Impact of permanent versus absorbable suture in vaginal suspension surgery for apical pelvic organ prolapse

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To systematically review the literature regarding how permanent versus absorbable suture impacts anatomic failure in women undergoing native-tissue vaginal apical suspension. MEDLINE and EMBASE were searched from their inception through 6/11/21 using pre-identified search terms. Our population included studies of women who underwent native-tissue vaginal apical suspensions (uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLF)). We excluded cadaver, tissue sample, or animal studies. We excluded hysteropexy and McCall culdoplasty. Our intervention was defined as permanent sutures (polytetrafluoroethylene, polypropylene, poliglecaprone 25, mersilene, silk, and nylon), excluding braided polyester suture. Our comparator group was absorbable or delayed absorbable sutures (polyglactin, polydioxanone, and polyglyconate). Outcomes included anatomic failure defined by POP-Q measurements, stage or grade, subjective symptoms of a bulge, re-operations, or re-treatments. A single composite anatomic failure proportion was determined for each study. Adverse events including suture exposure, surgery for suture complication, dyspareunia, and granulation tissue were collected. Abstracts were double-screened using Abstrackr, then full text articles were doubly screened, and then accepted articles were doubly extracted. Quality of studies was assessed using GRADE criteria. In studies using either absorbable or permanent sutures (single-arm studies), random effects meta-analyses of pooled proportions were used to assess anatomic failure. In studies investigating both suture types (comparative studies), random effect meta-analyses of pooled risk ratios were used. Analyses were performed using STATA, v.17 and p<=.05 was considered statistically significant. 4,357 abstracts were screened, 349 full-text papers assessed, and 20 studies met eligibility criteria (Figure 1). 4 studies (all USLS) compared both suture types, and 16 were single arm (8 USLS and 8 SSLF)(6 absorbable and 10 permanent). Mean follow up was 24.3 months. The proportional anatomic failure rate of absorbable suture (n=10) was 9% (95% CI 0.06, 0.13), and permanent suture (n=14) was 15% (95% CI 0.10, 0.20) with high heterogeneity. On meta-analysis, there was no difference in relative risk of failure for permanent sutures versus absorbable sutures (n=4), RR = 0.69 (95%CI 0.20, 2.36) with substantial heterogeneity (Figure 2). Overall, failure rate was low and similar for both absorbable and permanent suture for native tissue vaginal suspension with medium term follow-up.View Large Image Figure ViewerDownload Hi-res image Download (PPT)