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Pelvic Organ Prolapse and Uterine Preservation Urdzík et al. BMC Women’s Health (2020) 20:241 https://doi.org/10.1186/s12905-020-01105-3 RESEARCH ARTICLE Open Access Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey) Peter Urdzík1* , Vladimir Kalis2,3, Mija Blaganje4, Zdenek Rusavy2,3, Martin Smazinka3, Martin Havir3, Rastislav Dudič1 and Khaled M. Ismail2,5 Abstract Background: The aim of this study was to explore the personal views of female gynecologists regarding the man- agement of POP with a particular focus on the issue of uterine sparing surgery. Methods: A questionnaire based survey of practicing female gynecologists in the Czech Republic, Slovenia and Slovakia. Results: A total of 140 female gynecologists from 81 units responded to our questionnaire. The majority of respond- ents stated they would rely on a urogynecologist to aid them with their choice of POP management options. The most preferred options for POP management were sacrocolpopexy and physiotherapy. Almost 2/3 of respondents opted for a hysterectomy together with POP surgery, if they were menopausal, even if the anatomical outcome was similar to uterine sparing POP surgery. Moreover, 81.4% of respondents, who initially opted for a uterine sparing pro- cedure, changed their mind if the anatomical success of POP surgery with concomitant hysterectomy was superior. Discussing uterine cancer risk in relation to other organs had a less signifcant impact on their choices. Conclusions: The majority of female gynecologists in our study opted for hysterectomy if they were postmenopau- sal at the time of POP surgery. However, variation in information provision had an impact on their choice. Keywords: Preference, Survey, Attitude, Prolapse, Hysterectomy, Sparing surgery Background laparoscopic sacrocolpopexy were > 50 years. Until One in 9 women undergo a form of reconstructive sur- recently, vaginal hysterectomy was the most common gery for pelvic organ prolapse (POP) during the course of operation in POP management [7, 8]. Te main proposed their life and this is expected to increase with the prolon- reasons for removal of the uterus were to obtain access gation in life expectancy [1]. With improving operative to the supporting pelvic structures and/or to reduce the safety and anesthetic techniques, such surgical proce- size of the prolapsed mass [9]. Nevertheless, the uterus dures are more frequently performed on perimenopau- itself seems to play only a passive role in the etiology of sal and postmenopausal women [2–5]. Indeed, in a study prolapse [10, 11] and therefore its removal without a by Kalis et al. [6], 108 (89.3%) of 121 women undergoing thorough discussion with the patient, about the pros and cons of doing so, may be considered clinically substand- ard and unethical as it disregards the women’s autonomy *Correspondence: [email protected] and basic right of informed choice [12–14]. Tis issue is 1 Department of Gynecology and Obstetrics, Faculty of Medicine, Safarik’s University and L. Pasteur Teaching Hospital in Kosice, SNP Street No. 1, exacerbated by the paucity of long-term data on the psy- 04001 Košice, Slovak Republic chological impact of hysterectomy on women [15]. Full list of author information is available at the end of the article © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Urdzík et al. BMC Women’s Health (2020) 20:241 Page 2 of 8 Several studies [14, 16, 17] have explored women views Participants, inclusion and exclusion criteria about the issue of uterine preservation versus concomi- Participants were hospital-based female specialist obste- tant hysterectomy at the time of reconstruction pro- tricians and gynecologists who have completed their cedures for POP. Te heterogeneity in these studies’ postgraduate training and working as generalists or sub- fndings is not unexpected given the impact of several specialists in obstetrics and gynecology. factors including the individual’s values, cultural beliefs, level of education, ethnicity, age and family pressure [16, Variables 18–20]. However, in these studies the target population We used a bespoke questionnaire based on previously did not specifcally have prior medical knowledge hence published study exploring women’s perception of hys- their decision could have been biased not only by the terectomy and attitudes towards uterine preservation at information provision but rather by how they interpret the time of POP reconstructive surgery [16]. Te ques- such information. Tis is particularly relevant