|Ahead of print publication
Outcomes of laparoscopic hysteropexy and supracervical hysterectomy plus cervicopexy: A retrospective study
Pei-Chen Li1, Dah-Ching Ding2
1 Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
2 Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University; Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
|Date of Submission||15-Jun-2019|
|Date of Decision||17-Jul-2019|
|Date of Acceptance||05-Aug-2019|
|Date of Web Publication||12-Sep-2019|
Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien
Source of Support: None, Conflict of Interest: None
Objectives: The objective of this study is to compare the outcomes of laparoscopic hysteropexy (LHP) and laparoscopic supracervical hysterectomy plus cervicopexy (LSHCP) for the treatment of pelvic organ prolapse (POP). Materials and Methods: We retrospectively included patients who had undergone laparoscopic sacral hysteropexy or hysterectomy plus cervicopexy between January 2015 and May 2019 at Hualien Tzu Chi Hospital, Taiwan. Age at surgery, body mass index (BMI) at admission, the initial stage of genital prolapse, operative and postoperative data, and anatomical results were recorded. Cure for uterine prolapse was evaluated objectively through vaginal examinations using the POP quantification scale. Visual analog scale (VAS) scores were recorded at 24 h postoperatively. The Mann–Whitney U-test was used to compare continuous variables. Results: A total of 23 women were included in the study; 12 had received LHP (n = 12) and 11 had received LSHCP (n = 11). No differences existed in age, parity, BMI, blood loss, or hospital stay between groups. The difference in mean surgical times between the LHP and LSHCP groups was nonsignificant (154 and 176 min, respectively;P = 0.2). VAS scores were significantly lower in the LSHCP group than in the LHP group (0.1 vs. 1.75; P = 0.004). Furthermore, mean hospital stay was significantly longer in the LSHCP group than in the LHP group (4.0 vs. 3.1 days; P = 0.016). The procedure was successful in 100% of patients (23 of 23), with no objective evidence of uterine prolapse on examination at follow-up at 6 months. Conclusions: LHP had a significantly shorter hospital stay and a higher VAS score than LSHCP. LHP and LSHCP are both feasible and effective procedures for correcting uterine prolapse.
Keywords: Cervicopexy, Hysteropexy, Mesh, Pelvic organ prolapse, Pelvic organ prolapse-quantification
|How to cite this URL:|
Li PC, Ding DC. Outcomes of laparoscopic hysteropexy and supracervical hysterectomy plus cervicopexy: A retrospective study. Tzu Chi Med J [Epub ahead of print] [cited 2020 Feb 20]. Available from: http://www.tcmjmed.com/preprintarticle.asp?id=266814
| Introduction|| |
Pelvic organ prolapse (POP) is common in postmenopausal women, with a lifetime risk of 11%. The etiology of POP is multifactorial and includes neuromuscular dysfunction and fascial defect. Uterine prolapse may be caused by weakness of the ligament complex. Surgery with native tissue repair such as anterior or posterior colporrhaphy had a high recurrence rate.
Surgery choices for POP include vaginal hysterectomy and transvaginal mesh (TVM). However, vaginal hysterectomy has been associated with a high recurrence rate of apical prolapse because it cuts all ligaments attached to the uterus,. By contrast, TVM repair has not only high success rate but also increased complications such as mesh exposure, dyspareunia, and hematoma,,. The United States Food and Drug Administration announced that mesh repair is a high-risk procedure.
During the last decade, laparoscopic sacrocolpopexy has become popular because most TVM procedures have been unavailable, and POP correction has shown strong results. Both laparoscopic and abdominal sacrocolpopexy were recommended for POP treatment and yielded strong results. Uterine sparing surgery for POP (laparoscopic hysteropexy [LHP]) was one choice because it effectively eases prolapse symptoms and enhances sexual function and psychological well-being. Furthermore, this type of surgery preserves the ligaments around the cervix and can be strengthened using nonabsorbable materials. Laparoscopic total hysterectomy plus sacral colpopexy (LTHCP) had reported with a controversial outcome. One study reported despite the increased surgical time, there was no benefit in POP repair. On the contrary, another study reported LTHCP provided a durable outcome than LHP. The outcome of laparoscopic supracervical hysterectomy plus cervicopexy (LSHCP) was reported with benefit for POP repair,.
