Department of Obstetrics and Gynecology, University of Louisville, Louisville, KY.
Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX.
Am J Obstet Gynecol. 2018 Aug;219(2):129-146.e2. doi: 10.1016/j.ajog.2018.01.018. Epub 2018 Jan 17.
We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.
The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.
We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.
Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.
We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.
Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.
我们旨在系统地回顾有关保留子宫的子宫颈后盆腔器官脱垂手术与包括子宫切除术在内的脱垂手术的文献，并提供循证指南。
我们的数据来源为 MEDLINE、Cochrane 和临床Trials.gov 数据库，检索时间从建库至 2017 年 1 月。
我们纳入了比较保留子宫的脱垂手术与涉及子宫切除术的手术的随机和非随机研究。
研究提取了参与者信息、干预措施、对照、疗效结果和不良事件，并对其进行了个体和集体的方法学质量评估。如果 3 项或更多研究比较了相同的手术并报告了相同的结局，则进行荟萃分析。
我们筛选了 4467 篇摘要，确定了 94 项符合条件的研究，其中 53 项研究比较了保留子宫与子宫切除术在脱垂手术中的应用。总体而言，证据质量为中等。与子宫切除术联合网片骶骨阴道固定术相比，保留子宫的骶骨子宫固定术可减少网片暴露、手术时间、失血量和手术费用，而不会增加脱垂复发的风险。与阴道子宫切除术联合子宫骶骨悬吊术相比，腹腔镜骶骨子宫固定术在盆腔器官脱垂量化检查中改善 C 点和阴道长度、估计失血量、术后疼痛和功能以及住院时间，但开腹式骶骨子宫固定术会增加烦扰性尿症状、手术时间和生活质量。经阴道网片子宫固定术（与子宫切除术相比）可减少网片暴露、网片暴露后的再手术、术后出血和估计失血量，并改善后盆腔器官脱垂量化测量。与阴道子宫切除术联合固有组织悬吊术相比，经阴道子宫骶骨或骶棘韧带固定术或曼彻斯特手术保留子宫均能改善手术时间和估计失血量，且不会加重脱垂结局。然而，关于手术后 3 年以上的脱垂结局、子宫保留在闭塞性手术中的作用以及子宫保留后子宫病理学的长期风险，数据明显缺乏。
与类似的联合子宫切除术的手术途径相比，保留子宫的脱垂手术可改善手术时间、失血量和网片暴露的风险，且不会显著改变短期脱垂结局。对于希望在进行子宫颈后盆腔器官脱垂修复时保留子宫的合适女性，外科医生可以将保留子宫作为一种选择。
