and get started here. Well, welcome to the Augs FPMRS Fellows webinar series. My name is Dr. Abhishek Sripad and I'll be moderating today's webinar. Augs would like to thank the following sponsors for their support of this series, Allergan and AbbVie Company, Exonix, Coloplast and Medtronic. Today's webinar is, Do You Want to Keep Your Uterus? Hystereopathy Techniques, Outcomes and Patient Preferences presented by Dr. Livvy Chang. Dr. Chang will present for 45 minutes. The last 15 minutes of the webinar will be dedicated to question and answers. A bit about Dr. Chang. Dr. Chang is a Female Pelvic Medicine and Reconstructive Surgery Fellow at the Cleveland Clinic. Her clinical and research interests includes complex vaginal reconstruction, uterine preserving surgeries and the impact of the genital hiatus on prolapse outcomes. She has extensive experience in medical education and training simulation, particularly in low research settings. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live streamed. Please use the Q&A feature of the Zoom webinar to ask any questions to the speaker and please use the chat feature if you're having any technical issues. The Augs staff will be monitoring the chat and can assist. Without further ado, I'll turn it over to Dr. Chang. Thank you so much for that introduction. Again, my name is Livvy Chang and I'm excited to share with you about this topic that I'm very passionate about, which is hystereopexy, thinking about different techniques, looking at the outcomes and really discussing patient preferences when it comes to the surgery. Here are the objectives for this talk. So historically, hysterectomy has been and still is an integral part of pelvic organ prolapse surgeries. Many of the landmark studies that we have looking at prolapse outcomes included patients who were either undergoing prolapse surgery or have had one in the past. But globally, there has been an increase in the number of uterine preserving prolapse procedure being performed. And this is seen across the world in the United States, in South America, in Asia, and in Europe. And the reasons for this are diverse and poorly understood. And it's most likely influenced by both patient and surgeon attitudes towards uterine preserving surgeries. So in my opinion, there are multiple reasons as to the increase in uterine preserving surgeries. The first thing is I think there are better training and so fellows are being trained in uterine preserving surgery. So when they graduate, they're offering this procedure. And we also have better data on how patients do after uterine preserving surgeries. Lastly, I think we have better, or we are paying more attention to patients about how they feel about their uterus prior to proceeding with a hysterectomy or uterine preserving procedure. And one of the most cited studies is a study by Corbely et al, which looked at when women were asked to choose between a procedure that were equally efficacious, 60% of women would choose a uterine preserving procedure. And many of the women who were interviewed believed that uterus was important for their sense of self. And the woman who felt that way had 28 times the higher odds of preferring uterine preservation. And when we look at the data of not just American women, but Dutch women, of maybe Latino Americans in the United States, we found several studies and they're mostly survey studies looking at which variables were important to women. And these were the six recurring themes that seemed to be important. So women wanted to stay complete. They felt like their uterus was connected to their sense of personhood, their sense of womanhood. They felt like it was important with their relationship with their partner. And there was a concern that hysterectomy could result in hormonal changes and weight changes. So it was really helpful to have all these cross-sectional survey studies to identify these variables. But what I personally felt was hard is, I know that these variables are important to women, but how do I measure these patient preferences? How do I concisely and succinctly in an office visit ask them, how do they feel about their uterus? So you could say something like, do you wanna keep your uterus before hysterectomy? Or you can ask a woman, do you wanna keep your uterus before your hysterectomy? And that can be a very difficult question for some patients to explain or to answer because they've probably not, some patients may have, but not all patients are able to articulate the sense of connection that they have with their uterus. And there really is no objective way of measuring that. So what we did is that we actually developed an instrument to measure uterine preferences. This instrument is titled the Value of Uterus Scale. It was developed after several iterations. It first started off as a 10 question instrument, and we ran it through 152 patients who gave us feedback. And we then did a validation survey or a validation process for 50 women, which then validated the instrument. And I just wanna show you this tool. So this tool has nine questions, and it incorporates a lot of the themes that I previously showed you on themes that were important to women when they're thinking about uterine preservation. So the first part of the questionnaire asks whether the woman believes that the uterus is important for their sexual function, sexual pleasure, sense of self, and those variables listed. And then they answer based on how strongly or not strongly they feel about this. And the second part of the questionnaire asks whether the removal of the uterus can potentially result in the following scenarios. And this isn't so much to question their knowledge, but rather to evaluate how they feel about what removing their uterus could result in. And in our validation study, what we saw was a significant difference in women who wanted a hysterectomy versus women who wanted a hysterectomy. So in this bar chart, you can see that the yellow is women who underwent hysterectomy, and green are the