[Do we need to perform systematic supracervical hysterectomy during laparoscopic sacrocolpopexy?] / Doit-on réaliser systématiquement une hystérectomie subtotale dans le cadre d'une promontofixation cœlioscopique ?

OBJECTIVE: To evaluate the place of subtotal hysterectomy during laparoscopic sacrocolpopexy. METHODS: This retrospective observational study includes patients undergoing laparoscopic sacrocolpopexy between November 2010 and March 2015 at the Centre Hospitalier Régional de la Citadelle, Liège, Belgium. Patient characteristics, medical and surgical history were collected. Clinical data, operative and intraoperative complications were analyzed. The postoperative results were collected at 6 weeks, 4 months and then every year with a clinical and anatomical evaluation by POP-Q (Pelvic Organ Prolapse - Quantification). RESULTS: Ninety-four patients were included in the study. Sixty-four patients (68.1%) underwent sacrocolpopexy with subtotal hysterectomy, 12 patients (12.7%) had sacrocolpopexy with uterine preservation, 16 patients (17%) had a clinical history of hysterectomy and 2 patients (2.2%) have had sacrocolpopexy with total hysterectomy. The mean age of the patients was 61±20 years, parity 2±2 and BMI 25.2±7.32. The objective success rate, defined by a stage of POP-Q<2, was 93.75% in the sacrocolpopexy group with subtotal hysterectomy vs. 66.7% in the sacrocolpopexy group with uterine preservation (P=0.019). The subjective success rates were 98.4% and 83% respectively (P=0.063ns). CONCLUSION: Sacrocolpopexy offers good anatomical results, with better objective and subjective success rates when associated with a subtotal hysterectomy. The decision of hysterectomy should consider the risk/benefit balance and the patient's preferences.

[Does hysterectomy modifies the anatomical and functional outcomes of prolapse surgery?: Clinical Practice Guidelines]. / L'hystérectomie modifie-t-elle les résultats anatomiques et fonctionnels de la cure de prolapsus ? : Recommandations pour la pratique clinique.

OBJECTIVE: Provide guidelines for clinical practice concerning hysterectomy during surgical treatment of pelvic organ prolaps, with or without mesh. METHODS: Systematically review of the literature concerning anatomical and functionnal results of uterine conservation or hysterectomie during surgical treatment of pelvic organ prolaps. RESULTS: Sacrospinous hysteropexy is as effective as vaginal hysterectomy and repair in retrospective comparative studies and in a meta-analysis with reduced operating time, blood loss and recovery time (NP2). However, in a single RCT there was a higher recurrence rate associated with sacrospinous hysteropexy compared with vaginal hysterectomy. Sacrospinous hysteropexy with mesh augmentation of the anterior compartment was as effective as hysterectomy and mesh augmentation (NP2), with no significant difference in the rate of mesh exposure between the groups (NP3). Sacral hysteropexy is as effective as sacral colpopexy and hysterectomy in anatomical outcomes; however, the sacral colpopexy and hysterectomy were associated with increase operating time and blood loss (NP1). Performing hysterectomy at sacral colpopexy was associated with a higher risk of mesh exposure compared with sacral colpopexy without hysterectomy (NP3). There is no sufficient data in the literature to affirm that the uterine conservation improve sexual function (NP3). CONCLUSION: While uterine preservation is a viable option for the surgical management of uterine prolapse the evidence on safety and efficacy is currently lacking. © 2016 Published by Elsevier Masson SAS.

[Should we perform intra-operative endometrial biopsy during pelvic reconstructive surgery with uterine preservation?]. / Doit-on faire une biopsie d'endomètre peropératoire dans les cures de prolapsus avec conservation utérine?

OBJECTIVE: To evaluate the interest of systematic endometrial biopsy at the time of vaginal reconstructive surgery with uterine preservation. METHODS: We performed a retrospective monocentric study on all women who had vaginal reconstructive surgery with uterine preservation from 2005 to 2012. All following parameters have been studied: baseline characteristics (age, parity, BMI, hormonal status, medical history), prolapse stage using the POP-Q, preoperative pelvic ultrasound (endometrial thickness), and type of surgery. Women with previous hysterectomy were excluded. RESULTS: Four hundred and fourteen patients were operated during this period, and 268 have uterine preservation (64.7%). Baseline characteristics were mean age 64.7±10.7 (39 to 92), mean parity 2.6±1.5, mean BMI 25.5±4.2, menopause 238 (88.8%), HRT 32 (12%), previous breast cancer 16 (6%), diabetes mellitus 31 (11.6%), and hypertension 87 (32.5%). Prolapse were at stage II in 127 (47.3%), stage III in 99 (36.9%) and stage IV in 17 (6.3%). Preoperative pelvic ultrasound has been done in 255 patients (95.2%), and mean endometrial thickness was 5.1mm (range 1.6-16). Overall, 152 intra-operative endometrial biopsies were assessable (56.7%). In 24 cases (15.8%), samples were too small to be interpretable. Finally, the 128 interpretable biopsies (82.2%) have shown one carcinoma (0.8%), four hyperplasia (3.2%), two endometrial polyps (1.6%), and 121 normal endometria (94.5%). The only cancer was discovered on a 77 year old patient, with a history of previous breast cancer, and with a preoperative endometrial thickness of 7 mm. No patient with normal preoperative ultrasound endometrial screening had abnormal endometrial biopsy. CONCLUSION: Vaginal reconstructive surgery with uterine preservation implicates a preoperative endometrial evaluation by ultrasound. Intra-operative endometrial biopsy does not seem to be justified.