UROGYNECOLOGY

ORIGINAL RESEARCH n
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Minimally Invasive Total Versus Supracervical Hysterectomy

With Sacrocolpopexy
Importance Limited data exist comparing total laparoscopic hysterectomy Lauren E. Giugale, MD,*†
(TLH) versus laparoscopic supracervical hysterectomy (LSCH) at the time of Kristine M. Ruppert, MSN, Dr.PH,‡
minimally invasive sacrocolpopexy for uterovaginal prolapse. Sruthi L. Muluk, BA,†
Stephanie M. Glass Clark, MD, MSc,*†
Objectives The objective of this study was to compare TLH versus LSCH at
Megan S. Bradley, MD,*†
the time of minimally invasive sacrocolpopexy for uterovaginal prolapse, Jennifer M. Wu, MD, MPH,§ and
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hypothesizing that LSCH would demonstrate a higher proportion of Catherine A. Matthews, MDk
recurrent prolapse, but a lower proportion of mesh exposures.
Study Design This was a retrospective, secondary analysis comparing a Author affiliations, Conflicts of Interest, and
article information are provided at the end of
prospective cohort of patients undergoing TLH sacrocolpopexy versus a this article.
retrospective cohort of patients who had undergone LSCH sacrocolpopexy.
Our primary outcome was composite anatomic pelvic organ prolapse
recurrence (prolapse beyond hymen, apical descent > half vaginal length,
retreatment). Secondary outcomes included vaginal mesh exposures.
WHY THIS MATTERS
Results There were 733 procedures: 184 (25.1%) TLH sacrocolpopexy
The results of this study suggest
and 549 (74.9%) LSCH sacrocolpopexy. Median follow-up was longer in the
that total laparoscopic and lapa-
TLH cohort (369 [IQR 354–386] vs 190 [IQR 63–362] days, P < 0.01). roscopic supracervical hysterec-
There was no difference in composite prolapse recurrence between groups tomies are both acceptable
on bivariable analysis (3.3% vs 4.7%, P = 0.40). However, multivariable methods of concomitant hyster-
ectomy at the time of minimally
logistic regression demonstrated that TLH sacrocolpopexy had lower odds invasive sacrocolpopexy for
of composite pelvic organ prolapse recurrence than LSCH sacrocolpopexy uterovaginal prolapse, albeit with
(OR 0.21, 95% CI 0.05–0.82, P = 0.02). Among procedures with likely different risk profiles. Al-
though this study has certain limi-
lightweight mesh types, TLH demonstrated a higher proportion of mesh
tations, the current data represent
exposures compared to LSCH (10 [5.4%] vs 4 [1.1%], P < 0.01); however, one of the largest comparative
this was not significant after controlling for confounders (OR 4.51, 95% CI cohort studies addressing these
0.88–39.25, P = 0.08). There were no differences in retreatment clinical questions and add con-
temporary data to the existing lit-
or reoperation.
erature surrounding this topic.
Conclusion For the treatment of uterovaginal prolapse, both TLH and LSCH Surgeons can use the information
are acceptable methods of concomitant hysterectomy at the time of presented herein to guide surgi-
minimally invasive sacrocolpopexy, albeit with likely different risk profiles. cal decision making as well as
patient counseling regarding the
Urogynecology 2024;30:814–820 relative risk versus benefit ratio of
DOI: 10.1097/SPV.0000000000001530 total versus supracervical hyster-
ectomy at the time of minimally
invasive sacrocolpopexy.

he ultimate choice of surgical intervention for primary uterovaginal

T pelvic organ prolapse (POP) largely rests on individual surgeon and

patient preferences regarding risk versus efficacy.1 Sacrocolpopexy
with concomitant hysterectomy is often offered as a primary intervention2
due to lower rates of anatomic failure3,4 compared to native tissue vaginal
repairs, although without differences in patient-reported outcome measures Supplemental Digital Content

