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.
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.
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.
Uterine trial – 563 out of 565 randomised women had uterine prolapse surgery. Vault trial – 208 out of 209 randomised women had vault prolapse surgery.
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).
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).
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.
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.
Current Controlled Trials ISRCTN86784244.
Bibliographical noteThis report
The research reported in this issue of the journal was funded by the HTA programme as project number 11/129/183. The contractual start
date was in November 2012. The draft report began editorial review in February 2018 and was accepted for publication in August 2018. The
authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and
publisher have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on
the draft document. However, they do not accept liability for damages or losses arising from material published in this report.
- ABDOMINAL VAULT SURGERY
- UTERINE PRESERVATION
- UTERINE PROLAPSE
- VAGINAL HYSTERECTOMY
- VAGINAL VAULT SURGERY
- VAULT PROLAPSE
- COST-EFFECTIVENESS ANALYSIS
- RANDOMIZED CONTROLLED-TRIALS
- ABDOMINAL SACROCOLPOPEXY
- PELVIC ORGAN PROLAPSE
- SACROSPINOUS HYSTEROPEXY
- LAPAROSCOPIC SACROCOLPOPEXY
- LIFETIME RISK
- VAGINAL WALL PROLAPSE
- UTEROSACRAL LIGAMENTS
- ICS JOINT REPORT