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AUA 2018

AUA 2018: Concomitant Hysterectomy Lowers the Rate of Repeat Surgery for All Vaginal Pelvic Organ Prolapse in Nearly 100,000 Women

San Francisco, CA USA (UroToday.com) This session explored the role of hysterectomy in pelvic organ prolapse (POP) repair in two different, conflicting studies. Many surgeons perform hysterectomy in the treatment of POP, but some advocate for uterine-sparing procedures. The contribution of the uterus in prolapse recurrence is debated, with some arguing that the weight of the uterus increases the risk for prolapse recurrence. Those who advocate for uterine preservation argue that it improves sexual function and prevents the early onset of menopause that is though to occur with hysterectomy, even when the ovaries are spared. The authors of this study explored the risk of recurrence after POP repair with and without hysterectomy using a large database analysis.

The Office of Statewide Health Planning and Development (OSHPD) database was used to identify women who underwent an anterior, apical, or posterior repair in California from 2005 to 2011. Recurrence of POP after index repair was defined as undergoing repeat surgery for POP. The recurrence risk over time for POP repairs performed with and without a hysterectomy were analyzed and compared. Characteristics associated with recurrence were also evaluated.

93,831 women met inclusion criteria and were analyzed. Less than half (45.1%) had a hysterectomy in their initial POP repair. In total, over a mean follow up of 4.1 years, 3.8% of women underwent repeat surgery for POP. The rate of undergoing repeat POP surgery was significantly lower in hysterectomy patients than in uterine-sparing patients (3.0% vs 4.4% at one year, and 8.6% vs 12.9% at five years). This was found to be independent of compartment of initial repair (apical vs anterior vs posterior). On multivariate analysis, factors associated with repeat surgery included hypertension and private payer. Besides hysterectomy, factors associated with decreased occurrence of repeat surgery were race (Asian, Black, Hispanic) and posterior repair as the index procedure. The hysterectomy group had higher rates of blood transfusions and longer hospital stays.

Overall this study demonstrated an association between concomitant hysterectomy and decreased risk of repeat surgery for POP. The results should be interpreted with caution for several reasons:

1) Patients were only counted as a recurrence if they underwent repeat surgery, which will miss many cases of anatomic and symptomatic recurrence.
2) The type of repair performed was not analyzed and this differs when a hysterectomy is performed concomitantly. Therefore we may be comparing two very different procedures

Nevertheless, the study highlights an important topic in the field as we try to improve surgery for POP repair. Perhaps most importantly, the finding that race is associated with decreased risk of repeat surgery may reflect an issue of access to care in California which should be further explored.

Presented by: Kai Dallas, MD, Stanford

Co-Authors: Juan Garisto, Jaya Chavali, Jihad Kaouk, Cleveland, OH

Written by: Dena Moskowitz, MD; Fellow, Female Pelvic Medicine and Reconstructive Surgery, Virginia Mason Medical Center, Twitter: @demoskowitz, at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

Reference:

Farquhar CM, Sadler L, Harvey SA, Stewart AW. The association of hysterectomy and menopause: a prospective cohort study. BJOG Int J Obstet Gynaecol. 2005;112(7):956-962.