Pelvic organ prolapse and uterine preservation: A cohort study (POP-UP study)

Pelvic organ prolapse and uterine preservation: A cohort study (POP-UP study) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Pelvic organ prolapse and uterine preservation: A cohort study (POP-UP study) Daniel Gagyor, Vladimir Kalis, Martin Smazinka, Zdenek Rusavy, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-35323/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Feb, 2021 Read the published version in BMC Women's Health → Version 3 posted 7 You are reading this latest preprint version Show more versions Abstract Background: Abdominal and laparoscopic sacro-colpopexy (LSC) is considered the standard surgical option for the management of a symptomatic apical pelvic organ prolapse (POP). Women who have their uterus, and for whom an LSC is indicated, can have a laparoscopic sacro-hysteropexy (LSH), a laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH+LSC) or a total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH+LSC). The main aim of this study was to compare clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures. Methods: A retrospective analysis of clinical, imaging and patient reported outcomes at baseline, 3 and 12 months after LSH versus either LSCH+LSC or TLH+LSC between January 2015 and January 2019 in a tertiary referral urogynecology center in Pilsen, the Czech Republic. Results. In total, 294 women were included in this analysis (LSH n = 43, LSCH+LSC n = 208 and TLH+LSC n = 43). There were no differences in the incidence of perioperative injuries and complications. There were no statistically significant differences between the concomitant hysterectomy and the uterine sparing groups in any of the operative, clinical or patient reported outcomes except for a significantly lower anterior compartment failure rate (p= 0.017) and higher optimal mesh placement rate at 12 months in women who had concomitant hysterectomy procedures (p = 0.006). Conclusion. LSH seems to be associated with higher incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques compared to LSC with concomitant hysterectomy. Internal Medicine Preventive Medicine Laparoscopic Sacrocolpopexy Cervicopexy Hysteropexy LSC LSCH+LSC TLH+LSC LSH POP-Q mesh PFDI PGI-I compartment Figures Figure 1 Background It is estimated that one in three women are affected by pelvic organ prolapse (POP) and one in 10 require a surgical procedure for its correction during their lifetime [1, 2]. POP is associated with numerous bothersome clinical symptoms including pelvic discomfort, vaginal bulge, urinary incontinence, urinary tract symptoms, fecal incontinence or sexual dysfunction. These often have a significant negative impact on their quality of life (QOL) or, even, serious life threatening consequences [3–8]. There is no significant correlation between the severity of clinical symptoms and the stage of POP, but there is a correlation between clinical symptoms and location of the underlying defect [9]. Anterior compartment prolapse tends to be associated with urgency symptoms requiring surgical intervention in the majority of cases [10], while posterior compartment prolapse is more likely to be associated with distal bowel dysfunction [11, 12]. Conservative management of apical prolapse is commonly used as first line treatment in general and the main option for women who have not completed their childbearing or those deemed to be at high operative risks. Nonetheless, surgical correction is an option that should always be discussed when counseling women about their treatment options. POP with a dominant apical defect can be treated using a number of surgical approaches and this choice can be one of the most challenging problems in urogynecology [13, 14]. However, high level evidence indicates that abdominal and laparoscopic sacro-colpopexy (LSC) result in better anatomical outcomes compared to sacrospinous ligament fixation and transvaginal mesh insertion [14]. Women who have their uterus and opt for a laparoscopic approach have several surgical options to consider; sacro-colpopexy, uterosacral ligament colpopexy [15], lateral ligament suspension or pecto-colpopexy [16]. Based on the currently available evidence, LSC is the most commonly used laparoscopic method and this could be in the form of laparoscopic sacro-hysteropexy (LSH), laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH+LSC) or total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH+LSC). The American College of Obstetricians and Gynecologists considers involving and supporting patients in the discussion about uterine preservation in elective surgery as obligatory [17]. Furthermore, there seems to be an increasing tendency for women to explore uterine preserving procedures for their POP surgical management rather than just accept a hysterectomy [18–20]. Therefore, increasing the availability of options, that do not necessitate a hysterectomy, gives women viable options to individualize their POP management plan. Nonetheless, one of the important determinants of women’s choice about uterine preservation or concomitant hysterectomy is the outcome associated with either procedure [18–20]. There is evidence that the route of concomitant hysterectomy during LSC does not seem to be associated with the perioperative or postoperative outcomes [21, 22]. However, at present, there is heterogenous information about comparative anatomical and functional outcomes with no comprehensive analysis based on whether the uterus was spared or removed [23–26]. Furthermore, there is paucity of information on surgical outcomes including mesh placement on postoperative imaging. Methods The main aim of the study was to compare the clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures for a symptomatic apical POP. As a secondary aim we wanted to assess the peri- and postoperative complications associated with these procedures as an indicator of their safety profile. This is a retrospective cohort study undertaken in a tertiary referral urogynecology center in Pilsen, the Czech Republic. All women referred with an intact uterus and a symptomatic apical POP and who were listed for one of the LSC procedures between January 2015 and January 2019 were included in our analysis. For the purpose of this study, we were interested in comparing women who had an LSH (uterine preservation) versus LSCH+LSC or TLH+LSC (concomitant hysterectomy). Local ethics committee approval was granted for the study. All patients included in this study provided written informed consent for the procedure and for the future use of their perioperative and follow-up data. The departmental medical database was used to gather data on patients’ demographics, medical history, history of abdominal and/or gynecological surgery, previous reconstructive POP surgery, obstetric history, urinary or bowel symptoms and POP-Q staging points [27, 28]. We also collected data on hospital length of stay (LOS). Extended LOS was defined as hospitalization longer than the 75th percentile [29] . The impact of the woman’s symptoms on her quality of life during the pre- and postoperative periods was assessed using the Pelvic Floor Distress Inventory (PFDI). This is a validated quality-of-life questionnaire consisting of a Urinary Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (POPDI) and a Colorectal-Anal Distress Inventory (CRADI). UDI and POPDI have a score range of 0 (least impact) to 300 (greatest adverse impact) while CRADI has a range of 0 to 400 and an overall summary PFDI score ranging from 0 to 1000 [30]. Perioperative complications were categorized according to the Dindo-Clavien classification [31]. Surgical procedures were performed by one of four experienced urogynecological subspecialists. We used the same surgical technique, sutures and mesh materials for all LSC variants as previously published by our group [32, 33]. In the research unit, postoperative follow-up appointments are routinely arranged at 3 and 12 months for assessment of the impact of surgery on the woman’s clinical symptoms, evaluation of any postoperative complications and clinical examination including a POP-Q measurement. In addition to the PFDI, their overall satisfaction with the surgical procedure is routinely evaluated by means of a 7-point Patient Global Impression of Improvement (PGI-I) scale ranging from "Very much worse” (PGI-I=7) to "Very much better” (PGI-I=1) [34] . Any identified mesh related complications are reported using the current standardized international classification [35]. A 3D/4D transperineal ultrasound scans is also routinely performed at both follow-up appointments to assess the bladder neck and mesh positions. The ultrasound protocol has been previously published and is derived from the standardized assessment protocol suggested by Dietz et al [32, 33, 36]. Optimal mesh placement is assessed based on a set of composite parameters including: distance of the lowest margin of the anterior mesh strand from the bladder neck <20 mm [32, 33]; shape of the mesh; absence of folding ; and a vertical mesh descent on Valsalva ≤20 mm. For the purpose of this study, anatomical apical compartment failure was defined as a postoperative POP-Q point C ≥ -TVL/2 cm (apical descent lower than half of the vaginal length). Points Ba and Bp ≥ -1 cm were considered failure in the anterior and posterior compartment respectively. Subjective success of the procedure was defined as a PGI-I < 3 i.e. "Very Much" or "Much Better". Statistical analysis was performed using IBM SPSS Statistics software version 22 (Armonk, NY: IBM Corp.). A p<0.05 was considered statistically significant. In addition to the comparisons between uterine sparing versus concomitant hysterectomy LSC procedures, we undertook a sub-analysis comparing the three procedures (LSC, LSCH+LSC and TLH+LSC) to each other. Results A total of 421 LSC procedures were performed during the study period. Of these, 124 (29.5%) procedures were performed on women who previously had a hysterectomy and hence excluded from this study. A further 3 patients (0.7%) were not included because they had their procedure performed through a laparotomy. The remaining 294 (70.0%) women who have had one of the LSC variants for apical POP management were all included in our analysis. These included 43 (14.6%) women had a uterine sparing procedure LSH) and 251 (85.4%) had a concomitant hysterectomy, of these 208 (70.8%) had LSCH+LSC and 43 women (14.6%) had a TLH+LSC (Figure 1). Table 1 and supplementary table 1 summarize participants’ characteristics, preoperative POP-Q and PFDI scores grouped by whether the uterus was preserved or not and by type of procedure respectively. There were significant differences between the cohort of women who had LSH compared to LSCH+LSC / TLH+LSC with regards to BMI (25.2 kg/m 2 vs. 26.6 kg/m 2 , p = 0.006), age (49.0 years vs. 64.0 years, p < 0.0001) and comorbidities like cardiovascular disease (20.9% vs. 55.8%, p < 0.0001) and diabetes (2.3% vs. 15.5%, p = 0.02). There was also a significant difference in POP-Q staging based on point Ba between the 2 groups (p < 0.0001) (Table 1). There were significant differences in reported urinary hesitancy (30.2% vs. 49.0%, p = 0.023) and constipation (9.3% vs. 23.1%, p = 0.04) between both cohorts. However, no significant differences were found in other pre-operative POP-Q parameters, reported urinary or anal incontinence, or preoperative PFDI score. Operative characteristics and postoperative complications are presented in table 2 and supplementary table 2. Based on the Dindo-Clavien classification, there were no differences in the incidence of perioperative injuries and complications. However, operating time and blood loss were higher in the concomitant hysterectomy compared to the uterine sparing group (125 min vs. 120 min, p = 0.052). Table 3 shows anatomical and functional outcomes at 3 and 12 months postoperative. When comparing outcomes in women who had a concomitant hysterectomy at the time of LSC compared to LSH, there were no statistically significant differences in any of the clinical or patient reported outcomes except for a significantly higher anterior compartment failure rate at 12 month follow-up as assessed by POP-Q in women who had a uterine sparing procedure (21.1% vs. 7.7%, p= 0.017) (Table 3, supplementary table 3). Moreover, concomitant hysterectomy procedures were likely to be associated with absent mesh folding on at 3 (94.7% vs. 80.0%, p = 0.004) and 12 months (93.8% vs. 82.1%, p = 0.021) and optimal composite mesh placement at 12 months (81.7% vs. 67.6%, p = 0.006) as assessed by ultrasonography (Table 4). On subgroup analysis, the difference was only significantly longer for operating time in the TLH+LSC versus LSH subgroups (140 min vs. 120 min, p = 0.048). Furthermore, blood loss was significantly higher when comparing TLH+LSC to LSH (250 ml vs. 150 ml, p = 0.001) and TLH+LSC to LSCH+LSC (250 ml vs. 150 ml, p < 0.0001). Discussion Summary of findings This is among the first studies comparing outcomes of the different variants of LSC with a particular focus on comparing these outcomes based on whether the uterus was spared or concomitantly removed. Of the total number of women who had an LSC procedure during the study period, 70% of women who presented with a significant apical POP requiring surgery had their uterus in situ. The majority of these women had a concomitant hysterectomy at the time of LSC. Our study demonstrated that LSC procedures with a concomitant total hysterectomy were associated with statistically significantly longer operating time and intra-operative blood loss. However, the median differences between groups were only 5 minutes and 50 milliliters respectively. In contrast, uterine sparing LSCs were associated with a significantly higher likelihood of a suboptimally placed mesh at 