women who underwent hysterectomy. So there were significant differences in all the sub-questions from values one to values nine. So values one includes sexual function. Values two is on sexual pleasure. Values three is sense of self. Values four is staying complete as a woman. Values five is staying complete as a person. Values six is relationship with partner. So what this graph is trying to show is that in women who wanted a hysterectomy, there was a statistically significant difference in the importance of those variables that we discussed. In contrast, values nine definitely jumps out because the green bar is much higher. So, and what this question asks is whether a hysterectomy would remove a woman's current gynecologic issue. And you can see that an overwhelming 84.7% of women who wanted a hysterectomy truly believed that having a hysterectomy could remove their issues. And in contrast, only 8% of women who wanted a hysteropexy believed that a hysterectomy would resolve their issue. And what we found is that when you take the summation, so the addition of all nine questions, values one to values nine, a value score of greater than 23 had greater 95.8% sensitivity in predicting that a woman would undergo uterine preservation. So this is the first reliable and valid instrument that can truly measure a woman's valuation of her uterus. So you can use it in the office setting to really quickly get a sense of whether the patient sitting in front of you is someone who may be a better candidate for hysterepoxy or a candidate for hysterectomy. And even using this nine question instrument, you can really use it as a qualitative guide to understand what are the factors behind this woman's decision or choice to undergo hysterepoxy. So in addition to looking at patient preferences for hysterectomy, you know, other considerations include making sure to get a thorough history of if there are any gynecologic pathologies. So does a woman have abnormal urine bleeding from fibroids or adenomyosis? These are all things that may sway you from choosing hysterectomy over hysterepoxy. If a woman is at risk of developing a gynecologic cancer or being a carrier of a hereditary cancer gene, these are also perhaps considerations that may prompt you to do a hysterectomy. And the other thing is that you wanna be certain about their family planning goals. Obviously in a woman who desires future fertility with concurrent prolapse, hysterepoxy may be the better option for a woman in that category. And there are contraindications to hysterepoxy. When it comes to absolute contraindications, anybody with a GYN malignancy should probably not be keeping their uterus. Anybody with abnormal uterine bleeding without a workup should not really be allowed to undergo hysterepoxy unless the workup has been done. There are some relative contraindications. So women with current or persistent cervical dysplasia or patients with cervical elongation. And any talk on uterine preservation cannot not mention this amazing meta-analysis that was done by the SGS Systematic Review Group looking at uterine preservation versus hysterectomy in pelvic organ prolapse surgeries. What this meta-analysis has done is really succinctly captured a lot of the studies, a lot of the data we'd know on uterine preservation. And so a lot of the data I'll be presenting will be coming from the surgery. And I just wanna go through some of the techniques and outcomes of the different uterine preserving procedures. First, I wanna talk about vaginal native tissue hysterepoxy. This is probably the most relevant for my practice. And for patients who want hysterepoxy, this is generally what I gravitate towards. There are many different ways of performing hysterepoxy. And I'm sorry, I'm just gonna, I see a question pop up. So one is, can you elaborate why cervical elongation is a relative contraindication and to what length? So that's an excellent question. And I'll answer it now. I know I'm going a little out of sequence. So the reason that it's a contraindication is that if you suspend the D point, if you have cervical elongation, there's still a good length of the cervix within the vagina. So the patient may still feel that bulge. So one thing that you can consider is doing concurrent tracheolectomy at the time of hysterepoxy. And that's something that we've definitely done before. And in somebody who is adamant about hysterepoxy yet has cervical elongation, that's something that I would consider for them. Okay, so going back to native tissue hysterepoxies, one of the techniques that we often use is something called uterus sacral ligament hysterepoxy. So this is done the same way as you would for uterus sacral ligament copepoxy, but I just wanna share some of the pearls that you may find helpful. So first you make a posterior copotomy as you would in a vaginal hysterectomy. And then you would pack the bowels away as you would in a copepoxy. But the difference is that the vaginal copotomy is quite small. So what's gonna be really key in this procedure is making sure that you have good visualization with brisky retractors. And it is possible that you can only put in two stitches on each side instead of three stitches on each side, just because there's not enough space to pass all the sutures through. So this is what I recommend in terms of making your initial incision. And in this picture, we're grabbing onto the uterus sacral ligament in the standard way using Alice clamps and putting stitches through the uterus sacral ligaments. And what I prefer to use is to use delayed absorbable PDS sutures, because I find that these sutures can be used to anchor through the cervix without worrying, the worry of permanent sutures eroding through the vagina in the longterm. And there's two ways of anchoring these PDS sutures from the uterus sacral ligament into the cervix. So method one, you can see on the left, you can either put the needle end through the cervix and then the tail end through the vaginal epithelium and tie it down that way. Method