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Uterine Sparing Surgery: A Shift in Gynecological Care

Author Olivia Reid covers Uterine Sparing Surgery: A Shift in Gynecological Care on BackTable OBGYN

Olivia Reid • Mar 13, 2024 • 39 hits

The landscape of gynecological surgery is undergoing a paradigm shift, challenging the historical notion of hysterectomy as a panacea for women's health issues. OBGYN Dr. Olivia Chang highlights the inadequacies of hysterectomy in addressing prolapse, advocating for concurrent apical suspensions to fortify vaginal support and deter recurrence. Mesh augmentation and native tissue repair emerge as key strategies for apical support reconstruction, each presenting distinct technical challenges. Transitioning towards uterine-sparing procedures requires meticulous technique modification, particularly in approaches like the sacral hysteropexy which demands precise dissection to manage vascular risks.

As clinicians navigate this evolution, considerations of efficacy, complications, and patient preferences become paramount. Previous clinical studies underscore the importance of extended follow-up periods to refine outcomes data, and Dr. Chang champions more novel trials which aim to elucidate long-term treatment ramifications. Despite potential future interventions, urologist Dr. Suzette Sutherland underscores the immediate benefits of uterine preservation, echoing Dr. Chang's preference for hysteropexy based on its procedural advantages and patient-centered approach.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

•While hysterectomy has been historically used as a universal solution for various women's health issues, contemporary views underscore the significance of prioritizing uterine preservation over hysterectomy due to the potential of hysterectomy to exacerbate rather than resolve complications.

•To recreate apical support in uterine-sparing procedures as a means to prevent prolapse recurrence, there are two major options: mesh augmentation and native tissue repair. Mesh augmentation incorporates sacrocolpopexy, sacral hysteropexy, and vaginal mesh suspension, while native tissue repair includes extraperitoneal colpopexy and intraperitoneal colpopexy.

•Hysteropexy is generally favored in studies and medical practices due to its associated reduced blood loss and operation time compared to hysterectomy.

•Additional data and clinical trials are vital in evaluating the long-term impacts of uterine-sparing procedures, including efficacy, drawbacks, and patient outcomes.

Uterine Sparing Surgery: A Shift in Gynecological Care

Table of Contents

(1) Rethinking Hysterectomy: Advantages of Uterine Sparing Procedures in Prolapse Repair

(2) Apical Suspension in Uterine Sparing Surgery

(3) Evaluating the Efficacy & Safety of Hysterectomy vs. the Novel Hysteropexy

Rethinking Hysterectomy: Advantages of Uterine Sparing Procedures in Prolapse Repair

Historically, performing a hysterectomy has been seen as a “cure-all” for women’s problems, including mental health concerns, abnormal bleeding, painful menses, fibroids, and uterine prolapse. However, contemporary perspectives challenge this paradigm, emphasizing the importance of uterine preservation whenever possible, given the potential for hysterectomy to introduce more complications than it resolves.

Dr. Chang underscores the inadequacy of hysterectomy alone in prolapse repair, as it fails to address the underlying issue at the apex, potentially leading to prolapse recurrence. To counter this, an apical suspension can be performed concurrently with a hysterectomy to restore vaginal support and prevent relapse. This suspension, accomplished via mesh or sutures, is imperative irrespective of the hysterectomy method, whether vaginal or laparoscopic. While additional clinical studies are warranted, Dr. Chang suggests that incorporating a prophylactic vaginal apex suspension into hysterectomy procedures may enhance efficacy and long-term patient outcomes.

[Dr. Suzette Sutherland]
Let's just get started. I think historically the answer to all women's problems was always a hysterectomy. When we really look historically and look back at the turn of the last, last century, many women had a hysterectomy to try and fix their emotional hysteria, which is sometimes where the term comes from. We know today that removing a woman's uterus is not the answer to all of her problems, right? Then, on the contrary, it can actually cause some problems. There has been a movement to say, "Why do we always remove this uterus if it's not needing to be removed for another reason, like cancer? How can we utilize it in the repair and maybe actually even improve upon the repairs that we are doing?" That's what we're here to talk about today.

Let's get into the various issues pertaining to this: the hysterectomy and the uterine-sparing procedures. Just to think about, what are the advantages of keeping the uterus in place if we're doing a prolapse repair? Can you speak to that?

