Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs

Abstract

Background New surgical approaches for apical prolapse have gradually been introduced, with few prospective randomised controlled trial data to evaluate their safety and efficacy compared with traditional methods. Objective To compare surgical uterine preservation with vaginal hysterectomy in women with uterine prolapse and abdominal procedures with vaginal procedures in women with vault prolapse in terms of clinical effectiveness, adverse events, quality of life and cost-effectiveness. Design Two parallel randomised controlled trials (i.e. Uterine and Vault). Allocation was by remote web-based randomisation (1 : 1 ratio), minimised on the need for concomitant anterior and/or posterior procedure, concomitant incontinence procedure, age and surgeon. Setting UK hospitals. Participants Uterine trial – 563 out of 565 randomised women had uterine prolapse surgery. Vault trial – 208 out of 209 randomised women had vault prolapse surgery. Interventions Uterine trial – uterine preservation or vaginal hysterectomy. Vault trial – abdominal or vaginal vault suspension. Main outcome measures The primary outcome measures were women’s prolapse symptoms (as measured using the Pelvic Organ Prolapse Symptom Score), prolapse-specific quality of life and cost-effectiveness (as assessed by incremental cost per quality-adjusted life-year). Results Uterine trial – adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for uterine preservation was 4.2 (standard deviation 4.9) versus vaginal hysterectomy with a Pelvic Organ Prolapse Symptom Score of 4.2 (standard deviation 5.3) (mean difference –0.05, 95% confidence interval –0.91 to 0.81). Serious adverse event rates were similar between the groups (uterine preservation 5.4% vs. vaginal hysterectomy 5.9%; risk ratio 0.82, 95% confidence interval 0.38 to 1.75). There was no difference in overall prolapse stage. Significantly more women would recommend vaginal hysterectomy to a friend (odds ratio 0.39, 95% confidence interval 0.18 to 0.83). Uterine preservation was £235 (95% confidence interval £6 to £464) more expensive than vaginal hysterectomy and generated non-significantly fewer quality-adjusted life-years (mean difference –0.004, 95% confidence interval –0.026 to 0.019). Vault trial – adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for an abdominal procedure was 5.6 (standard deviation 5.4) versus vaginal procedure with a Pelvic Organ Prolapse Symptom Score of 5.9 (standard deviation 5.4) (mean difference –0.61, 95% confidence interval –2.08 to 0.86). The serious adverse event rates were similar between the groups (abdominal 5.9% vs. vaginal 6.0%; risk ratio 0.97, 95% confidence interval 0.27 to 3.44). The objective anterior prolapse stage 2b or more was higher in the vaginal group than in the abdominal group (odds ratio 0.38, 95% confidence interval 0.18 to 0.79). There was no difference in the overall prolapse stage. An abdominal procedure was £570 (95% confidence interval £459 to £682) more expensive than a vaginal procedure and generated non-significantly more quality-adjusted life-years (mean difference 0.004, 95% confidence interval –0.031 to 0.041). Conclusions Uterine trial – in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between uterine preservation and vaginal hysterectomy. Vault trial – in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between an abdominal and a vaginal approach. Future work Long-term follow-up for at least 6 years is ongoing to identify recurrence rates, need for further prolapse surgery, adverse events and cost-effectiveness. Trial registration Current Controlled Trials ISRCTN86784244. Funding This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 13. See the National Institute for Health Research Journals Library website for further project information.

Pelvic Organ Prolapse and Uterine Preservation: A survey of female gynaecologists (POP-UP survey)

“…Our ndings concur with other groups, [14,27,28], where we demonstrated that the issues of the impact of a hysterectomy on femininity, sex drive and sexual satisfaction, either for the woman or her partner, did not seem to be a priority in the decision-making process regarding hysterectomy at time of POP surgery. However, the impact of hysterectomy on clinical outcomes seemed to be an important factor when choosing the optimal procedure.…”

Pelvic Organ Prolapse and Uterine Preservation: A survey of female gynaecologists (POP-UP survey)

“…Similar to those of Korbly et al [14] and van IJsselmuiden et al [17] the number of women opting for uterine sparing surgery in our study signi cantly reduced if this was associated with slightly inferior anatomical outcomes (34.4% to 8.8 %; OR 11.6, p<.001). A large RCT comparing uterine preservation surgery versus vaginal hysterectomy for POP repair reported similar anatomical and functional outcomes at 12-months [29]. In our survey sacrocolpopexy was the most preferred surgical procedure amongst female gynecologists.…”

Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey)

“…Similar to those of Korbly et al [ 14 ] and van IJsselmuiden et al [ 17 ] the number of women opting for uterine sparing surgery in our study significantly reduced if this was associated with slightly inferior anatomical outcomes (34.4–8.8%; OR 11.6, p < 0.001). A large RCT comparing uterine preservation surgery versus vaginal hysterectomy for POP repair reported similar anatomical and functional outcomes at 12-months [ 29 ]. In our survey sacrocolpopexy was the most preferred surgical procedure amongst female gynecologists.…”