01 5-Year surgical outcomes of transvaginal apical approaches in women with advanced pelvic organ prolapse

Abstract

To compare 5-year surgical outcomes of uterosacral ligament suspension (ULS) versus (vs) sacrospinous ligament fixation (SSLF) in women with advanced pelvic organ prolapse (POP). Secondarily, to explore differences in outcomes between advanced vs stage II POP. A secondary analysis was conducted in a subset of women with advanced (stages III-IV) POP from a multicenter randomized trial comparing (1) SSLF vs ULS and (2) perioperative behavioral with pelvic floor muscle training (BPMT) vs usual care. Publicly accessible de-identified datasets of the index trial with 5-year follow-up were analyzed. The primary outcome was time to surgical failure, defined as (1) apical descent >1/3 into vaginal canal or anterior/posterior vaginal wall beyond the hymen, (2) bothersome vaginal bulge symptoms, or (3) retreatment (pessary or surgery) for POP. Secondary outcomes included symptom severity measured by the Pelvic Organ Prolapse Distress Inventory (POPDI), and adverse events (AEs). Outcomes in women with advanced stage POP were also compared to those with stage II POP. Of 285 women in the index study, 90 of 147 (61.2%) in the ULS group and 88 of 138 (63.8%) in SSLF had advanced POP. Baseline characteristics did not differ between groups (mean age ULS = 61.0 ± 10.1 vs SSLF = 60.2 ± 9.9, P = 0.58). Surgical failure increased over 5 years in both groups with no intergroup difference (P = 0.42, Figure). By year 5, the estimated surgical failure rate was 67.7% for ULS vs 71.5% for SSLF (adjusted difference [a-diff] = 3.8; 95% CI = 21.9, 14.2). No difference was noted in individual failure components (Figure); anatomic: 56.7% ULS vs 65.2% SSLF (a-diff = 8.4; 95% CI = 28.0, 11.2), symptomatic: 38.8% ULS vs 43.1% SSLF (a-diff = 4.3; 95% CI = 22.6, 14.1), retreatment: 20.0% USL vs 15.9% SSLF (a-diff = 4.1; 95% CI = 9.4, 17.7). POPDI scores improved from baseline to 5 years in both groups without intergroup difference (ULS = 68.0 ± 61.1 vs SSLF = 69.9 ± 60.3, a-diff = 0.1; 95% CI = 20.0, 19.9). AEs such as granulation tissue, suture exposure, and midurethral sling exposure did not differ over 5 years. Comparing women with advanced stages vs stage II POP, the estimated surgical failure did not differ over 5 years; 69.8% advanced vs 55.7% stage II (a-diff = 14.1%; 95% CI = 33.7, 5.6). However, anatomic failure was higher in women with advanced POP (61.1% advanced vs 33.8% stage II, a-diff = 27.3%; 95% CI = 47.5, -7.0). There was no difference in symptomatic failure (41.4% advanced vs 33.3% stage II, a-diff = 8.1; 95% CI = 25.3, 9.1) or retreatment (11.7% advanced vs 8.0% stage II, a-diff = 3.6; 95% CI = 12.0, 4.7). In women with advanced stage POP, surgical failure, symptom severity, and AEs did not differ between ULS and SSLF over 5 years. Compared to stage II POP, women with advanced POP had higher anatomic failure.