3 and 12 months postoperative and anterior compartment failures at 12 months. Nevertheless, other anatomical and patient reported outcomes were comparable in both groups. On head to head comparison of the different LSC variants there was no significant difference in anterior compartment failure rates. However, this observation should be interpreted with caution due to the small samples in some of the subgroups. Results in relation to what is known: Other groups have reported higher incidence of anatomical failures in association with LSH [23, 24]. Saliba et al. compared outcomes of 64 LSCH+LSC versus 12 LSH procedures and the anatomical failure, defined as POP stage ≥ 2, was significantly higher in the LSH groups in both any and apical compartments (33.3% vs. 6.2% and 16.7 % vs. 0 % respectively), however, the study authors did not provide the actual length of follow-up [24]. Similarly, Gracia and colleagues reported significantly higher apical compartment failures, defined as C stage ≥ 2, when comparing 12 months outcomes after 15 LSH compared to 30 LSCH+LSC (53.2% vs. 10.0%). Anterior compartment recurrence (Ba stage ≥ 2) was also more common in their LSH cohort (72.4% vs. 33.3%) [23]. The reported incidence of anterior compartment failures concur with our findings of 21.1% vs. 8.8% in our LSH and LSCH+LSC subgroups respectively. Nevertheless, our low incidence of apical compartment recurrences both in the main and subgroup analyses are in stark contrast to the rates reported in these studies. When comparing LSH and TLH+LSC, we did not have any apical compartment recurrences at 12 months compared to Pan et al who reported 13.9% and 5.9% recurrence rates for the equivalent procedures in a cohort of 65 and 34 women who had LSH and TLH+LSC respectively, albeit, after an average follow-up of 34 months. While their anterior compartment failure rates were 13.9% versus 11.8% compared to 21.1% versus 5.2% in our study. Moreover, their posterior compartment recurrence incidence were 4.6% versus 5.9% while it was 0% and 15.8% in our LSH and TLH+LSC respectively [25]. The identified posterior compartment failure rate in our TLH+LSC was also higher than that reported by Illiano and associates (15.8% compared to 2.4%) [26]. Due to the nature of our study we were not able to explore the reasons behind the aforementioned differences in recurrence rates between our study and previous reports, which could be related to the operative technique, patient selection or duration of follow-up. Another reason for discrepancy in reported outcome rates between various studies is the POP-Q cut-off used to determine failure. Indeed, if we use the Ba > 0 cut-off for cystocele recurrence adopted in other studies [32, 37] , our anterior compartment failure rates would have dropped to zero. We identified a significantly higher likelihood of suboptimal mesh placement in our LSH group, which probably is an indicator of the relative technical difficulty of inserting the mesh in LSH compared to other variants of LSC. It would be of interest to assess if there is any association between mesh placement and clinical outcomes. However, we did not undertake such analysis because we believe our study is underpowered to test such hypothesis. The incidence of postoperative mesh-related complications in our study falls within the range of 1.0 - 2.6%. However, the incidence of mesh erosions were similar in our subgroup analyses unlike the differences reported by other authors [38–40]. It is the technical challenge to achieve proper placement of the anterior mesh in LSH and be able to create a “de novo vaginal apex” that is considered to be a plausible reason for the higher anterior compartment failure in association with LSH and is the driver behind the suggestion of alternative modifications to the standard technique [41]. The process of refining the current LSH technique is crucially important since the number of women opting for uterine sparing surgery significantly falls if this technique is associated with inferior anatomical outcome [18, 19]. Strengths and limitations: We appreciate that there are some limitations to our work. First, the retrospective nature of the study has an inherent risk of introducing selection and recall bias into our data. Due to the rigor in our hospital database and the high level of specialism required for the surgical procedures being assessed, it is extremely unlikely we would have missed any procedures or data that was collected. However, the issue of selection bias is more challenging to tackle except within a context of a randomized trial. Indeed, our 2 groups of interest had significant differences in their demographics and associated comorbidities. Second, although we report 12-month follow-up data, in POP surgery, this is considered relatively short. We recognize that the longer the follow-up the higher attrition rate, hence, the current study will form the basis for our LSC database that will enable us to increase our sample size and asses longer term outcomes. Although our sample size in the uterine sparing cohort was relatively small, a post hoc power calculation showed that the power of our study to identify the difference in anterior compartment failure rates between our main cohorts at a significance level of 0.05 was 70% (supplementary information). Finally, it could be perceived that a report from a single center might limit the external validity of the study. However, the involvement of several independent trained surgeons, in a center accredited by the European Board & College of Obstetrics and Gynaecology (EBCOG) for training and the use of standardized operative technique and validated outcome measures make our findings generalizable. In contrast, the reporting on LSC variants based on whether the uterus was removed or spared using a comprehensive set of core outcomes and the novelty of the postoperative imaging information are major strengths to our study. Conclusion Many women referred with a symptomatic apical POP have their uterus in situ. LSH was associated with higher incidence of anterior compartment failures and suboptimal mesh placement compared to LSC with concomitant hysterectomy. LSCH+LSC appears to have the best balance between limiting operative time and blood loss against recurrence rates at 12 months. The availability of longer-term outcomes for the different LSC variants and the assessment of proposed new modifications to overcome challenges to mesh placement in LSH are essential to give women realistic prospects of making an equitable informed choice. Abbreviations CRADI: Colorectal-Anal Distress Inventory LSC: Laparoscopic sacro-colpopexy LSCH+LSC: Laparoscopic sacro-cervicopexy LSH: Laparoscopic sacro-hysteropexy PGI-I: Patient Global Impression of Improvement POP: Pelvic organ prolapse POPDI: Pelvic Organ Prolapse Distress Inventory POP-Q: Pelvic organ prolapse quantitation system PFDI: Pelvic Floor Distress Inventory TLH+LSC: Total laparoscopic hysterectomy and laparoscopic sacro-colpopexy QOL: Quality of life UDI: Urinary Distress Inventory Declarations Ethics approval and consent to participate: Local ethics committee approval was granted for the study by Lokální etická komise (Local ethical committee), Faculty Hospital Pilsen (approval number 239/2020). All patients included in this study provided written informed consent for the procedure and for the future use of their perioperative and follow-up data. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: The study was funded by National Sustainability Program I (NPU I) Nr. LO1503 and Charles University Research Fund (Progress Q39). The funders did not have a role in the collection, analysis and interpretation of data and in the writing of the manuscript. KI is part-funded by project No. CZ.02.1.01/0.0/0.0/16_019/0000787 “Fighting INfectious Diseases“, awarded by the Ministry of Education, Youth and Sports of the Czech Republic, financed from The European Regional Development Fund. Funders were not involved in the design, analysis or the reporting of this work. Authors' contributions DG: Literature search, Data collection, Manuscript writing VK: Project development, Literature search, Data collection, Manuscript writing MS: Data collection ZR: Data collection, Manuscript editing and revision RP: Project development, Manuscript editing and revision KMI: Project development, Literature search, Manuscript editing and revision Acknowledgement: some of the procedures analyzed in this study contributed data to other studies that were designed to answer different research questions [32, 33]. References Swift S, Woodman P, O’Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic Organ Support Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192:795–806. doi:10.1016/j.ajog.2004.10.602. Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime Risk of Stress Urinary Incontinence or Pelvic Organ Prolapse Surgery. 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Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. In: American Journal of Obstetrics and Gynecology. 2017. p. 38.e1-38.e11. Costantini E, Brubaker L, Cervigni M, Matthews CA, O’Reilly BA, Rizk D, et al. Sacrocolpopexy for pelvic organ prolapse: evidence-based review and recommendations. Eur J Obstet Gynecol Reprod Biol. 2016;205:60–5. doi:10.1016/j.ejogrb.2016.07.503. Stepanian AA, Miklos JR, Moore RD, Mattox TF. Risk of Mesh Extrusion and Other Mesh-Related Complications After Laparoscopic Sacral Colpopexy with or without Concurrent Laparoscopic-Assisted Vaginal Hysterectomy: Experience of 402 Patients. J Minim Invasive Gynecol. 2008;15:188–96. doi:10.1016/j.jmig.2007.11.006. Tan-Kim J, Menefee SA, Luber KM, Nager CW, Lukacz ES. Prevalence and risk factors for mesh erosion after laparoscopic-assisted sacrocolpopexy. Int Urogynecol J. 2011;22:205–12. doi:10.1007/s00192-010-1265-3. Kalis V, Rusavy Z, Ismail KM. Laparoscopic sacrohysteropexy: the Pilsner modification. Int Urogynecol J. 2020;31:1277–80. doi:10.1007/s00192-019-04150-1. Tables Table 1: Demographic details of study cohorts. Variable Total population N = 294 Uterine sparing (LSH) N = 43 Concomitant Hysterectomy (LSCH+LSC & TLH+LSC) N = 251 p BMI [Median (range)] 26.4 (17.7-37.2) 25.2 (17.7-31.6) 26.6 (19.2-37.2) 0.006 a Age [Median (range)] 63.0 (28-84) 49.0 (28-70) 64.0 (37-84) <0.0001 a Parity [Median (range)] 2.0 (0-9) 2.0 (1-5) 2.0 (0-9) 0.063 a Cardiovascular disease [N (%)] 149 (50.7%) 9 (20.9%) 140 (55.8%) <0.0001 b Diabetes mellitus [N (%)] 40 (13.6%) 1 (2.3%) 39 (15.5%) 0.020 b Previous DVT or pulmonary embolism [N (%)] 39 (13.3%) 3 (7.0%) 36 (14.3%) 0.188 b Asthma [N (%)] 22 (7.5%) 1 (2.3%) 21 (8.4%) 0.219 c Previous abdominal surgical history [N (%)] 137 (46.6%) 17 (39.5%) 120 (47.8%) 0.315 b Previous gynecologic surgery [N (%)] 90 (30.6%) 15 (34.9%) 85 (33.9%) 0.896 b Previous POP surgery [N (%)] 6 (2.0%) 2 (4.7%) 4 (1.6%) 0.214 c Point C POP Q stage 19 (6.5%) 5 (11.6%) 14 (5.6%) 0.073 b POP Q stage II 159 (54.1%) 24 (55.8%) 135 53.8%) POP Q stage III 78 (26.5%) 11 (25.6%) 67 (26.7%) POP Q stage IV 38 (12.9%) 3 (7.0%) 55 (21.9%) Point Ba POP Q stage I 3 (1.0%) 1 (2.3%) 2 (0.8%) <0.0001 b POP Q stage II 65 (22.1%) 28 (65.1%) 37 (14.7%) POP Q stage III 165 (56.1%) 11 (25.6%) 154 (61.4%) POP Q stage IV 51 (17.4%) 3 (7.0%) 48 (19.1%) Point Bp POP Q stage I 96 (32.7%) 13 (30.2%) 83 (33.1%) 0.634 b POP Q stage II 132 (44.9%) 22 (51.2%) 110 (43.8%) POP Q stage III 46 (15.6%) 7 (16.3%) 39 (15.5%) POP Q stage IV 20 (6.8%) 1 (2.3%) 19 (7.6%) Stress urinary incontinence [N (%)] 87 (29.6%) 11 (25.6%) 76 (60.3%) 0.533 b Urge urinary incontinence [N (%)] 66 (22.4%) 8 (18.6%) 58 (23.1%) 0.513 b Hesitancy: a delay in initiating micturition [N (%)] 136 (46.3%) 13 (30.2%) 123 (49.0%) 0.023 b Urinary retention [N (%)] 126 (42.9%) 21 (48.8%) 115 (45.8%) 0.714 b Constipation [N (%)] 62 (21.1%) 4 (9.3%) 58 (23.1%) 0.040 b Anal incontinence [N (%)] 102/266 (38.3%) 16/41 (39.0%) 86/225 (38.2%) 0.923 b Pre-op UDI [median (range)] 51.2 (0-189) 52.6 (5.8-164) 51.2 (0-189) 0.481 a Pre-op POPDI [median (range)] 68.5 (0-282) 58.9 (10.7-152) 69.6 (0-282) 0.204 a Pre-op CRADI [median (range)] 35.1 (0-216) 34.2 (0-164) 36.4 (0-216) 0.963 a Pre-op PFDI [median (range)] 171.7 (0-600) 148.0 (16.5-442) 1712.4 (0-600) 0.524 a a Mann-Whitney U test; b Chi-square Test; c Fisher’s exact Test BMI: body mass index, DVT: deep venous thromboembolism Table 2: Peri-operative characteristics amongst study cohorts Variable Total population N = 294 Uterine sparing (LSH) N = 43 Concomitant Hysterectomy (LSCH+LSC & TLH+LSC) N = 251 p Operating time [min] [Median (range)] 120.5 (60-240) 120.0 (70-225) 125.0 (60-240) 0.052 a Operating time more than 3 hours [N (%)] 16 (5.4%) 2 (4.7%) 14 (5.6%) 1.000 b Blood loss [ml] [Median (range)] 150 (50-1400) 150 (50-1400) 200 (50-800) 0.259 a Estimated blood loss more than 300 ml [N (%)] 14 (4.7%) 2 (4.7%) 12 (4.8%) 1.000 b Perioperative blood transfusion 2 (0.7%) 1 (2.3%) 1 (0.4%) 0.286 b Bladder injury [N (%)] 10 (3.4%) 2 (4.7%) 8 (3.2%) 0.657 b Rectal injury [N (%)] 0 (0.0%) 0 (0.0%) 0 (0.0%) - Vaginal injury [N (%)] 2 (0.7%) 0 (0.0%) 2 (0.8%) 1.000 b Early postoperative complications Dindo-Clavien grade 0 [N (%)] 281 (95.6%) 41 (95.3%) 240 (95.6%) 0.566 b Early postoperative complications Dindo-Clavien grade I [N (%)] 6 (2.0%) 1 (2.3%) 5 (2.0%) Early postoperative complications Dindo-Clavien grade II [N (%)] 3 (1.0%) 1 (2.3%) 2 (0.8%) Early postoperative complications Dindo-Clavien grade III [N (%)] 4 (1.4%) 0 (0.0%) 4 (1.6%) Prolonged hospitalization [N (%)] 6 (2.0%) 2 (4.7%) 4 (1.6%) 0.234 b a Mann-Whitney U test; b Fisher’s Exact Test Table 3: Post-operative follow-up at 3 months and at 12 months. 