Sacrospinous fixation and vaginal uterosacral suspension: evaluation in uterine preservation surgery

Abstract

To compare anatomic failure, prolapse symptoms, retreatment and incidence of peri-operative adverse events between patients undergoing vaginal uterosacral hysteropexy (USHP) and sacrospinous hysteropexy (SSHP) This was a multi-center retrospective cohort study of patients who underwent USHP or SSHP with a FPMRS surgeon between 2015 and 2019. Patients were excluded if they had no follow up greater than 6 weeks postoperatively. Anatomic failure was defined as prolapse beyond the hymen. Composite failure was defined as anatomic failure, bulge symptoms, and/or re-treatment for prolapse. At 4 sites, 147 patients underwent SSHP and 114 underwent USHP. SSHP patients were younger (62±13 vs 58±13 yrs, p=0.01) and had a higher BMI (28 vs 26 kg/m2, p=0.002) otherwise there were no differences in characteristics between groups. USHP patients were more likely to undergo concurrent anterior repair (86% vs 70%, p=0.002), posterior repair (84% vs 65%, p=0.001) and incontinence procedures (52% vs 38%, p=0.033). Operative time was longer in the USHP group (125 (105, 160) vs 91 (70, 118) min, p<0.001). 49% of USHP utilized permanent or permanent and delayed absorbable sutures, while 82% of SSHP were performed with delayed absorbable sutures (p<0.001). The 6-week follow up rate was 95% (138 SSHP and 111 USHP patients), at which time there were 4 (1.5%) anatomic failures: 1 (0.7%) SSHP and 3 (2.6%) USHP (p= 0.321) while 25 patients (9.9%) reported bulge symptoms (10%SSHP vs 9.8%USHP) and none underwent retreatment. At 1 year, the follow up rate was 32% (83/261) with no difference between groups. There were 10 (3.8%) anatomic failures: 3 (2%) SSHP and 7 (6.1%) USHP (p=0.109). There was no difference in bulge symptoms(10%), composite failure(13%) or median POP stage (2). Only 8 SSHP and 2 USHP patients had cervical elongation. 50% of the SSHP patients without trachelectomy required surgical retreatment. Of the 4 SSHP patients who underwent trachelectomy, none had retreatment for prolapse though 1 reported bulge symptoms. No USHP patients underwent partial trachelectomy or retreatment for prolapse but 1 patient had anatomic and symptomatic failure. The overall incidence of complications was low (7%) with a higher rate of ureteral kinking in the USHP group (7% vs 1.4%, p=0.023). With median follow up of 17 months, 12 patients (4.6%) underwent subsequent hysterectomy, 11 of which were for recurrent prolapse, with no difference between the groups (6.8%SSHP vs 1.8%USHP, p=0.073). Additionally, 17 patients (6.5%) underwent treatment for uterine/cervical pathology (12 SSHP vs 5 USHP, p=0.313) One year after hysteropexy, 1 in 3 patients were available for follow-up and there were no differences in prolapse recurrence between patients who underwent USHP versus SSHP. The incidence of adverse events was low and less than 5% of patients underwent subsequent hysterectomy for prolapse.