Uterine-preserving surgery offers safe, effective alternative for POP

Uterine-preserving surgery offers safe, effective alternative for POP | Image Credit: © natali_mis – © natali_mis – stock.adobe.com.

Uterine-preserving (UP) surgery is a safe and effective alternative to hysterectomy among patients with pelvic organ prolapse (POP), according to a recent study published in the American Journal of Obstetrics & Gynecology.¹

Advantages of UP surgery

POP occurs in 1 in 5 women by the age of 85 years, leading to symptoms such as pelvic pressure, urinary incontinence, and vaginal bulge and bleeding that significantly impact patient quality of life. Hysterectomy is the traditional method of treatment for this condition, yet data has indicated reduced perioperative risks from UP surgery.²

“These findings are critical for patient-centered decision-making; assuming clinical equipoise, 35% to 60% of affected people prefer to keep their uterus,” wrote investigators.¹ Therefore, the prospective cohort study was conducted to compare 1-year outcomes of POP surgery through minimally invasive hysterectomy vs UP native tissue surgery.

Comparing surgical methods

Patients with stage 2 or greater POP in any compartment, prolapse with apical descent of 50% or higher, up to date cervical cytologic screening, and no desire for fertility were included in the analysis. Those with abnormal uterine bleeding or a uterine pathology indicating a hysterectomy were excluded.

Patients individually decided whether to receive native tissue UP surgery through hysteropexy or hysterectomy and native tissue vaginal vault suspension. Variations were allowed for the surgical route and apical suspension, with a minimum of 2 permanent monofilament sutures used in both the uterosacral and sacrospinous ligament.

POP recurrence and clinical outcomes

Anatomic recurrence of apical POP within 1 year was reported as the primary outcome. This was determined by a Pelvic Organ Prolapse-Quantification System (POP-Q) point C of 50% of the total vaginal length or greater.

Perioperative, clinical, functional, and health care measures were reported as secondary outcomes. Individual POP-Q measurements and new urinary incontinence at 1 year were also measured.

Baseline prolapse and surgical approach differences

There were 321 participants included in the analysis, 170 of whom chose to undergo hysterectomy and 151 UP. Of these groups, 97.5% and 93.8%, respectively, had retention at 1 year. Increased odds of unpartnered marital status, nonpolar gender expression, never smoking, and a body mass index within normal range were reported in the UP group.

The UP group also had reduced odds of stage 2 or higher apical prolapse and stage 2 or higher anterior prolapse at the initial exam vs the hysterectomy group. Most instances of laparoscopic route and uterosacral ligament suspension were observed when managing apical prolapse.

In the hysterectomy group, 17.2% of patients reported anatomic recurrence of apical descent at 50% or higher of the total vaginal length at 1 year, vs 7.5% of the UP group. This indicated a double adjusted relative risk (aRR) of 0.35. However, 6-week and health care outcomes did not significantly differ between groups after double adjustment.

Procedural time, hospital stay, and complications

The length of surgery and length of hospital stay were also reduced in patients receiving UP vs hysterectomy, with adjusted mean differences of -0.68 hours and -4.34 hours, respectively. An aRR of 0.19 was reported for procedural complications, indicating they were less prevalent in the UP group.

UP also less often led to opioid use compared to hysterectomy, with an aRR of 0.79. Two cases of laparoscopic hysterectomy ended in open surgery to achieve hemostasis.

Composite recurrence rates at 1 year were 25.6% and 53.1% in the UP and hysterectomy groups, respectively. Rates of retreating for POP within 1 year were 2.3 vs 9%, respectively.

Conclusion

Additionally, while most questionnaire scores were similar between groups, the UP group had a slightly lower Pelvic Floor Impact Questionnaire urinary subscale score. These results indicated improved perioperative outcomes and reduced anatomic recurrence from UP surgery vs hysterectomy for POP repair.

“Given mounting evidence on safety, efficiency, and effectiveness of UP surgery and its alignment with the preferences of approximately half of patients to keep their uterus, the standard of care should include routine offering and patient choice between UP and hysterectomy-based surgery for POP,” wrote investigators.

Reference

1. Brennand EA, Scime NV, Huang B, et al. Hysterectomy versus uterine preservation for pelvic organ prolapse surgery: a prospective cohort study. Am J Obstet Gynecol. 2025;232:461.e1-20. doi:10.1016/j.ajog.2024.10.021
2. Meriwether KV, Antosh DD, Olivera CK, 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(2):129-146.e2. doi:10.1016/j.ajog.2018.01.018