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BackTable / OBGYN / Podcast / Transcript #32
Podcast Transcript: Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse
with Dr. Olivia Chang
This week on BackTable OBGYN, Dr. Suzette Sutherland (University of Washington) and Dr. Olivia Chang (UC Irvine) discuss reasons for uterine preservation and hysteropexy techniques for prolapse repair. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Beyond the Hysterectomy in Women's Health Surgeries
(2) Apical Support: Mesh Augmentation vs. Native Tissue Repair
(3) Assessing Hysteropexy: Data Insights & Clinical Perspectives
(4) Compartmental Complexity: Strategies for Comprehensive Prolapse Repair
(5) Sacrospinous Ligament Access: Techniques & Devices for Effective Suturing
(6) The Long-Term Landscape of Prolapse Repair
(7) The Importance of the Patient Perspective in Uterus Preservation
(8) Surgical Indications & Patient Considerations for Uterine Preservation
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[Dr. Mark Hoffman]
Hello everyone, and welcome to the BackTable OBGYN Podcast: your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com.
[Dr. Suzette Sutherland]
I'm Suzette Sutherland, your host today. I'm very excited to introduce Dr. Olivia Chang from the University of California, Irvine. She has a special interest in uterine-sparing procedures, predominantly for prolapse repairs, and she's here to talk to us about that. Welcome, Dr. Chang.
[Dr. Olivia Chang]
Thank you so much for having me.
(1) Beyond the Hysterectomy in Women's Health Surgeries
[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.
I wanted to briefly introduce, again, Dr. Chang. She did her urogynecology training at the Cleveland Clinic. I had the great privilege of working with her for a couple of years at the University of Washington in Seattle, and then she moved on to the University of California in Irvine, where she is in the Urology Department and a director of female urology there and plans to start an FPMRS fellowship there. Again, welcome Dr. Chang. Excited to have you here.
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.
(2) Apical Support: Mesh Augmentation vs. Native Tissue Repair
[Dr. Suzette Sutherland]
Right. I think again, in years past, when surgeons didn't pay attention to this detail after removing the uterus and just closing the vaginal cuff wherever it landed, I think sometimes that's what led to having prolapse problems in the future. What are the common ways to recreate that apical support today?
[Dr. Olivia Chang]
Absolutely. There are different ways, and the way I generally categorize them is using mesh augmentation or using native tissue. Mesh augmentation would include techniques such as sacrocolpopexy, there could be a sacral hysteropexy to suspend the vaginal apex. In some countries with availability and access to vaginal mesh, that's also another option to suspend the vaginal apex.
For native tissue repairs, there is the extraperitoneal colpopexy, which is the suspension to the sacral spinous ligament. For intraperitoneal colpopexy, that is the uterosacral ligament suspensions. Generally, these are the large buckets of categories there are out there currently.
[Dr. Suzette Sutherland]
Then, if we're doing a uterine sparing procedure, all of these procedures that you described, they're also all available. The attachment points are just to the uterus as opposed to the top of the vaginal canal. Is that correct or is there more to it than that?
[Dr. Olivia Chang]
Yes, absolutely, Suzette. If you do a uterosacral ligament hysteropexy, you're placing the sutures in the same location. The only difference is, like you said, you're anchoring the distal sutures to the cervix rather than the vaginal cuff. I would say technique-wise, the more drastic difference would be the difference between a sacrocolpopexy and a sacral hysteropexy. The reason is, in the case of sacral hysteropexy, you are applying mesh using two pieces of mesh, and you're using the mesh to wrap around the uterus. In the way I was taught to do this is that you essentially make two arms out of a rectangular piece of mesh. You take the two arms, you wrap it around the broad ligament of the uterus, and you suspend that to the anterior longitudinal ligament. That is technically more challenging than a standard sacrocolpopexy because of the additional dissection that is required and because of the possible bleeding risk as you're trying to wrap the mesh around the uterine arteries.
[Dr. Suzette Sutherland]
I was going to ask that. We can get into some of the differences too, in a little bit, but as long as you mentioned that, when you're doing a hysteropexy, especially one a little more involved, like you just described, as opposed to doing it with a sacrospinous ligament fixation extraperitoneal, but when you're doing it with a mesh and wrapping it around, do you really need to worry more about more bleeding because those uterine vessels are there? Is it really a little more technically challenging because of that as opposed to when the uterus isn't there and you're not so worried about those big vessels?