two is you're putting both the needle and the tail end through the cervix and then closing the copotomy with a 2-ovicrel and then tying it down. Both ways are really good for anchoring the sutures into the cervix. And the key point is to really taking a nice big bite into the cervix so that it's not tearing out of the cervix while you're tying it down. The other pearl is that you wanna complete the anterior repair prior to tying down the uterus sacral sutures. In terms of method one versus method two, there's no study that I know of that compares these two anchoring techniques to see if there is one advantage over the other. So what I would recommend is do what's comfortable for you. I personally prefer method two because I just like the idea of having more of my suture going through the cervix rather than going through the vaginal epithelium. And there are other ways to doing a hystereopexy and the other way is using the sacrospinous ligament suspension. And when I think of a sacrospinous hystereopexy, there are, to me it almost seems like three different procedures because we can either approach it from the anterior approach, the apical approach or the posterior approach. I think the anterior approach is really great for somebody with cysticeal predominant prolapse. This is a great example here. You can see that there is a large cysticeal so the anterior approach makes sense because you'll gain easier access into the sacrospinous and I think you'll get better suspension anteriorly with the anterior approach. With the apical approach, what I prefer to do is make a semilunar incision from nine o'clock to five o'clock and open the copotomy that way to get access to the sacrospinous ligament. And lastly, there is the posterior approach and I think this approach is really great for somebody who has a big stage two, stage three rectus seal and then that space is the most accessible. I also think you'll get better suspension in the posterior compartment when you have a posterior predominant defect using the posterior approach. And you can access the sacrospinous ligament and put sutures through it using a Mia hook, Dishop hook or using direct visualization. But I do think that when you're performing hystropexy, it's really nice to use the capule needle because a lot of times these dissections are just a little bit smaller as you would for a regular copopexy. So that's one advantage of using the capule hooks. So when it comes to native tissue vaginal hystropexies, this is sort of my preferred recipe of what type of hystropexy to use. So in somebody with anterior predominant uterovaginal prolapse, my preference is to go ahead with a sacrospinous hystropexy with an anterior approach. In somebody with a posterior predominant uterovaginal prolapse, I think a nice way technique is the sacrospinous hystropexy with a posterior approach. When it's somebody with an apical predominant uterovaginal prolapse, I think the nice option is a uterosacral ligament copopexy. And the reason I choose that is because I think it gives you that very nice suspension bilaterally with a uterosacral ligament hystropexy. And referring back to Dr. Merriweather's systematic review, there's been many comparisons looking at native tissue hystropexy versus a hysterectomy with native tissue suspension. And when looking at morbidity and differences in outcomes, it's pretty clear that uterine preservation incurs less blood loss and has shorter operative time. And based on the systematic review, there was nothing significant that favored hysterectomy. And one of the biggest studies in the last five to 10 years looking at uterine preserving procedures has been the SAVE-U trial. So this was a study that looked at the vaginal sacrospinous hystropexy versus the hysterectomy with uterosacral ligament suspension. It was a multicenter RCT non-blinded trial, and it was done from 2009 to 2012. They randomized 208 women, 103 into hystopexy, 105 into a batch test uterus sacral. And what their primary outcome was looking at recurrent stage two apical prolapse, bothersome bulge symptoms, or repeat surgery for recurrent apical prolapse. What's interesting about this study is that, and what they do differently from my practice, is that for their batch test uterus sacral, they actually use vicral sutures to suspend the uterus sacral ligaments to the vaginal cuff. And this is something different from my practice where we use PDS sutures instead. So when they looked at the primary outcome, they found that hystopexy had a primary outcome rate of zero percent, whereas batch test uterus sacral was four percent. Despite this sort of visually different outcome, it was not statistically significant. When they looked at anatomic failure of all compartments, hystopexy recurrence rate was 50 percent, batch test uterus sacral was 44 percent. And most of the failures were of the anterior compartment, which I think is congruent with many of our personal experiences. And many of their recurrent prolapse surgeries were to address the anterior compartment. So what they concluded from this study is that the sacrospinous hystopexy was not inferior to batch test uterus sacral for surgical failure of the apical compartment. And one of the things that jumped out is that women who had a hystopexy procedure, because they had a sacrospinous ligament suspension, there was more buttock pain, but the actual pain on the visual analog scale was quite low. They then followed the study out to five years to see if there was a difference, and 81 percent of the original cohort presented for follow-up. And the primary outcome was one percent in the hystopexy group versus eight percent in the batch test uterus sacral group. And again, when they looked at the anatomic outcome, it seemed like most of the failures were, again, of the anterior compartment. So you can see that still there was no statistically significant difference between the two groups, but it shows that over time, even at five years, that hystopexy was not inferior to batch test