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 Sacrocolpopexy and Type of Hysterectomy
ORIGINAL RESEARCH n

or reoperation rates.5 Sacrocolpopexy with synthetic epithelium.”10 Secondary aims included objective pro-
mesh, however, confers unique risks of mesh-related lapse recurrence beyond the vaginal introitus,
complications,6 which may influence patient decision retreatment with a pessary or surgery, and a bother-
making. some bulge that could be seen or felt per the Pelvic
The specific method of hysterectomy likely affects Floor Distress Inventory-20 question 3.11 Given that
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the risk versus efficacy ratio when performed at the the comparative retrospective dataset described as fol-
time of minimally invasive sacrocolpopexy (MISC). lows did not include patient-reported outcomes, these
Laparoscopic supracervical hysterectomy (LSCH) has were not assessed in the present study.
been associated with a lower risk of vaginal mesh ex- The second dataset was from a retrospective cohort
posure than total laparoscopic hysterectomy (TLH).7,8 of conventional or robot-assisted LSCH MISC per-
However, leaving the cervix in situ may increase the formed at a large academic medical center by Giugale
risk of recurrence. Limited data from a retrospective et al between 2009 and 2019 by 13 board-certified
cohort study of 83 women demonstrated an increased urogynecologists.3 This dataset comprised the LSCH
risk of recurrence in the anterior compartment in MISC cohort. Chart review was performed to obtain all
women undergoing LSCH as opposed to TLH.9 demographic, procedural, and postoperative data as
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To expand upon the limited data available, we documented in the medical record. All women who
sought to compare postoperative outcomes between underwent laparoscopic or robot-assisted LSCH MISC
TLH and LSCH at the time of MISC for uterovaginal over the aforementioned time frame and had a docu-
POP from 2 independent, preexisting datasets. We hy- mented postoperative Pelvic Organ Prolapse Quantifi-
pothesized that LSCH MISC would demonstrate a cation (POP-Q)12 examination were included in this
higher proportion of recurrent POP but a lower pro- dataset. We excluded patients who had undergone a
portion of mesh exposures than TLH MISC. prior apical suspension procedure or prior hysterec-
tomy. At our institution, after the supracervical hys-
terectomy is performed, surgeons typically attach the
STUDY DESIGN mesh to the vagina with delayed absorbable monofila-
We performed a retrospective, secondary analysis of 2 ment sutures. We recommend yearly examinations af-
preexisting datasets from different institutions. Our ter mesh prolapse repair. However, patients often
goal was to compare outcomes after minimally invasive choose to follow up as needed and, thus, follow-up time
total hysterectomy with sacrocolpopexy to was variable. For the current study, we limited the ret-
supracervical hysterectomy with sacrocolpopexy for rospective cohort to 2 years of follow-up; we excluded
the primary treatment of uterovaginal POP. The patients with follow-up beyond 2 years to make the
datasets were chosen for convenience purposes, as the maximum duration of follow-up comparable between
data had previously been collected as part of prior hysterectomy groups. Choosing this follow-up time
studies. The first dataset comprising the TLH MISC limited to 2 years for the retrospective cohort resulted
cohort was from a prospective, multicenter, random- in a median follow-up time that most closely approxi-
ized controlled trial of TLH MISC by Matthews et al mated the 1-year follow-up of the prospective cohort.
that enrolled women from 2015 to 2019 by 8 board- Our primary outcome was composite anatomic
certified urogynecologists. This study compared vagi- POP recurrence, which was defined as any prolapse
nal mesh or permanent suture exposure rates in women beyond the hymen, apical descent greater than half of
undergoing conventional or robotic-assisted TLH the total vaginal length, or retreatment with either pes-
MISC with a lightweight polypropylene y-mesh sary or surgery. Secondary outcomes included intra-
(25 g/m2) using permanent versus delayed absorbable operative complications, operative time, estimated
monofilament sutures.7 Concomitant procedures were blood loss, anatomic compartment of recurrent POP,
permitted and performed per surgeon preference. mesh complications, and reoperations for either pro-
Method of vaginal cuff closure was performed per the lapse recurrence or mesh complications. Intraoperative
surgeons' preference and could have included complications included bladder injury, ureteral injury,
interrupted or continuous sutures with barbed, mono- bowel injury, blood transfusion, and vascular injury.
filament or braided absorbable suture material.7 Pa- Bladder injuries related to the hysterectomy or
tients were objectively evaluated at 6 weeks and 1 year sacrocolpopexy were included; midurethral sling trocar
after the procedure. Mesh exposure was defined as injuries were not included as a bladder injury for the
“vaginal mesh visualized through separated vaginal present study. Operative time was defined as procedure

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 n ORIGINAL RESEARCH Sacrocolpopexy and Type of Hysterectomy

higher proportion of Black or African American pa-

tients (10.9% vs 1.0%, P < 0.01) and fewer current
smokers (1.1% vs 7.4%, P < 0.01). Preoperative
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TABLE 1. Demographic and Procedural Characteristics

