Introduction

Pelvic organ prolapse (POP) is a common condition, with up to 40% of women experiencing anatomic prolapse¹ and 11% of women with symptomatic prolapse requiring surgery.² Hysterectomies have an important role in the management of surgical prolapse, and prolapse is the fourth most common reason for performing hysterectomy.³ Hysterectomy is often performed to gain access to the tissues used to suspend the apex of the vagina. Apical suspension has been associated with a more durable prolapse surgery outcome.⁴ Robotic sacrocolpopexy (RSCP) continues to be a well-established standard for POP surgery. RSCP can be performed in women posthysterectomy, with concurrent hysterectomy, or without concurrent hysterectomy, giving surgeons and patients several options to best meet their needs. The goal of this article is to discuss management of the uterus in the context of robotic approaches to POP repair (Figure).

Figure. Evaluation and treatment considerations in women with a uterus considering pelvic organ prolapse surgery.

Preoperative Considerations

Gynecological history

In the evaluation for POP, a focused history and general gynecological history should include inquiring about prior hysterectomy. Apical support should be evaluated on exam.

For women undergoing concurrent hysterectomy

For women with a uterus and symptomatic POP where hysterectomy should be included in prolapse repair due to either clinical history or surgeon recommendation, a gynecological history should be performed. If women report abnormal or postmenopausal bleeding, prior cervical pathologies, or family history of endometrial or ovarian cancer–containing syndromes, then further gynecological evaluation should be pursued. If the patient reports none of these conditions, per gynecological practice guidelines, no additional imaging or testing is needed before prolapse treatment.⁵

In our practice, for our patients undergoing POP surgery with concurrent hysterectomy, we obtain a pelvic ultrasound with documentation of the thickness of the endometrial lining (to rule out endometrial malignancy) and evaluation of the adnexa. The ultrasound is a helpful supplement to our exam for preoperative planning and can also identify pathology not palpable on physical examination. For postmenopausal women without vaginal bleeding, if the thickness measures > 11 mm, the patient should be referred to gynecology for consideration of endometrial biopsy.⁶

Managing the ovaries and fallopian tubes

Discussion on management of the ovaries and fallopian tubes is also important in this context. Prophylactic or “opportunistic” salpingectomy is becoming standard practice for the prevention of ovarian cancer. However, guidelines on oophorectomy have risks and benefits that are relative to a women’s age, symptoms, and medical history. New evidence is lowering the age cutoff for oophorectomy benefit from 65 to 50 years of age.^7,8 The decision for ovarian preservation should be individualized with review of the evidence and clarification that a hysterectomy can be performed while conserving ovaries.

For women considering uterine sparing

Women with a normal documented uterus and the desire to keep their uterus are candidates to undergo uterine-sparing robotic hysteropexy. Women may have several reasons for desiring to spare their uterus, including fertility, concerns about sexual function, and personal desire. Pregnancy following sacrohysteropexy is rare, but there are case reports of successful pregnancies and deliveries via C-section,⁹ suggesting that mesh placement and prolapse repair can be performed without compromising future pregnancies. Some women may express concerns about hysterectomy affecting sexual function, though most studies have shown that it is not negatively impacted.¹⁰ The main motivator for uterine sparing is personal desire/preference. Some women link the uterus to their sense of self or have religious and cultural influences.¹¹

Operative Considerations: Concurrent Hysterectomy at Time of RSCP

The most common robotic approach to POP management with concomitant hysterectomy is the RSCP. RSCP is considered the gold standard prolapse repair with a lower recurrence rate than vaginal approaches.¹² The concurrent hysterectomy may be performed as either a total hysterectomy or a supracervical hysterectomy. Retaining the cervix may require ongoing tests for cervical dysplasias with routine Pap smears. The advantage of supracervical hysterectomy is to confer protection against vaginal mesh erosion.¹³ While supracervical hysterectomy continues to be commonly performed, this evidence was generated in the context of heavier polypropylene mesh (adopted from use for hernia repairs). The risk reduction of supracervical hysterectomy for mesh complications has not been borne out in contemporary series with lightweight and ultralightweight mesh.¹⁴ For the patient who has an indication for a total hysterectomy, or simply does not desire continued cervix surveillance, a total hysterectomy at the time of sacrocolpopexy with lightweight mesh in the current era is safe.

Operative Considerations: Uterine-Sparing Robotic Sacrohysteropexy

The most common robotic approach to prolapse management with uterine preservation is the sacrohysteropexy. There are a few studies that prospectively compare sacrohysteropexy to hysterectomy with sacrocolpopexy that show at medium-term follow-up no significant difference in subjective symptomatic or observed anatomical outcomes. The hysteropexy group had a shorter operative time, less estimated blood loss, and a shorter hospital stay.¹⁵ The results are favorable though lack longer-term follow-up, and cohorts were small, limiting the generalization of these data. Most studies looking at uterine-sparing prolapse surgeries focus on vaginal approaches, and these studies also show no difference in prolapse outcomes.¹⁶ With prolapse surgeries shifting toward abdominal minimally invasive approaches,³ this literature is expected to grow. The other consideration for retaining the uterus is the relative lack of literature on the longer-term risk of monitoring for uterine pathologies and their subsequent management following prolapse repair.¹⁷

Ultimately, the literature on robotic hysteropexy shows that it is a safe and efficacious surgical procedure. In an experienced surgeon’s hands, for the carefully counseled patient with no uterine pathologies or contrary personal preferences, uterine preservation prolapse repairs can be offered.

Conclusions

Management of the uterus at the time of minimally invasive robotic prolapse repair surgeries has several excellent options. Uterine preservation may have lower operative risk without an impact on medium-term prolapse outcomes. Concurrent hysterectomy and prolapse repair has the most durable longer-term outcomes, and both supracervical and total hysterectomies can safely be offered in the contemporary era of lightweight mesh. Ultimately the decisions surrounding hysterectomy during POP surgeries should be an individualized decision that weighs patient preferences, surgeon’s clinical assessment, endometrial pathologies, and the continued growing research on this topic.