Therefore, the aim of the present study was to compare the surgical outcomes of LHP and LSHCP for the treatment of POP.
| Materials and Methods|| |
This study was a retrospective study in our department for comparing two different surgical techniques for POP repair. This study was conducted in accordance with the Declaration of Helsinki and was approved by the Local Ethics Committee of the institute (Number: IRB 108-111-B). Informed written consent was waived because the study was a retrospective data analysis.
In this study, we retrospectively included patients who had undergone laparoscopic sacral hysteropexy or hysterectomy plus cervicopexy between January 2015 and May 2019 at Hualien Tzu Chi Hospital, Taiwan. The women with symptomatic uterine prolapse with POP Quantification (POP-Q) stage equal to or more than Stage 2 were included in the study. The exclusion criteria were cervical elongation and colpopexy only. If there were no uterine pathology, and the patients wanted to preserve their uterus, they were assigned to LHP group. The other patients choose to receive LSHCP. Data were extracted from the patients' medical charts: age at surgery, body mass index (BMI) at admission, the initial stage of genital prolapse, operative and postoperative data, and anatomical results. Genital prolapse stage was classified according to the International Continence Society POP-Q scale.
Laparoscopic sacral cervicopexy was performed by a single-trained surgeon in all cases. A nonabsorbable polypropylene mesh (Alyte Y-mesh, JUNE Medical, Buckinghamshire, London, UK) was sutured to the anterior and posterior wall of the cervix. Supracervical hysterectomy was performed if a uterine abnormality was diagnosed (menorrhagia or enlarged uterus).
When the Y-mesh was used during hysteropexy (uterus sparing surgery), we cut both leaves of the mesh into the same width as the posterior leaf (3 cm wide), leaving 5 cm in length on both leaves to enable circling the cervix and applying an extracorporeal nonabsorbable suture (2-0 Ethibond, Ethicon, J and J, New Brunswick, NJ, USA) at the anterior cervical region. We adapted the previously published hysteropexy method [Figure 1]. In brief, the peritoneum of the anterior and posterior cul-de-sacs was exposed using unipolar scissors, and holes were created over the bilateral uterine artery region. Subsequently, we placed both leaves of the mesh through the holes, circled the cervix, and fixed mesh using sutures. The mesh tail was nailed on the presacral region using a Protec device (Medtronic corp., Minneapolis, MN, USA). Next, we approximated the peritoneum with a 1/0 V-Loc suture (Medtronic corp.).
|Figure 1: Surgical technique of laparoscopic hysteropexy. (a) The mesh was inserted through windows in the broad ligament. (b) Both leaves of the mesh were approximated into the central portion of the cervix. (c) The mesh was sutured over the anterior cervix. (d) Closure of the uterovesical peritoneum was performed. (e) Peritonization of the mesh of the posterior cervical region was conducted prior to its fixation to the sacral promontory. (f) Peritonization was completed|
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Postoperative pain control
Postoperative pain was evaluated at the recovery room, 24 and 48 h after surgery. Only 24 h of pain score was included in this study. Pain score was obtained from the patients by the visual analog scale (VAS) with 10 cm length from 0 (no pain) to 10 (the most severe pain). In this study, postoperative pain control in both groups using the same regimen. Intravenous analgesics were including ketorolac 30 mg (Yung Shin Pharm. Ind. Co., Ltd., Taichung, Taiwan) and morphine 10 mg. Oral analgesics were including acetaminophen 500 mg (Yung Shin Pharm. Ind. Co., Ltd., Taichung, Taiwan) and naproxen 250 mg (China Chemical and Pharmaceutical Co., Ltd., Hsinchu, Taiwan). Intramuscular analgesic was Dynastat 40 mg (Pfizer, New York City, NY, USA).
Prolapse outcome evaluation
The primary outcome of the study was to evaluate the objective success rates of both types of laparoscopic surgical techniques.
The objective success is defined by anatomical position. The cure was defined when POP-Q < Stage 2 prolapse in all vaginal compartments (anterior, apical, and posterior) at 6-month postoperatively. Postoperatively (at 6 months of follow-up), clinical results were assessed objectively using the POP-Q scale.
The secondary outcomes were surgical and admission parameters, such as duration, blood loss, pain score, and hospital stay. The surgical time was counted from the first incision to last skin stitch. The blood loss amount was estimated from the suction bottle and deduction of irrigation water amount.
