Surgical retreatment after native-tissue apical prolapse surgery with hysterectomy versus hysteropexy.

Background: Interest in uterine-sparing procedures has increased due to the potential for lower blood loss and shorter operative time. Surgical efficacy of hysteropexy relative to traditional hysterectomy-based prolapse procedure remains uncertain over the long-term.

Objectives: The objective of our study was to determine if there is a difference in the rate of surgical retreatment for prolapse after native-tissue apical prolapse surgery with hysterectomy versus uterine-preservation.

Study Design: This was a retrospective cohort study utilizing the Medicare 5% Limited Data Set from 2010-2019. We included all female patients aged 65 years or older with a diagnosis of uterovaginal prolapse who underwent an apical native-tissue prolapse procedure (extraperitoneal or intraperitoneal colpopexy). We excluded those with transvaginal mesh, concurrent colorectal or oncologic surgeries, obliterative procedures, and abdominal hysterectomies. All patients were followed from the index procedure until death or loss to follow up. We compared those who had a hysteropexy (HPXY) versus those who underwent a concurrent vaginal or minimally invasive hysterectomy (HYST). The primary outcome was surgical retreatment for pelvic organ prolapse defined as any subsequent surgical treatment of anterior, apical, or posterior compartment prolapse after the index surgery. Time-to-event analysis was performed, and the two groups were compared using Cox regression analysis adjusting for covariates.

Results: We identified 2,341 patients who met inclusion and exclusion criteria (HPXY =584 vs HYST =1757). Patients in the HPXY group were older (73.4 vs 71.8 years, p<0.001) and predominantly located in the South (46.2% vs 34.1%, p <0.001). The mean Charlson comorbidity index score was higher for HPXY patients (1.6 vs 1.3, p=0.003). At 5 years, 9.1% (n=40) had surgical retreatment for prolapse in the hysteropexy group compared to 6.7% (n=91) for the HYST group (p=0.07). With adjustment for age, Charlson Comorbidity Index, Dual Medicare/Medicaid status, race and region, those with a HPXY had higher risk of surgical retreatment than those with a HYST (adjOR 1.52,1.04 - 2.21, p=0.03). For those in the HPXY group, the rate of subsequent hysterectomy in the 5 years following index surgery was 3.4% (n=14). When stratified by intraperitoneal (n=120) or extraperitoneal hysteropexy (n=464), there were no significant differences in rates of surgical retreatment between the two modes of apical suspension (p=0.49). The composite rate of surgical retreatment including prolapse retreatment or hysterectomy or uterine/cervical related procedures was 42 (9.7%) for the HPXY group and 94 (7.0%) for the HYST group (p=0.049) CONCLUSIONS: In this Medicare database, there was a higher risk of surgical retreatment for prolapse in those who had a hysteropexy compared to those who had a hysterectomy at the time of native-tissue prolapse surgery though the absolute difference is small. For those who had a hysteropexy, 3% of patients required a hysterectomy in the five years following index surgery.