Patient Risk Factors for Incidental Pathology After Uterovaginal Surgery for Apical Prolapse: Systematic Review and Global Expert Consensus Statements

Abstract

Abstract Introduction and Hypothesis Uterus preservation is increasingly used for uterovaginal prolapse (U-POP) repair despite ongoing concerns regarding future uterine, cervical, and adnexal pathology. We evaluated incidental pathology rates, associated risk factors, and created global consensus statements. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we searched for studies including women undergoing U-POP surgery with uterus present in ≥ 50% and cohorts of ≥ 30 participants exploring risk factors for pathology. Risk of bias was assessed using Risk Of Bias In Non-randomized Studies of Interventions and evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Meta-analyses were performed on the proportions of incidental pathology. Findings informed a modified Delphi process resulting in consensus statements on best practice. Results Of 4,148 screened records, 33 studies met the eligibility criteria. Meta-analysis showed that the pooled prevalence of malignant pathology at the time of surgery was 0.6% (95% CI 0.0–1.0%; I 2 = 93.5%, p < 0.05), ranging from 0% to 3.2%. Most studies excluded patients with known malignancy risk factors. Among six uterus-preserving studies, meta-analysis showed that malignancy rates did not differ between screened and unscreened populations (0.50% vs 0.58%, p = 0.88). Six retrospective cohort studies identified risk factors for incidental endometrial malignancy: older age, higher uterine weight, and abnormal preoperative ultrasound each emerged in two studies, with no factor consistent across them. Three consensus statements were supported by high-quality evidence and three were accepted through Delphi consensus. Conclusions Incidental pathology in U-POP surgery is rare (< 1%), and no single risk factor reliably predicts malignancy. Preoperative screening does not show significant reduced malignancy rates in uterus-preserving surgery. Global consensus statements offer guidance on when hysterectomy should be considered over uterus preservation.