[Dr. Olivia Chang]
Great point, Suzette. When we're trying to leave an organ in, and the organ that we're talking about is the uterus, we know it's a vascular organ. We know that there are a lot of vessels feeding into it, a lot of collateral vessels, so you do have to be very mindful when you're placing that mesh. That's something that definitely takes a lot of training and a lot of practice to be able to place that mesh safely at the time of a sacral hysteropexy to avoid complications.
(3) Assessing Hysteropexy: Data Insights & Clinical Perspectives
[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.
[Dr. Olivia Chang]
That's right.
(4) Compartmental Complexity: Strategies for Comprehensive Prolapse Repair
[Dr. Suzette Sutherland]
I wanted to move back for one second about recurrence rates after prolapse. In the SAVE U Trial, as well as in a number of other trials, they do talk about recurrence of prolapse, but we know today one person's prolapse isn't another person's prolapse. We need to look at what compartment is prolapsing, what compartment did we operate in, and is that the part that is re-prolapsing, so i.e. our intervention wasn't good enough? Or is that compartment okay and it's a different compartment, and maybe it wasn't addressed at the time, or our intervention made it weaker?
They did see this in the SAVE U Trial specifically, as well as some other trials, that there was a reoperation rate, but predominantly in the anterior compartment. Can you speak to that? How often do you feel like there is some attention paid surgically to the anterior compartment at the same time as the apical repair?
[Dr. Olivia Chang]
Yes, the anterior compartment is tricky. It's tricky. It's the most common site of recurrence for any type of prolapse surgery, no matter what the index procedure is. You're absolutely right. We really have to address the anterior compartment at the time of apical repair. I do find that, in my personal experience, for patients with advanced anterior prolapse, so somebody with a Stage 3 cystocele, for example. These patients, I routinely offer a sacrospinous ligament hysteropexy, but what I would modify is that I would perform an anterior approach to the sacrospinous ligament. In my experience, this allows for a better elevation of the anterior compartment, and just ultimately a better suspension at the end of the surgery. In doing so, if you do an anterior approach, you're addressing both the anterior compartment and the apical compartment through the same incision.
[Dr. Suzette Sutherland]
Then, I guess along those same lines, when might it be advantageous to do a posterior approach?
[Dr. Olivia Chang]
In my practice, I would do a posterior approach if the predominant or the leading edge of the prolapse is the posterior compartment. Say somebody comes in with a big Stage 3 rectocele, and in that, I would prefer a posterior reproach because it's the most accessible way to get the sacrospinous ligament. However, going back to your point earlier, even if I'm doing a posterior approach, I am still going to address that anterior compartment because the data shows that's the most likely site for the prolapse to recur.
(5) Sacrospinous Ligament Access: Techniques & Devices for Effective Suturing
[Dr. Suzette Sutherland]
Right. It can be in the range of 30% to 40% if the anterior compartment isn't addressed at the same time. That's information we've known for some time already, and many people are really incorporating that into their practices, which is wonderful for the patients, needless to say.
What products are available or what means are available today to access the sacrospinous ligament, as an example? There are a number of products that are on the market now that make it easier to access this. Do you have experience with these? I don't know if you're able to list them just for our listeners.
[Dr. Olivia Chang]
Of course. The most traditional suture-capturing device has been Capio. There's been different ligature carriers. Going back historically, we first started with ligature carriers, and there's the Miya hooks and the Deschamps that allows you to place a needle through the sacrospinous ligament and then pass the needle through. From there on, there was the Capio suture capturing device by Boston Scientific.
In the past five years or so, there has really been a great explosion of new products that allows for a more minimally invasive way of accessing and placing sutures through the sacrospinous ligament. One product is called Anchorsure. There is an anchor that is deployed through a tube that is connected to PS sutures or Prolene sutures that allows for a very effective and durable placement of an anchor through the sacrospinous ligament. Then, you can suspend the vaginal apex to these anchors.
There's also Saffron, which I think came out of the market in the past few months by Coloplast. It's most similar to a Capio, in my opinion. The difference is that rather than a suture that goes through the sacrospinous ligament, it's a little anchor that goes into the sacrospinous ligament. The difference is that you can directly palpate the sacrospinous ligament before placing the Saffron anchor onto.
EnPlace is another one. EnPlace is definitely the most unique compared to these other ones because you can actually place the anchor into the sacrospinous ligament transvaginally. What does that mean? That means you don't have to open up the perirectal space or the perivesical space to get to the sacrospinous ligament.