3 month follow-up N=283 12 month follow-up N=271 Total N = 283 Uterine sparing (LSH) N = 41 Concomitant hysterectomy (LSCH+LSC & TLH+LSC) N = 242 p Total N = 271 Uterine sparing (LSH) N = 38 Concomitant hysterectomy (LSCH+LSC & TLH+LSC) N = 233 p Postoperative mesh complications [N/N] (%) 2/283 (0.7%) 0/41 (0.0%) 2/242 (0.8%) 1.000 b 4/271 (1.5%) 1/38 (2.6%) 3/233 (1.3%) 0.456 b Failure in apical compartment Point C ≥ -TVL/2 [N/N] (%) 0/283 (0.0%) 0/41 (0.0%) 0/242 (0%) - 0/271 (0.0%) 0/38 (0.0%) 0/233 (0%) - Failure in anterior compartment Point Ba ≥ -1 [N/N] (%) 12/283 (4.2%) 4/41 (9.8%) 8/242 (3.3%) 0.079 b 26/271 (9.6%) 8/38 (21.1%) 18/233 (7.7%) 0.017 b Failure in posterior compartment Point Bp ≥ -1 [N/N] (%) 14/283 (4.9%) 0/41 (0.0%) 14/242 (5.8%) 0.114 b 15/271 (5.5%) 0/38 (0.0%) 15/233 (6.4%) 0.140 b PGI-I 1, 2 [N/N] (%) 243/283 (85.9%) 35/41 (85.4%) 208/242 (86.0%) 0.607 b 255/271 (94.1%) 33/38 (86.8%) 222/233 (95.3%) 0.055 b PGI-I 3 [N/N] (%) 28/283 (9.9%) 4/41 (9.8%) 24/242 (9.9%) 11/271 (4.0%) 3/38 (7.9%) 8/233 (3.4%) PGI-I 4 [N/N] (%) 8/283 (2.8%) 1/41 (2.4%) 7/242 (2.9%) 4/271 (1.5%) 2/38 (5.3%) 2/233 (0.9%) PGI-I 5 [N/N] (%) 2/283 (0.7%) 1/41 (2.4%) 1/242 (0.4%) 1/271 (0.4%) 0/38 (0.0%) 1/233 (0.4%) PGI-I 6 [N/N] (%) 2/283 (0.7%) 0/41 (0.0%) 2/242 (0.8%) 0/271 (0.0%) 0/38 (0.0%) 0/233 (0%) PGI-I 7 [N/N] (%) 0/286 (0.0%) 0/41 (0.0%) 0/242 (0%) 0/271 (0.0%) 0/38 (0.0%) 0/233 (0%) Δ UDI pre-op – post-op [median (range)] 20.1 (-159-153) 17.9 (-54.9-131) 20.1 (-159-153) 0.988 a 25.0 (-112-160) 17.6 (-99-160) 33.7 (-112-150) 0.585 a Δ POPDI pre-op – post-op [median (range)] 40.5 (-112-256) 35.7 (-56-127) 41.1 (-112-256) 0.559 a 39.3 (-74-253) 30.4 (-43-135) 48.2 (-189-253) 0.502 a Δ CRADI pre-op – post-op [median (range)] 7.7 (-189-199) 10.0 (-41-129) 7.1 (-189-199) 0.338 a 3.6 (-92-170) 10.7 (-38-112) 7.1 (-118-170) 0.187 a Δ PFDI pre-op – post-op [median (range)] 46.1 (-342-450) 50.7 (-206-373) 59.5 (-343-450) 0.889 a 70.4 (-182-460) 66.9 (-123-281) 82.5 (-338-460) 0.960 a a Mann-Whitney U test; b Fisher’s Exact Test; UUI: Urge urinary incontinence; SUI: Stress urinary incontinence. * If TVT or bulking agens performed between 3 and 12 months, the woman remained in SUI group. Table 4: Mesh placement on transperineal scanning at 3 months and at 12 months. 3 month follow-up N=283 12 month follow-up N=271 Total N = 283 Uterine sparing (LSH) N = 41 Concomitant hysterectomy (LSCH+LSC & TLH+LSC) N = 242 p Total N = 271 Uterine sparing (LSH) N = 38 Concomitant hysterectomy (LSCH+LSC & TLH+LSC) N = 233 p Regular shape of the mesh upon visualization of the whole mesh [N/N](%) 244/266(91.7%) 35/40(87.5%) 209/226 (92.5%) 0.345 b 238/265(89.8%) 32/39(82.1%) 206/226 (91.2%) 0.090 b No folding of the mesh [N/N](%) 248/268(92.5%) 32/40(80.0%) 216/228 (94.7%) 0.004 b 245/266(92.1%) 32/39(82.1%) 213/227 (93.8%) 0.021 b No mesh descent on Valsalva 196/226 (86.7%) [N/N](%) 266/268(99.3%) 39/40(97.5%) 227/228 (99.6%) 0.277 b 252/254(99.2%) 36/37(97.3%) 216/217 (99.5%) 0.271 b Overall evaluation: all criteria for a properly placed mesh fulfilled [N/N](%) 227/266(85.3%) 31/40(77.5%) 196/226 (86.7%) 0.146 b 214/254(84.3%) 25/37(67.6%) 189/217 (81.7%) 0.006 b a Mann-Whitney U test; b Fisher’s Exact Test; UUI: Urge urinary incontinence; SUI: Stress urinary incontinence. * If TVT or bulking agens performed between 3 and 12 months, the woman remained in SUI group. Supplementary Files POPUPstudysupplementarytable1Final.docx Supplementary Table 1: Demographic data amongst women undergoing LSH, LSCH+LSC and TLH+LSC POPUPstudysupplementaryTable2R2final.docx Supplementary Table 2: Perioperative characteristics amongst women undergoing LSH, LSCH+LSC and TLH+LSC POPUPstudySupplementaryTable3R2final.docx Supplementary Table 3: Postoperative follow-up at 3 months and 12 months by type of procedure PopUPstudySTROBEchecklistcohort.docx STROBE Checklist POPUPstudysupplementaryfileFinalR1.docx Supplementary File Cite Share Download PDF Status: Published Journal Publication published 17 Feb, 2021 Read the published version in BMC Women's Health → Version 3 posted Editorial decision: Minor revision 28 Jan, 2021 Review # 1 received at journal 25 Jan, 2021 Reviewers invited by journal 12 Jan, 2021 Reviewer # 1 agreed at journal 12 Jan, 2021 Editor assigned by journal 11 Jan, 2021 Submission checks completed at journal 11 Jan, 2021 Editor invited by journal 11 Jan, 2021 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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TLH+LSC","description":"","filename":"POPUPstudysupplementarytable1Final.docx","url":"https://assets-eu.researchsquare.com/files/rs-35323/v3/d670ceb0fbdb382ce9311b08.docx"},{"id":5167903,"identity":"99ecba22-e1a4-42d0-95f7-82b0871c3242","added_by":"auto","created_at":"2021-01-21 20:53:32","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25607,"visible":true,"origin":"","legend":"Supplementary Table 2: Perioperative characteristics amongst women undergoing LSH, LSCH+LSC and TLH+LSC","description":"","filename":"POPUPstudysupplementaryTable2R2final.docx","url":"https://assets-eu.researchsquare.com/files/rs-35323/v3/a3a1c28c61a6e2bdeb6c2d6d.docx"},{"id":5168132,"identity":"1a04b8bb-a715-419a-b31d-f62f1c0b4b09","added_by":"auto","created_at":"2021-01-21 20:59:32","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":30464,"visible":true,"origin":"","legend":"Supplementary Table 3: Postoperative follow-up at 3 months and 12 months by type of procedure","description":"","filename":"POPUPstudySupplementaryTable3R2final.docx","url":"https://assets-eu.researchsquare.com/files/rs-35323/v3/d17f63c24a47f4214d5c97ed.docx"},{"id":5168046,"identity":"40eecb9d-10ca-4ffa-aafb-efaf306f44cb","added_by":"auto","created_at":"2021-01-21 20:56:32","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":41986,"visible":true,"origin":"","legend":"STROBE Checklist","description":"","filename":"PopUPstudySTROBEchecklistcohort.docx","url":"https://assets-eu.researchsquare.com/files/rs-35323/v3/800ac564e91aeb4e3656a2f2.docx"},{"id":5167906,"identity":"bdc8ad0e-ac33-4cc7-87fc-5c1fe1c8f1ac","added_by":"auto","created_at":"2021-01-21 20:53:32","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":41850,"visible":true,"origin":"","legend":"Supplementary File","description":"","filename":"POPUPstudysupplementaryfileFinalR1.docx","url":"https://assets-eu.researchsquare.com/files/rs-35323/v3/b22c8bd4ef0c72a4f218ae6f.docx"}],"financialInterests":"","formattedTitle":"Pelvic organ prolapse and uterine preservation: A cohort study (POP-UP study)","fulltext":[{"header":"Background","content":"\u003cp\u003eIt is estimated that one in three women are affected by pelvic organ prolapse (POP) and one in 10 require a surgical procedure for its correction during their lifetime [1, 2]. POP is associated with numerous bothersome clinical symptoms including pelvic discomfort, vaginal bulge, urinary incontinence, urinary tract symptoms, fecal incontinence or sexual dysfunction. These often have a significant negative impact on their quality of life (QOL) or, even, serious life threatening consequences [3\u0026ndash;8]. There is no significant correlation between the severity of clinical symptoms and the stage of POP, but there is a correlation between clinical symptoms and location of the underlying defect [9]. Anterior compartment prolapse tends to be associated with urgency symptoms requiring surgical intervention in the majority of cases [10], while posterior compartment prolapse is more likely to be associated with distal bowel dysfunction [11, 12].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConservative management of apical prolapse is commonly used as first line treatment in general and the main option for women who have not completed their childbearing or those deemed to be at high operative risks. Nonetheless, surgical correction is an option that should always be discussed when counseling women about their treatment options. POP with a dominant apical defect can be treated using a number of surgical approaches and this choice can be one of the most challenging problems in urogynecology [13, 14]. However, high level evidence indicates that abdominal and laparoscopic sacro-colpopexy (LSC) result in better anatomical outcomes compared to sacrospinous ligament fixation and transvaginal mesh insertion [14]. Women who have their uterus and opt for a laparoscopic approach have several surgical options to consider; sacro-colpopexy, uterosacral ligament colpopexy [15], lateral ligament suspension or pecto-colpopexy [16]. Based on the currently available evidence, LSC is the most commonly used laparoscopic method and this could be in the form of laparoscopic sacro-hysteropexy (LSH), laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH+LSC) or total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH+LSC).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe American College of Obstetricians and Gynecologists considers involving and supporting patients in the discussion about uterine preservation in elective surgery as obligatory [17]. Furthermore, there seems to be an increasing tendency for women to explore uterine preserving procedures for their POP surgical management rather than just accept a hysterectomy [18\u0026ndash;20]. Therefore, increasing the availability of options, that do not necessitate a hysterectomy, gives women viable options to individualize their POP management plan. Nonetheless, one of the important determinants of women\u0026rsquo;s choice about uterine preservation or concomitant hysterectomy is the outcome associated with either procedure [18\u0026ndash;20]. There is evidence that the route of concomitant hysterectomy during LSC does not seem to be associated with the perioperative or postoperative outcomes [21, 22]. However, at present, there is heterogenous information about comparative anatomical and functional outcomes with no comprehensive analysis based on whether the uterus was spared or removed [23\u0026ndash;26]. Furthermore, there is paucity of information on surgical outcomes including mesh placement on postoperative imaging.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe main aim of the study was to compare the clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures for a symptomatic apical POP. As a secondary aim we wanted to assess the peri- and postoperative complications associated with these procedures as an indicator of their safety profile.\u003c/p\u003e\n\u003cp\u003eThis is a retrospective cohort study undertaken in a tertiary referral urogynecology center in Pilsen, the Czech Republic. All women referred with an intact uterus and a symptomatic apical POP and who were listed for one of the LSC procedures between January 2015 and January 2019 were included in our analysis. For the purpose of this study, we were interested in comparing women who had an LSH (uterine preservation) versus LSCH+LSC or TLH+LSC (concomitant hysterectomy). Local ethics committee approval was granted for the study. All patients included in this study provided written informed consent for the procedure and for the future use of their perioperative and follow-up data. The departmental medical database was used to gather data on patients\u0026rsquo; demographics, medical history, history of abdominal and/or gynecological surgery, previous reconstructive POP surgery, obstetric history, urinary or bowel symptoms and POP-Q staging points [27, 28]. We also collected data on hospital length of stay (LOS). Extended LOS was defined as hospitalization longer than the 75th percentile [29]\u003cstrong\u003e. \u003c/strong\u003eThe impact of the woman\u0026rsquo;s symptoms on her quality of life during the pre- and postoperative periods was assessed using the Pelvic Floor Distress Inventory (PFDI). This is a validated quality-of-life questionnaire consisting of a Urinary Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (POPDI) and a Colorectal-Anal Distress Inventory (CRADI). UDI and POPDI have a score range of 0 (least impact) to 300 (greatest adverse impact) while CRADI has a range of 0 to 400 and an overall summary PFDI score ranging from 0 to 1000 [30]. Perioperative complications were categorized according to the Dindo-Clavien classification [31].\u003c/p\u003e\n\u003ch1\u003e\u0026nbsp;\u003c/h1\u003e\n\u003cp\u003eSurgical procedures were performed by one of four experienced urogynecological subspecialists. We used the same surgical technique, sutures and mesh materials for all LSC variants as previously published by our group [32, 33].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the research unit, postoperative follow-up appointments are routinely arranged at 3 and 12 months for assessment of the impact of surgery on the woman\u0026rsquo;s clinical symptoms, evaluation of any postoperative complications and clinical examination including a POP-Q measurement. In addition to the PFDI, their overall satisfaction with the surgical procedure is routinely evaluated by means of a 7-point Patient Global Impression of Improvement (PGI-I) scale ranging from \"Very much worse\u0026rdquo; (PGI-I=7) to \"Very much better\u0026rdquo; (PGI-I=1) [34]\u003cstrong\u003e.\u003c/strong\u003e Any identified mesh related complications are reported using the current standardized international classification [35]. A 3D/4D transperineal ultrasound scans is also routinely performed at both follow-up appointments to assess the bladder neck and mesh positions. The ultrasound protocol has been previously published and is derived from the standardized assessment protocol suggested by Dietz et al [32, 33, 36]. Optimal mesh placement is assessed based on a set of composite parameters including: distance of the lowest margin of the anterior mesh strand from the bladder neck \u0026lt;20 mm [32, 33]; shape of the mesh; absence of folding ; and a vertical mesh descent on Valsalva \u0026le;20 mm.