Sacrospinous Colpopexy Research Articles

Easy way for elytrocele treatment by the vaginal route without mesh (with video)

Since elytrocele/enterocele may occur between 0.1% to 10% after hysterectomy, surgical techniques to repair elytrocele should be learnt to master. We propose the step-by-step description of the vaginal technique: dissection and resection of the peritoneal sac followed by a mini-invasive posterior transvaginal sacrospinous colpopexy.

A Study of 52 Cases of Uterovaginal Prolapse by New Procedure Sacro-Spinous Colpopexy in Rajshahi Bangladesh

The analysis intended to evaluate urogenital and defecatory signs, and life conditions ahead of and following a sacrospinous Colpopexy/hysteropexy for uterovaginal prolapse. To prevent recurrence of uterine prolapse and to maintain adequate vaginal length, a new surgical procedure Sacro-spinous Colpopexy was introduced in Rajshahi, Bangladesh. Fifty-two women with indicative uterovaginal prolapse were cured using sacrospinous Colpopexy/hysteropexy. Ahead of and following surgery, urogenital and defecatory signs and life conditions were evaluated with a authenticated question form. Data were obtained using a Standardized questionnaires forms which were completed by the patients. Questionnaires were about their basic demographic information, complaint history, patient obstetric history, gynecological history, patient examination history, patient operations performed, and patient post-operations follow-up. Anatomical results were evaluated by examining the pelvic ahead of and following surgery. The average return sequel timing was 6 months. Grades of all areas of urogenital and defecatory signs, fecal incontinency and pain improved substantially. Additionally, on all areas there is betterment of life and no main difficulties were confronted.

Long-term follow-up of 453 patients with pelvic organ prolapse who underwent transvaginal sacrospinous colpopexy with Veronikis ligature carrier

Sacrospinous ligament fixation (SSLF) is one of the most utilized surgeries in the management of pelvic organ prolapse (POP). We conducted a large-series study of SSLF in a tertiary center by an experienced urogynecologic team. The 453 women with POP who underwent SSLF at National Taiwan University Hospital in the period from 2002 to 2015 are reviewed. All patients received unilateral SSLF with Veronikis ligature carrier. Concomitant anterior colporrhaphy was performed in 75.3% of the cases and posterior colporrhaphy in 78.6%. The mean operation time was 92.3 ± 31.5 minutes. The intraoperative blood loss was 92.3 ± 91.4 ml. The objective cure rate was 82.5%, and 79 (17.5%) patients recurred. The Kaplan-Meier recurrence-free analysis showed a steep decline during the first postoperative year, and the yearly number of recurrent patients decreased as the follow-up period proceeded. A comparison of the site of recurrence found that anterior compartment prolapse was the most common with 57 cases (12.6%). Paravaginal repair is frequently implemented in the management of recurrent anterior prolapse. In conclusion, SSLF provides excellent support to the apex compartment, and our long-term results show that the anterior compartment is the most commonly encountered type of POP recurrence.

The two new surgical techniques for vaginal cuff prolapse and uterine prolapse

Pelvic organ prolapse and vaginal cuff prolapse are clinical conditions that affect women’s quality of life and require surgical treatment. In this study, we aimed to present apical vaginal prolapse and uterine descensus treatment with two new techniques. The classical sacrospinous ligament fixation technique fixes only one or two corners of the vaginal apex to the sacrospinous ligament, but it does not support the upper anterior and posterior vaginal fascia. Since it expands the upper part of the vagina with a suture put on the sides of the vaginal apex, it may not only expose the anterior and posterior vaginal walls to greater intraabdominal pressure and cause cystocele and enterocele development, but lead to sexual problems, as well. Apart from this, if sacrospinous colpopexy is performed to one side only, the vaginal apex is deviated towards the fixation, thus spoiling the vaginal anatomy. With our following methods, we imitate the physiological anatomy: Transapical circular Sacrospinous colpopexy (TACSAC) and Transcervical apical circular Sacrospinous uteropexy (TACSU). TACSAC: Bilateral side walls of the vaginal apex are marked with a color pencil 2 cm medially to the right and left ischial spine and 2 cm in length. Vaginal apex walls are bilaterally and vertically incised until the submucosa layer. Two submucosal tunnels are opened by using a right-angle clamp between the tips of two vertical incisions on the vaginal apex. The vaginal apex is fixed with a TOT mesh through these channels. In TACSU, the same procedure is followed for the cervix. These methods are more likely to mimic normal anatomy, easier to perform, and lower risk of complications.

