Chirurgia del Prolasso Conservazione dell’utero

ConMichele Meschia

Magenta

Chirurgia del prolassoChirurgia del prolassoRuolo dell’isterectomia?

…..Hysterectomy at the time of POP repairs is the standard practice in most part of the world despite the fact that descent of theuterus may be a consequence, not a cause of POP. Surprisingly, given its widespread use, concomitant hysterectomy is not an evidence-based practice.

Hysterectomy and prolapse surgeryHysterectomy and prolapse surgery

• Most common indication for hysterectomy in women over Most common indication for hysterectomy in women over 55 y of age in USA55 y of age in USA

• Common belief that maintenance of the uterus in situ Common belief that maintenance of the uterus in situ increase the risk of recurrenceincrease the risk of recurrence

• Hysterectomy at the time of prolapse surgery has not been Hysterectomy at the time of prolapse surgery has not been proved to improve the durability of the repairproved to improve the durability of the repair

• Hysterectomy has been be associated with increased Hysterectomy has been be associated with increased morbidity, new onset urinary, bowel and sexual dysfunctionmorbidity, new onset urinary, bowel and sexual dysfunction

Prolapse surgeryProlapse surgery

• Heterogeneous nature of the problemHeterogeneous nature of the problem• Variability in inclusion/exclusion criteriaVariability in inclusion/exclusion criteria• Plethora of surgical procedures performedPlethora of surgical procedures performed• Non standardized definitions of surgical outcomeNon standardized definitions of surgical outcome• Relatively short follow-up periodsRelatively short follow-up periods• Lack of controlled studies comparing surgeriesLack of controlled studies comparing surgeries

Published studies: criticismPublished studies: criticism

Vaginal hysterectomy

Sacrospinous hysteropexy

Manchester operation

Posterior IVS

Cure rates

Apical 88-100% 85-100% 93-100% 90-97%

Anterior 28-100% 62-100% 95% 91-97%

Posterior 36-100% 97-100% 99-100% 97-100%

Recurrent surgery

Apical prolapse 0-7% 0-5% 0-4% 3%

Any prolapse 0-12% 0-7% 0-4% 3%

Other conditions 0% 0-4% 0-2% 0-18%

Surgical approach: cure rates and recurrent surgery Surgical approach: cure rates and recurrent surgery

Dietz V. et al, IUJ 2009Dietz V. et al, IUJ 2009

Vaginal hysterectomy

Sacrospinous hysteropexy

Machester operation

Posterior IVS

Bladder Injury 0-2% 0% 0-1% 0%

Rectal Injury 0-2% 0-1% 0% 0-3%

Blood transfusion 0-11% 1% 0-3% 0-0.3%

Infection 0-21% 0-2% 0-13% 0-0.3%

LUT symptoms up to 20% up to 37% up to 22% 0-6%

Vault abscess/hematoma

0-7% 0% 0% 0%

Buttock pain 0% 3-27% 0% 0%

Surgical approach: complications Surgical approach: complications

Dietz V. et al, IUJ 2009Dietz V. et al, IUJ 2009

• 81 and 75 women undergoing two different procedures were 81 and 75 women undergoing two different procedures were retrospectively analysed retrospectively analysed VH group with greater degree of apical prolapse than theVH group with greater degree of apical prolapse than the Manchester group: point C Manchester group: point C 0.4 0.4 ± 3.4 vs –1.8 ± 2.6 (p = 0.000)At one yearAt one year • No difference in IIQ, UDI and DDI for all domainsNo difference in IIQ, UDI and DDI for all domains• There were no apical recurrences in the Manchester group There were no apical recurrences in the Manchester group compared with 4% in the VH groupcompared with 4% in the VH group• Both groups showed up to 50% anterior recurrence ( Both groups showed up to 50% anterior recurrence ( >> stage II) stage II)

de Boer et al. IUJ 2009de Boer et al. IUJ 2009

Cervical amputation with USL plication vs vaginal hysterectomy with high USL plication

Uterus Preservation in Surgical Correction of Urogenital Prolapse

CSPN=38

HSPN=34

P

Object. results 92% 91% ns

Subject. results 81.6% 85.3% ns

Satisfaction 86.8% 91% ns

Prospective comparative study on colposacropexy with uterus conservation (HSP) and hysterectomy followed by sacropexy (CSP)

Mean follow-up was 51 months (range 12-115).