They all have their advantages. They all have their different techniques in order to use them. To date, there's really no head-to-head trials comparing these anchors capturing devices at least with regard to surgical outcomes. The only trial that I'm aware of was one that came out of Wake Forest that compared Capio to Anchorsure. Their primary outcome was to look at postoperative gluteal pain, and they didn't see a difference between these two types of modalities. In my opinion, it really comes down to what you're familiar and comfortable using and whichever modality that is, whichever product that is, you're going to get good results.
[Dr. Suzette Sutherland]
Yes. I think some of the movement to develop these products also is about being able to access the sacrospinous ligament with less dissection and doing it more by feel: feeling the ischial spine, feeling the sacrospinous ligament with your hands deep in the endopelvic space and then passing the device and feeling where it needs to go, especially those where there's an anchor, like the Anchorsure, the Saffron, but even with the Capio device.
Whereas, before these devices, you were incumbent on being able to look at the sacrospinous ligament and get back there with a suture or the Miya hook, you mentioned, to make sure you are getting into that sacrospinous ligament. In order to get back there and see very well, there's quite a dissection that needs to happen, and with people holding retractors in order to get back there and see maybe even a headlight. These tools have really helped us to access where we need to be without doing such a big dissection, which limits tissue destruction back there, limits bleeding, and then hopefully post-op pain, which I think is what we are also seeing. That's been helpful. I don't know if there's one that you use predominantly that you feel you're most comfortable with.
[Dr. Olivia Chang]
I have explored all of these products in simulation settings. I've stuck with Capio because that's just the product that I feel most comfortable with. The other reason I favor the Capio is because I can take out the sutures. That's something that is important, that if I don't like the placement, that I have the ability to remove it entirely and replace it.
[Dr. Suzette Sutherland]
Yes, that's a really good point because the others have an anchor, and you may be able to slip the suture out of the anchor, such as in the Saffron device, but the anchor stays behind unless you're able to really pull on it hard, but then it might cause a little bit of tissue destruction in that process, so that's a really good point to make.
This is getting a little bit into the weeds, but for our listeners who are interested in doing these procedures, do you recommend using a permanent suture when you're doing a hysteropexy as opposed to maybe a delayed absorbable for when the uterus isn't in place in doing an apical repair? What do you generally do?
[Dr. Olivia Chang]
Great question, Suzette. I know you and I have talked about this a lot offline because we don't have concrete data for hysteropexy. A lot of the data that we're using to apply to this question is extrapolations for prolapse repairs at the time of hysterectomy. If you look at the optimal trial, which was a trial comparing uterosacral ligament suspension to sacrospinous ligament suspension, all of their suspensions utilize both delayed absorbable sutures with permanent sutures at the time of suspension.
Since then, there's been many studies that have come out that have asked that specific question, is there a difference between using permanent versus delayed absorbable? My interpretation of the data is that there is no difference, whether it is delayed absorbable versus permanent. I actually do favor the delayed absorbable sutures for the suspension because then you don't have to worry about the granulation tissues or the Prolene suture tails poking through, and you don't have to bury the knot as you're tying it.
The only exception to this is really when you're using the EnPlace because the EnPlace does rely on using permanent sutures to suspend the uterus. If you do use the EnPlace product, that is one place where you should not be using delayed absorbable sutures.
[Dr. Suzette Sutherland]
Here's another thought there too, is when you are, especially doing a hysteropexy versus without the uterus in place, pulling the uterus and/or the apex all the way up to the sacrospinous ligament or leaving a bit of a suture bridge, as we say, in my experience with a hysteropexy, especially if it's going to be a bilateral suspension repair, that pulling it all the way up to the sacrospinous ligament oftentimes, it doesn't quite reach right or left. It pulls it one side versus the other, and a bit of a suture bridge ends up being there, or you don't want to pull it up quite that high, in any case, depending on how you got your anchors in there. Leaving a little bit of a suture bridge has been advantageous, but in that, using a permanent suture rather than delayed absorbable.
I think that is also some of the thought process behind what's going on with the EnPlace device. As opposed to doing a unilateral suspension procedure just off to one side and then being able to pull it up a little bit further, pull it to that sacrospinous ligament, and then maybe being able to use delayed absorbable. Can you comment on what of what I just said resonates with you versus if you see it in a different way?