(n = 733)
Total Laparoscopic
Laparoscopic Supracervical
FIGURE 1. Flow diagram of participants. LSCH, laparoscopic supracervical Hysterectomy Hysterectomy
hysterectomy; MISC, minimally invasive sacrocolpopexy; TLH, total Sacrocolpopexy Sacrocolpopexy
laparoscopic hysterectomy.
Variable (n = 184) (n = 549) P
Age (y) 60.0 ± 10.3 60.0 ± 9.1 0.83
BMI 27.3 ± 4.6 27.3 ± 4.5 0.99
start time to procedure end time. All participants from Vaginal births 2 (2–3) 2 (2–3) 0.62
both cohorts were included in comparative analyses Diabetes 18 (9.8%) 40 (7.3%) 0.27
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except when comparing mesh complications. When Race <0.01

assessing mesh complications, we excluded mesh types Black or African 20 (10.9%) 5 (0.9%)
with a mesh density >25 g/m2, as heavier mesh types American
were only present in the retrospective LSCH MISC co- White 163 (89.1%) 522 (95.1%)
hort (Giugale et al) and mesh density is known to be Unknown 1 (0.5%) 22 (4.0%)
associated with an increased risk of mesh Smoking status <0.01
complications.13 Never 129 (70.5%) 377 (69.6%)
Continuous data were compared using t tests or the Former 52 (28.4%) 125 (23.1%)
Wilcoxon rank sum for parametric and nonparametric Current 2 (1.1%) 40 (7.4%)
data, respectively. Categorical data were compared Prior prolapse repair 9 (4.9%) 32 (5.9%) 0.72
using the chi-square test or Fisher exact test. Multivar- Baseline POP-Q
iable logistic regression was performed for the out- Ba 2.0 (1.0–4.0) 2.0 (1.0–3.5) 0.65
comes of composite anatomic prolapse recurrence and
C 0.0 (−3.0 to 3.0) 0.0 (−3.0 to 3.0) 0.35
mesh complications. Multivariable linear regression
GH 4.5 (4.0–5.5) 4.5 (4.0–5.5) 0.74
was performed for operative time. We were unable to
PB 3.0 (2.0–3.0) 3.5 (3.0–4.0) <0.01
perform any time to event analyses because there was
TVL 9.0 (8.0–10.0) 9.0 (8.0–9.5) <0.01
only 1 outcome time point at 1 year in the TLH MISC
Bp −1.0 (−2.0 to 0.0) −1.0 (−2.0 to 1.0) 0.13
data (Matthews et al). This study was IRB approved
Baseline POP-Q stage <0.01
(STUDY21100169) with a data usage agreement from
Stage 2 49 (26.8%) 109 (20.0%)
both institutions. The present study was granted with a
Stage 3 111 (60.7%) 403 (74.1%)
waiver of informed consent; patients who initially par-
ticipated in the randomized trial by Matthews et al Stage 4 23 (12.6%) 32 (5.9%)

provided informed written consent as described in the Surgical modality <0.01

original study.7 Laparoscopic 44 (24.4%) 300 (54.8%)
Robotic 136 (75.6%) 247 (45.2%)
Concomitant
procedures
RESULTS Anterior repair 1 (0.6%) 2 (0.7%) 0.83
The cohort consisted of 733 procedures, 184 (25.1%) Posterior repair 81 (44.0%) 23 (4.2%) <0.01
of which were TLH MISC (from the prospectively col- Perineorrhaphy 47 (26.1%) 38 (7.1%) <0.01
lected dataset) and 549 (74.9%) were LSCH MISC Midurethral sling 97 (53.9%) 41 (7.7%) <0.01
(from the retrospectively collected dataset) (Fig. 1). Operative time (min) 216 ± 68 194 ± 63 <0.01
Demographic, preoperative, and operative characteris- Follow-up (d) 369 (354–386) 190 (63–362) <0.01
tics are presented in Table 1. The 2 groups were similar Data presented as n (%), mean (±SD), or median (interquartile range). Race was
in terms of age (mean 60 years) and body mass index self-reported and obtained from demographic information in the medical record.
Any missing data were <5%.
(mean of 27 [calculated as weight in kilograms divided BMI, body mass index (calculated as weight in kilograms divided by height in me-
by height in meters squared]). The TLH group had a ters squared); POP-Q, Pelvic Organ Prolapse Quantification.