[Dr. Olivia Chang]
Of course, Suzette. I want to go back to what you started off by saying that hysterectomy is a historical treatment for many indications, not only within gynecology but even for mental health disorders. I think that is an important aspect because for so long, hysterectomy was known as the definitive surgical treatment for abnormal uterine bleeding, for pelvic pain, and the same thing for pelvic organ prolapse. If you survey women who were born 1940s to 1970s, many of them have had a hysterectomy and many of them can tell you that they had a hysterectomy having not tried anything else before leading to that surgical treatment.

Now, in 2023, we're really taking a closer look at the indication of hysterectomy. Is it really necessary? Is it really indicated? What advantages or disadvantages are there when we do a hysterectomy? You highlighted a great point about talking about hysterectomy at the time of prolapse repair. Again, this has been something that's considered sort of a dogma where it's always done at the time of prolapse surgeries, but we now know that this might not be the case and that the uterus might be an innocent bystander to this entire prolapse repair.

[Dr. Suzette Sutherland]
I'd really love to make the point that, again, removing the uterus, though, doesn't always solve the problem in the case of prolapse. Again, when we look more historically, the uterus was removed without any attention to, okay, how do we recreate this apical support for the vagina? Right? Today, hopefully, all training for residents and fellows brings home the importance of that point. Can you speak a little bit more to that and what your experience has been when you see patients that have either had an apical repair at the time of hysterectomy or not?

[Dr. Olivia Chang]
Absolutely. That's such an important point and something that really needs to be highlighted. You're absolutely right; if you simply do a hysterectomy at the time of prolapse repair without addressing the apex, that prolapse will return. The way to get about it is that you actually commit to performing an apical suspension at the time of hysterectomy. Mind you, there are many ways of doing hysterectomy. You can do a vaginal hysterectomy, you can do a laparoscopic hysterectomy, but no matter the mode of hysterectomy, it's important to resuspend that vaginal apex, either with mesh or with sutures, to prevent recurrence of prolapse.

That actually brings on an interesting point, Suzette, what you're saying is that, what if a woman doesn't have prolapse, she simply has a hysterectomy for let's say abnormal uterine bleeding? Should we prophylactically suspend her vaginal apex? I think that is a wonderful question that hasn't been studied in prospective trials. I know that if it was myself undergoing a hysterectomy, I would request for a prophylactic suspension of the vaginal apex because I do believe in the value of doing so.

Listen to the Full Podcast

Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang on the BackTable OBGYN Podcast)
Ep 32 Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang
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Apical Suspension in Uterine Sparing Surgery

A crucial aspect of uterine-sparing procedures involves recreating apical support to prevent prolapse recurrence. Dr. Chang delineates two primary approaches: mesh augmentation and native tissue repair. Mesh augmentation techniques encompass sacrocolpopexy, sacral hysteropexy, and vaginal mesh suspension, providing robust support. Alternatively, native tissue repairs include extraperitoneal colpopexy and intraperitoneal colpopexy, which anchor to the sacral spinous ligament or uterosacral ligaments, respectively.

When performing uterine-sparing procedures, attachment points shift to the uterus, necessitating precise technique modifications. Notably, the sacral hysteropexy presents unique challenges as its mesh wraps around the uterine arteries; this placement demands meticulous dissection to mitigate bleeding risks. Effective navigation on the physician’s side is crucial to ensure optimal outcomes and minimize complications.

[Dr. Suzette Sutherland]
Right. I think again, in years past, when surgeons didn't pay attention to this detail after removing the uterus and just closing the vaginal cuff wherever it landed, I think sometimes that's what led to having prolapse problems in the future. What are the common ways to recreate that apical support today?

[Dr. Olivia Chang]
Absolutely. There are different ways, and the way I generally categorize them is using mesh augmentation or using native tissue. Mesh augmentation would include techniques such as sacrocolpopexy, there could be a sacral hysteropexy to suspend the vaginal apex. In some countries with availability and access to vaginal mesh, that's also another option to suspend the vaginal apex.

For native tissue repairs, there is the extraperitoneal colpopexy, which is the suspension to the sacral spinous ligament. For intraperitoneal colpopexy, that is the uterosacral ligament suspensions. Generally, these are the large buckets of categories there are out there currently.

[Dr. Suzette Sutherland]
Then, if we're doing a uterine sparing procedure, all of these procedures that you described, they're also all available. The attachment points are just to the uterus as opposed to the top of the vaginal canal. Is that correct or is there more to it than that?

