Of the 120 approached departments, questionnaires were returned from 81 (67.5%) of them. A total of 140 female gynecologists completed the questionnaire with a mean age of 38.7 years (range 28 – 67 years). Of these, 84 (60.0%), 31 (22.1%) and 25 (17.9%) were from the Czech Republic, Slovakia and Slovenia respectively. Participants were based at university or teaching hospitals (n=82, 58.6%), regional hospitals (n=39, 27.8%) and district hospitals (n=19, 13.6%). All participants were fully specialized gynecologists, of these 23 (16.4%) were feto-maternal, 16 (11.4%) urogynecology and 4 (2.9%) oncogynecology subspecialists. With regard to future fertility plans, 49 participants (35.0%) stated that they completed their family while the remaining 91 (65.0%) either partially or not at all.
Based on the requested assumed scenario that participants were healthy, postmenopausal, with no prior gynecological surgeries and suffering with a significant POP involving all compartments, relying on a urogynecologist as a source of information was chosen by 130 (92.9%) of the participants as the main information resource. While searching the medical literature, consulting their partner or colleague was chosen by 54 (38.6%), 24 (17.1%) and 14 (10.0%) of the respondents respectively. Ten participants only have indicated that they would also seek assistance from online resources (n=6, 4.3%), a female friend (n=3, 2.1%) or an oncogynecologist (n=1, 0.7%).
Using the same assumption above, participants were asked to rate their likelihood of choosing different management options for POP on a 4-point Likert scale which was later dichotomized to “yes”, for definitely and likely, and “no”, for not likely and not at all (Figure 1). The options favored by respondents, when combining definitely and likely responses, were sacrocolpopexy and physiotherapy. While a Manchester repair, no treatment, colpocleisis, and the use of a pessary were the least favored amongst female gynecologists.
Factors impacting decision about hysterectomy
Participants were asked about their views regarding the importance of various factors on their decision to opt for or decline a hysterectomy, during POP reconstructive surgery, if both were feasible options. Professionals’ opinion and risk of surgical complications were considered important by 100% and 99% of respondents respectively. The list of factors assessed ranked in order of their importance based on participants’ responses are demonstrated in Figure 2.
When asked about their personal perception about the importance of the uterus for their sense of self, 79/136 (58.1%) of respondents did not support this view. Of the 57 female gynecologists considering the uterus to be important for their sense of self, 33 (57.9%) said they would opt for a uterine sparing surgery than a hysterectomy compared to 18 of the 79 (22.8%) who did not support this view (OR=4.66, p<0.05).
Impact of clinical outcome and risk of cancer on choice of surgery
When participants were asked about choice of surgery if there was evidence to suggest that anatomical outcomes following POP surgery with uterine sparing were similar to concomitant hysterectomy, 82/125 (65.6%) still opted for a concomitant hysterectomy. When asked about their choice if there was evidence that uterine sparing is associated with slightly worse outcomes, 35/43 (81.4%) who initially opted for uterine sparing changed their mind to a concomitant hysterectomy (Figure 3).
When information on actual background potential risk of uterine cancer in relation to other types of cancers in females was provided while still assuming equal effectiveness of uterine sparing and concomitant hysterectomy POP procedures, 5 (6.1%) women changed their decision from hysterectomy to uterus sparing surgery and 6 (13.9%) women from uterus sparing surgery to hysterectomy (Figure 4). Additionally, 122 (87.1%) respondents stated that they would need to know the recent cervical screening result and 93 (66.4%) to have a transvaginal ultrasound assessment of their endometrial thickness preoperatively to enable them to make a well informed decision regarding hysterectomy or uterus sparing procedure. The choice of surgery depending on the different scenarios by country is presented in Table 1.