Uterine Sparing Surgery: A Shift in Gynecological Care

[Dr. Suzette Sutherland]
Let's just get started. I think historically the answer to all women's problems was always a hysterectomy. When we really look historically and look back at the turn of the last, last century, many women had a hysterectomy to try and fix their emotional hysteria, which is sometimes where the term comes from. We know today that removing a woman's uterus is not the answer to all of her problems, right? Then, on the contrary, it can actually cause some problems. There has been a movement to say, "Why do we always remove this uterus if it's not needing to be removed for another reason, like cancer? How can we utilize it in the repair and maybe actually even improve upon the repairs that we are doing?" That's what we're here to talk about today.

Let's get into the various issues pertaining to this: the hysterectomy and the uterine-sparing procedures. Just to think about, what are the advantages of keeping the uterus in place if we're doing a prolapse repair? Can you speak to that?

[Dr. Olivia Chang]
Of course, Suzette. I want to go back to what you started off by saying that hysterectomy is a historical treatment for many indications, not only within gynecology but even for mental health disorders. I think that is an important aspect because for so long, hysterectomy was known as the definitive surgical treatment for abnormal uterine bleeding, for pelvic pain, and the same thing for pelvic organ prolapse. If you survey women who were born 1940s to 1970s, many of them have had a hysterectomy and many of them can tell you that they had a hysterectomy having not tried anything else before leading to that surgical treatment.

Now, in 2023, we're really taking a closer look at the indication of hysterectomy. Is it really necessary? Is it really indicated? What advantages or disadvantages are there when we do a hysterectomy? You highlighted a great point about talking about hysterectomy at the time of prolapse repair. Again, this has been something that's considered sort of a dogma where it's always done at the time of prolapse surgeries, but we now know that this might not be the case and that the uterus might be an innocent bystander to this entire prolapse repair.

[Dr. Suzette Sutherland]
I'd really love to make the point that, again, removing the uterus, though, doesn't always solve the problem in the case of prolapse. Again, when we look more historically, the uterus was removed without any attention to, okay, how do we recreate this apical support for the vagina? Right? Today, hopefully, all training for residents and fellows brings home the importance of that point. Can you speak a little bit more to that and what your experience has been when you see patients that have either had an apical repair at the time of hysterectomy or not?

[Dr. Olivia Chang]
Absolutely. That's such an important point and something that really needs to be highlighted. You're absolutely right; if you simply do a hysterectomy at the time of prolapse repair without addressing the apex, that prolapse will return. The way to get about it is that you actually commit to performing an apical suspension at the time of hysterectomy. Mind you, there are many ways of doing hysterectomy. You can do a vaginal hysterectomy, you can do a laparoscopic hysterectomy, but no matter the mode of hysterectomy, it's important to resuspend that vaginal apex, either with mesh or with sutures, to prevent recurrence of prolapse.

That actually brings on an interesting point, Suzette, what you're saying is that, what if a woman doesn't have prolapse, she simply has a hysterectomy for let's say abnormal uterine bleeding? Should we prophylactically suspend her vaginal apex? I think that is a wonderful question that hasn't been studied in prospective trials. I know that if it was myself undergoing a hysterectomy, I would request for a prophylactic suspension of the vaginal apex because I do believe in the value of doing so.

[Dr. Suzette Sutherland]
What does the data show, and what has your experience been? Does a hysteropexy stand the test of time just like a hysterectomy and apical repair? Are they equivalent, or are there some differences there with respect to efficacy and safety of doing the procedure?

[Dr. Olivia Chang]
Another great question. Like I said at the beginning, we're really looking at this question about the utility of hysterectomy at the prolapse repair with a new lens in the past few years. There's many ways we can go about this; we can look at efficacy, like you said, we can look at complications, or we can look at patient preferences.


Starting with efficacy, there's data out there. There has been a great systematic review by Dr. Kate Meriwether, who did a fantastic job in summarizing the available data out there that compares different types of uterine-sparing prolapse procedures to hysterectomy-based prolapse procedures. In her study, the biggest limitation is really the follow-up time; most of these studies have follow-up times at one to three years, only. Based on these, there isn't a definitive difference in outcomes between these two modalities. There are some adverse events that contributed to favoring hysteropexy because hysterectomy was always associated with more blood loss and a longer operative time. If you look at these numbers closely, the blood loss was often not significant, that a difference of 100 to 200 is probably not so significant, but statistically on these papers, it did show a difference. Then with regard to adverse outcomes, we talked about the benefit by decreasing the operative time and also with the blood loss.