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the purpose of this study, anatomical apical compartment failure was defined as a postoperative POP-Q point C \u0026ge; -TVL/2 cm (apical descent lower than half of the vaginal length). Points Ba and Bp \u0026ge; -1 cm were considered failure in the anterior and posterior compartment respectively. Subjective success of the procedure was defined as a PGI-I \u0026lt; 3 i.e. \"Very Much\" or \"Much Better\". Statistical analysis was performed using IBM SPSS Statistics software version 22 (Armonk, NY: IBM Corp.). A p\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003eIn addition to the comparisons between uterine sparing versus concomitant hysterectomy LSC procedures, we undertook a sub-analysis comparing the three procedures (LSC, LSCH+LSC and TLH+LSC) to each other.\u003c/p\u003e"},{"header":" Results","content":"\u003cp\u003eA total of 421 LSC procedures were performed during the study period. Of these, 124 (29.5%) procedures were performed on women who previously had a hysterectomy and hence excluded from this study. A further 3 patients (0.7%) were not included because they had their procedure performed through a laparotomy. The remaining 294 (70.0%) women who have had one of the LSC variants for apical POP management were all included in our analysis. These included 43 (14.6%) women had a uterine sparing procedure LSH) and 251 (85.4%) had a concomitant hysterectomy, of these 208 (70.8%) had LSCH+LSC and 43 women (14.6%) had a TLH+LSC (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 1 and supplementary table 1 summarize participants\u0026rsquo; characteristics, preoperative POP-Q and PFDI scores grouped by whether the uterus was preserved or not and by type of procedure respectively. There were significant differences between the cohort of women who had LSH compared to LSCH+LSC / TLH+LSC with regards to BMI (25.2 kg/m\u003csup\u003e2\u003c/sup\u003e vs. 26.6 kg/m\u003csup\u003e2\u003c/sup\u003e, p = 0.006), age (49.0 years vs. 64.0 years, p \u0026lt; 0.0001) and comorbidities like cardiovascular disease (20.9% vs. 55.8%, p \u0026lt; 0.0001) and diabetes (2.3% vs. 15.5%, p = 0.02). There was also a significant difference in POP-Q staging based on point Ba between the 2 groups (p \u0026lt; 0.0001) (Table 1). There were significant differences in reported urinary hesitancy (30.2% vs. 49.0%, p = 0.023) and constipation (9.3% vs. 23.1%, p = 0.04) between both cohorts. \u0026nbsp;However, no significant differences were found in other pre-operative POP-Q parameters, reported urinary or anal incontinence, or preoperative PFDI score.\u0026nbsp;Operative characteristics and postoperative complications are presented in table 2 and supplementary table 2. Based on the Dindo-Clavien classification, there were no differences in the incidence of perioperative injuries and complications. However, operating time and blood loss were higher in the concomitant hysterectomy compared to the uterine sparing group (125 min vs. 120 min, p = 0.052). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 shows anatomical and functional outcomes at 3 and 12 months postoperative. When comparing outcomes in women who had a concomitant hysterectomy at the time of LSC compared to LSH, there were no statistically significant differences in any of the clinical or patient reported outcomes except for a significantly higher anterior compartment failure rate at 12 month follow-up as assessed by POP-Q in women who had a uterine sparing procedure (21.1% vs. 7.7%, p= 0.017) (Table 3, supplementary table 3).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, concomitant hysterectomy procedures were likely to be associated with absent mesh folding on at 3 (94.7% vs. 80.0%, p = 0.004) and 12 months (93.8% vs. 82.1%, p = 0.021) and optimal composite mesh placement at 12 months (81.7% vs. 67.6%, p = 0.006) as assessed by ultrasonography (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn subgroup analysis, the difference was only significantly longer for operating time in the TLH+LSC versus LSH subgroups (140 min vs. 120 min, p = 0.048). Furthermore, blood loss was significantly higher when comparing TLH+LSC to LSH (250 ml vs. 150 ml, p = 0.001) and TLH+LSC to LSCH+LSC (250 ml vs. 150 ml, p \u0026lt; 0.0001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSummary of findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is among the first studies comparing outcomes of the different variants of LSC with a particular focus on comparing these outcomes based on whether the uterus was spared or concomitantly removed. Of the total number of women who had an LSC procedure during the study period, 70% of women who presented with a significant apical POP requiring surgery had their uterus in situ. The majority of these women had a concomitant hysterectomy at the time of LSC. Our study demonstrated that LSC procedures with a concomitant total hysterectomy were associated with statistically significantly longer operating time and intra-operative blood loss. However, the median differences between groups were only 5 minutes and 50 milliliters respectively. In contrast, uterine sparing LSCs were associated with a significantly higher likelihood of a suboptimally placed mesh at 3 and 12 months postoperative and anterior compartment failures at 12 months. Nevertheless, other anatomical and patient reported outcomes were comparable in both groups. On head to head comparison of the different LSC variants there was no significant difference in anterior compartment failure rates. However, this observation should be interpreted with caution due to the small samples in some of the subgroups.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResults in relation to what is known:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOther groups have reported higher incidence of anatomical failures in association with LSH [23, 24]. Saliba et al. compared outcomes of 64 LSCH+LSC versus 12 LSH procedures and the anatomical failure, defined as POP stage \u0026ge; 2, was significantly higher in the LSH groups in both any and apical compartments (33.3% vs. 6.2% and 16.7 % vs. 0 % respectively), however, the study authors did not provide the actual length of follow-up [24]. Similarly, Gracia and colleagues reported significantly higher apical compartment failures, defined as C stage \u0026ge; 2, when comparing 12 months outcomes after 15 LSH compared to 30 LSCH+LSC (53.2% vs. 10.0%). Anterior compartment recurrence (Ba stage \u0026ge; 2) was also more common in their LSH cohort (72.4% vs. 33.3%) [23]. The reported incidence of anterior compartment failures concur with our findings of 21.1% vs. 8.8% in our LSH and LSCH+LSC subgroups respectively. Nevertheless, our low incidence of apical compartment recurrences both in the main and subgroup analyses are in stark contrast to the rates reported in these studies.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhen comparing LSH and TLH+LSC, we did not have any apical compartment recurrences at 12 months compared to Pan et al who reported 13.9% and 5.9% recurrence rates for the equivalent procedures in a cohort of 65 and 34 women who had LSH and TLH+LSC respectively, albeit, after an average follow-up of 34 months.\u0026nbsp; While their anterior compartment failure rates were 13.9% versus 11.8% compared to 21.1% versus 5.2% in our study. Moreover, their posterior compartment recurrence incidence were 4.6% versus 5.9% while it was 0% and 15.8% in our LSH and TLH+LSC respectively [25]. The identified posterior compartment failure rate in our TLH+LSC was also higher than that reported by Illiano and associates (15.8% compared to 2.4%) [26]. Due to the nature of our study we were not able to explore the reasons behind the aforementioned differences in recurrence rates between our study and previous reports, which could be related to the operative technique, patient selection or duration of follow-up. Another reason for discrepancy in reported outcome rates between various studies is the POP-Q cut-off used to determine failure. Indeed, if we use the Ba \u0026gt; 0 cut-off for cystocele recurrence adopted in other studies [32, 37]\u003cstrong\u003e,\u003c/strong\u003e our anterior compartment failure rates would have dropped to zero.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe identified a significantly higher likelihood of suboptimal mesh placement in our LSH group, which probably is an indicator of the relative technical difficulty of inserting the mesh in LSH compared to other variants of LSC. It would be of interest to assess if there is any association between mesh placement and clinical outcomes. However, we did not undertake such analysis because we believe our study is underpowered to test such hypothesis. The incidence of postoperative mesh-related complications in our study falls within the range of 1.0 - 2.6%. However, the incidence of mesh erosions were similar in our subgroup analyses unlike the differences reported by other authors [38\u0026ndash;40]. It is the technical challenge to achieve proper placement of the anterior mesh in LSH and be able to create a \u0026ldquo;de novo vaginal apex\u0026rdquo; that is considered to be a plausible reason for the higher anterior compartment failure in association with LSH and is the driver behind the suggestion of alternative modifications to the standard technique [41]. The process of refining the current LSH technique is crucially important since the number of women opting for uterine sparing surgery significantly falls if this technique is associated with inferior anatomical outcome [18, 19].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStrengths and limitations:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate that there are some limitations to our work. First, the retrospective nature of the study has an inherent risk of introducing selection and recall bias into our data. Due to the rigor in our hospital database and the high level of specialism required for the surgical procedures being assessed, it is extremely unlikely we would have missed any procedures or data that was collected. However, the issue of selection bias is more challenging to tackle except within a context of a randomized trial. Indeed, our 2 groups of interest had significant differences in their demographics and associated comorbidities. Second, although we report 12-month follow-up data, in POP surgery, this is considered relatively short. We recognize that the longer the follow-up the higher attrition rate, hence, the current study will form the basis for our LSC database that will enable us to increase our sample size and asses longer term outcomes. Although our sample size in the uterine sparing cohort was relatively small, a post hoc power calculation showed that the power of our study to identify the difference in anterior compartment failure rates between our main cohorts at a significance level of 0.05 was 70% (supplementary information). Finally, it could be perceived that a report from a single center might limit the external validity of the study. However, the involvement of several independent trained surgeons, in a center accredited by the European Board \u0026amp; College of Obstetrics and Gynaecology (EBCOG) for training and the use of standardized operative technique and validated outcome measures make our findings generalizable. In contrast, the reporting on LSC variants based on whether the uterus was removed or spared using a comprehensive set of core outcomes and the novelty of the postoperative imaging information are major strengths to our study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMany women referred with a symptomatic apical POP have their uterus in situ. LSH was associated with higher incidence of anterior compartment failures and suboptimal mesh placement compared to LSC with concomitant hysterectomy. LSCH+LSC appears to have the best balance between limiting operative time and blood loss against recurrence rates at 12 months. The availability of longer-term outcomes for the different LSC variants and the assessment of proposed new modifications to overcome challenges to mesh placement in LSH are essential to give women realistic prospects of making an equitable informed choice.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n\u003cli\u003eCRADI: Colorectal-Anal Distress Inventory\u003c/li\u003e\n\u003cli\u003eLSC: Laparoscopic sacro-colpopexy\u003c/li\u003e\n\u003cli\u003eLSCH+LSC: Laparoscopic sacro-cervicopexy\u003c/li\u003e\n\u003cli\u003eLSH: Laparoscopic sacro-hysteropexy\u003c/li\u003e\n\u003cli\u003ePGI-I: Patient Global Impression of Improvement\u003c/li\u003e\n\u003cli\u003ePOP: Pelvic organ prolapse\u003c/li\u003e\n\u003cli\u003ePOPDI: Pelvic Organ Prolapse Distress Inventory\u003c/li\u003e\n\u003cli\u003ePOP-Q: Pelvic organ prolapse quantitation system\u003c/li\u003e\n\u003cli\u003ePFDI: Pelvic Floor Distress Inventory\u003c/li\u003e\n\u003cli\u003eTLH+LSC: Total laparoscopic hysterectomy and laparoscopic sacro-colpopexy\u003c/li\u003e\n\u003cli\u003eQOL: Quality of life\u003c/li\u003e\n\u003cli\u003eUDI: Urinary Distress Inventory\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate: \u003c/strong\u003eLocal ethics committee approval was granted for the study by Lok\u0026aacute;ln\u0026iacute; etick\u0026aacute; komise (Local ethical committee), Faculty Hospital Pilsen (approval number 239/2020). All patients included in this study provided written informed consent for the procedure and for the future use of their perioperative and follow-up data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003eThe study was funded by National Sustainability Program I (NPU I) Nr. LO1503 and Charles University Research Fund (Progress Q39). The funders did not have a role in the collection, analysis and interpretation of data and in the writing of the manuscript. KI is part-funded by project No. CZ.02.1.01/0.0/0.0/16_019/0000787 \u0026ldquo;Fighting INfectious Diseases\u0026ldquo;, awarded by the Ministry of Education, Youth and Sports of the Czech Republic, financed from The European Regional Development Fund. Funders were not involved in the design, analysis or the reporting of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDG: Literature search, Data collection, Manuscript writing\u003c/p\u003e\n\u003cp\u003eVK: Project development, Literature search, Data collection, Manuscript writing\u003c/p\u003e\n\u003cp\u003eMS: Data collection\u003c/p\u003e\n\u003cp\u003eZR: Data collection, Manuscript editing and revision\u003c/p\u003e\n\u003cp\u003eRP: Project development, Manuscript editing and revision\u003c/p\u003e\n\u003cp\u003eKMI: Project development, Literature search, Manuscript editing and revision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e some of the procedures analyzed in this study contributed data to other studies that were designed to answer different research questions [32, 33]. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSwift S, Woodman P, O\u0026rsquo;Boyle A, Kahn M, Valley M, Bland D, et al. Pelvic Organ Support Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol. 2005;192:795\u0026ndash;806. doi:10.1016/j.ajog.2004.10.602.\u003c/li\u003e\n\u003cli\u003eWu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime Risk of Stress Urinary Incontinence or Pelvic Organ Prolapse Surgery. Obstet Gynecol. 2014;123:1201\u0026ndash;6. doi:10.1097/AOG.0000000000000286.\u003c/li\u003e\n\u003cli\u003eObinata D, Yamaguchi K, Ito A, Murata Y, Ashikari D, Igarashi T, et al. Lower urinary tract symptoms in female patients with pelvic organ prolapse: Efficacy of pelvic floor reconstruction. Int J Urol. 2014;21:301\u0026ndash;7. doi:10.1111/iju.12281.\u003c/li\u003e\n\u003cli\u003eHanda VL, Cundiff G, Chang HH, Helzlsouer KJ. Female Sexual Function and Pelvic Floor Disorders. Obstet Gynecol. 2008;111:1045\u0026ndash;52. doi:10.1097/AOG.0b013e31816bbe85.\u003c/li\u003e\n\u003cli\u003eSlieker-ten Hove MCP, Pool-Goudzwaard AL, Eijkemans MJC, Steegers-Theunissen RPM, Burger CW, Vierhout ME. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J. 2009;20:1037\u0026ndash;45. doi:10.1007/s00192-009-0902-1.\u003c/li\u003e\n\u003cli\u003eAdjoussou SA, Bohoussou E, Bastide S, Letouzey V, Fatton B, de Tayrac R. Pr\u0026eacute;valence des troubles fonctionnels et associations anatomo-fonctionnelles chez les femmes pr\u0026eacute;sentant un prolapsus g\u0026eacute;nital. Progr\u0026egrave;s en Urol. 2014;24:511\u0026ndash;7. doi:10.1016/j.purol.2013.11.015.\u003c/li\u003e\n\u003cli\u003eLucassen EA, la Chapelle CF, Krouwel E, Groeneveld M. Renal failure caused by severe pelvic organ prolapse. BMJ Case Rep. 2019;12:e229318. doi:10.1136/bcr-2019-229318.\u003c/li\u003e\n\u003cli\u003eMiyagi A, Inaguma Y, Tokoyoda T, Nakajima T, Sezaki R, Matsukawa T. A case of renal dysfunction caused by pelvic organ prolapse. CEN Case Reports. 2017;6:125\u0026ndash;8. doi:10.1007/s13730-017-0257-2.\u003c/li\u003e\n\u003cli\u003eWu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women. Obstet Gynecol. 2014;123:141\u0026ndash;8. doi:10.1097/AOG.0000000000000057.\u003c/li\u003e\n\u003cli\u003eMartan A, Svab\u0026iacute;k K, Masata J, El-Haddad R, Pavlikova M. [Correlation between stress urinary incontinence or urgency and anterior compartment defect before and after surgical treatment]. Ces Gynekol. 2010;75:118\u0026ndash;25. http://www.ncbi.nlm.nih.gov/pubmed/20518265.\u003c/li\u003e\n\u003cli\u003eDigesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V. The relationship of vaginal prolapse severity tosymptoms and quality of life. BJOG An Int J Obstet Gynaecol. 2005;112:971\u0026ndash;6. doi:10.1111/j.1471-0528.2005.00568.x.\u003c/li\u003e\n\u003cli\u003eCollins SA, O\u0026rsquo;Sullivan DM, Lasala CA. Correlation of POP-Q posterior compartment measures with defecatory dysfunction. Int Urogynecol J. 2012;23:743\u0026ndash;7. doi:10.1007/s00192-011-1643-5.\u003c/li\u003e\n\u003cli\u003eBarber MD, Maher C. Apical prolapse. Int Urogynecol J. 2013;24:1815\u0026ndash;33. doi:10.1007/s00192-013-2172-1.\u003c/li\u003e\n\u003cli\u003eMaher CM, Feiner B, Baessler K, Glazener CMA. Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J. 2011;22:1445\u0026ndash;57. doi:10.1007/s00192-011-1542-9.\u003c/li\u003e\n\u003cli\u003eDavidson ERW, Casas-Puig V, Paraiso MFR, Ridgeway B, Ferrando CA. 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BMC Womens Health. 2020;20:241. doi:10.1186/s12905-020-01105-3.\u003c/li\u003e\n\u003cli\u003eKorbly NB, Kassis NC, Good MM, Richardson ML, Book NM, Yip S, et al. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol. 2013;209:470.e1-470.e6. doi:10.1016/j.ajog.2013.08.003.\u003c/li\u003e\n\u003cli\u003eFrick AC, Barber MD, Paraiso MFR, Ridgeway B, Jelovsek JE, Walters MD. Attitudes Toward Hysterectomy in Women Undergoing Evaluation for Uterovaginal Prolapse. Female Pelvic Med Reconstr Surg. 2013;19:103\u0026ndash;9. doi:10.1097/SPV.0b013e31827d8667.\u003c/li\u003e\n\u003cli\u003eCardenas-Trowers O, Stewart JR, Meriwether K V., Francis SL, Gupta A. Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database. J Minim Invasive Gynecol. 2020;27:953\u0026ndash;8. doi:10.1016/j.jmig.2019.08.010.\u003c/li\u003e\n\u003cli\u003eDavidson ERW, Thomas TN, Lampert EJ, Paraiso MFR, Ferrando CA. Route of hysterectomy during minimally invasive sacrocolpopexy does not affect postoperative outcomes. Int Urogynecol J. 2019;30:649\u0026ndash;55. doi:10.1007/s00192-018-3790-4.\u003c/li\u003e\n\u003cli\u003eGracia M, Perell\u0026oacute; M, Bataller E, Espu\u0026ntilde;a M, Parellada M, Gen\u0026iacute;s D, et al. Comparison between laparoscopic sacral hysteropexy and subtotal hysterectomy plus cervicopexy in pelvic organ prolapse: A pilot study. Neurourol Urodyn. 2015;34:654\u0026ndash;8. doi:10.1002/nau.22641.\u003c/li\u003e\n\u003cli\u003eSaliba E, Nisolle M, Tchente C, De Landsheere L. Doit-on r\u0026eacute;aliser syst\u0026eacute;matiquement une hyst\u0026eacute;rectomie subtotale dans le cadre d\u0026rsquo;une promontofixation c\u0026oelig;lioscopique ? Gyn\u0026eacute;cologie Obs Fertil S\u0026eacute;nologie. 2019;47:549\u0026ndash;54. doi:10.1016/j.gofs.2019.04.007.\u003c/li\u003e\n\u003cli\u003ePan K, Cao L, Ryan NA, Wang Y, Xu H. Laparoscopic sacral hysteropexy versus laparoscopic sacrocolpopexy with hysterectomy for pelvic organ prolapse. Int Urogynecol J. 2016;27:93\u0026ndash;101. doi:10.1007/s00192-015-2775-9.\u003c/li\u003e\n\u003cli\u003eIlliano E, Giannitsas K, Costantini E. Comparison between laparoscopic sacrocolpopexy with hysterectomy and hysteropexy in advanced urogenital prolapse. Int Urogynecol J. 2020. doi:10.1007/s00192-020-04260-1.\u003c/li\u003e\n\u003cli\u003eHaylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016;27:165\u0026ndash;94. doi:10.1007/s00192-015-2932-1.\u003c/li\u003e\n\u003cli\u003eHaylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. Erratum to: An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016;27:655\u0026ndash;84. doi:10.1007/s00192-016-3003-y.\u003c/li\u003e\n\u003cli\u003eKrell RW, Girotti ME, Dimick JB. Extended Length of Stay After Surgery. JAMA Surg. 2014;149:815. doi:10.1001/jamasurg.2014.629.\u003c/li\u003e\n\u003cli\u003eBarber MD, Kuchibhatla MN, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol. 2001;185:1388\u0026ndash;95. doi:10.1067/mob.2001.118659.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien P-A. Classification of Surgical Complications. Ann Surg. 2004;240:205\u0026ndash;13. doi:10.1097/01.sla.0000133083.54934.ae.\u003c/li\u003e\n\u003cli\u003eSmazinka M, Kalis V, Havir M, Havelkova L, Ismail KM, Rusavy Z. Obesity and its long-term impact on sacrocolpopexy key outcomes (OBELISK). Int Urogynecol J. 2019. doi:10.1007/s00192-019-04076-8.\u003c/li\u003e\n\u003cli\u003eKalis V, Smazinka M, Rusavy Z, Blaganje M, Havir M, Havelkova L, et al. Laparoscopic sacrocolpopexy as the mainstay management for significant apical pelvic organ prolapse (LAP) study. Eur J Obstet Gynecol Reprod Biol. 2020;244:60\u0026ndash;5. doi:10.1016/j.ejogrb.2019.10.049.\u003c/li\u003e\n\u003cli\u003eSrikrishna S, Robinson D, Cardozo L. Validation of the Patient Global Impression of Improvement (PGI-I) for urogenital prolapse. Int Urogynecol J. 2010;21:523\u0026ndash;8. doi:10.1007/s00192-009-1069-5.\u003c/li\u003e\n\u003cli\u003eHaylen BT, Maher C, Deprest J. IUGA/ICS terminology and classification of complications of prosthesis and graft insertion\u0026ndash;rereading will revalidate. Am J Obstet Gynecol. 2013;208:e15. doi:10.1016/j.ajog.2012.08.004.\u003c/li\u003e\n\u003cli\u003eDietz HP, Haylen BT, Broome J. Ultrasound in the quantification of female pelvic organ prolapse. Ultrasound Obstet Gynecol. 2001;18:511\u0026ndash;4. doi:10.1046/j.0960-7692.2001.00494.x.\u003c/li\u003e\n\u003cli\u003eGutman RE, Rardin CR, Sokol ER, Matthews C, Park AJ, Iglesia CB, et al. Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. In: American Journal of Obstetrics and Gynecology. 2017. p. 38.e1-38.e11.\u003c/li\u003e\n\u003cli\u003eCostantini E, Brubaker L, Cervigni M, Matthews CA, O\u0026rsquo;Reilly BA, Rizk D, et al. Sacrocolpopexy for pelvic organ prolapse: evidence-based review and recommendations. Eur J Obstet Gynecol Reprod Biol. 2016;205:60\u0026ndash;5. doi:10.1016/j.ejogrb.2016.07.503.\u003c/li\u003e\n\u003cli\u003eStepanian AA, Miklos JR, Moore RD, Mattox TF. Risk of Mesh Extrusion and Other Mesh-Related Complications After Laparoscopic Sacral Colpopexy with or without Concurrent Laparoscopic-Assisted Vaginal Hysterectomy: Experience of 402 Patients. J Minim Invasive Gynecol. 2008;15:188\u0026ndash;96. doi:10.1016/j.jmig.2007.11.006.\u003c/li\u003e\n\u003cli\u003eTan-Kim J, Menefee SA, Luber KM, Nager CW, Lukacz ES. Prevalence and risk factors for mesh erosion after laparoscopic-assisted sacrocolpopexy. Int Urogynecol J. 2011;22:205\u0026ndash;12. doi:10.1007/s00192-010-1265-3.\u003c/li\u003e\n\u003cli\u003eKalis V, Rusavy Z, Ismail KM. Laparoscopic sacrohysteropexy: the Pilsner modification. Int Urogynecol J. 2020;31:1277\u0026ndash;80. doi:10.1007/s00192-019-04150-1.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic details of study cohorts.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"945\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 294\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine sparing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSH)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 43\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant Hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSCH+LSC \u0026amp; TLH+LSC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 251\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eBMI [Median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e26.4 (17.7-37.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e25.2 (17.7-31.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e26.6 (19.2-37.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.006\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eAge [Median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e63.0 (28-84)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e49.0 (28-70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e64.0 (37-84)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e\u0026lt;0.0001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eParity [Median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e2.0 (0-9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e2.0 (1-5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e2.0 (0-9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.063\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eCardiovascular disease [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e149 (50.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e9 (20.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e140 (55.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e\u0026lt;0.0001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eDiabetes mellitus [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e40 (13.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e39 (15.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.020\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePrevious DVT or pulmonary embolism [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e39 (13.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e3 (7.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e36 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.188\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eAsthma [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e22 (7.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e21 (8.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.219\u003csup\u003e c\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePrevious abdominal surgical history [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e137 (46.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e17 (39.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e120 (47.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.315\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePrevious gynecologic surgery [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e90 (30.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e15 (34.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e85 (33.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.896\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePrevious POP surgery [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e6 (2.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e2 (4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e4 (1.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.214\u003csup\u003e c\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" width=\"49\"\u003e\n\u003cp\u003ePoint C\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e19 (6.