[Dr. Olivia Chang]
Yes, absolutely, Suzette. If you do a uterosacral ligament hysteropexy, you're placing the sutures in the same location. The only difference is, like you said, you're anchoring the distal sutures to the cervix rather than the vaginal cuff. I would say technique-wise, the more drastic difference would be the difference between a sacrocolpopexy and a sacral hysteropexy. The reason is, in the case of sacral hysteropexy, you are applying mesh using two pieces of mesh, and you're using the mesh to wrap around the uterus. In the way I was taught to do this is that you essentially make two arms out of a rectangular piece of mesh. You take the two arms, you wrap it around the broad ligament of the uterus, and you suspend that to the anterior longitudinal ligament. That is technically more challenging than a standard sacrocolpopexy because of the additional dissection that is required and because of the possible bleeding risk as you're trying to wrap the mesh around the uterine arteries.

[Dr. Suzette Sutherland]
I was going to ask that. We can get into some of the differences too, in a little bit, but as long as you mentioned that, when you're doing a hysteropexy, especially one a little more involved, like you just described, as opposed to doing it with a sacrospinous ligament fixation extraperitoneal, but when you're doing it with a mesh and wrapping it around, do you really need to worry more about more bleeding because those uterine vessels are there? Is it really a little more technically challenging because of that as opposed to when the uterus isn't there and you're not so worried about those big vessels?

[Dr. Olivia Chang]
Great point, Suzette. When we're trying to leave an organ in, and the organ that we're talking about is the uterus, we know it's a vascular organ. We know that there are a lot of vessels feeding into it, a lot of collateral vessels, so you do have to be very mindful when you're placing that mesh. That's something that definitely takes a lot of training and a lot of practice to be able to place that mesh safely at the time of a sacral hysteropexy to avoid complications.

Evaluating the Efficacy & Safety of Hysterectomy vs. the Novel Hysteropexy

To assess the advantages and limitations of transitioning away from hysterectomies and towards uterine-sparing procedures, it's crucial to examine efficacy, complications, and patient viewpoints. In terms of efficacy, Dr. Kate Meriwether's study found no significant differences in outcomes between patients undergoing hysterectomy versus hysteropexy, although limited follow-up time (1-3 years) may have influenced these findings. Despite this, the patients in this study generally favored hysteropexy due to reduced blood loss and operation time compared to hysterectomy. An additional clinical trial, The Save U Trial, had a follow-up of up to five years and demonstrated the non-inferiority of hysteropexy, highlighting its low recurrence rates.

Dr. Chang advocates for the current Canadian and Medicare trials which attempt to look at these issues with longer durations to refine data and explore surgical retreatment rates post-procedure. Despite potential future treatments following uterine-sparing procedures, Dr. Sutherland emphasizes the immediate benefits of preserving the uterus. Additionally, Dr. Chang favors hysteropexy in her practice, citing shorter operating times, decreased bleeding, and addressing patient concerns about hysterectomy as primary reasons.

[Dr. Suzette Sutherland]
What does the data show, and what has your experience been? Does a hysteropexy stand the test of time just like a hysterectomy and apical repair? Are they equivalent, or are there some differences there with respect to efficacy and safety of doing the procedure?

[Dr. Olivia Chang]
Another great question. Like I said at the beginning, we're really looking at this question about the utility of hysterectomy at the prolapse repair with a new lens in the past few years. There's many ways we can go about this; we can look at efficacy, like you said, we can look at complications, or we can look at patient preferences.


Starting with efficacy, there's data out there. There has been a great systematic review by Dr. Kate Meriwether, who did a fantastic job in summarizing the available data out there that compares different types of uterine-sparing prolapse procedures to hysterectomy-based prolapse procedures. In her study, the biggest limitation is really the follow-up time; most of these studies have follow-up times at one to three years, only. Based on these, there isn't a definitive difference in outcomes between these two modalities. There are some adverse events that contributed to favoring hysteropexy because hysterectomy was always associated with more blood loss and a longer operative time. If you look at these numbers closely, the blood loss was often not significant, that a difference of 100 to 200 is probably not so significant, but statistically on these papers, it did show a difference. Then with regard to adverse outcomes, we talked about the benefit by decreasing the operative time and also with the blood loss.