[Dr. Olivia Chang]
That's a great point. When you're doing bilaterals, it is challenging because you only have so much space in the vaginal vault. If you're trying to pull it up to both sacrospinous ligaments, the fear is that if it doesn't reach, and if it doesn't reach, it might not scar into place, if you're using delayed absorbable sutures. I agree with you 100% that if you don't anticipate that the vaginal vault will reach both sacrospinous ligaments, it is a good idea to use permanent sutures in that situation. However, if you're doing the unilateral suspension, you should be able to reach that sacrospinous ligament. If that's the case, I do recommend a delayed absorbable suture.
[Dr. Suzette Sutherland]
You're doing predominantly unilateral with a hysteropexy or bilateral?
[Dr. Olivia Chang]
I almost exclusively only do unilateral suspensions. Because I favor using delayed absorbable sutures, it's more important to me to make sure the vaginal vault is really right at the sacrospinous ligament, rather than utilizing or relying on suture bridges to suspend the vaginal vault. Again, I think that's a great question that really warrants more attention with even some retrospective studies to better understand. Now, with EnPlace coming out, I think that is an arena where we'll start to get data where we can understand whether delayed absorbable unilateral suspension is just as good as bilateral suspension but with the suture bridge.
(6) The Long-Term Landscape of Prolapse Repair
[Dr. Suzette Sutherland]
Yes. You mentioned a few studies already that have taken place, but again, just to bring home that point, you're making comparisons between permanent versus delayed absorbable, unilateral versus bilateral, so on and so forth. They're all great studies that just don't go out long enough. The data is immature, and so it goes out to a year, maybe three. That's not really long enough to tell the story because we're making choices about what we do for this prolapse repair with longevity in mind, and longevity is much longer than three, even five years, I would argue. All of our studies should be going out for 10 plus years if we can. Of course, it takes money to do studies. That's often the limiting factor, unfortunately.
[Dr. Olivia Chang]
Yes, I tell my patients that too. I tell them that keeping the uterus in at the time of prolapse repair is possible. The current data shows not a significant difference in outcomes. I tell them that the data is immature, but I tell them that there's nothing glaring in the current data that would make me advise them against it. I'm very transparent with my patients about this. Like I said, many of my patients have gravitated towards hysteropexy because of less downtime, because of the shorter operative time, and the less amount of bleeding.
[Dr. Suzette Sutherland]
I think it's important to disclose to patients what's in the literature, but also it's important to notice what your experience has been. Longer-term experience just because our experience didn't get published, so to speak, it wasn't part of a trial, but as an example, I've been doing hysteropexies for well over 10 years, more like 15 years. What I can say is those patients I've had an opportunity to be able to follow up on, they're doing quite well. We do think that, this is why we focus on this, there's longevity involved as long as they're done well.
[Dr. Olivia Chang]
Mechanically it makes sense that there's some advantage to keeping the uterus. We know at the time of hysterectomy, we are cutting the uterosacral ligament, which is a critical part of pelvic organs’ prolapse support. If we can keep the uterus and not disrupt the existing, whatever is left suspension mechanism that a person was born with, that can't be a bad thing. Mechanically it does make sense to just avoid a hysterectomy, if possible, at the time of prolapse repair.
(7) The Importance of the Patient Perspective in Uterus Preservation
[Dr. Suzette Sutherland]
Yes, and that's a great way to talk to patients about it too. I often say that "Why would I disrupt your natural support only to recreate it?" Right? Even if there's some prolapse, but predominantly it is a cystocele, but there's also some apical prolapse coming down maybe halfway, at the same time, I'm going to disrupt all of the support that they have, but then have to recreate it. Yes, they understand that I think.
There are some other reasons, of course, why a woman doesn't want to give up her uterus. We know that there's some very personal reasons or often cultural reasons. Some of them are based on some real factual things, other things, just a feeling that a woman has. Can you speak to some of those things? I know there's some data out there looking at these concepts that people have sort of poo-pooed in the past. Now, we see there's actually been some studies to look at these more psychosocial or emotional aspects of the uterus in a woman.
[Dr. Olivia Chang]
Sure. Actually, this has been a passion of mine for a very long time. When I was a fellow at Cleveland Clinic, I noticed that there was no good way to ask the patient how they felt about their uterus. A lot of times, people would just ask, "Do you want to keep your uterus?" It becomes a very binary yes or no question, but for many of the patients, it might not be something that they actively think about on a daily basis. The analogy I have is somebody asking me about whether I value the carbonator in my car. I would say, "What is that? Do I need it? I don't know. I don't even know what that is. Do I even have a carbonator in my car?”
