Route of Hysterectomy at the Time of Sacrocolpopexy: A Multicenter Retrospective Cohort Study

Abstract

Objectives: This study aimed to compare the incidence of mesh exposure based on route of hysterectomy at the time of minimally invasive sacrocolpopexy. Secondary outcomes included perioperative outcomes and prolapse recurrence.Methods: This was a multicenter, retrospective cohort study. Patients who underwent sacrocolpopexy between 2007 and 2017 were stratified by hysterectomy approach: total vaginal hysterectomy (TVH), total laparoscopic or robotic hysterectomy (TLH), and laparoscopic or robotic supracervical hysterectomy (LSH). Total vaginal hysterectomy was subdivided into vaginal and laparoscopic mesh attachment to the cuff. Statistical analyses were performed, with P < 0.05 denoting statistical significance.Results: Seven institutions participated, and 502 minimally invasive sacrocolpopexies with concomitant hysterectomy were performed by 23 surgeons: 263 TVH, 128 TLH, and 111 LSH. The median follow-up interval was 10 months, and this was significantly different between the groups (months): TVH, 11 (3-13); TLH, 2 (2-9); and LSH, 12 (5-24; P < 0.01). The overall incidence of vaginal mesh exposure was 4.0% (20/502). There were no significant differences in vaginal mesh exposure based on hysterectomy route: TVH, 5.7% (15/263); TLH, 1.6% (2/128); and LSH, 2.7% (3/111; P = 0.11). Within the TVH group, there was no significant difference in vaginal mesh exposure comparing vaginal and laparoscopic mesh attachment: 1.9% (1/52) versus 6.6% (14/211; P = 0.48). Laparoscopic supracervical hysterectomy demonstrated a significantly higher incidence of recurrence compared with TVH and TLH: 10.8% (12/111) versus 3.4% (9/263) and 2.3% (3/128; P < 0.01). Conclusions:The incidence of sacrocolpopexy mesh exposure was not significantly different based on route of hysterectomy or mode of mesh attachment to the vagina. There was a significant increase in prolapse recurrence with supracervical hysterectomy.

Rate of Mesh Erosion After Sacrocolpopexy With Concurrent Supracervical Compared With Total Hysterectomy

“…Excluding this study, treatment outcomes in 97 women (including women with a history of prior hysterectomy) with mesh erosion noted that 54% (52/97) required re-operation for a mesh related complication. 7,8,10,11,13,15,16,27,28 This study has several strengths, including a prospectively disclosed protocol, a comprehensive search scheme with no limitations of language that included populaces from varied parts of the world, and study of contemporary surgical practices for abdominal sacrocolpopexy. Limitations of our study should be noted.…”

“…22 Limited studies have observed that preservation of the cervix may contribute to an increased risk of prolapse recurrence. 12,14,16 Further, the after effect of leaving the cervix in situ is the morcellation of a uterus with unforeseen pathology, although risk can be mitigated with tissue-containment systems. Total hysterectomy has the advantage of removing the necessity of continued cervical cancer screening and any risk of recurring vaginal bleeding if the cervix is left intact.…”

“…Excluding this study, treatment outcomes in 97 women (including women with a history of prior hysterectomy) with mesh erosion noted that 54% (52/97) required re-operation for a mesh related complication. 7,8,10,11,13,15,16,27,28…”

Recurrence of Anterior Vaginal Prolapse After Robotic Sacrocolpopexy: Does Cervical Preservation Affect Outcome?

“…[5][6][7][8][9][10][11][12][13][14][15][16] Studies directly comparing success rates after SCH versus TH during SCP demonstrated that overall recurrence rates were 9-22% higher after SCH. 19,20 Thus, a difference between groups of 15% was chosen for the study's power calculation as an educated estimate based on the limited existing evidence. Furthermore, 15% was thought to represent a clinically meaningful difference that would potentially change practice.…”

“…17,18 Urogynecologists have increasingly transitioned to supracervical hysterectomy (SCH) over total hysterectomy (TH) at the time of SCP to prevent mesh erosion, but limited evidence suggests that cervical preservation may increase the risk of prolapse recurrence by 9-22%. [19][20][21][22][23] However, these studies have focused on overall failure rates, not compartment specific recurrence. Because rates of failure are highest in the anterior compartment after SCP, it is important to determine if cervical preservation is an independent risk factor for anterior recurrence.…”