because, in tionnaire was distributed in the native language of each essence, they are making a decision to remove a healthy of the participating countries (the questionnaires in the organ based on projected assumed risks [14, 16, 21]. participating countries native languages are available In order to mitigate the risk of such bias while ensur- on request, the questionnaire in English language—see ing that the woman’s perspective is taken into account, in Additional fle 1). Demographic details collected we decided to target a cohort of women with specialist included participants’ age, country of residence, type of knowledge in the feld of gynecology in general and uro- hospital they work at, sub-specialization or main area of gynecology in particular. In this study we undertook a special interest (materno-fetal medicine, oncogynecol- survey of female gynecologists from diferent European ogy, urogynecology, reproductive medicine, others, no countries with the aim of exploring their personal views sub-specialty). We also asked about future fertility plans about diferent aspects of management of POP. We also using a 4-point Likert scale ranging from “not at all” to “I wanted to particularly focus on their choice of whether to defnitely will”. preserve the uterus or not in response to diferent clinical Participants were asked to assume they are postmeno- scenarios. pausal healthy women, with no prior major gynecologi- cal surgeries, sufering from a signifcant POP involving all compartments (i.e. anterior, apical, posterior), par- Methods ticipants were then asked to respond to a set of ques- Te study was undertaken between January and Decem- tions and hypothetical scenarios to explore the following ber of 2018 and involved 120 departments of Gynecology issues: and Obstetrics located in the Czech Republic, Slove- nia and Slovakia. A national coordinating center (NCC) • Resources or people they would consult to aid them located in each of the participating countries managed with the decision making about the best treatment the study elements in that country. Te NCCs were for their POP. based at the Departments of Gynecology and Obstet- • Teir preferred type of management for their POP. rics Safarik’s University and L. Pasteur Teaching Hospi- • Te importance of the uterus to them. tal (SULPTH), University Hospital in Pilsen (UHP) and • Potential factors that can afect their decision to have University Medical Centre Ljubljana (UMCL) in Slovakia, a hysterectomy. Czech Republic and Slovenia respectively. Anonymized • How important is anatomical outcome on their questionnaires were sent by email from the lead inves- choice about concomitant hysterectomy with POP tigator of each of the NCCs (UP, KV, BM) to the heads surgery. of departments of all the obstetrics and gynecology units • Would presenting life-long risk of uterine cancer in in their relevant countries. Tey were asked to cascade the context of other organ cancers impact their deci- them as hard copies to practitioners who fulflled a set of sion about choice of procedure? a priori specifcations. Completed questionnaires were returned by post to the relevant NCC for data extraction. Te study received ethical approval from the relevant eth- Statistical methods ics committee at Ethics committee at L. Pasteur Teach- Sample characteristics were summarized using descrip- ing Hospital in Košice in Slovakia (No. 2020/EK/04024). tive statistics. Where relevant exact McNemar, Fischer While UHP in Czech Republic (waiver—April 30, 2020) tests and chi-squared test were performed using IBM and UMCL in Slovenia (waiver—April 22, 2018) commit- SPSS Statistics 21.0 and Stata/SE 11.1 (StataCorp LP, Col- tees waived ethical approval because of the nature of the lege Station, TX, USA) statistical softwares. Te cut-of study. for statistical signifcance was set at p < 0.05. Urdzík et al. BMC Women’s Health (2020) 20:241 Page 3 of 8 Results 4.3%), a female friend (n = 3, 2.1%) or an oncogynecolo- Sample description gist (n = 1, 0.7%). Of the 120 approached departments, questionnaires were returned from 81 (67.5%) of them. A total of 140 Management preference female gynecologists completed the questionnaire with Using the same assumption above, participants were a mean age of 38.7 years (range 28–67 years). Of these, asked to rate their likelihood of choosing diferent man- 84 (60.0%), 31 (22.1%) and 25 (17.9%) were from the agement options for POP on a 4-point Likert scale which Czech Republic, Slovakia and Slovenia respectively.
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