[Dr. Suzette Sutherland]
I think there's the SAVE U Trial that went out to three years that was comparing hysterectomy with uterosacral ligament suspension versus transvaginal, of course, and then transvaginal hysteropexy. Then, they carried it out for five years. There is that data out to five years. To your point, when we look at, we call long-term success, no one has really been able to define long-term success, but you see in the abstract, conclusion, or in the discussion of the papers, and they say long-term success. I would argue even five years isn't long-term when you're dealing with a woman who's 40 years old, 45 years old, and she has prolapse. You're going to tell her, "It'll last you for about five years.

Now, clearly we know that they don't all come down at five years, but we are searching for prolapse repairs that last much, much longer, of course, and hopefully, be the definitive surgery for the woman. Still, what we do have so far, the SAVE U Trial, it showed non-inferiority of the hysteropexy, correct?

[Dr. Olivia Chang]
Absolutely. The numbers actually look quite good favoring hysteropexy with very low clinically significant apical recurrence rate between the two groups. Like I said, we're highlighting this new clinical question, so I believe that the data will definitely continue to mature because right now, we have this one randomized controlled trial, but I know that there's one underway by the Canadian group, and that is also examining this issue. One thing that we're trying to do ourselves is utilize Medicare data to see if there is a difference of surgical retreatment rate after these two different types of procedures.

One other clinical question that is relatively unknown is that for people where we do keep the uterus, what is the rate of surgical intervention, not just for prolapse after, but for abnormal bleeding, for abnormal pap smears, for an ultimate hysterectomy down the line? Because if you look at the existing data, the reoperation is very much focused on prolapse, but we know that if you were to keep a uterus in, just over time, statistically speaking, a small percentage of women may have abnormal bleeding. How many of those, if we left their uterus in, end up with a second procedure for a non-prolapse indication? That is unknown as well. That's what we are trying to answer with the Medicare data. Hopefully, that will just shed new light to better understand the overall, composite reoperation rate for prolapse bleeding and pain, after a uterine preserving procedure.

[Dr. Suzette Sutherland]
Yes, that's a great point. So many people ask, "If I need my uterus out, then, at a later date, isn't it going to be more difficult to remove it surgically if you did this repair and even using some permanent material like mesh or permanent suture?" The answer is that there are some nuances to that, but it's definitely not impossible, and in most cases, readily doable. I think to that point, being worried that you might have to have a hysterectomy in 20 years shouldn't be a reason to not do a uterine-sparing procedure now.

[Dr. Olivia Chang]
Absolutely. There are so many advantages in my mind for a hysteropexy. For some of my patients, a difference of operative time of 30 minutes is significant, and having less bleeding even if it's not clinically significant bleeding, but just having less bleeding in general, is better and advantageous to patients. I've noticed a faster recovery after a hysteropexy compared to a hysterectomy prolapse procedure.

I do favor hysteropexy in my practice, as you know, because of these clinical advantages. I also feel for patients. The idea of a hysterectomy can be scary. It feels like major surgery. For them, that might be the barrier for them to seek more definitive treatment. What I've seen in my own practice is that I have had ladies who've worn pessaries for 10, 20 years, and they were afraid of a hysterectomy. When they heard of the option for a hysteropexy, they were delighted. They were delighted to know that there was a surgical procedure that didn't involve a hysterectomy that would fix their prolapse. All these patients were just so happy after the surgery, after their hysteropexy because they felt great. There was minimal downtime, and they didn't have to wear their pessaries anymore.

[Dr. Suzette Sutherland]
Yes. I will say, for patients that I see that transition from a pessary to hysteropexy are usually very, very pleased. With long-term pessary, with the uterus in, oftentimes you get cervical rubbing, erosion somewhat, and then some bleeding and discharge, and they're so happy to not have to deal with that aspect any longer either.

Podcast Contributors

Dr. Olivia Chang discusses Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse on the BackTable 32 Podcast

Dr. Olivia Chang

Dr. Olivia Chang is an assistant professor of clinical urology and the chief of female urology, pelvic reconstructive surgery and voiding dysfunction in the department of Urology at UC-Irvine in California.

Dr. Suzette Sutherland discusses Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse on the BackTable 32 Podcast

Dr. Suzette Sutherland

Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 13). Ep. 32 – Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang on the BackTable OBGYN Podcast)

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Uterine-Sparing Prolapse Surgery: Techniques & Technologies

Uterine-Sparing Prolapse Surgery: Techniques & Technologies

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