Do most pelvic organ prolapse (POP) procedures follow a hysterectomy?

From the Guidelines

Most pelvic organ prolapse (POP) procedures do not necessarily follow a hysterectomy. While hysterectomy and POP repair are sometimes performed together, many women undergo POP repair procedures without having a hysterectomy first or simultaneously. POP repairs can be performed independently using various techniques such as vaginal approaches (anterior or posterior colporrhaphy), abdominal approaches (sacrocolpopexy), or transvaginal mesh procedures. The decision to perform a hysterectomy along with POP repair depends on several factors including the presence of uterine pathology, the type and severity of prolapse, patient preferences, and surgeon recommendation, as noted in the acr appropriateness criteria® pelvic floor dysfunction in females 1.

In fact, there is growing evidence supporting uterine preservation during prolapse repair (hysteropexy) as it may offer advantages such as shorter operative time, less blood loss, and preservation of fertility in pre-menopausal women. The uterus itself is not necessarily the cause of prolapse; rather, prolapse results from weakening of the supporting ligaments and fascia of the pelvic floor. Therefore, addressing these supportive structures is the primary goal of prolapse repair, whether or not the uterus is present. The lifetime risk of undergoing a surgical procedure for POP or UI is approximately 11% 1, and the reoperation rate is as high as 29% 1, highlighting the importance of careful consideration in the approach to POP repair.

Some key points to consider in the management of POP include:

• The type and severity of prolapse
• Presence of uterine pathology
• Patient preferences
• Surgeon recommendation
• Potential for uterine preservation during prolapse repair
• Risks and benefits of hysterectomy and POP repair, including the potential for subacute or chronic complications such as contraction or shrinkage, mesh exposure, infection, voiding dysfunction, or pain/dyspareunia 1.

Overall, the primary goal of POP repair is to improve the patient’s quality of life by addressing the supportive structures of the pelvic floor, and this can often be achieved without a hysterectomy.

From the Research

Pelvic Organ Prolapse Procedures and Hysterectomy

• Most pelvic organ prolapse (POP) procedures do not necessarily follow a hysterectomy, as the decision to perform a hysterectomy is based on various factors, including the patient's overall health, the severity of the prolapse, and the presence of other gynecological conditions 2.
• According to a study published in the International Urogynecology Journal, 60.0% of patients who underwent apical POP repair had a concomitant hysterectomy (CH), while 40.0% were post-hysterectomy (PH) 2.
• Another study found that the risk of subsequent POP surgery was higher in patients who had undergone hysterectomy, particularly those who had undergone vaginal hysterectomy (VH) or laparoscopy-assisted VH (LAVH) 3.

Surgical Approaches for Pelvic Organ Prolapse

• The surgical approach for POP repair can vary, with some studies suggesting that abdominal sacrocolpopexy (ASC) and vaginal suspensions are common procedures 2.
• A systematic review of published data found that performing variations of McCall culdoplasty at the time of hysterectomy may be an effective prophylactic surgical procedure for preventing post-hysterectomy pelvic organ prolapse 4.
• However, the choice of surgical approach depends on various factors, including the patient's age, medical history, and the severity of the prolapse 2, 5.

Risk Factors for Pelvic Organ Prolapse After Hysterectomy

• Studies have identified several risk factors for POP after hysterectomy, including history of laparoscopic-assisted vaginal hysterectomy, vaginal deliveries, and concomitant stress urinary incontinence operations 5, 3.
• A national cohort study in Taiwan found that patients who underwent VH or LAVH had a higher risk of subsequent POP surgery compared to those who underwent abdominal hysterectomy 3.
• These findings suggest that the type of hysterectomy performed may influence the risk of subsequent POP surgery 5, 3.