Recurrence of prolapse after total vs supracervical laparoscopic hysterectomy at time of minimally invasive sacrocolpopexy

Abstract

To determine if type of hysterectomy, total laparoscopic hysterectomy (TLH) vs supracervical laparoscopic hysterectomy (SLH), at the time of sacrocolpopexy (SCP) impacts prolapse outcomes at 1 year. The primary outcome was prolapse recurrence as defined as prolapse of greater than or equal to stage II in any compartment. The secondary outcome was a composite surgical success, with success defined as no mesh exposure and no prolapse at or beyond the hymen noted by exam. This is a retrospective study comparing prolapse recurrence rates in patients undergoing TLH or SLH with SCP at a tertiary care referral center from 2011 to 2018. Subjects were identified using Current Procedural Terminology codes for TLH, SLH, and SCP. Patient demographics, operative characteristics, and perioperative complications were abstracted from medical records. Primary outcome was prolapse recurrence at 1-year. Group comparisons were performed using student’s t-test, chi square Fisher’s exact test, and Mann Whitney tests as appropriate. A p value of <.05 was considered significant. We performed a multivariate logistic regression model to see if type of hysterectomy remained associated with prolapse recurrence at 1 year while controlling for potential confounding factors. 403 women undergoing SCP met inclusion criteria; 91 SLH and 312 TLH. No clinically significant differences in demographic characteristics were noted between groups. Median follow-up was 52 weeks (IQR 17-52 weeks). Half of patients had lightweight mesh (n=203), while the other half had ultralightweight mesh (n=200). Vaginal mesh fixation was done with permanent suture in 86% (n=344) and with delayed absorbable suture in 14% (n=56) of patients. Follow up data for prolapse recurrence was available for 90% (n=361) of patients at 4 months and 48% (n=193) of patients at 1 year. At 4 months, women undergoing SLH were more likely to have recurrent prolapse ≥ stage II at any compartment (35% SLH vs 17% TLH, p=.002). At 1 year, there was no difference in prolapse recurrence by route of laparoscopic hysterectomy (34% SLH vs 29% TLH, p=0.57). There was no difference in composite surgical success between groups at 1 year (86% SLH vs 84% TLH, p=0.82). Recurrence most commonly involved the posterior compartment (80% Ap, Bp points), followed by both anterior and posterior (11% Aa, Ba, Ap, Bp points), anterior (7%, Aa, Ba points), and apical (2% C point). On multivariate logistic regression controlling for pre-operative POP-Q stage, mesh type, and higher BMI, type of hysterectomy was not associated with an increased likelihood of prolapse recurrence. Prolapse outcomes at 1-year following SLH and TLH at time of SCP are similar. Surgeons should decide when to perform a SLH vs TLH based on individualized assessment of patient factors and shared decision-making.View Large Image Figure ViewerDownload Hi-res image Download (PPT)