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

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

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

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

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

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

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

8. Options available 1. Manchester repair
Described for cervical elongation and intact uterosacral – cardinal ligaments.
Quicker &  blood loss than vaginal hysterectomy (Thomas J Repr Med 1995)
Recurrence of prolapse >20% in first few months. (Williams Am J Obstet Gyn 1966)
Fertility , pregnancy wastage 
Future cervical & endometrial sampling difficult
Only 40% success rate based on overall stage in the Manchester group.
( de Booer, et al int urogynecol j pelvic floor dys 2009

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

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

11. 2. sacrospinous hysteropexy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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