[Dr. Suzette Sutherland]
I think there's the SAVE U Trial that went out to three years that was comparing hysterectomy with uterosacral ligament suspension versus transvaginal, of course, and then transvaginal hysteropexy. Then, they carried it out for five years. There is that data out to five years. To your point, when we look at, we call long-term success, no one has really been able to define long-term success, but you see in the abstract, conclusion, or in the discussion of the papers, and they say long-term success. I would argue even five years isn't long-term when you're dealing with a woman who's 40 years old, 45 years old, and she has prolapse. You're going to tell her, "It'll last you for about five years.

Now, clearly we know that they don't all come down at five years, but we are searching for prolapse repairs that last much, much longer, of course, and hopefully, be the definitive surgery for the woman. Still, what we do have so far, the SAVE U Trial, it showed non-inferiority of the hysteropexy, correct?

[Dr. Olivia Chang]
Absolutely. The numbers actually look quite good favoring hysteropexy with very low clinically significant apical recurrence rate between the two groups. Like I said, we're highlighting this new clinical question, so I believe that the data will definitely continue to mature because right now, we have this one randomized controlled trial, but I know that there's one underway by the Canadian group, and that is also examining this issue. One thing that we're trying to do ourselves is utilize Medicare data to see if there is a difference of surgical retreatment rate after these two different types of procedures.

One other clinical question that is relatively unknown is that for people where we do keep the uterus, what is the rate of surgical intervention, not just for prolapse after, but for abnormal bleeding, for abnormal pap smears, for an ultimate hysterectomy down the line? Because if you look at the existing data, the reoperation is very much focused on prolapse, but we know that if you were to keep a uterus in, just over time, statistically speaking, a small percentage of women may have abnormal bleeding. How many of those, if we left their uterus in, end up with a second procedure for a non-prolapse indication? That is unknown as well. That's what we are trying to answer with the Medicare data. Hopefully, that will just shed new light to better understand the overall, composite reoperation rate for prolapse bleeding and pain, after a uterine preserving procedure.

[Dr. Suzette Sutherland]
Yes, that's a great point. So many people ask, "If I need my uterus out, then, at a later date, isn't it going to be more difficult to remove it surgically if you did this repair and even using some permanent material like mesh or permanent suture?" The answer is that there are some nuances to that, but it's definitely not impossible, and in most cases, readily doable. I think to that point, being worried that you might have to have a hysterectomy in 20 years shouldn't be a reason to not do a uterine-sparing procedure now.

[Dr. Olivia Chang]
Absolutely. There are so many advantages in my mind for a hysteropexy. For some of my patients, a difference of operative time of 30 minutes is significant, and having less bleeding even if it's not clinically significant bleeding, but just having less bleeding in general, is better and advantageous to patients. I've noticed a faster recovery after a hysteropexy compared to a hysterectomy prolapse procedure.

I do favor hysteropexy in my practice, as you know, because of these clinical advantages. I also feel for patients. The idea of a hysterectomy can be scary. It feels like major surgery. For them, that might be the barrier for them to seek more definitive treatment. What I've seen in my own practice is that I have had ladies who've worn pessaries for 10, 20 years, and they were afraid of a hysterectomy. When they heard of the option for a hysteropexy, they were delighted. They were delighted to know that there was a surgical procedure that didn't involve a hysterectomy that would fix their prolapse. All these patients were just so happy after the surgery, after their hysteropexy because they felt great. There was minimal downtime, and they didn't have to wear their pessaries anymore.

[Dr. Suzette Sutherland]
Yes. I will say, for patients that I see that transition from a pessary to hysteropexy are usually very, very pleased. With long-term pessary, with the uterus in, oftentimes you get cervical rubbing, erosion somewhat, and then some bleeding and discharge, and they're so happy to not have to deal with that aspect any longer either.