European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Anatomic outcomes after pelvic-organ-prolapse surgerycomparing

uterine preservation with hysterectomy
Julian Marschalek a,*, Marie-Louise Trofaier a, Guelen Yerlikaya a, Engelbert Hanzal a,
Heinz Koelbl a, Johannes Ott a, Wolfgang Umek a,b
a
b

Department of General Gynecology and Gynecologic Oncology, Medical University of Vienna, Vienna, Austria
Karl Landsteiner Institut fuer spezielle Gynaekologie und Geburtshilfe, Vienna, Austria

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 22 July 2014
Received in revised form 17 September 2014
Accepted 4 October 2014

Objective: Pelvic organ prolapse (POP) is of growing importance to gynecologists, as the estimated
lifetime risk of surgical interventions due to prolapse or incontinence amounts to 1119%. Conicting
data exist regarding the effectiveness of POP surgery with and without uterine preservation. We aimed to
compare anatomic outcomes in patients with and without hysterectomy at the time of POP-surgery and
identify independent risk factors for symptomatic recurrent prolapses.
Study design: In this single-centre retrospective analysis we analyzed 96 patients after primary surgical
treatment for POP. These patients were followed up with clinical and vaginal examination six months
postoperatively. For comparison of the groups, the chi-squares test were used for categorical data and
the u-test for metric data. A logistic regression model was calculated to identify independent risk factors
for recurrent prolapse.
Results: Of 96 patients, 21 underwent uterus preserving surgery (UP), 75 vaginal hysterectomy (HE).
Median operating time was signicantly shorter in the UP group (55 vs. 90 min; p = 0.000). There was no
signicant difference concerning postoperative urinary incontinence or asymptomatic relapse
(p > 0.05), whereas symptomatic recurrent prolapses were signicantly more common in the UP
group (23.8% vs. 6.7%; p = 0.023). However, in multivariate analysis, only vaginal parity and sacrospinous
ligament xation were identied as independent risk factors for recurrent prolapse after POP surgery.
Conclusion: Uterus-preservation at time of POP-surgery is a safe and effective alternative for women
who wish to preserve their uterus but is associated with more recurrent symptomatic prolapses.
2014 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Hysterectomy
Natural orice surgery
Organ preservation
Pelvic organ prolapse
Sacrospinous ligament xation

Introduction
Due to increasing life expectancy, pelvic organ prolapse (POP) is
of growing importance to gynecologists. According to population
based studies, the estimated prevalence of POP ranges between
three and eight percent [13].
The differentiation between symptomatic and asymptomatic
POP is clinically relevant, as approximately 40% of women are
found to have POP stage II or greater upon routine pelvic
examination [47]. Especially surgical treatment is only indicated
in symptomatic women and the estimated lifetime risk of surgical
interventions due to prolapse or incontinence amounts to 1119%
[8,9].

* Corresponding author. Tel.: +43 1 40400 2839; fax: +43 1 40400 2993.
E-mail address: julian.marschalek@meduniwien.ac.at (J. Marschalek).
http://dx.doi.org/10.1016/j.ejogrb.2014.10.011
0301-2115/ 2014 Elsevier Ireland Ltd. All rights reserved.

Hysterectomy is the most common surgical treatment to

correct POP, often combined with other surgical procedures like
colporrhaphy and vaginal vault xation. More and more, this
procedure has been questioned in its role as part of POP surgery
[10,11]. Women have several reasons why they would wish to
preserve their uterus, among them the preservation of fertility and
intact body image [12].
Conicting data exist regarding the effectiveness of POP surgery
with and without uterine preservation [10,11,1316]. Dietz et al.
report that uterine preservation with concomitant vaginal
sacrospinous hysteropexy is safe and effective regarding functional
outcome and quality of life, but associated with more apical
prolapse recurrences than vaginal hysterectomy at the time of
POP-repair [10]. These results conict with data by Maher et al.
who found vaginal sacrospinous hysteropexy to be equally
effective to vaginal hysterectomy combined with sacrospinous
xation in a retrospective analysis of 70 women operated for
symptomatic POP. Maher et al. suggest that vaginal hysterectomy

34

J. Marschalek et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336

Table 1
Baseline patient characteristics.

