Care este rolul histerectomiei în tratamentul prolapsului organelor pelviene?

I. Introduction

Pelvic organ prolapse (POP) is a common health problem which manifests with herniation of one or more pelvic organs through the vaginal walls. It affects more than 40% of women over 50 years old, being a major influence in their quality of life. Considering the extended life expectancy, there is a three-fold greater risk of having to go through pelvic correction surgery in the next 30 years. One-third of people with POP surgical treatment need a second reintervention throughout life^(1-3).

The main risk factors associated with POP are pregnancy and vaginal delivery. It is thought that, even though it is a physiological event, childbirth is traumatic to the connective tissue and pelvic floor muscle, leading to tearing of the muscle, nerves and ligaments that support the pelvic floor. Secondary, an increased Body Mass Index, chronic constipation, coughing or persistent lifting of heavy objects increase the risk of developing POP by sustained elevated intraabdominal pressure⁽⁴⁾.

II. Anatomy of pelvic support

The anatomy of the pelvic floor consists of an interpenetration of muscle fibers and ligaments that provide support by attaching to the bone walls, having a functional role in the continence and evacuation capacity of the pelvic organs⁽⁵⁾.

Three levels of pelvic support were described by Delancey. Level I is represented by the pelvic ligaments: the uterosacral ligaments, the cardinal ligaments, and pubovesical fascia.  This ligament assembly is also known as the pericervical ring, being considered a crucial element in the integrity of the pelvic floor. They fix the uterus and the upper portion of the vagina to the sacrum and the lateral pelvic wall. Functional deficits in this area lead to uterine or vaginal apex prolapse. The second level of support is represented by paravaginal fibers that suspend the vagina anteriorly at the arcus tendineus fasciae pelvis or linea alba. Additionally, there are ligamentous fibers that suspend the posterior vaginal wall from the superior fascia of the levator ani. The weakening of these suspensory ligaments leads to the appearance of cystocele or to prolapse in the anterior compartment. The third level of support is provided by the perineal membrane, the deep and superficial muscle groups, and by the perineal body. The occurrence of functional deficits in this area increases the risk of urethral hypermobility and the occurrence of anterior (cystocele) or posterior (rectocele) prolapse^(5-7).

III. Hysterectomy in pelvic organ prolapse: surgical approaches and outcomes

When proper therapeutic conduct is chosen, there should be many additional factors that need to be taken into account. The surgical treatment is reserved for patients with symptomatic prolapse, where a conservative treatment is beyond its limits, or it is not tolerated by the patient⁽⁸⁾.

Firstly, there is a wide spectrum of pathology that indicates hysterectomy, POP representing the third most frequent, with one in three women going through uterus removal surgery for pelvic procidence conditions. It is proposed for prolapse repair procedures when it is situated in the apical segment of the vaginal vault. A special care should be given to anterior floor POP also, as it is proven to be a causal relation between cystocele (point Ba) and apical prolapse (point C)^(8,9).

Secondly, when deciding to remove the uterus, the surgeon should evaluate the dimension and mobility, and a special attention should be given to the possibility of access to the pelvic floor. As a result, it is essential to carry out a pelvic assessment in order to exclude a secondary condition that could also impose the need for hysterectomy, while taking into account the patient’s preference and the cost implied⁽¹⁰⁾.

Regarding the available therapy, in case of apical vaginal prolapse, three repair procedures are described⁽¹¹⁾:

1. Hysterosacropexy – using prostetic material to anchor the uterus and proximal portion of the vagina to the sacral promontorium.
2. Subtotal hysterectomy followed by sacrocervicocolpopexy.
3. Sacrocolpopexy after total hysterectomy and enclosing of the vaginal cuff.

Referring strictly to hysterectomy surgical approaches in POP cases, we are talking about the classic abdominal access and performing the transvaginal procedure, with or without laparoscopic or robotic assistance⁽¹⁰⁾.

