Uterine-sparing mesh repair outperforms hysterectomy for prolapse

1. Vaginal mesh hysteropexy resulted in fewer composite treatment failures than vaginal hysterectomy with uterosacral suspension over 10 years of follow-up in women with symptomatic uterovaginal prolapse.

2. Failure rates in both the hysteropexy and hysterectomy groups converged and remained low from years six through 10.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Mesh-augmented sacrospinous hysteropexy offers a uterus-sparing alternative to hysterectomy for prolapse repair. However, little is known about the long-term comparative outcomes between these two repair approaches. This multicenter randomized trial followed 175 women over ten years and found that hysteropexy had a lower overall failure rate than hysterectomy, driven mainly by differences that accumulated in the first several years rather than subsequent divergence. Patient-reported symptoms, sexual function, and complication rates were largely similar between groups, and most anatomic failures were not symptomatic. Mesh exposure was common early but mostly resolved with simple management, such as vaginal estrogen cream, and no operating room mesh removals were needed. A major caveat is that the specific mesh kit used was withdrawn from the U.S. market, which limits direct clinical applicability domestically. Additionally, generalizability is limited by the lack of racial diversity. In summary, the findings from this study support hysteropexy as a durable, low-risk option for prolapse repair, but the lack of widely available commercial mesh kits limits translation of this strategy into current U.S. clinical practice.

Click to read the study in JAMA Surgery

Relevant Reading: Apical suspension repair for vaginal vault prolapse: a randomized clinical trial 

In-Depth [randomized controlled trial]: This multicenter superiority randomized clinical trial enrolled 183 postmenopausal women across nine U.S. Pelvic Floor Disorders Network sites between April 2013 and February 2015. The study compared vaginal mesh hysteropexy against vaginal hysterectomy with uterosacral ligament suspension for symptomatic uterovaginal prolapse. After ineligibility exclusions, 175 women entered the intention-to-treat analysis (88 hysteropexy, 87 hysterectomy), with 112 (64%) continuing into extended follow-up through 10 years. The primary composite outcome was retreatment, anatomic prolapse beyond the hymen, or bothersome bulge symptoms. This outcome occurred in 40% (35/88) of the hysteropexy group versus 53% (46/87) of the hysterectomy group, with time-to-failure modeling demonstrating a lower failure risk for hysteropexy (HR 0.64, 95% CI 0.41-1.00, P = .05). Model-estimated 10-year failure probability was 43% for hysteropexy versus 59% for hysterectomy (risk difference, -15 percentage points, 95% CI -33 to 2). Only 10 new failures occurred during years six to 10 (6 hysteropexy, 4 hysterectomy). Additionally, the proportional hazards assumption was violated, indicating convergence of risk between groups after year six. Patient Global Impression of Improvement rates were similar between groups (85% vs. 83%, risk difference 2 percentage points, 95% CI -13 to 16, P = .81). Hysteropexy demonstrated lower rates of suture-related granulation tissue (1% vs. 12%, risk difference -11%, 95% CI -18 to -4, P = .003) and suture exposure (3% vs. 21%, risk difference -18%, 95% CI -27 to -8, P < .001) than hysterectomy. Mesh exposure occurred in 8% (7/91) of hysteropexy patients initially, decreasing to 2% by the last follow-up, with no malignancies or operating room mesh excisions required. Findings from this study support mesh hysteropexy as a durable, low-risk uterine-sparing alternative to hysterectomy, although market withdrawal of the studied mesh kit limits its direct applicability in current American practice.

Image: PD

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