uterus sacral. And again, I think this is really good data and one of probably the most robust and the best prospective randomized data that we have looking at native tissue hystopexy versus batch test uterus sacral. But my own concern about this data is that I do think the surgical technique is different than how our group practices at the Cleveland Clinic. So I would like to think that our outcomes after our batch test uterus sacral would be a little better than what was shown in this group, and maybe that difference would show something statistically different in a similar study like this. Other native tissue ways of performing hystopexy is often in Lefort copolysis, and it's not something that intuitively one would think of when people think of hystopexy, but if you think about it, you're not doing a hysterectomy at the time of the surgery. So when you compare Lefort copolysis compared to hysterectomy, total copolysis, you know, there's, it's obvious that there's shorter OR time and actually less blood loss. So I think the take-home from this is even if you have an 80-something-year-old who wants a copolysis of some sort, it's still important to evaluate their thoughts about uterine preservation prior to proceeding with an obliterative surgery. Another quite uncommonly done procedure is the Manchester's procedure, and this procedure I've only seen once in my fellowship training, and there might be other centers who are doing more of it. But in this procedure, essentially you are doing a trachelectomy and then placating the ligaments across from it, and thus suspending the uterus. And compared to TVH native tissue repair, again, less blood loss, less blood transfusions, and less OR time. Next, I want to jump into mesh-based hysterectomies, starting with sacrohysterectomy. And this might not be, might not be a procedure that's familiar to everybody, and I think it's because it is a challenging procedure to do, and it's not commonly done, and I think that adds on to the surgical complexity of it. And there are additional techniques that differ from a regular sacral colpexy. So the key things is that you need generally two pieces of mesh. You have the posterior mesh, which suspends the posterior cervix and vagina to the sacrum, and you have an anterior mesh, which you should, which one should usually cut or fashion themselves from a piece of L-mesh that essentially wraps around the uterus through the broad ligament, and all three strips of the mesh will then be suspended to the sacrum at the anterior longitudinal ligament. What's challenging about the surgery is probably threading of these arms through the broad ligament, and the key is to be lateral to the uterine arteries so that you are lateral to them so that you don't incur any bleeding during this, this surgery. The other technical, technical point I've learned in my training is that the, the temptation is to secure all your mesh at the sacrum right away and tie down and then close the peritoneum, but what we found is that if you do that, it's going to be really hard to reach that, that bottom edge of that posterior peritoneum, and while I, I know that some practices don't always close the peritoneum, but in the people who do, it's probably a good idea to thread, to put your stitch through the anterior longitudinal ligament, thread it through the mesh, but don't tie it down, resist that temptation, but actually close the peritoneum first, and when you just have a little bit of that sacrum left exposed, then you tie down the anterior, anterior longitudinal ligament sutures, and then finally close the peritoneum. So that'll just save you a few tears towards the end of surgery when you're having a really hard time closing that peritoneum. An alternative way of doing the surgery is to use a single mesh, and so you're only using a posterior piece of mesh and suspending the posterior vagina and the cervix to the anterior longitudinal ligament. The benefit of doing that is that it's a faster procedure, less dissection, you're not at risk of injuring the uterine arteries, but the downside is that you may not be addressing that anterior compartment as well. So when looking at systematic reviews, abdominal mesh-based hystropexies, when compared to hysterectomy sacral complexes, have less mesh erosion, less blood loss, less OR time, less surgical costs, and when compared to native tissue repairs, it seems to have better anatomic outcomes with longer TVL, higher POPQC point, but it does take longer in the operating room. And this again is a recent study that looked at a comparison of vaginal and laparoscopic mesh hystropexy for uterovaginal prolapse. So this study compared vaginal mesh hystropexy to laparoscopic sacral hystropexy, and they had a primary outcome that was a composite anatomic and subjective outcome. It was a multi-center randomized trial that was conducted between 2011 and 2014 with about 70 patients per group. And this sacral hystropexy was performed with the two pieces of mesh, and patients in the vaginal mesh group had their mesh placed with the uphold mesh kit. And you can see that composite outcomes were not different between the two groups at one year. The vaginal mesh hystropexy did have shorter operative time, 64 minutes compared to 174 minutes in the laparoscopic group. The patients in the laparoscopic group had better apical spore and longer TVL. What was notably different between the two groups is that there was higher mesh exposure rate in the vaginal mesh group, and complications were higher in the vaginal mesh group, namely mostly from bladder injury, which is at 4% versus 0% in the laparoscopic hystropexy group. So even though vaginal mesh hystropexies are not currently available in the United States, I think this data is still very relevant and very helpful when you're counseling a patient who desires to undergo mesh hystropexy laparoscopically. So if you have a patient maybe who doesn't want mesh and you're intending on doing a laparoscopic and minimally invasive procedure, one