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 Sacrocolpopexy and Type of Hysterectomy
ORIGINAL RESEARCH n

TABLE 2. Primary and Secondary Outcomes (n = 733) use of Y-mesh types of varying mesh densities: mesh
Total Laparoscopic weighing 19 g/m2 (n = 322, 58.8%), mesh weighing
Laparoscopic Supracervical 42 g/m2 (n = 188, 34.3%), and other lightweight mesh
Hysterectomy Hysterectomy types ≤25 g/m2 (n = 38, 6.9%) ( P < 0.001).
Sacrocolpopexy Sacrocolpopexy
P For the primary outcome of composite anatomic
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Variable (n = 184) (n = 549)

Composite anatomic 6 (3.3%) 26 (4.7%) 0.40 POP recurrence, there was no difference in composite
prolapse recurrence POP recurrence between TLH MISC and LSCH MISC
Anatomic compartment on bivariable analysis (3.3% [n = 6] vs 4.7% [n = 26],
of prolapse P = 0.40) (Table 2). Given baseline differences between
recurrence
groups, we performed a multivariable logistic regres-
Anterior compartment 3 (1.6%) 13 (2.4%) 0.77
recurrence* sion controlling for POP stage, laparoscopic versus ro-
Posterior 3 (1.7%) 5 (0.91%) 0.42 botic surgical modality, posterior repair,
compartment perineorrhaphy, midurethral sling, and follow-up time.
recurrence* On regression modeling, TLH MISC had lower odds of
Apical recurrence† 2 (1.1%) 4 (0.7%) 0.64 composite POP recurrence than LSCH MISC (OR
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Retreatment for 0.21, 95% CI 0.05–0.82, P = 0.02; Table 3). There was
recurrent prolapse
no difference in the specific anatomic compartment of
Surgery 1 (0.6%) 7 (1.3%) 0.69
POP recurrence or in retreatment for POP recurrence
Pessary 1 (0.6%) 5 (0.9%) 1.00
between TLH and LSCH MISC. A post-hoc power
Mesh exposure‡ 10 (5.4%) 4 (1.1%) <0.01
calculation for composite anatomic POP recurrence
Reoperation for mesh 2 (1.1%) 3 (0.8%) 1.00 revealed that we were underpowered to detect a differ-
exposure‡
ence between groups on uncontrolled analysis (with an
Any reoperation (for 3 (1.6%) 9 (2.5%) 0.76
prolapse recurrence estimated sample size of more than 2,000 patients
or mesh exposure)‡ needed per group). However, as noted, regression
Estimated blood 75 (50–100) 40 (30–60) <0.01 analysis demonstrated a significant association after
loss (mL) controlling for confounders.
Intraoperative For secondary outcomes, the TLH MISC cohort had
complications
longer mean operative time on bivariable analysis
Bladder injury 4 (2.2%) 1 (0.2%) 0.02
(216 ± 68 vs 194 ± 63 minutes, P < 0.01; Table 1). On
Ureteral injury 1 (0.5%) 0 (0%) 0.27
multivariable linear regression controlling for robotic
Bowel injury 1 (0.5%) 1 (0.2%) 0.46
versus laparoscopic surgical modality and concomitant
Data presented as n (%), mean (±SD), or median (interquartile range).
procedures, LSCH MISC remained significantly asso-
*Defined as prolapse beyond the hymen.
†Defined as apical descent > half of total vaginal length.
ciated with a shorter procedure time (β −17.9 minutes,
‡Subanalysis excluded n = 188 from supracervical hysterectomy group with
mesh type >25 g/m2.
TABLE 3. Multivariable Logistic Regression for Composite
Anatomic Prolapse Recurrence (n = 733)
POP-Q points were similar between groups; however,
Odds 95% Confidence
the TLH group had greater proportions of stage 2 and
Variable Ratio Interval P
stage 4 prolapse and a lower proportion of stage 3 pro-
Total hysterectomy 0.21 0.05–0.82 0.02
lapse than the LSCH group (Table 1). Additionally, the (reference: supracervical)
TLH group had significantly longer median follow-up Baseline POP-Q stage
than the LSCH group (369 [IQR 354–386] vs 190 [IQR (reference: stage 3)
63–362] days, P < 0.01). Stage 2 0.86 0.33–2.22 0.27
There were also important operative differences be- Stage 4 2.36 0.71–7.85 0.13
tween groups. The TLH cohort had higher proportions Laparoscopic approach 0.48 0.22–1.07 0.07
of robot-assisted procedures, (75.6% vs 45.2%) and (reference: robotic)
concomitant procedures, including posterior repair, Posterior repair 0.42 0.12–1.54 0.19
perineorrhaphy, and midurethral sling (Table 1). Addi- Perineorrhaphy 0.99 0.27–3.63 0.99
tionally, because of the study design, all of the TLH Midurethral sling 0.77 0.23–2.62 0.68
MISCs (n = 184, 100%) involved use of a Y-mesh with a Follow-up (d) 1.003 1.001–1.005 <0.01
mesh density of 25 g/m2. However, the LSCHs involved POP-Q, Pelvic Organ Prolapse Quantification.