Statistical analyses were performed using SPSS 20.0 (IBM, Armonk, NY, USA). The Mann–Whitney U-test was used to compare continuous variables; values of P < 0.05 were considered statistically significant.
| Results|| |
In total, 23 patients received LHP (n = 12) or LSHCP (n = 11); their mean ages were 60 and 59 years, mean BMI values were 24.5 and 23.4, and mean parities were 2.9 and 2.7, respectively [Table 1].
The surgical outcomes revealed that the mean surgical time in the LHP group was shorter than in the LSHCP group but without statistical significance (154 and 176 min, respectively; P = 0.2). Furthermore, postoperative VAS pain scores were significantly higher in LHP than in LSHCP group (1.75 and 0.1 in the LHP and LSHCP groups, respectively, P = 0.004). Moreover, the mean blood loss amounts were 64.1 and 54.4 mL in the LHP and LSHCP groups, respectively (P = 0.5). The mean hospital stays were 3.1 and 4.0 days in the LHP and LSHCP groups (P = 0.016), respectively [Table 1].
All the women were available for follow-up at the clinic 6 months after their operations. The procedure was successful in 23 out of 23 women (100%), with no objective evidence of uterine prolapse on examination at follow-up [Table 2]. No statistical difference was found between groups in terms of POP-Q stage.
|Table 2: Objective outcomes of laparoscopic hysteropexy (Group 1, n=12) and laparoscopic supracervica hysterectomy plus cervicopexy (Group 2, n=11): Pelvic organ prolapse quantification measurements|
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| Discussion|| |
Both LHP and LSHCP resulted in objective improvements without the evidence of uterine prolapse at the 6-month follow-up. LHP was significantly associated with shorter hospital stay and higher pain scores than LSHCP. Age, parity, BMI, and operation blood loss were similar in both groups. Thus, our findings provide support for LHP being feasible for the clinical treatment of women who require fertility conservation with satisfactory outcomes.
A recent systematic review of 94 studies suggested that uterine-preserving prolapse surgeries decrease operating time, blood loss, and morbidities without worsening short-term prolapse outcomes. In our study, the LHP group had blood loss 64.1 ± 8.9 mL compare to LSHCP group 54.4 ± 4.5 mL (P = 0.5) and with longer operation time in LSHCP group than in LHP group (P = 0.2). However, blood loss and operative time were not significant between both groups in our study. We speculated other pelvic reconstruction procedure such as colporrhaphy may contribute to longer blood loss and operative time.
In this study, the mean hospital stay was significantly longer in the LSHCP group than in the LHP group (4.0 vs. 3.1 days; P = 0.016), whereas Visual analog scale scores were significantly lower in the LSHCP group than in the LHP group (0.1 vs. 1.75; P = 0.004). The reason for a longer hospital stay in LSHCP group despite low VAS score, we thought that may be due to the health insurance regulation. The insurance provided 4 days of hospital stay for LSHCP, but no regulation for LHP. Therefore, we speculated that would cause longer hospital stay for LSHCP. The pain in LHP may cause by mesh traction cervical ring toward the presacral region.
Vaginal hysterectomy was considered a traditional surgical treatment for uterine prolapse, even in the absence of uterine disease. Today, surgeons may offer several management options to women with symptomatic POP, including vaginal, abdominal, laparoscopic, and robotic procedures. Studies have suggested that hysterectomy is associated with hypertension, hyperlipidemia, coronary artery disease, obesity, and lower urinary tract symptoms,,. Furthermore, uterine conservation is crucial for women who wish to preserve their fertility, improve their sexual function, and retain their self-confidence, self-esteem, or the sense of femininity. In addition, a randomized controlled trial showed higher rates of repeat apical surgery at 1 year in its vaginal hysterectomy group compared with its LHP group. In another study, the repeat apical surgery rate in patients undergoing LHP was low (2.8%) based on a cohort studied over 10 years. Therefore, the popularity of preserving the uterus during prolapse surgery has increased.