consideration is a laparoscopic uterocycle ligament hystropexy. And some technical points to doing this procedure is that it's really, the surgery will be so much easier to do if you can actually see the uterocycle ligaments. And one technique you can do is to insert a uterine manipulator and tilt the uterus upward so that you can really exaggerate the uterocycle ligament. And this picture does a really nice job, and you can see the exaggerated uterocycle ligament. And while you're doing that, you can identify the ureters, and that will help you avoid the ureters. And in our practice, what we do is we use OPDS sutures. We take two bites around the uterocycle sutures and anchor it into the cervix posteriorly and tie it down. Typically, we do two sutures on each side, so a total of four sutures for the uterocycle ligament copepxy, and we have very nice results of the apical compartment. I do find that inpatient with multi-compartment prolapse, you know, with this technique alone, we'll see that the apex is suspended, but oftentimes you will still need to do an anterior repair or posterior repair after this laparoscopic uterocycle histopexy. So when compared to vaginal hysterectomy with native tissue repair or sacral copepxy, again, a non-mesh-based histopexy has less EBL, shorter OR time, and a longer TBL. And, you know, the current data on this is really limited to retrospective reviews. I haven't seen many studies looking at long-term outcomes of laparoscopic uterocycle histopexies, and I think it would be a great idea for future studies, but there are some really great retrospective studies on this topic. This one is a study from Israel that compared laparoscopic uterocycle histopexy to TVH uterocycle. It was a single-center retrospective study, and they looked at both an anatomic cure and a subjective cure. For this study, they used Gore-Tex sutures for both the uterocycle ligament suspension, both vaginally and laparoscopically. And the top line here shows the anatomic cure between the two groups. They were both really high, 85% in the vaginous uterocycle group versus 94% in the laparoscopic uterocycle group. And this was not statistically significant, but also reassuring to find that both of these modalities have excellent cures at one year. So next, I want to just quickly go over vaginal histopexies. I realize that this is not something that's available in the United States currently, but I think both in the sort of historical context and the possibility that this modality may be available in the future in another shape, way, or form, it's important to go over this data. So looking at, this is again from Dr. Merriweather's systematic review, you can start to see the recurring advantage of histopexy. Again, less mesh erosion, lower reoperation rate for mesh exposure, shorter OR time, less EBL, less blood transfusions. And again, these were seen in this comparison. The landmark study for this comparison group is the SUPER trial. It was first published in JAMA, and this was a study look at TBH with apical suspension versus transvaginal mesh histopexy. It's a multicenter randomized controlled trial at nine clinical sites that was conducted by the PFDN between 2013 and 2015. The primary outcome was a composite outcome that's commonly used, retreatment or prolapse, prolapse beyond the hymen, or prolapse symptoms. A total of 183 women were randomized, roughly half in the histopexy group, half in the TBH uterine sacral group. For the mesh histopexy, the uphold mesh was used, and for the uterine sacral ligament suspension, four sutures were used, one permanent and one delayed absorbable on each side. At three years, there were no statistically significant differences in composite failure between the two groups. There were very few, and most failures were actually anatomic or anatomic slash symptomatic. There were very few symptomatic only failures, which is consistent with a lot of the studies we've seen showing that, you know, patients might have recurrence, but they're not really bothered by it. And, you know, because even though what the state picture shows on the right, so the dotted, sorry, the solid line is the curve showing failure probability over time, and the shaded area is the confidence interval. So it does look like the point estimate is favoring towards histopexy, but the confidence interval was quite wide, and it just, there was a lot of overlap with the hysterectomy group. So there was too much uncertainty for the study group to determine whether there was or was not a difference between these two groups. But what was reassuring is that significant improvement in sexual function between the two groups, but there was a mesh exposure rate of eight percent in the vaginal mesh group. And again, the study was then followed out to five years to see if there was difference. So at five years, the failure rate in the histopexy group was 37 percent versus 54 percent in the hysterectomy group. So at five years, this was statistically significant, the p-value 0.03, and essentially there was a difference of 18 percent between the two groups. But when you look at patient reported outcomes, there really wasn't a difference between the two groups, six percent on both sides. Again, the mesh exposure rate was eight percent in the vaginal mesh group, but all of them were managed with vaginal estrogen and office trimming. So what the authors concluded at five years is that there was demonstrated superiority of the mesh augmented transvaginal prolapse approach that was seen at 16 months, that wasn't really seen in the original study. And so my thoughts are is that, you know, yes, there is a difference in composite failure between these two studies, but there really isn't a difference in symptomatic failures. So I think the decision is a little easier now because we don't have vaginal mesh kits available in the United States, but if it were to be available in the near future, I think it would certainly challenge us again to look at this data and see which modality we