Benefits of Offering Uterine Conservation in Appropriate Pelvic Organ Prolapse Cases

Modern hysteropexy techniques for pelvic organ prolapse (POP) have been around for nearly two decades and have built a solid track record of improving function and patient quality-of-life.

While the less-invasive hysteropexy is not advisable for every patient, it is important that clinicians consider it when medically appropriate, that they understand their patient’s goals, and that they provide them with information to make empowered decisions. Specifically, shared decision-making should include considerations of the patient’s wishes with regard to her uterus.

That’s the message from Amy Park, MD, Section Head, Urogynecology and Reconstructive Pelvic Surgery in Cleveland Clinic’s Obstetrics & Gynecology Institute. As well established as hysteropexy is for treatment of POP, it hasn’t yet become standard even though many patients, if given the choice, would prefer to retain their uterus.

“People shouldn’t think that they can't have their prolapse repaired if they really want to retain their uterus,” says Dr. Park. “They can, and they may have better outcomes with hysteropexy.”

Women who wish to avoid hysterectomy report a number of reasons, including a desire to retain fertility; a belief that the uterus affects sexual function; concerns about the risks of hysterectomy; and culture-based attitudes about femininity, identity and/or body image.

Still, an estimated 74,000 hysterectomies are performed each year for prolapse in the United States for a variety of reasons.

Among them is that hysterectomy has a long history as the standard intervention. If it is laid out to a patient as the only option for POP repair, says Dr. Park, there is a risk that patients either may experience post-surgical regrets or simply never get the care they need.

“Sometimes patients will hear from their doctors, ‘You need to have a hysterectomy and prolapse repair.’ If the patient is psychologically or emotionally attached to their uterus, they may not come back in, because they don't want to have their uterus removed.”

While more research may be needed before hysteropexy is included as standard of care for POP, Dr. Park says a number of considerations can help inform clinicians and patients.

• The uterus matters. A prevailing myth holds that the loss of a uterus has no effect on function. Moorman, et al., have shown that women who had a hysterectomy for prolapse and who retained their ovaries were at twice the risk for ovarian failure and were more likely to enter menopause two years earlier on average than those who had had uterine-preserving procedures.
• Recurrence rates are comparable. Hysteropexy stacks up well against hysterectomy in effectively treating prolapse repair. “Prolapse recurrence rates are pretty similar between the two, and even a little better with retaining the uterus, although not by a lot,” says Dr. Park. “What becomes important, then, is how people feel about their uterus and the best option for them.”
• Anatomical vs. subjective results. In a retrospective study of laparoscopic sacrohysteropexy compared with total laparoscopic hysterectomy with sacrocolpopexy, Pan, et al., found that the two groups provided a similar anatomic cure, although the hysterectomy group experienced greater subjective cure and quality-of-life improvement at a mean follow-up of 33 months.
• Surgical outcomes. In a prospective cohort study of 321 participants, Brennan, et al., found that uterine-preserving surgery was associated with shorter OR times, reduced length of hospital stay, less opioid use during the first 24 hours, and fewer complications. Through the first year, uterine-preserving surgery was associated with lower risk of composite recurrence than hysterectomy.
• When hysteropexy is not a fit. Contraindications for hysteropexy include undiagnosed uterine bleeding; cervical or uterine pathology; family history of syndromes that put a patient at risk of uterine or ovarian cancers; severe obesity; tamoxifen use; and cervical elongation. Additionally, women with stage IV uterovaginal prolapse with Pelvic Organ Prolapse Quantification (POP-Q) measures greater than 8 to 10 cm are not ideal hysteropexy candidates; the areas targeted for suspension may be above the planned point of attachment.

Finally, says Dr. Park, “Prolapse is a quality-of-life issue. Our approach at Cleveland Clinic focuses very much on symptoms, to what degree they bother the patient, and how people feel about their uterus. A lot of patients are fine with having a hysterectomy at the time of their prolapse repair. But for those who aren’t, there are lots of options now. Prolapse no longer automatically means that repair automatically equals hysterectomy.”