Uterine Preservation vs Hysterectomy in Pelvic Organ Prolapse Surgery: A Systematic Review With Meta-analysis and Clinical Practice Guidelines

Hysterectomy performed at the time of pelvic organ prolapse (POP) repair allows the surgeon to gain access to tissues used for apical suspension. However, hysterectomy adds surgical time and costs and may increase morbidity. Accumulating data suggest that uterine preservation during POP repair may have advantages. Proponents of preservation argue that there is decreased morbidity and higher patient satisfaction with uterine preservation without sacrificing efficacy. However, there are few high-quality data comparing uterine preservation prolapse surgery with procedures performed with concomitant hysterectomy. The authors hypothesized that uterine preservation would improve operating time and morbidity in apical POP surgery but would increase risk of prolapse recurrence. The aim of this systematic review and meta-analysis was to create evidence-based clinical practice guidelines addressing the relative risks and benefits of uterine preservation during apical surgical repair for POP and to test this hypothesis. A search of MEDLINE, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials was performed from inception until January 2017 to identify studies comparing surgical procedures for apical POP preserving the uterus with surgical interventions for POP removing all or part of the uterus. Randomized and nonrandomized studies that compared uterine-preserving prolapse surgeries with those involving hysterectomy were included. Data were extracted for patient information, intervention, comparator, efficacy outcomes, and adverse events, and studies were individually and collectively assessed for methodological quality. A meta-analysis was performed if 3 or more studies compared the same surgeries and reported the same outcome. The quality of evidence was evaluated in accordance with the Grades for Recommendation, Assessment, Development, and Evaluation System. A total of 4467 abstracts were screened; among these, 94 studies meeting study criteria were identified, 53 of which compared uterine preservation to hysterectomy in prolapse surgery. The overall quality of the evidence was moderate. Use of uterine preservation with sacrohysteropexy reduced mesh exposure, operative time, blood loss, and surgical cost without short-term differences in prolapse recurrence compared with hysterectomy plus mesh sacrocolpopexy. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation using laparoscopic sacrohysteropexy improved the C point and vaginal length on the POP quantification examination, decreased estimated blood loss, postoperative pain and functioning, and length of hospital stay; however, open abdominal sacrohysteropexy worsened bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy—compared with transvaginal mesh with hysterectomy—decreased mesh exposure, reoperation for mesh exposure, postoperative bleeding, estimated blood loss, and improved posterior POP quantification measurement. Compared with vaginal hysterectomy using native tissue suspension, transvaginal uterosacral or sacrospinous hysteropexy www.obgynsurvey. com | 680 GYNECOLOGY Volume 73, Number 12 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright© 2018 Wolters Kluwer Health, Inc. All rights reserved. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. or the Manchester procedure improved operative time and decreased estimated blood loss without worsening prolapse outcomes with uterine preservation. Few data are in the literature for any prolapse outcomes of more than 3 years after surgery, the role of uterine preservation in obliterative procedures, and long-term risk of uterine pathology after uterine preservation. These findings show that uterine preservation decreases risk of mesh exposure, operating time, and blood loss compared with prolapse repairs with hysterectomy and does not significantly worsen short-term prolapse outcomes. Uterine preservation may be considered as an option in women without contraindications who do not desire hysterectomy.