The results of this large, population-based register study indicate that cervical amputation performs equally as well as vaginal hysterectomy in the treatment of women with uterine prolapse. There was no difference in patient-reported symptom relief and satisfaction 1 year after surgery, but the rate of severe complications was significantly lower in the cervical amputation group. The findings corroborate those of previous studies comparing these two techniques [8, 13, 14]. In the subgroup of patients where no concomitant anterior colporrhaphy was performed, the cervical amputation group had a significantly lower symptomatic recurrence rate 1 year after surgery than the vaginal hysterectomy group, indicating that cervical amputation may be superior to vaginal hysterectomy in the treatment of apical descent.
In this study, cured prolapse was solely symptomatically defined, as we did not have information about postoperative POP-Q status. An absence of vaginal bulge symptoms strongly correlates with patient-reported improvement and treatment success . Using the definition described above, treatment success was similar (81 %) in each group. In a study by Thys et al. comparing the Manchester Fothergill (MF) procedure with vaginal hysterectomy (VH), the objective recurrence rates were 18 % in the MF group and 19 % in the VH group with a median follow-up time of 75 months and there were no differences in POP-related symptoms postoperatively . De Boer et al. compared the modified Manchester procedure (cervical amputation with uterosacral ligament plication) with vaginal hysterectomy. Both procedures performed excellently in the middle compartment . In a review article from 2009 by Dietz et al., the anatomical cure rate in apical support ranged between 93 and 100 % in the Manchester procedure group.
In the present study, the preoperative degree of uterine prolapse was more pronounced in the vaginal hysterectomy group compared with the cervical amputation group (Table 1). This may reflect a general conception that suspension of the vaginal cuff is needed for proper repair of advanced apical prolapse. However, similar treatment results persisted after a multivariate regression analysis adjusting for preoperative POP-Q stage, among other variables. When comparing the results of vaginal hysterectomy with cervical amputation in each subgroup of preoperative POP-Q stage, there were no significant differences. Hence, cervical amputation with ligament attachment can also be considered in advanced uterine prolapse.
Uterine prolapse is often associated with co-existing prolapse in the anterior vaginal wall , which is reflected in this study, where the vast majority of patients had concomitant anterior vaginal wall repair. This study cannot answer the question: does the presence of prolapse symptoms postoperatively represent a failure in the apical or the anterior compartment? In both groups, significant improvement was seen in all self-reported bladder dysfunction symptoms, as expected after an anterior colporrhaphy [19, 20]. It was notable, however, that self-reported symptoms of obstructive defecation also became significantly less frequent, indicating that symptoms of uterovaginal prolapse do not necessarily correlate with compartment-specific defects .
Increasing age and excess weight are established risk factors for pelvic organ prolapse . In the present study, women with a lower BMI had less symptomatic recurrence than the group with higher BMI. However, symptomatic recurrence correlated inversely with age and the preoperative grade of prolapse did not affect the risk of recurrence. One could speculate that younger women might be more physically active and thus performing “heavy activities” postoperatively to a greater extent, which increases the risk of recurrence.
Various surgical methods have been developed to improve the outcome after surgery for apical prolapse. Sacrocolpopexy and sacrospinous fixation can be performed not only in the treatment of vaginal vault prolapse, but also as uterus-sparing techniques. Open abdominal sacrocolpopexy is the most successful method in the surgical treatment of apical prolapse regarding recurrence rates, but the procedure is associated with an increased length of hospital stay, analgesic requirements, and costs compared with transvaginal procedures [2, 22]. Laparoscopic and robot-assisted sacrocolpopexies also provide excellent short- to medium-term reconstructive outcomes for patients with POP, but involve a shorter recovery time than with open procedures . These techniques, though, can only partly replace the traditional ones, as they require both high-technology operating facilities and experienced surgeons. Their cost-effectiveness is currently unclear . The use of mesh in prolapse surgery has reduced recurrence rates and has therefore been used more frequently over the last decade. However, the benefits must be weighed against the disadvantages, such as mesh erosion (5–10 %) and dyspareunia [24–26]. Sacrospinous hysteropexy is another uterus-preserving technique that is aimed at fixing the uterus to the sacrospinous ligament—most commonly to the right side to prevent lesions of the rectum. A newly published randomized trial by Detollenaere et al. showed equal outcomes of sacrospinous hysteropexy compared with vaginal hysterectomy .
Strengths of this study include prospective data collection and a large study population treated in a routine medical care setting. The operating clinics vary from large-scale teaching hospitals to smaller private practitioners and the geographical distribution of the patients is wide, which also increases the external validity. The overall response rate of 78 % must be considered an acceptable figure in a questionnaire-based study and the possibility of response bias is relatively low .
The lack of objective measures postoperatively is a limitation of our study, as this could have provided relevant information about prolapse symptoms in relation to anatomical outcome after uterine prolapse surgery. However, the aim of POP surgery is symptom relief regardless of postoperative anatomy. The register data provide no information about the position of the isthmus and cervical length. Therefore, it is not possible to evaluate the influence of possible cervix elongation on the choice of surgical method. The literature contains no clear definition of cervical elongation. Some authors suggest a definition including the corpus uteri/cervix ratio (CCR) of < 1.5 [28, 29]. Using that definition, Mothes et al. found that cervical elongation was present in 97.6 % of patients undergoing hysterectomy due to objective and symptomatic uterine POP stage II–IV, which would suggest that a considerable amount of the patients in the present study might have had some degree of cervical elongation . Suspension of the vaginal apex or cervical end is a standard procedure in vaginal hysterectomy and cervical amputation, but the methods vary. The database does not contain information regarding whether a suspension of the cuff/stump was performed and details of the suspension techniques are not registered. It is, in our opinion, highly important to perform some kind of cuff suspension to restore apical support, as it is not the hysterectomy alone that corrects the prolapse.
The follow-up time of 1 year allows us to evaluate only short-term outcomes. One long-term disadvantage of cervical amputation is the possibility of cervical stenosis and thus complications such as hematometra and difficulties in diagnosing endometrial pathological conditions using histological samples. These complications are not possible to evaluate in the present study.
Another limitation of this study is that the patient questionnaires used in the register database are not validated POP questionnaires. However, the primary outcome question regarding vaginal bulging sensation has been validated.
In conclusion, this study shows no difference between cervical amputation and vaginal hysterectomy in symptomatic outcomes or patient satisfaction in the treatment of uterine prolapse 1 year after surgery. Cervical amputation is a less invasive procedure with a short operation time, reduced blood loss, low complication rates, and fast postoperative recovery time compared with vaginal hysterectomy. The use of prophylactic antibiotics and low molecular weight heparin can also be reduced when performing a cervical amputation rather than a vaginal hysterectomy. Based on these outcomes, we suggest that cervical amputation is a reliable option with few complications in the treatment of women with uterine prolapse, when no other indication for removal of the uterus exists. Randomized controlled trials with long-term follow-up are still needed to evaluate a comparison of cervical amputation not only with vaginal hysterectomy, but also with other uterine-preserving procedures.