What we did when I was a fellow, is that we actually developed a questionnaire. It's called the Value of Uterus questionnaire. Short form is called VALUS. It was published in the American Journal of OB-GYN. It's a six-question survey instrument that allows you to quantify how a woman values her uterus. Within this questionnaire, we're asking people about how they value their uterus with regard to sexual function, their personhood, their womanhood, their relationship to others, and their sense of self. We ask these questions because, in the existing literature, these are the themes that have been shown to be valuable to women when they describe personal traits or qualities and values that they place on the uterus. We validated this instrument, and it is an excellent instrument for predicting whether a woman would choose a uterine-preserving procedure. In our field, I know we give out lots of questionnaires and instruments for patients to fill out and this can be another tool that could really streamline your clinic visit, rather than asking that binary question of, "Do you want to keep your uterus?" You can give them this six-minute questionnaire so that you can visually see what is valuable to the patient. It also gives patients that feedback about where they rank amongst others with regard to how they feel about their uterus.
We actually applied this questionnaire to people in Cleveland, and we did a cross-sectional survey and what we found was that the major predictor for placing high value on the uterus was a desire to be sexually active. There's some correlation there that people do associate or value their uterus with sexual activity and sexual desire. Whether there is a biological explanation to that, there's none in my opinion, but for the patient, that's something that they value.
[Dr. Suzette Sutherland]
That brings up another really interesting point, I think, especially when we're talking about the uterus in sexual function, I think that there's not a lot in the literature to support the role of the uterus in sexual function, especially when it comes to the idea of sexual desire. We think of that as more of a hormonal issue, right? We know that removing the ovaries and deplenishing a woman's source of estrogen, progesterone, and testosterone can certainly affect the hormonal milieu and affect her sexual desire, her libido, but just isolating the uterus, that shouldn't do that. We still see a lot of women still tied to their uterus and with respect to sexual function. We also hear, anecdotally, reports of women who say, "Ever since my hysterectomy, even though I still have my ovaries and I'm not postmenopausal, I've had issues in the area of sexual functioning." Have you had that same kind of experience or you want to address some of that as well?
[Dr. Olivia Chang]
You're absolutely right that with sexual desire and sexual function, most of it is driven by ovarian function and testosterone production as well in women. The thing is, a lot of people do associate some of these changes in their symptoms after a hysterectomy. I do think that for some patients it's hard to sometimes take inventory of what was taken out at the time of hysterectomy, whether it's a full hysterectomy, meaning cervix, uterus, the ovaries, versus a partial. It can be very confusing for the patients.
You bring up a really good question because we've seen that in patients who've had a hysterectomy, there may be some influence to the blood supply of the ovary. Now, what does that mean? There are some small studies that show that there is a slightly earlier menopause for people who've had a hysterectomy, possibly because of the disruption of the collateral blood supply to the ovaries. Now, whether that's clinically significant or not, we don't really know, and that's not really something that people actively counsel for or against at the time of hysterectomy. However, in our patient population for pelvic organ prolapse, most of our patients are really beyond the age of natural menopause, so this is really less relevant of a problem.
I do want to bring up what you asked about earlier about the geographical and cultural valuation of the uterus. We just don't know much about that. If you ask people from around the country, they'll say, "Where I practice, everybody wants a hysterectomy," versus the other extreme where maybe a place like Seattle, maybe people didn't want a hysterectomy as much. There's really just not a lot of truth to that. There hasn't been good robust data to really suggest and confirm that that is a thing.
That's why one of the studies that I'm doing with the Society of Gynecologic Surgeons is that we're actually interviewing women across the United States in a mixed-method study to openly talk about how they feel about their uterus. I do think this data will just shed more light onto, who are the people that place value on the uterus, who are the people who don't? Is it a cultural thing? Is it a geographical thing? Is it a racial thing? Is it an educational thing? All of this information will just help us better identify who are the patients who value their uterus so that we can appropriately offer this surgical treatment option for their prolapse, or if you don't provide uterine preserving prolapse surgeries, to refer onto somebody who does so that we can really place the patient's values at the forefront of their surgical treatment.