Age, years
Menopause, n (%)
BMI* (kg/m2)
Number of vaginal deliveries
Assisted operative vaginal delivery, n (%)
Preoperative POP-stage
Most dependant point** (cm)

Uterine preservation (n = 21)

Hysterectomy (n = 75)

p-value

47.0
11
26.5
2
3
2
+1

59.6
55
26.7
2
7
3
+2

0.04
0.07
0.33
0.43
0.46
0.11
0.32

(38.368.9)
(52.4)
(22.527.7)
(23)
(14.3)
(23)
(03.5)

(59.968.4)
(73.3)
(24.129.0)
(23)
(9.3)
(23)
(03)

Numbers are presented as median and inter-quartile range (IQR).

*
BMI (body mass index).
**
Most dependant point is measured in centimeters from the hymenal ring.

might not be necessary in the surgical treatment of uterine

prolapse [11].
The purpose of our study was to compare anatomic outcomes in
patients with and without uterus-preserving POP-surgery and
identify independent risk factors for the development of symptomatic recurrent prolapses.

metric data. A logistic regression model was calculated to identify

independent risk factors for recurrent prolapse. Statistical software
SPSS 18.0 for Mac (SPSS 18.0, SPSS Inc, Chicago, IL, USA) was used for
statistical analysis.

Materials and methods

Of 245 women who underwent primary surgery for POP at our

centre, uterus preserving (UP) surgeries were performed in
25 patients (10.2%), vaginal hysterectomy (HE) combined with
pelvic organ reconstruction in 220 patients (89.8%).
Ninety-six of 245 patients (39.2%; UP n = 21, HE n = 75) met all
our inclusion criteria for statistical analysis. Of these, 75 women
had undergone HE (78.1%) and in 21 patients (21.9%), the uterus
had been preserved. The rst follow-up visit was scheduled at six
months postoperatively (IQR: 37). Patients in the UP-group were
younger than patients who underwent vaginal hysterectomy (UP:
47 years, HE: 60 years; p = 0.04). There were no signicant
differences regarding other demographic data (see Table 1). In our
study population, no patient suffered from any comorbidity
relevant to POP (e.g. chronic obstructive pulmonary disease,
connective tissue diseases).
All patients with uterine preservation (n = 21) underwent
anterior and/or posterior colporrhaphy. Sacrospinous-ligamenthysteropexy was performed in 7 of 21 patients (33%). A tensionfree vaginal tape (TVT) was performed in 4 of 21 patients (19%), a
modied McCall-culdoplasty technique in one patient (5%).
Seventy-ve had undergone vaginal hysterectomy. In 69 of
75 patients (92%) an additional anterior and/or posterior colporrhaphy was performed, in 9 patients (12%) a sacrospinous ligament
xation of the vagina was performed. Additionally, Mc-Callculdoplasty was performed in 13 patients (17%), a TVT procedure
was performed in 3 patients (4%).
The median operating time differed signicantly between the
two groups (55 min, IQR: 4475 in the UP group versus 90 min,
IQR: 71105 in the HE group; p < 0.001) (see Table 2.) The median
postoperative hospital stay did not differ signicantly between
the UP and the HE group and was 7 days (IQR: 68) and 6 days (IQR:
67), respectively (p = 0.60).
All patients were seen for a routine follow-up 6 months (IQR:
37) postoperatively. A total of 37 recurrent prolapses had
occurred at this point in time. Nine relapses (43%) occurred in

The present study was conducted as a single-centre retrospective analysis of patients who underwent primary surgical
treatment for POP. The study was approved by the ethics
committee of the Medical University of Vienna (EK 2011/677).
Between January 2004 and November 2010, 245 women
underwent primary surgical treatment for POP at an academic
tertiary referral centre. All patients had been offered pessary
treatment and pelvic oor muscle training as a primary therapy
and only women who failed this treatment or declined it were
operated. Uterus preserving surgeries were performed in
25 patients on their individual request, vaginal hysterectomy
combined with pelvic organ reconstructive surgery was performed
in 220 patients. Six surgeons experienced in urogynecology
performed all operations.
Inclusion criteria were symptomatic POP, a complete preoperative history, no previous POP-surgery, no previous hysterectomy
as well as postoperative physical and vaginal examination. Patients
were excluded from the study, if they had an incomplete pre- and
postoperative history or missing preoperative pelvic-organprolapse-quantication score (POP-Q), previous surgery because
of POP or hysterectomy for any cause.
Before surgery, all patients underwent comprehensive urogynecological examination including history, vaginal speculumexam, and urinalysis. Prolapse was graded using the POP-Q-system
[17]. Preoperative urodynamic evaluation was performed in
women with bladder dysfunction and consisted of residual volume
quantication, lling-cystometry, clinical stress-test with and
without reduction of prolapse using a Sims speculum.
For statistical analysis, a p-value of <0.05 was considered
signicant. Values are given as mean (standard deviation [SD])
when normally distributed or as median (inter-quartile range [IQR])
at presence of skewed distribution. For comparison of the groups, the
chi-squares test were used for categorical data and the u-test for