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e5 (11.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e14 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" width=\"95\"\u003e\n\u003cp\u003e0.073\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e159 (54.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e24 (55.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e135 53.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e78 (26.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e11 (25.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e67 (26.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e38 (12.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e3 (7.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e55 (21.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" width=\"49\"\u003e\n\u003cp\u003ePoint Ba\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage I\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e3 (1.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e2 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" width=\"95\"\u003e\n\u003cp\u003e\u0026lt;0.0001\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e65 (22.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e28 (65.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e37 (14.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e165 (56.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e11 (25.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e154 (61.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e51 (17.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e3 (7.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e48 (19.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"4\" width=\"49\"\u003e\n\u003cp\u003ePoint Bp\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage I\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e96 (32.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e13 (30.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e83 (33.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" width=\"95\"\u003e\n\u003cp\u003e0.634\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e132 (44.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e22 (51.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e110 (43.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e46 (15.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e7 (16.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e39 (15.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"261\"\u003e\n\u003cp\u003ePOP Q stage IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e20 (6.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e19 (7.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eStress urinary incontinence [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e87 (29.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e11 (25.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e76 (60.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.533\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eUrge urinary incontinence [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e66 (22.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e8 (18.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e58 (23.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.513\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eHesitancy: a delay in initiating micturition\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e136 (46.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e13 (30.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e123 (49.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.023\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eUrinary retention [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e126 (42.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e21 (48.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e115 (45.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.714\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eConstipation [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e62 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e4 (9.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e58 (23.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.040\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003eAnal incontinence [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e102/266 (38.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e16/41 (39.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e86/225 (38.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.923\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePre-op UDI [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e51.2 (0-189)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e52.6 (5.8-164)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e51.2 (0-189)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.481\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePre-op POPDI [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e68.5 (0-282)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e58.9 (10.7-152)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e69.6 (0-282)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.204\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePre-op CRADI [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e35.1 (0-216)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e34.2 (0-164)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e36.4 (0-216)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.963\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"310\"\u003e\n\u003cp\u003ePre-op PFDI [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e171.7 (0-600)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"178\"\u003e\n\u003cp\u003e148.0 (16.5-442)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e1712.4 (0-600)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e0.524\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Mann-Whitney U test; \u003csup\u003eb\u003c/sup\u003e Chi-square Test; \u003csup\u003ec\u003c/sup\u003e Fisher\u0026rsquo;s exact Test\u003c/p\u003e\n\u003cp\u003eBMI: body mass index, DVT: deep venous thromboembolism\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Peri-operative characteristics amongst study cohorts\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"888\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 294\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine sparing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSH)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 43\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant Hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSCH+LSC \u0026amp; TLH+LSC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 251\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eOperating time [min] [Median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e120.5 (60-240)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e120.0 (70-225)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e125.0 (60-240)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0.052\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eOperating time more than 3 hours\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e16 (5.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e2 (4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e14 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eBlood loss [ml] [Median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e150 (50-1400)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e150 (50-1400)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e200 (50-800)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0.259\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eEstimated blood loss more than 300 ml [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e14 (4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e2 (4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e12 (4.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003ePerioperative blood transfusion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e2 (0.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e1 (0.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0.286\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eBladder injury [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e10 (3.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e2 (4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e8 (3.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0.657\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eRectal injury [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eVaginal injury [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e2 (0.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e2 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eEarly postoperative complications Dindo-Clavien grade 0 [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e281 (95.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e41 (95.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e240 (95.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"4\" width=\"104\"\u003e\n\u003cp\u003e0.566\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eEarly postoperative complications Dindo-Clavien grade I [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e6 (2.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e5 (2.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eEarly postoperative complications Dindo-Clavien grade II [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e3 (1.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e1 (2.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e2 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eEarly postoperative complications Dindo-Clavien grade III [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e4 (1.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e0 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e4 (1.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"240\"\u003e\n\u003cp\u003eProlonged hospitalization [N (%)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"145\"\u003e\n\u003cp\u003e6 (2.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"191\"\u003e\n\u003cp\u003e2 (4.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e4 (1.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003e0.234\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Mann-Whitney U test; \u003csup\u003eb\u003c/sup\u003e Fisher\u0026rsquo;s Exact Test\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Post-operative follow-up at 3 months and at 12 months.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"1042\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"435\"\u003e\n\u003cp\u003e\u003cstrong\u003e3 month follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=283\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"435\"\u003e\n\u003cp\u003e\u003cstrong\u003e12 month follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=271\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 283\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine sparing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSH)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 41\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSCH+LSC \u0026amp; TLH+LSC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 242\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 271\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine sparing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSH)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 38\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSCH+LSC \u0026amp; TLH+LSC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 233\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePostoperative mesh complications [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2/283 (0.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/41 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2/242 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e1.000\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e4/271 (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e1/38 (2.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e3/233 (1.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.456\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eFailure in apical compartment\u003c/p\u003e\n\u003cp\u003ePoint C \u0026ge; -TVL/2 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/283 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/41 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/242 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0/271 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0/38 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e0/233 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eFailure in anterior compartment\u003c/p\u003e\n\u003cp\u003ePoint Ba \u0026ge; -1 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e12/283 (4.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e4/41 (9.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e8/242 (3.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.079\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e26/271 (9.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e8/38 (21.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e18/233 (7.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.017\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eFailure in posterior compartment\u003c/p\u003e\n\u003cp\u003ePoint Bp \u0026ge; -1 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e14/283 (4.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/41 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e14/242 (5.