Modified Sacrospinous Colpopexy with Standard Needle and Needle-Holder: Video Presentation

Modified Sacrospinous Colpopexy with Standard Needle and Needle-Holder: Video Presentation

Responsibility toward affordable healthcare: disposable versus reusable methods for pelvic floor repair.

BackgroundThe adverse publicity surrounding the use of mesh for correction of pelvic organ prolapse has driven a renewed interest in native tissue repair. Established techniques used reusable instruments, while recent innovations have generally involved disposable equipment. Here, we compare outcomes between the two techniques used for sacrospinous ligament fixation for the correction of apical prolapse: Miya Hook (reusable) and Capio® (single-use) suturing devices.MethodsA prospective cohort study of women undergoing vaginal sacrospinous colpopexy or hysteropexy was undertaken. The patients were assessed preoperatively and 1 year post-operatively. The primary outcomes were improvement in vaginal scores and patient-reported absence of a vaginal bulge. Secondary outcomes included impact on sexual function, quality of life, perioperative complications and apical recurrence. The cost of instruments, operative times and length of stay were analyzed.ResultsIn total, 133 women with advanced prolapse in the apical compartment underwent colpopexy or hysteropexy (63 using the reusable Miya Hook and 40 with the disposable Capio device). Mean follow-up was 16.9 months (SD 7.8) and 14 months (SD 3.1), respectively. There were no significant differences in baseline characteristics or preoperative Pelvic Organ Prolapse Quantification staging between the two cohorts. Significant improvements in vaginal scores, sexual function and quality of life (International Consultation on Incontinence Questionnaire – Vaginal Symptoms) were observed in both groups postoperatively (P<0.01). Both groups had low apical recurrence in the medium term (<3%). There were no significant differences in operative times or length of stay. The use of disposable equipment was associated with higher cost.ConclusionSacrospinous fixation using either the Miya Hook or the Capio device is equally effective for the management of apical prolapse. In the absence of clinical benefit, the choice of instrument should reflect the cost in a financially constrained health-sector environment.

Recent trends in the management of pelvic organ prolapse in Australia and New Zealand.

To compare current practice in the management of female pelvic organ prolapse in Australia and New Zealand with that in 2007, and assess the impact on practice of the withdrawal of Prolift® and Prosima® mesh kits in 2015. In early 2015, two invitations to participate in a survey, including a link to Surveymonkey, were emailed to 2506 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) trainees and fellows. The online survey closely resembled a printed survey that was posted to RANZCOG trainees and fellows in 2007 and had additional questions relating to the impact of withdrawal of Prolift® and Prosima® products. Four-hundred-and-three doctors participated, giving a response rate of 16%. Native tissue repair was the procedure of choice for primary and recurrent prolapse of the anterior and posterior vaginal wall. An implant was used to treat 45% of anterior recurrences and 25% of posterior recurrences. Vaginal hysterectomy and repair were the procedures of choice for uterovaginal prolapse. Sacrospinous hysteropexy was the uterine preservation procedure of choice, preferred by 41%. For post-hysterectomy vault prolapse, sacrospinous colpopexy and vaginal repair was preferred by 65% of respondents. Between 2007 and 2015, there was a substantial decrease in respondents' usage of implants across all indications except for midurethral slings and sacrocolpo/hysteropexy. Forty-two percent of respondents changed their practice as a result of Prolift® and Prosima® being withdrawn. There is a trend toward increasing use of various native tissue prolapse repair procedures and midurethral slings, and less utilisation of transvaginal mesh for prolapse.

A descriptive study on the efficacy and complications of the Capio (Boston Scientific) suturing device for sacrospinous ligament fixation.

