Retreatment After Pelvic Organ Prolapse Surgery with Hysterectomy vs Hysteropexy

Objectives: Interest in uterine-sparing procedures has increased due to the potential for lower blood loss and shorter operative time. Surgical efficacy of hysteropexy relative to traditional hysterectomy-based prolapse procedure remains uncertain. Thus, the objective of our study was to determine if there is a difference in the rate of surgical retreatment for prolapse after native-tissue apical prolapse surgery with hysterectomy versus uterine-preservation.

Methods: This was a retrospective cohort study utilizing the Medicare 5% Limited Data Set from 2010-2019. We included all female patients aged 65 years or older with an ICD 9/10 diagnosis of uterovaginal prolapse who underwent an apical native-tissue prolapse procedure (extraperitoneal colpopexy and intraperitoneal colpopexy). We excluded those with transvaginal mesh, concurrent colorectal or oncologic surgeries, obliterative procedures, and abdominal hysterectomies . All patients were followed from the index procedure until death or loss to follow up. We compared those who had a hysteropexy (HPXY) versus those who underwent a concurrent vaginal or minimally invasive hysterectomy (HYST). The primary outcome was surgical retreatment for pelvic organ prolapse defined as any subsequent surgical treatment of the anterior, apical, or posterior compartment prolapse after the index surgery. Time-to-event analysis was performed with comparison of the two groups with Cox regression analysis adjusting for covariates.

Results: 2341 patients were identified that met our inclusion and exclusion criteria (HPXY =584 patients vs HYST =1757)). Patients in the HPXY group were older (73.4 vs 71.8 years, p< 0.001) and predominantly located in the South (46.2% vs 34.1%, p < 0.001). The mean Charlson comorbidity index score was higher for HPXY pts (1.6 vs 1.8, p=0.003). The Kaplan-Meier survival curve of the two groups is shown in Figure 1. With adjustment for confounders, those with a HPXY had higher risk of surgical retreatment than those with a HYST (adjOR 1.52,1.04 – 2.21, p=0.03) (Table 1). Younger patients had lower risk of prolapse recurrence (adjHR 0.95, 0.92-0.99, p=0.005). For those in the HPXY group, the rate of subsequent hysterectomy in the 5 years following index surgery was 3.4% (n=14). When stratified by intraperitoneal (n=120) or extraperitoneal hysteropexy (n=464), there were no significant differences in rates of surgical retreatment for between these two modes of apical suspension (p=0.49).

Conclusions: In this Medicare database, there was a higher risk of surgical retreatment for prolapse in those who had a hysteropexy compared to those who had a hysterectomy at the time of native-tissue prolapse surgery. For those who had a hysteropexy, 3% of patients required a hysterectomy in the 5 years following index surgery.