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 n ORIGINAL RESEARCH Sacrocolpopexy and Type of Hysterectomy

95% CI −31.12 to −4.73, P < 0.01) (Supplemental Ta- TLH at the time of MISC was associated with a
ble, http://links.lww.com/FPMRS/A509). decreased odds of composite anatomic POP recurrence
The TLH MISC cohort demonstrated a significantly compared to LSCH MISC. Although there were more
greater proportion of bladder injury compared to the vaginal mesh exposures in the TLH group, TLH was
LSCH MISC cohort (2.2% vs 0.2%, P = 0.02). There not an independent risk factor for mesh exposure af-
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were no differences in ureteral or bowel injury. There ter controlling for potential confounding variables.
was a statistically higher estimated blood loss in the Notably, the overall number of POP recurrence and
TLH group, although this likely does not represent mesh exposures were low. Both TLH and LSCH at the
clinical significance (Table 2). time of MISC were associated with low POP recurrence
For analysis and comparison of mesh complications, and low risk of mesh exposure within 1 year of surgery.
we included only mesh types with a density ≤25 g/m2 Our results suggest that TLH and LSCH are both ac-
(n = 545). There were a total of 14 (2.6%) vaginal mesh ceptable methods of concomitant hysterectomy at the
exposures. The TLH MISC cohort demonstrated a time of MISC for uterovaginal prolapse, albeit with
higher proportion of mesh exposure compared to the likely different risk profiles. Surgeons can use these data
LSCH MISC cohort (5.4% [n = 10] vs 1.1% [n = 4]; to inform surgical decision making as well as patient
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P < 0.01). However, on multivariable logistic regres- counseling regarding the relative risk versus benefit ra-
sion, TLH MISC was not an independent risk factor for tio of TLH versus LSCH at the time of MISC.
mesh exposure when adjusting for smoking, surgical We demonstrate an association between LSCH
modality, and follow-up time (OR 4.51, 95% CI MISC and composite anatomic prolapse recurrence
0.88–39.25, P = 0.08) (Table 4). A post-hoc power after controlling for other factors that may affect pro-
calculation revealed that we were adequately powered lapse recurrence. Our results are consistent with the
at 85% to detect a difference in mesh complications limited previously published data on this topic. In a
between groups on bivariable analysis. Reoperation for small retrospective cohort study of 83 women, Myers
mesh exposure was similar between groups (Table 2). et al demonstrated a 2.8-fold increased risk of prolapse
Vaginal mesh exposure was the only mesh complication recurrence in the anterior compartment in women un-
noted within the 2 cohorts without any cases of mesh dergoing LSCH as opposed to TLH MISC.9 Although
complications involving other viscera. When we com- theoretical, it is possible that leaving the cervix in situ
bined reoperations for either prolapse recurrence or decreases the length of dissection along the anterior
mesh exposure, there was no difference in the propor- vaginal wall, limiting a surgeon's ability to suspend the
tion of total reoperations between hysterectomy groups entire anterior vaginal wall effectively and potentially
(Table 2). also affecting mesh tensioning. Another possible ex-
planation is that TLH results in a shorter anterior vag-
inal wall compared to LSCH MISC. However, given
DISCUSSION that short-term retreatment and reoperation rates were
In this large, retrospective, multicenter comparison of similar between hysterectomy groups, the clinical sig-
women undergoing MISC for uterovaginal prolapse, nificance of increased anatomic prolapse recurrence in
the LSCH MISC group is unknown. It should be noted
that, although the LSCH cohort did have a proportion
TABLE 4. Multivariable Logistic Regression for Mesh of MISC performed using higher mesh densities, we do
Exposure (n = 545) not anticipate this would have affected our prolapse
Exact 95% recurrence outcomes based on recent data demonstrat-
Odds Confidence
Variable Ratio Interval P
ing no difference in overall composite prolapse recur-
Total laparoscopic hysterectomy 4.52 0.88–39.25 0.08
rence between mesh types of different densities.13
(reference: supracervical) Although there were significantly more mesh expo-
Smoking status (reference: current) sures in the TLH group on bivariable analysis, TLH
Never 0.12 0.01–1.51 0.08 was not an independent risk factor for mesh exposure
Former 0.14 0.01–2.16 0.10 compared to LSCH after adjusting for potential con-
Laparoscopic approach 0.19 0.004–1.37 0.14 founders. For many years, data regarding mesh expo-
Follow-up 1.00 0.99–1.01 0.83 sure rates after LSCH versus TLH MISC have been
Subanalysis excluded n = 188 from supracervical hysterectomy group with mesh
conflicting. A recent systematic review and meta-
type >25 g/m2. analysis of 19 observational studies, which included