Laparoscopic uterine preservation surgery for POP has developed rapidly because it is a minimally invasive surgical approach with superior visualization, reduced blood loss, shorter hospital stay, and decreased postoperative pain. Several types of procedure have been reported that involve laparoscopic suspension of the uterus: from the round ligaments (ventrosuspension), uterosacral ligaments, or sacral promontory. LHP, which was performed in our study, is a laparoscopic procedure with a bifurcated synthetic mesh anchoring the uterus to the sacral promontory for uterovaginal prolapse; it was first reported in 2001 by Leron and Stanton. Studies on LHP have demonstrated high success rates after a medium-term follow-up (14–48 months), ranging between 90% and 100%,,,,. Gracia et al. were the first to compare the two laparoscopic approaches for POP repair (LHP and LSHCP) in the Spanish population. Their study indicated that LSHCP achieved higher success rates at the apex compared with LHP (90% and 46.7% at 12 months, respectively; P = 0.002). However, in the present study, no significant difference was observed in postoperative changes of POP-Q scores in all compartments (anterior, posterior, and apical) between the two groups. Therefore, the addition of hysterectomy may be unnecessary for POP repair if there is no uterine lesion. Besides, uterine sparing surgery may harbor many advantages regarding cardiovascular disease developed after hysterectomy,.
Relevant studies have argued that hysteropexy alone was linked to a risk of cervical elongation, requiring repeat surgery,,. In a prospective study by Rosen et al., 14.3% of patients had cervical elongation or level-1 prolapse after laparoscopic pelvic floor repair without hysterectomy. They postulated that inadequately tensioned fixation high in the pelvis without counter pressure from an adequate pelvic floor resulted in the cervical elongation. However, the prevalence of cervical elongation in women with POP has ranged from 40% to 97.6%,. Most studies have not measured the cervical length before and after operations and thus have been unable to prove an association between de novo cervical elongation and hysteropexy.
This is the first study to compare LHP and LSHCP in the Asian population. All laparoscopic operations were performed by the same surgeon, ensuring consistency in intervention procedures. Despite a limited number of participants, the demographic characteristics were similar in both groups. We acknowledge several limitations of the study, including the retrospective method, small sample size, and short-term follow-up. Moreover, this study also lacked subjective outcomes such as lower urinary tract symptoms before and after the operation. Furthermore, some patients received anterior and posterior colporrhaphy concurrently (3 patients underwent a-p colporrhaphy, 2 patients posterior colporrhaphy, and 4 patients anterior colporrhaphy), but we did not eliminate the repair time; the actual surgical time could be shorter.
| Conclusions|| |
The study showed that uterine-preserving prolapse procedures had a significantly shorter hospital stay than LSHCP. The safer and efficient transabdominal mesh repair for POP should be further developed and investigated in future studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501-6.
Dällenbach P, Kaelin-Gambirasio I, Dubuisson JB, Boulvain M. Risk factors for pelvic organ prolapse repair after hysterectomy. Obstet Gynecol 2007;110:625-32.
Dällenbach P, Kaelin-Gambirasio I, Jacob S, Dubuisson JB, Boulvain M. Incidence rate and risk factors for vaginal vault prolapse repair after hysterectomy. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:1623-9.
Hong MK, Chu TY, Wei YC, Ding DC. High success rate and considerable adverse events of pelvic prolapse surgery with prolift: A single center experience. Taiwan J Obstet Gynecol 2013;52:389-94.
Hong MK, Liao CY, Chu TY, Chen PC, Ding DC. Internal pudendal artery injury during prolapse surgery using nonanchored mesh. J Minim Invasive Gynecol 2011;18:678-81.
Liao CY, Ding DC. Different management strategies for postoperative hematoma after pelvic organ prolapse surgery. Taiwan J Obstet Gynecol 2012;51:656-9.
Iyer S, Botros SM. Transvaginal mesh: A historical review and update of the current state of affairs in the United States. Int Urogynecol J 2017;28:527-35.
Lee RK, Mottrie A, Payne CK, Waltregny D. A review of the current status of laparoscopic and robot-assisted sacrocolpopexy for pelvic organ prolapse. Eur Urol 2014;65:1128-37.
Onwude JL. Genital prolapse in women. BMJ Clin Evid 2012;2012. pii: 0817.
Zucchi A, Lazzeri M, Porena M, Mearini L, Costantini E. Uterus preservation in pelvic organ prolapse surgery. Nat Rev Urol 2010;7:626-33.
Rahmanou P, Price N, Jackson SR. Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: A prospective randomized pilot study. Int Urogynecol J 2015;26:1687-94.