would offer to patients. So again, looking at all these different comparisons, you know, mesh, no mesh, laparoscopic, vaginal, robotic, or vaginal, what is consistent theme throughout all this is that there are advantages to hystropexy that is less EBL, shorter OR time, and decreased mesh exposure. And that's consistent across all studies. What our group also wanted to look at is looking specifically at adverse events after vaginal, non-mesh hystropexy, and because we've been doing hystropexies for at least 10 years at the Cleveland Clinic, we wanted to do a match cohort study to see if there was a difference in perioperative adverse events between these two group cohorts. So this was actually done by my second-year fellow, Dr. Angela Yuan. So what she did, what we did is that we retrospectively matched patients in a two-to-one ratio of women who underwent hysterectomy versus those who underwent hysterectomy with native tissue repair. And we found that the incidence of adverse events was higher in the hysterectomy group, which is seen in existing literature when compared to hysterectomy group. And the major difference actually came from the difference in intraoperative complications. So patients in the VACHES uterus sacral group had higher rates of ureteral kinking and also greater EBL. And what I find interesting about this is that we do a fair number of uterus sacral hystropexies, but I cannot recall a single time that we've kinked the ureter with uterus sacral ligament hystropexy. And I don't have a good explanation to that, and this data suggests that there is a difference between the two, and I think that would be an interesting topic in the future as well. And again, there was, when looking just at postoperative complications, which was predominantly UTIs, there was no difference between the two. When looking at operative time, there was certainly less time spent in hystropexy procedures, which was significantly different, and again, less blood loss in this group. So another thing to think about is what about cost effectiveness of hystropexy? Just, you know, think about this in a different angle, not looking at morbidity, not looking at outcome, just looking at cost effectiveness in a very objective way. So this is a study that our group did as well, looking at hysterectomy versus hystropexy at the time native tissue prolapse repair, and looking at it from a cost-effectiveness angle. And what we ended up doing is comparing batch hyst, uterus sacral to transvaginal hystropexy with sacral spinous ligament suspension. And one of the things that we wanted to do, sorry, I'm going to go back. One of the things that we wanted to do was actually look at this from an angle of, you know, what if this woman develops postmenopausal bleeding? What if she needs workup for postmenopausal bleeding? All that incurs cost, and all these risks are effectively removed if you get a hysterectomy. So accounting for these possibilities, is it a cost-effective modality? So when we looked at that and we pooled a lot of data in the literature and we plugged into 3-H Pro to help us come up with these point estimates, what we found is that patients with, who had a hysterectomy, have essentially a lifetime risk of needing some sort of workup with for postmenopausal bleeding. So 1.1% of women will need an ultrasound evaluation for postmenopausal bleeding. 0.7% will need an endometrial biopsy, 0.1% on a hysterectomy, and 0.2% will need a hysterectomy for suspected cancer. And I think in isolation, these figures don't seem very high, like 1 out of 100 will need workup for postmenopausal bleeding. But when you add that to the slight advantage of hysterectomy, prolapse advantage, you know, there is a slight difference between the probability of prolapse recurrence or endometrial cancer requiring a major surgery between the two groups. So when accounting for this possibility of workup for postmenopausal bleeding, the possibility of developing endometrial cancer, we then weighed that against the cost of treating endometrial cancer. And what we concluded is that because the cost of treating endometrial cancer is so high, it is cost effective to perform a hysterectomy at the time of prolapse repair. Granted, cost effective analysis come from a very objective point of view and completely do not account for patient preferences. But I do think it's important and nice to have this data to know that for women who keep their uterus, there's roughly 1% chance that they will need a workup for postmenopausal bleeding in the future. And another thing that patients probably ask about, and this is probably limited to our younger patients, is that what are outcomes of pregnancy after hysterectomy? So it turns out that we just don't have that much, that really good robust data on pregnancy outcomes after hysterectomy. There are, you know, some case series showing that yes, women can get pregnant after hysterectomy. But I think what makes this study or these studies hard to interpret is that it's hard to know whether the woman who didn't get pregnant, did they not get pregnant because of infertility or did they not want to have children? So I sort of take these studies with a grain of salt. And the way I think about it is that because we're not affecting the integrity of the uterus or affecting any hormonal, you know, inducing hormonal changes with our surgery, I personally don't believe that doing a hysterectomy could affect pregnancy outcomes. Oh, sorry, I misspoke. That could affect the ability for one to conceive after hysterectomy. But what is interesting is looking at prolapse recurrence in somebody who's had a hysterectomy. And so this is a systematic review that really just summarizes case series. And you can see on the far right here, I mean, there aren't that many patients, we're looking at 13 patients. So it looks like 12 to 15%, sorry, 12 to 50% of patients develop some form of prolapse recurrence after delivery. So that is something to think about after hysterectomy. And I don't think this is