Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingoplasty operation

Abstract

It has been reported that, by the age of 80, the risk of women to undergo surgery for the treatment of pelvic organ prolapse (POP) exceeds 10%, a percentage expected to increase with the rise in life expectancy. The vaginal approach for POP reconstructive operations is associated with fewer complications and results in a shorter rehabilitation period than the abdominal route, whereas hysterectomy is widely performed concomitantly whenever the uterus is significantly prolapsed. However, there is no clear evidence supporting the role of hysterectomy in improving surgery outcome. We present our experience with a new minimally invasive procedure--the posterior intravaginal slingplasty (PIVS) for correction of advanced uterine prolapse--at the same time, comparing additive vaginal hysterectomy to uterine preservation, to evaluate the therapeutic significance of hysterectomy when vaginal apical prolapse is reconstructed with PIVS. Seventy-nine women presenting with moderate to severe uterine prolapse were enrolled into the current PIVS study. Vaginal hysterectomy was concomitantly performed upon patient's request (44 patients), whereas those wishing to preserve their uterus underwent reconstructive surgery only (35 patients). No intraoperative or postoperative major complications were recorded during an average follow-up of 29.8 months: One patient (1.3%) presented with surgical failure, whereas 71 (89.9%) of the operated patients reported satisfaction with the therapeutic results. Bladder overactivity symptoms declined from three thirds of the patients preoperatively to below 10% postoperatively. Ten (12.7%) patients had vaginal tape protrusion; all underwent segmental tape resection at the out-patient clinic. Because the PIVS procedure does not require either laparotomy or deep transvaginal dissection, as previously required for operative intervention, the hospitalization period was relatively short: 4.2 days for the hysterectomy group and 1.5 for the non-hysterectomy group. Other statistically significant differences between the hysterectomy and non-hysterectomy groups were the average ages (63.5 vs 51.0 years, respectively) and concomitant surgery (87% vs 69%, respectively, the higher percentage due to additive amputation of elongated uterine cervices). No other significant differences were recorded. The current results support the previously reported efficacy, safety, and simplicity of the PIVS procedure as well as the legitimacy of uterine preservation. Moreover, unstable bladder symptoms were found to be improved after this operation. However, long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operation.

Vaginal surgery for uterine descent; which options do we have? A review of the literature

“…However, as with the majority of studies reported in this review, well-designed studies with clear outcomes (both anatomical and functional) on the IVS posterior procedure have to be awaited. Removal of the uterus during the procedure did not alter the erosion rate but it did increase the hospital admission time (1.5 versus 4.2 days, P=0.002) [37].…”

“…After assessment of the 32 reports and their reference lists, only four studies describing posterior intravaginal slingplasty in women preserving their uterus were available [37][38][39][40]. Because Mattox et al did not describe their subgroup of only two women with preservation of the uterus separately (21 women without a uterus), this report was excluded from the analyses of anatomical and functional outcomes [40].…”

“…In none of the studies were complications separately described for the subgroup of women in which the uterus was preserved. Therefore, for describing complications, we used data for women who underwent a posterior intravaginal slingplasty with and without preservation of the uterus [37][38][39][40][41][42][43][44][45][46][47].…”

“…Therefore, after cervical amputation, a risk of stenosis is present, which could influence the occurrence of alarming symptoms (vaginal blood loss) in the development of adenocarcinoma of the uterus. After a posterior intravaginal slingplasty (with and without preservation of the uterus) mesh erosion problems were reported in 0% to 21% of women [37][38][39][40][41][42][43][44][45][46][47]. Baessler et al described erosion problems in 13 women who were referred to their clinic after implantation of a multifilament mesh at other clinics [56].…”

Estudo randômico da correção cirúrgica do prolapso uterino através de tela sintética de polipropileno tipo I comparando histerectomia versus preservação uterina

“…A extrusão da tela ocorreu em 13,6% no grupo histerectomizado versus 11,4% no grupo de preservação uterina. Os autores concluíram que a correção do prolapso uterino com tela sintética é eficaz e segura 17 . Pelo exposto, justifica-se a necessidade do desenvolvimento de técnicas cirúrgicas menos invasivas, que preservem a anatomia e as funções do assoalho pélvico feminino, o que estimulou o desenvolvimento deste estudo, que objetiva comparar os resultados anatômicos pós-operatórios de pacientes portadoras de prolapso uterino tratadas por meio de tela de polipropileno para correção do defeito apical, comparando histerectomia vaginal (HV) com a histeropexia(HP).…”