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 Sacrocolpopexy and Type of Hysterectomy
ORIGINAL RESEARCH n

The clinical significance and patient-centered im-

Simply Stated portance of our research findings are unknown. This is
highlighted by the fact that retreatment for recurrent
The goal of this study was to compare the recurrence of
pelvic organ prolapse and mesh complications between prolapse, reoperation for mesh exposure, and total re-
2 modes of hysterectomy (total laparoscopic hysterec- operation rates were similar between groups. Follow-
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tomy vs laparoscopic supracervical hysterectomy) at the up was limited; however, and it is plausible that
time of minimally invasive sacrocolpopexy for reoperations for recurrent prolapse will increase over
uterovaginal prolapse. We compared a prospective co-
time. Although we demonstrate a statistically signifi-
hort of patients undergoing total laparoscopic hysterec-
tomy to a retrospective cohort of patients who had un- cant decrease in composite anatomic prolapse with
dergone laparoscopic supracervical hysterectomy per- TLH MISC, there was a trend toward more mesh ex-
formed at the time of minimally invasive sacrocolpopexy. posures in this group. Prior research has demonstrated
We demonstrate that, regardless of the type of hyster- that perceptions of complications and outcomes differ
ectomy performed, both procedures were associated significantly between patients and surgeons14; thus,
with low risks of pelvic organ prolapse recurrence and
understanding patient-centered outcomes and the clin-
vaginal mesh exposures within 1 year of surgery. Total
ical meaningfulness of these findings would aid in our
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laparoscopic hysterectomy was associated with de-

creased odds of composite anatomic prolapse recur- surgical counseling and risk-benefit discussion.
rence compared to laparoscopic supracervical hyster- Lastly, there is a paucity of data regarding the conse-
ectomy at the time of minimally invasive sacrocolpopexy. quences of leaving the cervix in situ at the time of hyster-
Although there were a greater proportion of vaginal
ectomy with sacrocolpopexy. Unfortunately, we cannot
mesh exposures in the total hysterectomy group, this
was not significant after controlling for potential con- comment on this topic based upon our available data.
founding variables. The total number of mesh exposures Theoretical concerns include future abnormal cervical
was low, limiting our ability to draw definitive conclusions. cytology and cyclic bleeding. However, these concerns
have not been well studied in a postmenopausal popula-
tion, which is likely at lower a priori risk. Potential nega-
tive consequences of LSCH in a postmenopausal patient
more than 10,000 women who underwent hysterec- population should be an area of further investigation.
tomy with sacrocolpopexy, reported that LSCH was A main strength of our study is the multicenter study
associated with a decreased risk of mesh exposure design and large sample size. The procedures in the current
compared to TLH (pooled OR 0.26, 95% CI 0.18–0. study were performed by more than 20 board-certified fe-
38).8 Of importance, this meta-analysis included male pelvic medicine and reconstructive surgeons spanning
women who had sacrocolpopexy procedures from 6 institutions. In contrast to single-institution studies,3,9,15
1995 to 2019, which would have included abdominal our results should have substantially improved generaliz-
procedures as well as polypropylene mesh types with ability. Additionally, this represents one of the largest single
higher densities that are no longer as commonly used.8 studies8,16 comparing sacrocolpopexy mesh exposure rates
For analysis of mesh complications in the present study, between LSCH and TLH.15
we excluded mesh types with mesh densities >25 g/m2 The main limitation of our study is that we are sec-
previously shown to be associated with an increased ondarily comparing 2 independent, preexisting datasets
risk of mesh complications.13 Our analysis of only containing different types of data: prospective versus
lighter weight mesh types may account for our finding retrospective. Although comparing data collected via
that TLH was not associated with an increased risk of different study designs may limit our ability to draw de-
vaginal mesh exposure on multivariable regression finitive conclusions, our data provide meaningful infor-
modeling. It is plausible that the type of hysterectomy is mation until comparative prospective studies are avail-
an important factor for mesh exposures with heavier able. There is a larger potential for bias in retrospective
mesh types, but as the urogynecology community data; thus, complications and prolapse recurrence could
moves toward the use of meshes with lighter densities, be underrepresented in the LSCH cohort. However, the
type of hysterectomy (TLH vs LSCH) is less important. majority of contemporary data that exist on this topic is
It should be noted that even though we were able to retrospective, and our mesh complication rates are higher
demonstrate significance on bivariable analysis, our than previously published data,8,15 suggesting both
total number of mesh exposures was small. Future thoroughness and adequacy of data collection. Another
research and meta-analyses in particular should prioritize important limitation is that follow-up time was relatively
contemporary studies utilizing lighter weight mesh types. short and significantly different between the groups (with

