uterine preservation operation to Data Availability
another, such as Manchester vs. SSHP. Furthermore, surgical
techniques employed for each surgery, whether abdominally or
vaginally, can differ significantly. As a result, results reported The authors declare that data supporting the findings of this
on a specific surgical approach may not be similar between study are available within the article.
studies because surgical technique can have a major impact on
reported outcomes. In addition, the performance of associated References
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