How and on whom to perform uterine-preserving surgery for uterine prolapse

Apical support is critical for successful prolapse repair, and performing a concomitant hysterectomy is key when surgeons are planning apical supporting procedures. According to a recent survey, the number of women who favor uterine preservation is steadily increasing [ 1 , 2 ]. Women wish to conserve their uterus for several reasons, including the desire to maintain future fertility and body image, beliefs regarding the adverse effects of sexual dysfunction and their sense of identity, and concerns about the risks of hysterectomy. Survey data indicate that more than one-third of women will choose uterine-preserving prolapse surgery, provided the outcomes are similar, and more than one-fifth of them still prefer uterine preservation, even if it is associated with inferior outcomes [ 1 , 2 ]. Although hysterectomy is routinely performed at the time of uterovaginal prolapse repair, high-level evidence-based data regarding the potential benefits of uterine preservation with hysterectomy are lacking in the literature. Moreover, several reviews have demonstrated that patients may benefit from hysteropexy as opposed to pelvic organ prolapse (POP) surgery with hysterectomy [ 1 , 3 , 4 ]. Therefore, in this review, we aim to share the current evidence surrounding uterine-preserving surgery in uterovaginal prolapse repair. This may help surgeons and patients have a balanced discussion that will help identify in whom and how to perform uterine-preserving surgery.

Seventeen pregnancies from several different studies were reported after sacrospinous hysteropexy, with half of the deliveries being vaginal and half being cesarean deliveries at term, followed by 2 recurrences [ 3 ]. Several case reports have noted pregnancies and deliveries after uterosacral hysteropexy as well as SHP, with very few prolapse recurrences [ 11 ]. Despite relatively good outcomes, the available evidence is limited and of low quality. Thus, it is unclear how hysteropexy affects fertility and pregnancy, or how pregnancy affects hysteropexy. Basically, conservative management, such as observation, pessary, or pelvic floor muscle exercise, is the first line of treatment for women with uterovaginal prolapse who have not completed childbearing. Hysteropexy may be an option for women for whom a pessary cannot be fitted or for younger patients who refuse conservative management for a prolonged time [ 3 ]. Some experts recommended vaginal hysteropexy using native tissue for this group of women, while they perform SHP using only a posterior mesh for those with stage IV prolapse. They assume that placing an anterior mesh could restrict lower anterior uterine segment changes, which are required for uterine expansion [ 11 ].

In summary, hysteropexy may be a considerable alternative for women with mild uterine prolapse who desire to undergo the procedure, have no contraindications to uterine preservation, and understand the prognosis of uterine-preserving surgery [ 21 ]. Vaginal sacrospinous hysteropexy, vaginal or abdominal uterosacral hysteropexy, SHP, and hysteropectopexy are the available options.