01: Minimally invasive sacrocolpopexy versus vaginal uterosacral ligament suspension: Comparing anatomic outcomes at 1 year

Abstract

Our aim was to compare anatomic outcomes 1-year after surgery between patients who underwent minimally invasive sacrocolopopexy (MISC) (laparoscopic or robotic) with synthetic mesh to those who underwent vaginal uterosacral suspension (USLS) for management of apical prolapse. Secondary outcomes included comparing intra and postoperative complications. This was a multi-center, retrospective cohort study through the Fellows Pelvic Research Network. Patients with prolapse who underwent apical suspension with USLS or MISC from January 2013 to January 2016 with at least 1-year postoperative anatomic data were included. Patients with prior apical repairs, prior vaginal repair with biologic/synthetic graft, or history of connective tissue disorders were excluded. Eligible patients were identified using current procedural terminology codes. Relevant pre, intra, and postoperative data were abstracted from medical records. Prolapse recurrence beyond the hymen and/or POPQ stage 2 or higher were identified at 1-year postoperatively. Categorical data were compared using chi-square and Fisher’s exact tests, and continuous data were compared using the Wilcoxon rank sum test. During the study period, 311 patients underwent MISC (159 laparoscopic and 152 robotic) and 129 patients underwent USLS. They all had 1-year POPQ data available. The proportion of patients in MISC and USLS group were similar with respect to stage of prolapse (47.3% vs. 44.2% with stage 2 and 47.9% vs. 46.5% with stage 3). The median (interquartile range) preoperative apical point C was higher in the MISC group at -2.5 (-4.0, 1.0) than in the USLS group at 0.0 (-4.0, 2.5). The anterior and posterior walls were similar: Aa/Ba at 1.0 (0.0, 2.0) and Ap/Bp at -1.0 (-2.0, 0.0). Intra and perioperative complications such as blood loss (P < 0.0001), conversion to laparotomy (P = 0.002), urinary dysfunction (P = 0.02), and fever (P = 0.007) were higher in the USLS group, but operative time was longer in MISC group (P = 0.002). Three patients in the MISC group had mesh erosion and 5 patients in the USLS group had suture erosions. Postoperative pelvic pain, dyspareunia, voiding and bowel dysfunction were comparable in the two groups. At 1-year postoperatively, 50 patients (38.8%) in the USLS group had apical descent beyond the hymen compared to 77 (24.8%) patients in the MISC group (P = 0.003). Recurrence in the anterior compartment beyond the hymen was also higher in the USLS versus MISC group: 29 (22.5%) vs 19 (6.1%) patients (P < 0.0001), respectively. Posterior compartment recurrences were comparable: 5 (3.9%) versus 16 (5.1%) patients in the USLS versus MISC group (P = 0.57), respectively. At 1-year postoperatively, stage 2 prolapse or greater were noted in 69 (45.7%) patients in the USLS group versus 108 (34.7%) patients in the MISC group. While MISC had longer operative times and risk of mesh erosion, anterior and apical compartment prolapse recurrence rates were lower at 1 year compared to USLS. Future studies comparing bothersome bulge symptoms and need for repeat surgery or pessary placement are currently underway to better assess both symptomatic and anatomic failure within 1-year from initial prolapse surgery.