Costantini et al, 2005

Female Pelvic Med Reconstr Surg. 2012 Sep-Oct;18(5):286-90.Abdominal sacral hysteropexy: a pilot study comparing sacral hysteropexy to sacral colpopexy with hysterectomy.Cvach K1, Geoffrion R, Cundiff GW. OBJECTIVES:Treatment of pelvic prolapse with uterine conservation using the sacral hysteropexy may be associated with less patient morbidity but has uncertain subjective and objective outcomes. We sought to compare abdominal sacral hysteropexy (ASH) with sacral colpopexy/total abdominal hysterectomy (ASC/TAH).METHODS:This is an ambispective (retrospective/prospective) cohort pilot study comparing ASH to ASC/TAH. The primary outcome was global impression of improvement. Secondary outcomes were based on validated quality-of-life questionnaires and surgical complications.RESULTS:Eighteen ASHs were compared to 9 ASC/TAHs after a mean follow-up of 19 months. Whereas subjective outcomes did not differ, anterior failure (55%) and subsequent uterine pathology (22%) were higher in the ASH cohort. Graft erosion occurred in 33% of the ASC/TAH group.CONCLUSIONS:The ASH offers advantages and disadvantages that warrant further investigation with a prospective study.

• 82 women with stage II-IV uterine prolapse were randomized to 82 women with stage II-IV uterine prolapse were randomized to treatmentstreatmentsAt one yearAt one year • The vaginal group scored significantly better in 3 domainsThe vaginal group scored significantly better in 3 domains of the UDI (pain/discomfort, OAB, obstructive micturition)of the UDI (pain/discomfort, OAB, obstructive micturition)• Higher rate of repeat surgery in the abdominal group (RR 9.00, Higher rate of repeat surgery in the abdominal group (RR 9.00, 95% CI 1.19-67.85). 13% for recurrent cystocele and 10.5% for95% CI 1.19-67.85). 13% for recurrent cystocele and 10.5% for recurrent uterine prolapse vs 2.4% for recurrent vault prolapse.recurrent uterine prolapse vs 2.4% for recurrent vault prolapse.

Roovers et al. BJOG 2004; 111:50-56Roovers et al. BJOG 2004; 111:50-56

Abdominal sacral hysteropexy vs vaginal hysterectomy with uterosacral vault suspension

Success rate:1y after surgery

Sacrospinous hysteropexy

( n=34)

Vaginal hysterectomy

(n =31)

Difference P

Apical 27 (79%) 30 (97%) 17% 0.03

Anterior 17 (50%) 11 (35%) -15% 0.2

Posterior 28 (82%) 22 (71%) -11% 0.3

Recovery time (days) Hospital stay 3 (3-7) 4 (3-14) 0.03

Return to daily activities

34 + 13 33 + 21 0.9

Return to work 43 + 21 66 + 34 0.02

One year follow-up after sacrospinous hysteropexy and vaginal One year follow-up after sacrospinous hysteropexy and vaginal hysterectomy for uterine descent: a randomized study hysterectomy for uterine descent: a randomized study

Dietz V. et al, IUJ 2010Dietz V. et al, IUJ 2010No difference in UDI e IIQ scores

Perché conservare un organoPerché conservare un organo

prolassato?prolassato?

Reasons for uterine preservationReasons for uterine preservation

• Childbearing desire until a later ageChildbearing desire until a later age• Belief that the uterus plays a role in sexual satisfactionBelief that the uterus plays a role in sexual satisfaction• Hysterectomy might be associated with increased morbidity, in Hysterectomy might be associated with increased morbidity, in

particular new onset urinary dysfunctionparticular new onset urinary dysfunction• Decrease in peri-operative morbidity including mesh erosionDecrease in peri-operative morbidity including mesh erosion

Reasons for uterine preservationReasons for uterine preservationFertilityFertility

Reasons for uterine preservationReasons for uterine preservationFertilityFertility