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.114\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e15/271 (5.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0/38 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e15/233 (6.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.140\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePGI-I 1, 2 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e243/283 (85.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e35/41 (85.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e208/242 (86.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"6\" width=\"76\"\u003e\n\u003cp\u003e0.607\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e255/271 (94.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e33/38 (86.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e222/233 (95.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"6\" width=\"66\"\u003e\n\u003cp\u003e0.055\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePGI-I 3 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e28/283 (9.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e4/41 (9.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e24/242 (9.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e11/271 (4.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e3/38 (7.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e8/233 (3.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePGI-I 4 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e8/283 (2.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e1/41 (2.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e7/242 (2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e4/271 (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e2/38 (5.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e2/233 (0.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePGI-I 5 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2/283 (0.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e1/41 (2.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e1/242 (0.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1/271 (0.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0/38 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e1/233 (0.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePGI-I 6 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2/283 (0.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/41 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e2/242 (0.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0/271 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0/38 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e0/233 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003ePGI-I 7 [N/N] (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/286 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/41 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e0/242 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0/271 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e0/38 (0.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e0/233 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u0026Delta; UDI pre-op \u0026ndash; post-op [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e20.1 (-159-153)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e17.9 (-54.9-131)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e20.1 (-159-153)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.988\u003csup\u003e a\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e25.0 (-112-160)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e17.6 (-99-160)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e33.7 (-112-150)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.585\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u0026Delta; POPDI pre-op \u0026ndash; post-op [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e40.5 (-112-256)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e35.7 (-56-127)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e41.1 (-112-256)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.559\u003csup\u003e a\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e39.3 (-74-253)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e30.4 (-43-135)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e48.2 (-189-253)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.502\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u0026Delta; CRADI pre-op \u0026ndash; post-op [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e7.7 (-189-199)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e10.0 (-41-129)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e7.1 (-189-199)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.338\u003csup\u003e a\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e3.6 (-92-170)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e10.7 (-38-112)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e7.1 (-118-170)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.187\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u0026Delta; PFDI pre-op \u0026ndash; post-op [median (range)]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e46.1 (-342-450)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e50.7 (-206-373)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e59.5 (-343-450)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.889\u003csup\u003e a\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e70.4 (-182-460)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e66.9 (-123-281)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e82.5 (-338-460)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.960\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Mann-Whitney U test; \u003csup\u003eb\u003c/sup\u003e Fisher\u0026rsquo;s Exact Test; UUI: Urge urinary incontinence; SUI: Stress urinary incontinence.\u003c/p\u003e\n\u003cp\u003e* If TVT or bulking agens performed between 3 and 12 months, the woman remained in SUI group.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Mesh placement on transperineal scanning at 3 months and at 12 months.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"1042\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"435\"\u003e\n\u003cp\u003e\u003cstrong\u003e3 month follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=283\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"4\" width=\"435\"\u003e\n\u003cp\u003e\u003cstrong\u003e12 month follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=271\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 283\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine sparing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSH)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 41\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSCH+LSC \u0026amp; TLH+LSC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 242\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eTotal \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 271\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e\u003cstrong\u003eUterine sparing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSH)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 38\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e\u003cstrong\u003eConcomitant hysterectomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(LSCH+LSC \u0026amp; TLH+LSC)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN = 233\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eRegular shape of the mesh upon visualization of the whole mesh [N/N](%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e244/266(91.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e35/40(87.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e209/226 (92.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.345\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e238/265(89.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e32/39(82.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e206/226 (91.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.090\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eNo folding of the mesh [N/N](%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e248/268(92.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e32/40(80.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e216/228 (94.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.004\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e245/266(92.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e32/39(82.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e213/227 (93.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.021\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eNo mesh descent on Valsalva 196/226 (86.7%) [N/N](%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e266/268(99.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e39/40(97.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e227/228 (99.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.277\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e252/254(99.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e36/37(97.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e216/217 (99.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.271\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"173\"\u003e\n\u003cp\u003eOverall evaluation:\u0026nbsp; all criteria for a properly placed mesh fulfilled [N/N](%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e227/266(85.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e31/40(77.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"120\"\u003e\n\u003cp\u003e196/226 (86.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e0.146\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e214/254(84.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"123\"\u003e\n\u003cp\u003e25/37(67.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"113\"\u003e\n\u003cp\u003e189/217 (81.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e0.006\u003csup\u003e b\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Mann-Whitney U test; \u003csup\u003eb\u003c/sup\u003e Fisher\u0026rsquo;s Exact Test; UUI: Urge urinary incontinence; SUI: Stress urinary incontinence.\u003c/p\u003e\n\u003cp\u003e* If TVT or bulking agens performed between 3 and 12 months, the woman remained in SUI group.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopic, Sacrocolpopexy, Cervicopexy, Hysteropexy, LSC, LSCH+LSC, TLH+LSC, LSH, POP-Q, mesh, PFDI, PGI-I, compartment","lastPublishedDoi":"10.21203/rs.3.rs-35323/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-35323/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAbdominal and laparoscopic sacro-colpopexy (LSC) is considered the standard surgical option for the management of a symptomatic apical pelvic organ prolapse (POP). Women who have their uterus, and for whom an LSC is indicated, can have a laparoscopic sacro-hysteropexy (LSH), a laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH+LSC) or a total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH+LSC). The main aim of this study was to compare clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A retrospective analysis of clinical, imaging and patient reported outcomes at baseline, 3 and 12 months after LSH versus either LSCH+LSC or TLH+LSC between January 2015 and January 2019 in a tertiary referral urogynecology center in Pilsen, the Czech Republic. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003eIn total, 294 women were included in this analysis (LSH n = 43, LSCH+LSC n = 208 and TLH+LSC n = 43). There were no differences in the incidence of perioperative injuries and complications. There were no statistically significant differences between the concomitant hysterectomy and the uterine sparing groups in any of the operative, clinical or patient reported outcomes except for a significantly lower anterior compartment failure rate (p= 0.017) and higher optimal mesh placement rate at 12 months in women who had concomitant hysterectomy procedures (p = 0.006).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion. \u003c/strong\u003e\u0026nbsp;LSH seems to be associated with higher incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques compared to LSC with concomitant hysterectomy.\u003c/p\u003e","manuscriptTitle":"Pelvic organ prolapse and uterine preservation: A cohort study (POP-UP study)","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2021-01-21 20:50:30","doi":"10.21203/rs.3.rs-35323/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-01-29T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-01-26T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThank to the authors for their response to the requested revisions. I believe that this is a strong paper and should be accepted pending a few small typographic edits.\n\n(Of note -- line numbers are from the tracked changes document.)\n\nLine 215: Consider rephrasing this sentence for clarity: \"On subgroup analysis, the only significant difference was that operative time was longer in the TLH+LSC subgroup compared to LSCH.....\"\n\nLine 260: This sentence appears to need to be tagged to the following.\n\nLine 262: Should read \"incidences were....\"\n\nLine 301: Should read \"assess\" rather than \"asses\"\n\nSupplemental Table 2: There is a typo -- the top row, second to last column should be TLH+LSC (the C was forgotten)\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2021-01-13T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-01-13T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-01-12T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-01-11T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-01-11T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-12-07 20:29:45","doi":"10.21203/rs.3.rs-35323/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-12-16T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-15T00:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThank you to the authors for their study. My line references refer to the tracked changes copy of the manuscript.