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Copyright © 2024 American Urogynecologic Society. Unauthorized reproduction of this article is prohibited.
 n ORIGINAL RESEARCH Sacrocolpopexy and Type of Hysterectomy

longer median follow-up in the TLH group because of 3. Giugale LE, Melnyk AI, Ruppert KM, et al. Total vaginal hysterectomy
with uterosacral ligament suspension compared with supracervical
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2 datasets compared are heterogenous with regard to
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ARTICLE INFORMATION sacrocolpopexy. Int Urogynecol J. 2015;26(4):585–589. doi:10.1007/
From the *Magee-Womens Hospital of UPMC; †University of Pittsburgh s00192-014-2551-2.
School of Medicine; ‡University of Pittsburgh, Pittsburgh, PA; §University 10. Haylen BT, Freeman RM, Swift SE, et al. An International
of North Carolina–Chapel Hill, Chapel Hill, NC; and kAtrium Wake Forest
Urogynecological Association (IUGA)/International Continence
Baptist Health, Winston-Salem, NC.
Society (ICS) joint terminology and classification of the complications
Correspondence: Lauren E. Giugale, MD. E-mail: [email protected]. related directly to the insertion of prostheses (meshes, implants, tapes)
and grafts in female pelvic floor surgery. Neurourol Urodyn. 2011;
C.A.M. is a consultant and has received grant funding from Boston Scien-
30(1):2–12. doi:10.1002/nau.21036.
tific and Coloplast. J.M.W. has received grant funding from Boston Scien-
tific. M.S.B. has received research funding from Axonics and Hologic. The 11. Barber MD, Walters MD, Bump RC. Short forms of two condition-
remaining authors report no conflicts. Statistical analysis was supported by specific quality-of-life questionnaires for women with pelvic floor
the National Institutes of Health through grant number UL1TR001857. The disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005;193(1):
funding source had no other study involvement. 103–113. doi:10.1016/j.ajog.2004.12.025.
Presentation information: Abstract presented at the 49th Annual Scientific 12. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology
Meeting of the Society of Gynecologic Surgeons in Tucson, AZ; March of female pelvic organ prolapse and pelvic floor dysfunction. Am J
19–22, 2023. Obstet Gynecol. 1996;175(1):10–17. doi:10.1016/s0002-9378(96)
Supplemental digital content is available for this article. Direct URL citations 70243-0.
appear in the HTML and PDF versions of this article on the journal’s website 13. Giugale LE, Hansbarger MM, Askew AL, et al. Assessing pelvic organ
(www.urogynecologyjournal.org). prolapse recurrence after minimally invasive sacrocolpopexy: does
The editors wish to thank Peter Aziz for his contribution to the review of this mesh weight matter? Int Urogynecol J. 2021;32(8):2195–2201. doi:
article. 10.1007/s00192-021-04681-6.

© 2024 American Urogynecologic Society. All rights reserved. 14. Fitzgerald J, Richter HE, Sung V, et al. Development of a simplified
patient-centered pelvic floor surgery complication scale. Female Pelvic
Med Reconstr Surg. 2022;28(4):233–239. doi:10.1097/SPV.
0000000000001099.
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