Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study.
BACKGROUND
There is growing interest in uterine conservation at the time of surgery for uterovaginal prolapse, but limited data compare different types of hysteropexy.


OBJECTIVE
We sought to compare 1-year efficacy and safety of laparoscopic sacral hysteropexy and vaginal mesh hysteropexy.


METHODS
This multicenter, prospective parallel cohort study compared laparoscopic sacral hysteropexy to vaginal mesh hysteropexy at 8 institutions. We included women ages 35-80 years who desired uterine conservation, were done with childbearing, and were undergoing 1 of the above procedures for stage 2-4 symptomatic anterior/apical uterovaginal prolapse (anterior descent at or beyond the hymen [Aa or Ba ≥ 0] and apical descent at or below the midvagina [C ≥ -TVL/2]). We excluded women with cervical elongation, prior mesh prolapse repair, cervical dysplasia, chronic pelvic pain, uterine abnormalities, and abnormal bleeding. Cure was defined as no prolapse beyond the hymen and cervix above midvagina (anatomic), no vaginal bulge sensation (symptomatic), and no reoperations. Pelvic Organ Prolapse Quantification examination and validated questionnaires were collected at baseline and 12 months including the Pelvic Floor Distress Inventory Short Form, Female Sexual Function Index, and Patient Global Impression of Improvement. In all, 72 subjects/group were required to detect 94% vs 75% cure (80% power, 15% dropout). Intention-to-treat analysis was used with logistic regression adjusting for baseline differences.


RESULTS
We performed 74 laparoscopic sacral hysteropexy and 76 vaginal mesh hysteropexy procedures from July 2011 through May 2014. Laparoscopic patients were younger (P < .001), had lower parity (P = .006), were more likely premenopausal (P = .008), and had more severe prolapse (P = .02). Laparoscopic procedure (174 vs 64 minutes, P < .0001) and total operating time (239 vs 112 minutes, P < .0001) were longer. There were no differences in blood loss, complications, and hospital stay. One-year outcomes for the available 83% laparoscopic and 80% vaginal hysteropexy patients revealed no differences in anatomic (77% vs 80%; adjusted odds ratio, 0.48; P = .20), symptomatic (90% vs 95%; adjusted odds ratio, 0.40; P = .22), or composite (72% vs 74%; adjusted odds ratio, 0.58; P = .27) cure. Mesh exposures occurred in 2.7% laparoscopic vs 6.6% vaginal hysteropexy (P = .44). A total of 95% of each group were very much better or much better. Pelvic floor symptom and sexual function scores improved for both groups with no difference between groups.


CONCLUSIONS
Laparoscopic sacral hysteropexy and vaginal mesh hysteropexy had similar 1-year cure rates and high satisfaction.
MedStar Washington Hospital Center/Georgetown University, Washington, DC. Electronic address: Robert.E.Gutman@MedStar.net.
Robert E
RE
Gutman
Alpert Medical School of Brown University/Women & Infants Hospital of Rhode Island, Providence, RI.
Charles R
CR
Rardin
Stanford University School of Medicine, Stanford, CA.
Eric R
ER
Sokol
University of North Carolina, Chapel Hill, NC.
Catherine
C
Matthews
MedStar Washington Hospital Center/Georgetown University, Washington, DC.
Amy J
AJ
Park
MedStar Washington Hospital Center/Georgetown University, Washington, DC.
Cheryl B
CB
Iglesia
University of British Columbia, Vancouver, British Columbia, Canada.
Roxana
R
Geoffrion
MedStar Washington Hospital Center/Georgetown University, Washington, DC.
Andrew I
AI
Sokol
Christ Hospital/University of Cincinnati, Cincinnati, OH.
Mickey
M
Karram
University of British Columbia, Vancouver, British Columbia, Canada.
Geoffrey W
GW
Cundiff
Greater Baltimore Medical Center, Towson, MD.
Joan L
JL
Blomquist
Cleveland Clinic, Cleveland, OH.
Matthew D
MD
Barber
D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology*; D011446:Prospective Studies; D012447:Sacrum; D013526:Surgical Mesh; D014596:Uterine Prolapse / Q000601:surgery*; D014621:Vagina
hysteropexy; laparoscopic sacral hysteropexy; pelvic organ prolapse; uphold; uterine conservation; uterine preservation; vaginal mesh