A. Primary outcomes

Considering the rate of recurrence as prolapse stage II or more, a point C>0 in Pelvic Organ Prolapse Quantification System (POP-Q), a qualitative review consisting of ten studies compared hysterectomy to hysteropreservation procedures. With a follow-up of roughly 18 months, the results revealed no statistical difference in both groups when the surgical routes were compared undifferentiated. Subsequently, when the procedures were grouped around the access route or type of surgery, there was a significantly lower recurrence rate for vaginal hysterectomy as against vaginal hysteropexy, without taking into account the method of apical fixation (RR 10.61; 95% CI; 1.26-88.94; p=0.03). Similar recurrence rate between hysterectomy and hysteropexy with the placement of prosthetic material or between the same procedures performed transabdominally was observed⁽¹²⁾.

When comparing hysterectomy with uterosacral ligament fixation to sacrospinous hysteropexy, two recent studies found a significantly reduced apical recurrence in the hysterectomy group versus the sacrospinous fixation (3% versus 21%; p=0.03)⁽⁸⁾.

On the other hand, a comparison between hysterectomy and Manchester procedure alone summarized in three studies inclined in favor of the hysteropreservation method. One study found a symptomatic recurrence after vaginal hysterectomy of 15%, compared with 10% in Manchester procedure (p=0.28), with the need for reintervention of only 3% in the second group⁽¹³⁾.

When it comes to the rate of reintervention, the 10 aforementioned studies described POP occurrence after repair surgery in any vaginal compartment as significantly lower in the hysterectomy group⁽¹²⁾.

B. Secondary outcomes

Regarding the duration of the intervention, four studies that analyzed 314 procedures found a statistically significant reduction in the operative time in case of hysteropexy procedures compared to hysterectomy (MD = -12.43; 95% CI; -14.11 to -10.74; p<0.00001). These results are constant in the literature and when subgroups are analyzed based on the surgical method or the chosen approach. Thus, five studies comparing the surgical time of the Manchester operation versus hysterectomy concluded an average operation time of 62.4 to 110 minutes in the case of Manchester procedure versus 77.8 to 130 minutes in case of hysterectomy. Of course, an important factor is the experience of the surgeon^(12,13).

On the same note, it was found that hysterectomy results in a greater blood loss when analyzed over 223 procedures in three studies (MD = -60.42; 95% CI; -71.31 to -49.53; p<0.00001). There was a longer hospital stay in hysterectomy patients, a tendency for a prolonged need for catheterization, and an increased risk for reintervention over secondary complications, such as hematoma, perioperative infection or iatrogenic trauma to the bladder (p=0.002). No statistically significant difference was found between the two groups regarding dyspareunia^(12,13).

IV. Conclusions

The preferred surgical route at the moment for pelvic organ prolapse is, without question, hysterectomy with further ligament fixation of the vaginal apex. However, the advancement and improvement of hysteropexy procedures have raised a series of questions related to the necessity of removing the uterus in prolapse repair procedures. Thus, although the data from the literature demonstrate a lower recurrence rate of POP in the case of vaginal hysterectomy and ligament fixation with own tissue, compared in general, there is no statistically significant difference between hysteropexy and hysterectomy procedures, regardless of the chosen approach. Adding to the invasive nature and the need for a wide dissection of the tissues, hysterectomy requires more intervention time, results in a longer duration of hospitalization and the prolongation of the moment in which the patients resume their activity. Moreover, no significant difference was found regarding the quality of life, from the point of view of sexual satisfaction, both POP correction operations resulting in a significant decrease in sexual capacity, more likely due to the psychological impact^(8,12).

Considering the heterogeneity of the surgical treatment of POP, as well as the different methods of ligament suspension and the possibility of combining them, large studies with a long follow-up period are needed to provide a clear conclusion related to the choice of the right treatment and to provide an individualized treatment suitable for each patient. Until then, it should be noted that a decisive factor in choosing the right surgical procedure is the history of gynecological antecedents: metropathies, endometrial polyps, fibromatous nodules or cervical dysplasia, as well as the reproductive state of the patient. The decision of removing the uterus should be made with the patient, after presenting the advantages and disadvantages of each procedure, and finding what works best for each individual.


 

Conflict of interest: none declared  
Financial support: none declared
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