Results

Table 2
Peri- and postoperative results.

Operating time (min)

Hospital stay, days
Recurrent prolapse, n (%)
Symptomatic prolapse, n (%)

Uterine preservation (n = 21)

Hysterectomy (n = 75)

p-value

55
7
9
5

90
6
28
5

<0.001
0.60
0.65
0.02

(4475)
(5.58)
(42.9)
(23.8)

Numbers are presented as median and inter-quartile range (IQR).

(71105)
(67)
(37.3)
(6.7)

J. Marschalek et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336

35

Table 3
Uni- and multivariate analysis predicting independent risk factors for recurrent symptomatic prolapse. Coefcient estimates b and standard error se (b), and corresponding
p-values are summarized in the table. Categorical factors are compared to the missing category, i.e., no colporrhaphy, no hysterectomy, no McCall culdoplasty, and no
sacrospinous ligament xation.
Risk factor

Age at surgery (years)

BMI (kg/m2)
Number of vaginal deliveries
Most dependant pointb (cm)
Colporrhaphy, n (%)
Hysterectomy, n (%)
McCall culdoplasty, n (%)
Sacrospinous ligament xation, n (%)

R.S.P.a

No R.S.P.a

Univariate analysis

(n = 10)

(n = 86)

56.3
27.7
2
1
9
5
2
4

58.7
26.6
2
2
81
70
12
12

(39.969.7)
(23.830.4)
(13)
(02)
(90)
(50)
(20)
(40)

(47.768.4)
(23.728.7)
(23)
(23)
(94.2)
(81.4)
(14)
(14)

0.017
0.049
1.730
0.226
1.204
1.476
0.433
1.414

Multivariate analysis

se ()

p-value

se ()

p-value

0.028
0.079
0.810
0.209
0.897
0.690
0.850
0.717

0.535
0.533
0.033c
0.280
0.179
0.033c
0.610
0.049c

3.687

1.393

3.489

1.317

1.008

1.403

0.005c

0.167

0.013c

Data are presented as median and interquartile range for numeric parameters and as numbers (frequency) for categorical parameters.
a
R.S.P.recurrent symptomatic pelvic organ prolapse.
b
The most dependant point is measured in centimeters from the hymenal ring.
c
Bold letters indicate statistical signicance.

the UP group, 28 relapses (37%) occurred in the HE group. The

difference between the groups did not reach statistical signicance
(p = 0.65).
Twenty-seven recurrent prolapses were asymptomatic. Ten
prolapses were symptomatic (ve in the UP group and ve in the
HE group, respectively) and needed either conservative or
operative treatment. Symptomatic prolapses were more common
in the UP group (p = 0.023).
There was no signicant difference concerning postoperative
urinary incontinence between the groups (UP n = 6, 29%; HE n = 17,
23%; p = 0.575).
Uterine preservation allowed one patient to give birth without
symptomatic prolapse thereafter. Patho-histologic examination
detected two incidental endometrial cancers, grade 1 in previously
asymptomatic patients undergoing HE.
In a second step we aimed to identify independent risk factors
for symptomatic prolapse recurrence after POP surgery (see
Table 3). In a univariate analysis, we could ascertain the number
of vaginal deliveries, uterine preservation, and sacrospinousligament xation as independent risk factors. In a multivariate
analysis the number of vaginal deliveries and sacrospinous
ligament xation, but not uterine preservation, were independent
risk factors for recurrent prolapse after POP surgery.
Comment
In this study, symptomatic prolapses with the need for either
conservative or operative treatment were four times more
frequent after uterus preserving surgery for POP. The frequency
of asymptomatic recurrences did not differ in patients who
received hysterectomy or uterus preservation. There were no
differences regarding postoperative urinary incontinence between
the groups. As patients in the UP group were younger, they did not
differ regarding other confounders including BMI, parity, assisted
operative vaginal delivery and co-morbidities relevant to POP.
Previous studies showed objective advantages of uterus
preserving surgery over hysterectomy including a signicant
decrease in operating time and blood loss, as well as a shorter
postoperative hospital stay and quicker recovery time
[11,13,14]. Our data support some of these ndings with a
signicantly shorter operating time of 55 versus 90 min. Length of
stay was not shorter after uterus preserving surgery. We did not
evaluate intraoperative blood loss or recovery time. In addition,
this surgical procedure allows maintaining a womans fertility.
Notably, uterine preservation allowed one patient to give birth
without symptomatic prolapse.