\n\nAbstract:\n1) As in the manuscript, please do not list the shorter operative time and blood loss as differences between your main groups or at least that these were statistically significant. This was not statistically significant between the uterine sparing and hysterectomy groups (p=0.05, the defined cut off for your study). The differences between the two other groups should only be listed if you define this subgroup comparison in your planned methods within the abstract.\n\nFigure 1:\n1) Consider clearly showing in this flowchart that the LSCH+LSC and TLH+LSC group are one group for your primary outcome.\n\nTables\n1) The titles of the tables need to reflect that these are not cases/controls but instead cohorts.\n2) Table 3: \"C1-C7\" --\u003e this is unclear to most readers. Consider eliminating this and keeping it just \"mesh complication\".\n3) Table 3: There is a large amount of data Table 3 not reported in detail within the manuscript's main text. Consider moving these to supplemental tables. and keeping the main tables more simple.\n4) Table 3: Recommend moving the mesh imaging information to its own table for clarity. This will need referenced separately in the manuscript as well.\n5) Table 2: There is a type of a comma instead of a period before \"566\" in table 2 in the p value for Clavien-Dindo complications.\n\nIntroduction:\n1) Line 64-66: This final line about posterior POP is incomplete. Recommend addending it to the previous sentence or eliminating the word \"while.\"\n2) Line 92: \"Furthermore, there seems to be AN...\" -- \"an\" is missing.\n3) Line 104: Could the authors clarify that \"mesh placement\" refers to postoperative mesh imaging?\n\nMethods:\n1) Line 131: \"Hence...\" is an incomplete sentence and should be addended to the previous sentence.\n2) Line 132-133: Please keep \"Clavien-Dindo\" or \"Dindo-Clavien\" consistent This is listed differently in the tables.\n3) Lines 135-138: I understand the authors' wish to not repeat their cited paper on technique. However, I recommend at least describing that all techniques used the same suture type, mesh type, and sacral fixation techniques.\n4) Lines 164-166: Please list all the comparisons made -- I am assuming you mean LSH to each hysterectomy-LSC type but also to each other? It should be clear here.\n\nResults:\n1) In the presentation of results, please list your secondary analysis (between subgroups) separately from your initial comparison. The primary objective should be completely described first.\n2) Both in the abstract and in the results, you list time as statistically significant but it is actually \u003e0.05 (the authors' point of significance). Please remove time as a difference between groups (although the subgroup differences could be described in a separate paragraph according to the point above). The EBLs in each group are also not listed with their own p value -- in fact, these are NOT significant. The subgroups are, but these should be reported after the primary outcome.\n\nConclusions:\n1) In the restatement of findings, as above, only list what is statistically significant between main groups. Alternatively, you could state that EBL difference was approaching significance (only true for time), but this is not necessary as the 5 minutes are not clinically significant either. This is also true in the final paragraph/Conclusion section.\n2) Line 254: This sentence should be addended to the prior as it is incomplete.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorAssigned","content":"","date":"2020-11-16T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-16T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-16T00:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-15T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-15T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-06-26 14:45:22","doi":"10.21203/rs.3.rs-35323/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-10-27T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-10-14T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThank you to the authors for performing this study and adding to the literature regarding sacrocolpopexy (SCP) with and without uterine preservation as a technique. While I do think this work merits publication given the large number of patients included, I have a few concerns and recommended edits.\n\n1) Title and design: The two groups of patients (uterine preservation or no) were defined by their intervention and not outcome. As such, the proper title and methodology is a cohort study.\n\n2) Other literature: While this study does add to the literature, there have been other studies looking at uterine preservation, cervical preservation, and total hyst with SCP that should be included and referenced in this work. \n\nPlease see more granular suggestions/edits as below:\n\nTitle: As above, correct this to be a cohort study\n\nAbstract:\n1) Lines 25-27: \"the preferred option\" is very strong wording given that native tissue repair is still an excellent option. Consider \"is considered the standard surgical option\" or that is the authors preferred surgical management.\n2) Line 38 (and throughout manuscript): The word rates is used incorrectly here. It should be \"incidence\" throughout as rates are incidents over time.\n3) Lines 46-48: The second part of this sentence is incomplete. Consider: \"nevertheless, uterine preservation with LSC was associated with increased incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques.\"\n\nBackground:\n1) Lines 69-70: It is unclear what the authors are referring to regarding \"this option\". Perhaps they mean, \"The choice of route of apical surgical correction is one of the most challenging...\"\n2) Line 73: outcome is missing an s-- should read as \"outcomes\"\n3) Lines 74-78: Consider rephrasing to \"In women who have their uterus and who desire a laparoscopic procedure with mesh...\" The reason to make this more specific there are a number of other options here not including sacrocolpopexy -- one option is to perform a laparoscopic native tissue suspension. This has been compared to LSC sacrocolpopexy and this data should be included in the manuscript at least in the discussion.. Davidson ERW, Casas-Puig V, Paraiso MFR, Ridgeway B, Ferrando CA. Pelvic Organ Prolapse Recurrence and Patient-Centered Outcomes Following Minimally Invasive Abdominal Uterosacral Ligament and Mesh-Augmented Sacrohysteropexy. Female Pelvic Med Reconstr Surg. 2019 Mar 6. PMID: 30845072.\n4) Lines 88-91: There is actually a decent amount of data here, both cited by the authors and a few other studies I recommend adding. In addition, multiple studies do describe the differences in techniques with hysterectomy and SCP. I would consider rephrasing to say that the data is evolving. This study does also add the additional imaging and this may be worth mentioning here.\n\nOther studies re: SCP and hysterectomy\nCardenas-Trowers O, Stewart JR, Meriwether KV, Francis SL, Gupta A. Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database. J Minim Invasive Gynecol. 2019.\nDavidson ERW, Thomas TN, Lampert EJ, Paraiso MFR, Ferrando CA. Route of hysterectomy during minimally invasive sacrocolpopexy does not affect postoperative outcomes. International Urogynecology Journal. 2019;30(4):649-655.\n\nMethods:\n1) Line 99: As above, this is actually a cohort study.\n2) Lines 103-104: As this is a cohort study, define the two cohorts as LSH (uterine preservation) vs non-uterine preservation (TLH+LSC, LSCH+LSC). \n3) Lines 135-142: Could the authors further elaborate if this is a part of routine postop care for their practice? I am curious about the cost to patients here. I also recommend defining what clearly what optimal vs suboptimal mesh placement was -- did they need to meet all these criteria for optimal postoperative mesh location?\n4) For the C point, consider adding a parenthetical explanation of C \u003e/= -TVL/2 cm such as \"apical descent less than half of the vaginal length\" for those not as familiar with the POPQ. \n5) Line 147: Consider stating that this was \"Very Much\" or \"Much Better\" here.\n6) Could the authors comment on anticipated power, even if it is a post-hoc calculation of power? \n7) Line 150: again, this should be cohort comparisons. \n8) Were the subanalyses planned a priori?\n9) While the authors have published their surgical technique, I recommend briefly reviewing the procedures here, especially where mesh was placed for the hysteropexy group.\n\nResults:\n1) Lines 166-167: I recommend listing the important differences between the cohorts here.\n2) Line 176: \"rates\" should be incidence.\n3) Lines 177-179: Please clarify -- I believe that the authors mean that \"When looking at subgroups, however, operating time was only longer for LSCH vs TLH+LSC subgroup (p=0.048), not the LSH-LSC group. In addition, TLH appeared to be associated with increased blood loss compared to the LSH and LSCH (insert p-values).\"\n4) Lines 189-190: \"Not\" instead of \"neither\". This failure to see significance is likely due to power with smaller numbers. Since the primary outcome was to look at the two groups, not the subgroups. I would leave this in the supplemental outcomes.\n5) Consider putting the mesh details in another paragraph. Again, the \"optimal mesh placement\" should be defined clearer in the methods.\n6) Lines 160-161: Recommend summarizing how many were in each group as defined by your cohorts and then clarifying how many in each type of hyst.\n7) Throughout the results section, recommend putting in the actual values and not just p-values (especially when significant). Actual difference in blood loss and OR time is important to see not just in tables. A difference in EBL of 150mL and OR time of only 15 minutes is very little and likely not clinically relevant. This really shapes the conclusions.\n\nDiscussion:\n1) I recommend stating that this is AMONG the first studies to discuss. You cited the Iliano study and there are many studies that include the different routes of hysterectomy (cited above) at time of SCP.\n2) Recommend discussion the clinical relevance in the benefits of uterine-preservation at time of SCP -- worse POP and mesh outcomes and OR \"savings\" including EBL and OR time are minimal.\n3) Lines 274-277: As above, I do not think that this is the first to report this comparison. However, it does add the novelty of imaging.\n\nConclusion:\n1) Line 280-281: Consider limiting this to your population or say \"many women\" -- this is not universally true.\n2) Lines 282-283: Similar to the abstract, this last phrase is not a complete sentence.\n3) Consider, \"LSCH+LSC appears to have the best balance between limiting operative time and blood loss with balancing recurrence.\"\n\n* Publons Reviewer Recognition. 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For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-15T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nThis is a retrospective case control study evaluating uterine sparing surgery vs. tradition sacrocolpopexy with hysterectomy for uterine prolapse.\n\n\nIntro\nLine 53: you say 1 in 3 and 1 in 10. Is this suppose to be a range- there is only one reference and you are only referring to POP so not sure why it says respectively.\n\nLine 67: change family to childbearing\nLine 68- what is your reference that surgery is the mainstay management. I do not believe that surgery is the gold standard for prolapse treatment.\n\n\n\nMaterials and methods\n\nLine 139: have you found that measuring mesh placement on 3D ultrasound is clinically relevant to either surgeon or patient in reference to failure?\n\nLine 145: point c failure is within tvl -2? It is unclear.\nHow is the primary outcome defined? Composite score? Popq alone? PFDI?- please calrify\n\nResults\n\nLine 183: this paragraph should come after your table 1 data paragraph. This is your primary outcome.\n\nI would add specific number for operative time and EBL. Yes they are significant but only by 5 minutes and a few ccs.\n\nLine 187: what percentage had a failure?\n\nConclusion\n\nI would mention further that although EBL and op time are longer are these clinically relevant. If outcomes were the same 5 minutes longer would not make a difference.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **'I declare that I have no competing interests' below.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-07T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-06-25T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-06-22T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-11T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-06-10T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-06-10T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-06-10T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6a6aad7-0859-4df0-bab8-1759452cc0b8","owner":[],"postedDate":"January 21st, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1370423,"name":"Internal Medicine"},{"id":1370424,"name":"Preventive Medicine"}],"tags":[],"updatedAt":"2021-02-21T15:00:36+00:00","versionOfRecord":{"articleIdentity":"rs-35323","link":"https://doi.org/10.1186/s12905-021-01208-5","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2021-02-17 15:00:27","publishedOnDateReadable":"February 17th, 2021"},"versionCreatedAt":"2021-01-21 20:50:30","video":"","vorDoi":"10.1186/s12905-021-01208-5","vorDoiUrl":"https://doi.org/10.1186/s12905-021-01208-5","workflowStages":[]},"version":"v3","identity":"rs-35323","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-35323","identity":"rs-35323","version":["v3"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}