Pregnancy Outcomes after Sacrospinous Hysteropexy

1. Pregnancy Outcomes after Sacrospinous Hysteropexy Ayman Qatawneh Jordan University Hospital

2. Disclosures • Sponsered by Astellas to attend this ICS congress.

3. Background • Pelvic organ prolapse (POP) affects millions of women • 11 – 19 % of women will undergo surgery for prolapse or incontinence • 30% will require an additional prolapse repair procedure . • Traditionally: Surgical correction of uterovaginal prolapse has included a hysterectomy. ((a passive structure)). • More recently: women have opted for uterine preservation for a variety of reasons.

4. Why uterine preservation? • Vaginal hysterectomy is NOT treatment for prolapse • Retain fertility. • Childbirth deferred to later age. • Improved sexual function. • Removal non diseased organ. • Improvement of menorrhagia treatments. • Cervix cornerstone pelvic floor fascia.

5. Contraindications to uterine –preserving surgery • Fibroids, adenomyosis, endomertrial pathology • Cervical dysplasia • Abnormal bleeding • Familial BRAC 1and BRAC 2 • Familial non-polyposis colonic cancer • Tamoxifen therapy

6. Patient preferences • This multicenter, cross sectional study evaluated patient preferences for uterine preservation vs hysterectomy in women with prolapse symptoms. • 213 women participated. Korbly et al Nov 2013 AJOG.

7. Patient preferences • Assuming equal outcomes. • Uterine preservation …………….36% • Hysterectomy……………………20% • No preference……………………44% • Assuming uterine preservation is superior. • Uterine preservation…………..46% • Hysterectomy …………………11% • Assuming hysterectomy is superior. • Preservation …………………...21%

8. Options available1. Manchester repair • Described for cervical elongation and intact uterosacral – cardinal ligaments. • Quicker &  blood loss than vaginal hysterectomy (Thomas J Repr Med 1995) • Recurrence of prolapse >20% in first few months. (Williams Am J Obstet Gyn 1966) • Fertility , pregnancy wastage  • Future cervical & endometrial sampling difficult • Only 40% success rate based on overall stage in the Manchester group. ( de Booer, et al int urogynecol j pelvic floor dys 2009

9. The Manchester procedure versus vaginal hysterectomy in the treatment of uterine prolapse. A review 2017 Inturogynecol J • In total, 9 studies published from 1966 to 2014 comparing the MP to VH were included. • Results The anatomical recurrence rate for the middle compartment was 4–7 % after VH, whereas recurrence was very rare after the MP. • The re-operation rate because of symptomatic recurrence was higher after VH (9–13.1 %) compared with MP (3.3–9.5 %)

10. The Manchester procedure versus vaginal hysterectomy in the treatment of uterine prolapse. A review 2017 Int urogynecol J • After VH, postoperative bleeding and blood loss tended to be greater, bladder lesions and infections more frequent and the operating time longer. • Conclusions This review is in favour of the MP, which seems to be an efficient and safe treatment for uterine prolapse. We suggest that the MP might be considered a durable alternative to VH in uterine prolapse repair.

11. 2. sacrospinous hysteropexy

12. 2. sacrospinous hysteropexy • RCT ( Dietz 2010 int urogyn j ) • Sacrospinous hysteropexy 37 women • Vaginal hysterectomy with uterosacral suspension 34 women • Results: high apical recurrence in the hysteropexy group 21% vs 3% p=0.03 • Subjective and objective outcome improved in both • Quicker recovery, shorter hospitalization, longer vaginal length in the hysteropexy group.

13. 2. sacrospinous hysteropexy • RCT ( Dietz 2010 int urogyn j ) • Both groups has high anterior vaginal wall recurrence (51% and 64%) • Three women had stage 4 uterine prolapse in the hysteropexy group before surgery and all had recurrence.

