Mesh Exposure According to Type and Route of Hysterectomy

Objectives: Much variety in surgical technique and preference exists among FPMRS surgeons who perform sacrocolpopexy. No standard exists regarding type and route of hysterectomy when performed in conjunction with sacrocolpopexy. Some evidence suggests that performing supracervical hysterectomy reduces the risk of mesh exposure when compared with total hysterectomy. Currently, few comparisons exist in the literature between contemporary techniques for total laparoscopic, vaginal, and supracervical hysterectomy in regards to risk of mesh exposure in the vagina. This study primarily aims to describe the risk of mesh exposure for each type of hysterectomy. Secondarily, we will compare complication rates and subjective outcomes between the three types of hysterectomy.

Methods: Charts were extracted using CPT codes for hysterectomy and sacrocolpopexy, from procedures performed at 2 institutions between 2015 and 2020. Patients were included If concomitant hysterectomy and sacrocolpopexy were performed, Chart review was performed retrospectively, and demographic and clinical data were extracted into RedCAP. To reduce loss to follow-up, patients were recruited by telephone to complete an interview which included the POP-DI, PGI-I, and questions to detect mesh complications and possible retreatments. 3 attempts were made to call each patient. Primary outcomes are expressed as risk ratios, and secondary outcomes compared with three-way ANOVA and Chi-squared tests.

Results: 394 charts met inclusion criteria. The overall rate of mesh exposure was 1.2%. 2 of 4 exposures occurred in supracervical hysterectomies, 1/4 occurred after robotic total, and 1/4 occurred after vaginal hysterectomy. Repeat/additional surgery rates were 10.6%. Of the patients who agreed to telephone interview, 9.1% answered "yes" to the question, "As far as you know, did or do you have any problems with stitches/sutures or mesh?". Types of hysterectomy were as follows: total (120, 35.6%), supracervical (217, 64.4%). Routes of hysterectomy included Robotic (145, 42.8%), Vaginal (77, 22.7%), Laparoscopic (116, 34.2%). Pathology was malignant or pre-malignant in 1.5% of cases. There were no Clavien-Dindo Grade IV or higher complications.

Conclusions: Despite our large sample size, our study was underpowered to compare rates of exposure according to type and route of concomitant hysterectomy, due to the low rate of mesh exposure (1.2%). All procedures were done with ultralight microporous polypropylene Y mesh which may have contributed to low mesh exposure rates. From these results, surgeons can feel assured that, no matter the route or type of hysterectomy, the risk of mesh exposure is low. Limitations of this study include retrospective data collection, and inadequate power to detect differences among the cohorts. Strengths include large cohort, and increased follow-up generated by the addition of a phone call.