Rosen DM, Shukla A, Cario GM, Carlton MA, Chou D. Is hysterectomy necessary for laparoscopic pelvic floor repair? A prospective study. J Minim Invasive Gynecol 2008;15:729-34.
Bedford ND, Seman EI, O'Shea RT, Keirse MJ. Effect of uterine preservation on outcome of laparoscopic uterosacral suspension. J Minim Invasive Gynecol 2013;20:172-7.
Gracia M, Perelló M, Bataller E, Espuña M, Parellada M, Genís D,et al
. Comparison between laparoscopic sacral hysteropexy and subtotal hysterectomy plus cervicopexy in pelvic organ prolapse: A pilot study. Neurourol Urodyn 2015;34:654-8.
Campagna G, Panico G, Morciano A, Vacca L, Anchora LP, Gallucci V,et al
. Laparoscopic supracervical hysterectomy and sacral colpopexy for pelvic organ prolapse with percutaneous surgical system: Results from a pilot study. Eur J Obstet Gynecol Reprod Biol 2018;221:160-5.
Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P,et al
. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7.
Price N, Slack A, Jackson SR. Laparoscopic hysteropexy: The initial results of a uterine suspension procedure for uterovaginal prolapse. BJOG 2010;117:62-8.
Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for pain (VAS pain), Numeric Rating Scale for pain (NRS pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S240-52.
Meriwether KV, Antosh DD, Olivera CK, Kim-Fine S, Balk EM, Murphy M,et al
. Uterine preservation vs. hysterectomy in pelvic organ prolapse surgery: A systematic review with meta-analysis and clinical practice guidelines. Am J Obstet Gynecol 2018;219:129-4600.
Jha S, Moran P. The UK national prolapse survey: 5 years on. Int Urogynecol J 2011;22:517-28.
Kow N, Goldman HB, Ridgeway B. Management options for women with uterine prolapse interested in uterine preservation. Curr Urol Rep 2013;14:395-402.
Li PC, Tsai IJ, Hsu CY, Wang JH, Lin SZ, Ding DC,et al
. Risk of hyperlipidemia in women with hysterectomy-A retrospective cohort study in Taiwan. Sci Rep 2018;8:12956.
Ding DC, Tsai IJ, Hsu CY, Wang JH, Lin SZ. Hysterectomy is associated with higher risk of coronary artery disease: A nationwide retrospective cohort study in Taiwan. Medicine (Baltimore) 2018;97:e0421.
Ding DC, Tsai IJ, Hsu CY, Wang JH, Lin SZ, Sung FC. Risk of hypertension after hysterectomy: A population-based study. BJOG 2018;125:1717-24.
Neuman M, Lavy Y. Conservation of the prolapsed uterus is a valid option: Medium term results of a prospective comparative study with the posterior intravaginal slingoplasty operation. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:889-93.
Jefferis H, Price N, Jackson S. Laparoscopic hysteropexy: 10 years' experience. Int Urogynecol J 2017;28:1241-8.
Leron E, Stanton SL. Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse. BJOG 2001;108:629-33.
Seracchioli R, Hourcabie JA, Vianello F, Govoni F, Pollastri P, Venturoli S. Laparoscopic treatment of pelvic floor defects in women of reproductive age. J Am Assoc Gynecol Laparosc 2004;11:332-5.
Rozet F, Mandron E, Arroyo C, Andrews H, Cathelineau X, Mombet A,et al
. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: Experience with 363 cases. Eur Urol 2005;47:230-6.
Krause HG, Goh JT, Sloane K, Higgs P, Carey MP. Laparoscopic sacral suture hysteropexy for uterine prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:378-81.
Rahmanou P, White B, Price N, Jackson S. Laparoscopic hysteropexy: 1- to 4-year follow-up of women postoperatively. Int Urogynecol J 2014;25:131-8.
Hyakutake MT, Cundiff GW, Geoffrion R. Cervical elongation following sacrospinous hysteropexy: A case series. Int Urogynecol J 2014;25:851-4.
Berger MB, Ramanah R, Guire KE, DeLancey JO. Is cervical elongation associated with pelvic organ prolapse? Int Urogynecol J 2012;23:1095-103.
Mothes AR, Mothes H, Fröber R, Radosa MP, Runnebaum IB. Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol 2016;200:40-4.
[Table 1], [Table 2]