limited to hysterectomy. I think this could happen to any sort of prolapse repair if the woman's pelvic organs are being challenged to carrying a pregnancy and delivery. Lastly, looking at further areas of interest is, you know, I think I had mentioned a few things. I think, you know, better data looking at laparoscopic utero-sacral hystereopexy, I think is a great avenue and something that's not really studied well prospectively. And I think that would be great. I think the other thing is that is there a difference in sexual function in women who have had a hysterectomy compared to those who undergo uterine preservation? And when we do have more data on prolapse outcomes, the other thing I think about is, like, is there a difference in utero-sacral ligament hystereopexy versus utero-sacral ligament or hystereopexy? Maybe a study like the Optimum trial can be repeated, specifically looking at uterine preservation. So, in summary, hysterectomy, hystereopexy is an increasingly popular surgical treatment option. It has decreased surgical morbidity compared to hysterectomy. It has less EBL and shorter OR time. And this is seen for all modalities of hystereopexy. But hystereopexy is not cost-effective for preventing cancer. Women who keep their uterus are still at risk of cervical disease. are still at risk of cervical dysplasia, of endometrial cancer, of postmenopausal bleeding, all of which does incur costs. And this is something to consider. And it's important to measure your patient's preferences for uterine preservation. And now there is a tool with a values instrument where you can both qualitatively measure what is important to a woman before they decide on whether they want a uterine preserving versus hysterectomy procedure. And also, it can give you a quantitative guide with our cutoff of 23 by telling you whether a woman has high or low valuation of her uterus. Long-term outcomes of prolapse repair after hystereopexy is limited with very few prospective studies. And, of course, with each study, there are strengths and limitations. But I do think there is just a great need of doing more research in this area so that we can better counsel women on what to do. And lastly, I think it's really important for surgical trainees to be exposed to hystereopexies because I do believe that this is a procedure that a lot of women would want if it is offered to them. And the onus is on us as surgeons to make sure that we have the training to provide the surgery. So that is my talk. And these are my references. And I'm happy to take questions. And I'm actually going to turn on my living room light because it's getting very dark. I'll be right back. All right. So as Dr. Chang does that, we have about 15 minutes here for questions. So please do submit your questions into the Q&A feature. So as they start to come in, Dr. Chang, I'll ask a question that I was thinking of. Obviously, that values instrument is incredibly important work. Is that something that you give to every new patient or potential surgical patient? Or do you sort of clinically ask a pared-down version of that? Yeah, thank you for that great question. I love the values instrument because we developed it ourselves. And it's sort of like a baby for us because we had to look at the themes. And then we really cut down the questions and made sure that every question was important. And right now, I like to give it to every single patient who is considering surgery. What I don't want is for a patient to have that sense of regret after surgery because they felt like they had to get a hysterectomy. And sometimes it's really hard to answer that question about how important is the uterus to you in a limited office setting where you're talking about mesh, you're talking about occult stress incontinence. There simply isn't enough time. So I think having the patient fill that out, maybe while they're waiting for you, when you're finishing for another patient or in the waiting area is a really nice way to get that information before you see them. Terrific. A couple of questions that have come in about delivery route after hysterectomy sort of what you would recommend and if that recommendation would change based off whether it was a mesh, hysterepexy or native tissue. Yeah, that is a really excellent question. And I can't think of really good data to give you a very scientific answer. So I'm going to tell you what I think with the caveat that it's not backed up by anything scientific. As you can see, the pregnancy outcome slides I showed just a few slides ago is that there are only 13 patients in that systematic review looking at prolapse outcomes and half of them had a C-section, half of them had a vaginal delivery and all of them had some sort of prolapse recurrence. So I think that is sort of a bigger question beyond hysterepexy but rather by route of delivery and what their prior parity was. But I would not say that a woman who has had a hysterepexy needs to have a C-section. I would not say that. I think it's still important for the woman to make that decision. But I do think it's important to let the woman know that she has a higher risk of prolapse recurrence after a delivery after pregnancy. And that's something that is a risk that the woman should be ready to take. In terms of vaginal mesh hysterepexies or sacral hysterepexies, in a woman who does want future fertility, if we are planning an abdominal procedure, I would probably only use a single piece of mesh rather than the two pieces of mesh with a wrap around the uterus. I think the single mesh makes sense to me because it allows for the dissension of the uterus and once a woman is done with childbearing that you can even go back and attach that second piece of mesh anteriorly. Perfect, thank you. Another question that's come in is sort of concurrent risk-reducing procedures that you might or might not offer at the time of hysterepexy. So do you perform like a concurrent bilateral self-injectomy to decrease the risk of ovarian cancer or a BSO in patients