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Department of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Vienna, Austria
Karl Landsteiner Institut fuer spezielle Gynaekologie und Geburtshilfe, Vienna, Austria
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 22 July 2014
Received in revised form 17 September 2014
Accepted 4 October 2014
Objective: Pelvic organ prolapse (POP) is of growing importance to gynecologists, as the estimated
lifetime risk of surgical interventions due to prolapse or incontinence amounts to 1119%. Conicting
data exist regarding the effectiveness of POP surgery with and without uterine preservation. We aimed to
compare anatomic outcomes in patients with and without hysterectomy at the time of POP-surgery and
identify independent risk factors for symptomatic recurrent prolapses.
Study design: In this single-centre retrospective analysis we analyzed 96 patients after primary surgical
treatment for POP. These patients were followed up with clinical and vaginal examination six months
postoperatively. For comparison of the groups, the chi-squares test were used for categorical data and
the u-test for metric data. A logistic regression model was calculated to identify independent risk factors
for recurrent prolapse.
Results: Of 96 patients, 21 underwent uterus preserving surgery (UP), 75 vaginal hysterectomy (HE).
Median operating time was signicantly shorter in the UP group (55 vs. 90 min; p = 0.000). There was no
signicant difference concerning postoperative urinary incontinence or asymptomatic relapse
(p > 0.05), whereas symptomatic recurrent prolapses were signicantly more common in the UP
group (23.8% vs. 6.7%; p = 0.023). However, in multivariate analysis, only vaginal parity and sacrospinous
ligament xation were identied as independent risk factors for recurrent prolapse after POP surgery.
Conclusion: Uterus-preservation at time of POP-surgery is a safe and effective alternative for women
who wish to preserve their uterus but is associated with more recurrent symptomatic prolapses.
2014 Elsevier Ireland Ltd. All rights reserved.
Keywords:
Hysterectomy
Natural orice surgery
Organ preservation
Pelvic organ prolapse
Sacrospinous ligament xation
Introduction
Due to increasing life expectancy, pelvic organ prolapse (POP) is
of growing importance to gynecologists. According to population
based studies, the estimated prevalence of POP ranges between
three and eight percent [13].
The differentiation between symptomatic and asymptomatic
POP is clinically relevant, as approximately 40% of women are
found to have POP stage II or greater upon routine pelvic
examination [47]. Especially surgical treatment is only indicated
in symptomatic women and the estimated lifetime risk of surgical
interventions due to prolapse or incontinence amounts to 1119%
[8,9].
* Corresponding author. Tel.: +43 1 40400 2839; fax: +43 1 40400 2993.
E-mail address: julian.marschalek@meduniwien.ac.at (J. Marschalek).
http://dx.doi.org/10.1016/j.ejogrb.2014.10.011
0301-2115/ 2014 Elsevier Ireland Ltd. All rights reserved.
34
J. Marschalek et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336
Table 1
Baseline patient characteristics.
Age, years
Menopause, n (%)
BMI* (kg/m2)
Number of vaginal deliveries
Assisted operative vaginal delivery, n (%)
Preoperative POP-stage
Most dependant point** (cm)
Hysterectomy (n = 75)
p-value
47.0
11
26.5
2
3
2
+1
59.6
55
26.7
2
7
3
+2
0.04
0.07
0.33
0.43
0.46
0.11
0.32
(38.368.9)
(52.4)
(22.527.7)
(23)
(14.3)
(23)
(03.5)
(59.968.4)
(73.3)
(24.129.0)
(23)
(9.3)
(23)
(03)
The present study was conducted as a single-centre retrospective analysis of patients who underwent primary surgical
treatment for POP. The study was approved by the ethics
committee of the Medical University of Vienna (EK 2011/677).
Between January 2004 and November 2010, 245 women
underwent primary surgical treatment for POP at an academic
tertiary referral centre. All patients had been offered pessary
treatment and pelvic oor muscle training as a primary therapy
and only women who failed this treatment or declined it were
operated. Uterus preserving surgeries were performed in
25 patients on their individual request, vaginal hysterectomy
combined with pelvic organ reconstructive surgery was performed
in 220 patients. Six surgeons experienced in urogynecology
performed all operations.
Inclusion criteria were symptomatic POP, a complete preoperative history, no previous POP-surgery, no previous hysterectomy
as well as postoperative physical and vaginal examination. Patients
were excluded from the study, if they had an incomplete pre- and
postoperative history or missing preoperative pelvic-organprolapse-quantication score (POP-Q), previous surgery because
of POP or hysterectomy for any cause.
Before surgery, all patients underwent comprehensive urogynecological examination including history, vaginal speculumexam, and urinalysis. Prolapse was graded using the POP-Q-system
[17]. Preoperative urodynamic evaluation was performed in
women with bladder dysfunction and consisted of residual volume
quantication, lling-cystometry, clinical stress-test with and
without reduction of prolapse using a Sims speculum.
For statistical analysis, a p-value of <0.05 was considered
signicant. Values are given as mean (standard deviation [SD])
when normally distributed or as median (inter-quartile range [IQR])
at presence of skewed distribution. For comparison of the groups, the
chi-squares test were used for categorical data and the u-test for
Results
Table 2
Peri- and postoperative results.
Hysterectomy (n = 75)
p-value
55
7
9
5
90
6
28
5
<0.001
0.60
0.65
0.02
(4475)
(5.58)
(42.9)
(23.8)
(71105)
(67)
(37.3)
(6.7)
J. Marschalek et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336
35
Table 3
Uni- and multivariate analysis predicting independent risk factors for recurrent symptomatic prolapse. Coefcient estimates b and standard error se (b), and corresponding
p-values are summarized in the table. Categorical factors are compared to the missing category, i.e., no colporrhaphy, no hysterectomy, no McCall culdoplasty, and no
sacrospinous ligament xation.
Risk factor
R.S.P.a
No R.S.P.a
Univariate analysis
(n = 10)
(n = 86)
56.3
27.7
2
1
9
5
2
4
58.7
26.6
2
2
81
70
12
12
(39.969.7)
(23.830.4)
(13)
(02)
(90)
(50)
(20)
(40)
(47.768.4)
(23.728.7)
(23)
(23)
(94.2)
(81.4)
(14)
(14)
0.017
0.049
1.730
0.226
1.204
1.476
0.433
1.414
Multivariate analysis
se ()
p-value
se ()
p-value
0.028
0.079
0.810
0.209
0.897
0.690
0.850
0.717
0.535
0.533
0.033c
0.280
0.179
0.033c
0.610
0.049c
3.687
1.393
3.489
1.317
1.008
1.403
0.005c
0.167
0.013c
Data are presented as median and interquartile range for numeric parameters and as numbers (frequency) for categorical parameters.
a
R.S.P.recurrent symptomatic pelvic organ prolapse.
b
The most dependant point is measured in centimeters from the hymenal ring.
c
Bold letters indicate statistical signicance.
J. Marschalek et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336
36
[6]
[7]
[8]
Funding
[9]
None.
[10]
Contribution to authorship
[11]
[12]
[13]
Condensation
Symptomatic recurrent prolapses are signicantly more common in patients with uterus preserving pelvic-organ-prolapse
surgery.
[14]
[15]
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