14. 2. Sacrospinous hysteropexy • 3 cohort studies compared sacrospinous hysteropexy with vaginal hysterectomy. • No difference in anatomical outcomes. • Three fold increase in OAB and UI in the hysterectomy group • Shorter OT, less blood loss, faster recovery and fewer complications. Hefni Am j ob gyn 2003, Maher int urogyn j 2001, Van Brummen int urogyn j 2003

15. 2. sacrospinous hysteropexy • Lin TY J formos Med Ass 2005 • Risk factors of failures after sshysteropexy • 1. cervical elongation (partial trachelectomy) • 2. severe prolapse. • (alternative approach)

16. 3.Vaginal mesh hysteropexy • Level 1 evidence demonstrates improved anterior vaginal wall support with the addition of vaginally placed mesh. • Hysteropexy with anterior mesh placement seems ideal to improve anterior vaginal wall support and decrease recurrences in women desiring uterine conservation ( Maher et al 2010 Cochrane database)

24. changes in female sexual function after POP repairrole of hysterectomy • Int urogynecology J 2013 (E Costantini) • 107 women • FSFI Q • UDI 6 , IIQ 7 • Conclusion: POP plays a role in female sexual dysfunction. Uterus sparing surgery is associated with greater improvement in sexual function.

25. Childbirth after pelvic floor surgery • 10 fold increase in subsequent prolapse after vaginal delivery. Mant J. Epidemiology 97 BJOG Quiroz LH vaginal parity &POP 2011 • Lack of published data on outcome of women delivered after prolapse surgery. Few case reports. • No enough information on the incidence and safety of childbirth following pelvic floor surgery.

26. Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008. A Pradhan. BJOG 2012 • 603 women between age 22-44 year had delivery episode after pelvic floor surgery. • 2/3 delivered by Cesarean section. • 1/3 delivered vaginally. • 42 (7%) had subsequent pelvic floor surgery. • Conclusion: the incidence of repeat surgery episode was higher in the vaginal group (13.6%) than the Cesarean section group (4.4%).

27. Pregnancy outcomes after transvaginal sacrospinous hysteropexy • Recently women with uterine prolapse demand uterine preserving procedures to plan future pregnancy. Uterine preserving pop surgery. Int urogyn j 2013 • No clear consensus whether vaginal or abdominal route is better in uterus preserving. • decreased morbidity and patient preference are the advantages of vaginal route. ss hysteropexy review and metaanalysis int urogyn j 2017

28. Pregnancy outcomes after transvaginal sacrospinous hysteropexy • SS hysteropexy is the most popular technique with satisfactory anatomic and functional outcomes. • Recent review: SS hyteropexy has been reported as a safe and effective procedure with similar apical failures rates compared to vaginal hysterectomy. hysteropexy evidence and insights. M ClinObstet Gynecol 2017.

29. Pregnancy outcomes after transvaginal sacrospinous hysteropexy • Between 2005-2015. • 94women had Sacrospinous hysteropexy. • All had stage II or more uterovaginal prolapse • 20 (21%) women pregnant had live births. • Mean age 35 (24-42) • Mean parity 3 (2-7) • None had previous prolapse surgery. • No comorbidity except 4 gestational diabetes.

30. Pregnancy outcomes after transvaginal sacrospinous hysteropexy • All had concomitant anterior and posterior repair. • Cervical amputation done in 6 patients. • TOT done for 3 patients. • Follow-up since surgery 5 years. • Interval between surgery and delivery ranges from 1 to 4 years. • 2 patients had assisted IVF. • All delivered by cesarean sections. 2 had 2 subsequent Cesarean sections. • None had cervical cerclage.

31. Pregnancy outcomes after transvaginal sacrospinous hysteropexy • Completed 37 weeks except 3 preterm cesarean sections. • Point C POP-Q before surgery 2.9 cm. • Point C POP-Q after delivery – 5 cm. • Recurrence occurred in 4 patients. • Cystocele in all of them, cervical descent in 3. • Re-operation. Vaginal hysterectomy in one. • Amputation of cervix in one and cystocele repair. • Satisfaction 80%.

32. Literature review on pregnancy after sacrospinous hysteropexy Study n preg follow-up delivery recurrence Kovac 5 37 VD 20% Maher 2 26 CS 50% Lin 6 90 CS --- Kavkaytar 8 45 CS 12.5% This 20 60 CS 20%

33. Conclusion • Uterine preservation is a suitable option in women with uterine prolapse. • Long term data are limited. • Sacrospinous hysteropexy is as effective as vaginal hysterectomy and repair. • Severe prolapse and long cervix are risks for recurrence. • SS hysteropexy with mesh augmentation of anterior compartment is safe and effective

34. Conclusion • Cesarean section is a better delivery route for women had Sacrospinous hysteropexy. • Limited data about fertility conditions, pregnancy outcomes, delivery route after uterine preserving surgery.