Reasons for uterine preservationReasons for uterine preservationFertilityFertility

30 pts30 pts

Three women had pregnancies that were conceived spontaneously, that led to three early legal abortions

Hysterectomy and sexual function

No Hyst n.15

Hyst.n. 22

P

* FSFI total score 22.8 21.1 ns

Sexual satisfaction 47% 46% ns

• Female Sexual Function Index: six domains (desire, arousal, lubrification, orgasm, satisfaction and pain)

CSP with and without hysterectomyCSP with and without hysterectomy

Zucchi et al, J Sex Med 2008Zucchi et al, J Sex Med 2008

Hysterectomy and risk of SUI surgeryHysterectomy and risk of SUI surgery

Rate of SUI surgery• 179 vs 76 per 105 person-year with and without

hysterectomy OR 2.4 (95% CI 2.3-2.5)

A 30 years population based observational study

165.260 vs 479.506 women who had or had not undergone 165.260 vs 479.506 women who had or had not undergone hysterectomy for bening indicationshysterectomy for bening indications

Altman, Lancet 2007Altman, Lancet 2007

Hysterectomy and Incontinence• Age• Parity• Indication for hyst.• Type of hyst.• Other

Confounding variables

Jolleys,1988Jolleys,1988

Prevalene of urinary incontinencePrevalene of urinary incontinence

0

10

20

30

40

50

60

< 25 25-34 35-44 45-54 55-64 65-74 75-84 > 85

Annual hysterectomy rates/1000 by age groupsAnnual hysterectomy rates/1000 by age groups

Jacobson, Obstet Gynecol 2006Jacobson, Obstet Gynecol 2006

Alluce valgoVene varicose

Altman et al, 2007Altman et al, 2007

HysterectomyHysterectomyUrinary incontinenceUrinary incontinence

Aumentata chirurgia per:Aumentata chirurgia per:

Hysterectomy and Incontinence

No Hyst n.83

Hyst.n. 83

P

SUI 53 (63%) 42 (50%) .028

UUI 33 (40%) 26 (31%) .194

SUI significantly less common after hysterectomy: OR 0.55 (95% CI 0.30-1.00) Adjusted Multivariate analysis

No relationship between hyst. and SUI withexclusion of twin pairs with history of PFD surgeryOR 0.79 (95% CI 0.4-1.40)

Evanston Twins Sister StudyEvanston Twins Sister Study

Miller, Am J Obstet Gynecol, 2008Miller, Am J Obstet Gynecol, 2008

• Preservation of uterus =Preservation of uterus = 0% (0/48)0% (0/48)

20.3% (26/126) 20.3% (26/126) 10.5% (4/38) to10.5% (4/38) to

Hysteropexy: a mesh driven choice?Hysteropexy: a mesh driven choice?

Collinet et al, Int Urogyn J, 2005

Rates of mesh exposureRates of mesh exposure

• Hysterectomy =

69 pz

Uterine preservationUterine preservationWhen?When?

• Tutte le donne con cistocele e C fino a -1 cm dall’imene• Donne con cistocele e C fino a 0 cm con limitazioni anestesiologiche

To evaluate the rate of pre-cancerous and cancerous endometrial lesions in patients undergoing hysterectomy

In the analysis of 136 cases, precancerous and cancerous lesions have been diagnosed while ultrasonography or cervical smear were normal

• 2 (1.4%) endocervical dysplasia,• 1 (0.7%) cervical epidermoid carcinoma• 10 (7.35%) endometrial complex non-atypical hyperplasia, • 7 (5.1%) endometrial atypical hyperplasia • 2 (1.4%) endometrioid endometrial carcinoma.

16% cervical and endometrial pathology

Risk of malignancy

Mansoor et al, 2013

• The role of hysterectomy remains controversial in the surgical strategy for POP

ConclusionsConclusions

ICI 2005

• There is little evidence to suggest that hysterectomy for benign conditions may place a woman at risk for UI• Hysterectomy alone does not contribute to sexual dysfunction

• Hysteropexy with or without cervical amputation must be offered in young women

• Selection bias have to be considered when analysing existing data