(8) Surgical Indications & Patient Considerations for Uterine Preservation
[Dr. Suzette Sutherland]
That's a super point, and I look forward to the outcome of that for sure. We talk about this often, and I think we often attribute some things to cultural differences because we just don't know. We say, "It's a cultural thing," but is it really a cultural thing, or is it more of a female thing regardless of the culture or the race? It'll be very interesting to see that data. There are many women who just say, "I want to leave this world with all the parts that God gave me at the beginning, if that's possible," and the uterus is one of those. And so, just removing different organs without really having concrete reason to, I think no matter what part of the body we're working in, we just need to be careful about that.
You've given us lots of good information about why to save the uterus when it's possible. Not only patient issues but also other anatomical issues and surgical outcomes issues. Let's just talk about one more category here about what might be some contraindications to uterine sparing procedure. When might we not want to leave the uterus in? Can you speak to that?
[Dr. Olivia Chang]
That's a great question, and it's important to really identify who are the good candidates and who are not the good ones. The patients who are not good candidates are those with abnormal uterine bleeding that has not been worked up because there's a concern for cancer. Part of the workup would be an ultrasound and the necessary biopsy to make sure you understand the source of the abnormal uterine bleeding before you suspend or keep the uterus. The scene for people with abnormal cervical pathology, so, people with abnormal pap smears that haven't been resolved. If my patient has either of these concerns, I would fully work that up before recommending uterine preservation, but even with recommendation of uterine preservation, I explain to them that the workup can be limited, and this is the opportunity for shared decision-making so that we can decide whether it makes sense to preserve the uterus or to perform a hysterectomy.
[Dr. Suzette Sutherland]
Along the same lines then, I know that this is debated back and forth, but what are your thoughts about, if you're leaving the uterus in, an obligatory transvaginal ultrasound to make sure everything looks copacetic in the side before making a decision about leaving it in? Do you think every woman needs that or needs an endometrial biopsy before deciding to leave it in? If she doesn't have any other untoward symptoms like postmenopausal bleeding or heavy bleeding.
[Dr. Olivia Chang]
Another great question. For these folks, I really employ a symptom and risk stratification approach. I work things up if they are symptomatic. If they are bleeding, I will work them up. However, if they're beyond the age of requiring a pap smear, if they don't have any bleeding, I do not routinely obtain a pelvic ultrasound or a pap.
[Dr. Suzette Sutherland]
Are there specific guidelines for that, do you know, either through AOGs or ACOG, that speaks to that specifically?
[Dr. Olivia Chang]
Yes, the ACOG does recommend workup for abnormal uterine bleeding, not so much in the context of prolapse repairs, but just abnormal uterine bleeding in general. I think what you're getting at, Dr. Sutherland, is the preoperative workup for somebody who does not have postmenopausal bleeding, and there's really no firm guidelines on this. This is really practitioner-dependent. The best data that we have to extrapolate this from is actually a preoperative workup before a LeFort colpocleisis. As you know LeFort colpocleisis is an obliterative procedure where we keep the uterus in. That's another form of hysteropexy that we often don't immediately think about. In that case, again, you don't have to do an ultrasound beforehand. In my practice, I do get an ultrasound before I leave the uterus in, at the time of a colpocleisis, because it is a very challenging procedure to do if you were to remove the uterus afterwards.
[Dr. Suzette Sutherland]
Yes, that would be a little more difficult in that scenario. That's a great project for someone to undertake to really look at the literature and come up with some concrete practice guidelines in this area because I know I get this question all the time, and it'd be nice to have some practice guidelines.
With that, I'd like to thank you for joining us, Dr. Chang. It's just been a pleasure. We've been talking about hysteropexy versus hysterectomy, some of the surgical details and advantages for doing a hysteropexy, and then also some of the patient selection issues, as well as how the patient feels about her uterus. It's been a great discussion, and I thank you for all of your expertise and look forward to what is coming out of your research projects as you look more in these areas in the future.
This is Suzette Sutherland, your host for this episode, and it's been a great pleasure. Thank you again, Dr. Chang.
[Dr. Olivia Chang]
Thank you so much for having me.
Podcast Contributors
Dr. Olivia Chang
Dr. Olivia Chang is an assistant professor of clinical urology and the chief of female urology, pelvic reconstructive surgery and voiding dysfunction in the department of Urology at UC-Irvine in California.
Dr. Suzette Sutherland
Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.
Cite This Podcast
BackTable, LLC (Producer). (2023, September 13). Ep. 32 – Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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