who are over 65? That's the question. Yeah, I actually recently had a patient who asked for that. She was young. She was about 37, wanted a tubal ligation at the time of hysterepexy. So for a patient like that, I would advocate for utero-sacral hysterepexy for obvious reasons to get access into the peritoneal cavity. But it's not going to be an easy procedure and I think you have to let the patient know that the success rates might not be as high as you would for a regular bachelor's copepexy where you have access to the peritoneal cavity. But it is feasible. I do think the bilateral self-injectomy is doable if you're a good vaginal surgeon, but the oophorectomy I do think would be really hard. So if you're very set on doing a native tissue hysterepexy, you could consider doing a laparoscopic utero-sacral hysterepexy and then laparoscopically either doing the self-injectomy or self-veno oophorectomy that way. Perfect, thank you. Another question has come in about management of recurrent prolapse after hysterepexy. Would you offer a second hysterepexy or go to something else? Yeah, that is an excellent question. And I think, you know, now that we're doing more hysterepexies, I'm sure we'll be seeing, unfortunately, some recurrences come down the line. And the question is, what do you do next? Like, do you consider them to be a failed native tissue repair and offer mesh procedure, or do you give them a hysterectomy native tissue repair? I would not offer another hysterepexy. I think I would be between offering them maybe a sacral copeplexy versus a vagus uterus sacral. And I would make that a patient-centered decision, looking at their willingness to accept mesh and their willingness to incur risks and what their desires are. But I would not redo a hysterepexy. Okay. And I encourage, we still have about, you know, seven or eight minutes of Q&A time. So if anyone continues to have questions, please do ask in the chat or Q&A section, rather. Another question I had about the mesh, abdominal mesh hysterepexy, where the strips of mesh go lateral to the uterine arteries, is there, like, intraoperative findings, like an enlarged uterus or fibroids that would, you know, give you pause and sort of reconsider another type of suspension procedure? Yeah, absolutely. I think if we go in there and there is a huge cervical fibroid, anything that would prevent the mesh from laying down flat and doing its job, I think, is a reason to not do it. And I would always worry about increased vascularity in that area, especially as we're tumbling through the broad ligament. So absolutely, those would be reasons for us to not do that. And I think in that case, you could consider just proceeding with a single mesh sacrohysterepexy by attaching the posterior arm and doing a really good anterior repair. Okay, terrific. And then I found that the paper that you guys had published about perioperative adverse events with the ureteral kinking after, like, a vagus uterus sacral is interesting that it was higher than the uterus sacral hysterepexy. Do you, in terms of sort of, like, highlighting the uterus sacral vaginally, do you do anything to deviate the uterus one way or another that might highlight the uterus sacral ligaments a little in a more pronounced way when you're taking the vaginal approach? Yeah, you know, I can't figure that one out either. I just don't know why there is such a big difference in the rates of ureteral kinking because we don't do anything different. We do the same thing. We open up the copotomy, we pack the bowels, we use two briskey retractors, you know, to both cephalad and also just to protect the rectum. You know, we put the, we grab the uterus sacral ligament the same way with lung analysis. So I have no idea why there is a difference. And my only thought is that maybe because the copotomy is smaller, so we're taking less, they give a purchase the uterus sacral ligament, but it continues to be a mystery to me. So, and I would love to hear anybody's thoughts on this, but I don't have a good explanation as to why. Yeah, and I think it's, it's such great work you're doing in an area that we don't know a lot about. And one sort of question that did come through is if you have a resource to review your technique of laparoscopic uterus sacral hystereopexy or sort of any type of resource that might help with that. Yeah, so Dr. Allison Wyman is really an expert in this field. And if you Google any of her name and her work, she's published quite a bit on laparoscopic hystereopexy. And she does have several videos, which are, which are really good. They're slightly different than what I've been trained in, which is using OPDS sutures. I believe she uses permanent, permanent silk sutures, if I believe. But it's, it's a, they're really great videos. And I think they're really good ways to look at that. And you can also consider joining IAPS, which is the International Academy of Pelvic Surgery. There are also great videos on uterus sacral hystereopexy in there. And again, I think it's, it's sort of the newest type of hystereopexy procedure. And, and I think it has a lot of promise to be really as good as a vagist, sorry, as a uterus sacral hystereopexy. Fantastic. So that looks like most of the, the questions that have kind of come through are all the questions. There is one plug for a FPRN study that's ongoing. That's a retrospective study looking at sacrospinous hystereopexy versus uterus sacral hystereopexy. So just to sort of give that some, some publicity. So I think we're probably rounding down on our time here, but on behalf of AUGS, I'd like to thank you, Dr. Chang for this very, very important and informative talk and everyone for joining us today. Our next FPMRS fellows webinar will be held on Tuesday, June 22nd at 8pm. So please do visit the AUGS website to sign up. And I think that's what we got. Thank you.

webinar

uterus

hystereopathy techniques

outcomes

patient preferences

hystereopexy

surgical morbidity

laparoscopic hystereopexy

long-term outcomes