The disadvantages of uterine preservation are the need for

continuing cervical cancer screening, potential need for supportive
hormone therapy and continuous risk for menstrual disorders.
According to a retrospective analysis of pathology ndings at
reconstructive pelvic surgery with hysterectomy, 2.6% had
unexpected uterine (pre-)malignancies, 0.3% had endometrial
carcinoma [18]. We incidentally found endometrial carcinoma in
two postmenopausal women (2.1%) at vaginal hysterectomy.
However, if and how this would translate into a better prognosis
remains elusive. Possibly, an intraoperative dilatation and curettage with frozen section diagnosis in UP cases could prove
benecial.
Of note, we could ascertain a signicant trend towards more
symptomatic recurrences in the uterus-preservation group. This
supports the nding of Dietz et al. that sacrospinous hysteropexy
seems to be associated with more recurrent apical prolapses, as
women who underwent vaginal hysterectomy had fewer recurrences (3%) compared to women after sacrospinous hysteropexy
(27%) [10].
In a second step, we aimed to identify women in our cohort,
who are at increased risk for the development of symptomatic
recurrent prolapses after POP surgery. Number of vaginal
deliveries, uterus preserving surgery and sacrospinous ligament
xation were identied as independent risk factors in univariate
analysis. However, in multivariate analysis we could ascertain
number of vaginal deliveries and sacrospinous ligament xation as
independent risk factors for symptomatic recurrent prolapse after
POP surgery, but not uterus preserving surgery.
Vaginal parity is a known risk factor for recurrent apical
prolapse after POP surgery [19]. According to the ndings of Dietz
et al. sacrospinous ligament xation is associated with more
recurrences after UP surgery [10]. We assume that sacrospinous
ligament xation of the vaginal vault in patients undergoing
vaginal hysterectomy for POP is an associated, not a causal risk
factor, because sacrospinous ligament xation is routinely
performed at our centre in patients with higher prolapse-stages.
This data have to be interpreted within its major limitation,
namely the retrospective design and the short follow-up period.
However, in conclusion, our study lends support to the hypothesis
that uterus-preserving surgery is a safe and effective alternative for
women who prefer to preserve their uterus and are aware of a higher
risk of recurrent apical prolapse. Of note, shorter operating time and
decreased blood loss are advantageous for high risk patients, but the
increased risk of apical prolapse recurrence after uterus-preservation
should be included in the informed consent. The higher recurrence
rate in patients with uterus-preservation warrants further testing of

J. Marschalek et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 3336

36

surgical approaches that include xation and suspension methods of

the uterus, like sacrospinous hysteropexy, uterosacral ligament
suspension and abdominal approaches like Mesh-sacrocolpopexy.
Conict of interest statement
The authors of this manuscript have no conicts of interest to
disclose as described by the European Journal of Obstetrics &
Gynecology and Reproductive Biology.

[6]

[7]

[8]

Funding

[9]

None.

[10]

Contribution to authorship
[11]

J Marschalek: data collection/management/analysis, Manuscript writing/editing, ML Trofaier: data collection, G Yerlikaya:

data collection, E Hanzal: protocol development, H Koelbl:
manuscript editing, J Ott: data analysis; Manuscript editing, W Umek:
protocol development, Manuscript writing/editing.

[12]

[13]

Condensation
Symptomatic recurrent prolapses are signicantly more common in patients with uterus preserving pelvic-organ-prolapse
surgery.

[14]

[15]

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