Sacrospinous colpopexy is an effective vaginal apical support operation. Due to morbidity associated with traditional approaches which require wide dissection, slim-line suture delivery devices have been introduced in the hope of reducing morbidity without compromise to outcomes. The aim of our series was to report outcomes and complications (particularly buttock pain and blood loss) of the sacrospinous colpopexy using the Capio suturing device and evaluate it against published results using the Miya hook. This is a prospective, multi-centre descriptive study. The primary outcome is objective success at 12months. Secondary outcomes include subjective success at 12months, patient-reported outcomes at 12months, operating time, estimated blood loss and post-operative buttock pain. Fifty-one consenting patients undergoing sacrospinous colpopexy were recruited at four Queensland hospitals. Objective success at 12months was 95% (41/43) and subjective success at 12months was 92% (44/48). Eighty-four percent of patients reported buttock pain at oneweek, reducing to 16% by sixweeks, of which 7% required analgesia. At a mean of 17months follow up, we found that the sacrospinous colpopexy using the Capio suturing device provided excellent apical support with a low requirement for blood transfusion and an average operating time of sevenminutes. We found a high rate of buttock pain immediately post-operatively, but our rates became consistent with previous reports by sixweeks post-operation.

Sacrospinous hysteropexy: review and meta-analysis of outcomes.

Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery. Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration's Review Manager software to perform meta-analysis of randomized controlled studies and observational studies. Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n = 651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76-5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41-2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy. Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.

Readmission and Prolapse Recurrence After Abdominal and Vaginal Apical Suspensions in Older Women.

Our objective was to evaluate 30-day readmission, 12-month prolapse recurrence, and complications after apical surgeries in older women. A retrospective cohort study was conducted using 2002-2011 Medicare data in women 65 years or older who underwent abdominal sacrocolpopexy with synthetic mesh, vaginal uterosacral, or sacrospinous colpopexy with 12 months follow-up. Vaginal mesh procedures were excluded. The primary outcome was 30-day inpatient readmission. Secondary outcomes were complications and prolapse recurrence, defined as either reoperation or pessary insertion. We used Pearson χ, Fisher exact tests, and analyses of variance to examine difference between surgical treatment groups. Odds ratios (ORs) utilizing Charlson Comorbidity Index, age, race, and procedure type were calculated to assess the differences in the outcomes probability. Of 3,015 women, 863 underwent abdominal sacrocolpopexy, 510-uterosacral and 1,642-sacrospinous ligament suspensions. The 30-day readmission was 7.4% (95% confidence interval [CI] 5.7-9.2%; OR 2.4, 95% CI 1.7-3.5, P<.01) after abdominal sacrocolpopexy and 4.5% (95% CI 2.7-6.3%; OR 1.3, 95% CI 0.8-2.1, P=.3) after uterosacral compared with 3.5% (95% CI 2.6-4.4% P<.01) after sacrospinous ligament suspensions. Prolapse recurrence did not differ between the groups (8.2%, 95% CI 6.4-10.1%; 10.6%, 95% CI 7.9-13.3%; and 9.9%, 95% CI 8.4-11.3%, P=.3, respectively). Women had 30-day gastrointestinal complications (6.1%, 95% CI 4.5-7.7%; 1.2%, 95% CI 0.2-2.1%; and 1.1%, 95% CI 0.6-1.6%, P<.01), surgical site infections (5.9%, 95% CI 4.3-7.5%; 3.1%, 95% CI 1.6-4.7%; and 3.7%, 95% CI 2.8-4.6%, P=.01), genitourinary complications (10.9%, 95% CI 8.8-13%; 17.7%, 95% CI 14.3-21%; and 13.6%, 95% CI 12-15.3%, P<.01), and medical complications (7.4%, 95% CI 5.7-9.2%; 7.8%, 95% CI 5.5-10.2%; and 4.4%, 95% CI 3.4-5.4%, P<.01; all after abdominal sacrocolpopexy, uterosacral, and sacrospinous ligament suspensions, respectively). Vaginal apical suspensions compared with abdominal sacrocolpopexy with synthetic mesh are associated with lower rates of postoperative 30-day readmission without an increase in prolapse recurrence among older women.

Abdominal Sacrocolpopexy versus Sacrospinous Colpopexy: A Prospective Analysis

Abdominal Sacrocolpopexy versus Sacrospinous Colpopexy: A Prospective Analysis

Impact of Sacrospinous Colpopexy Associated with Anterior Colporrhaphy for the Treatment of Dome Prolapse on all Three Vaginal Compartments.

To evaluate the results of sacrospinous colpopexy surgery associated with anterior colporrhaphy for the treatment of women with post-hysterectomy vaginal vault prolapse. This prospective study included 20 women with vault prolapse, Pelvic Organ Prolapse Quantification System (POP-Q) stage ≥ 2, treated between January 2003 and February 2006, and evaluated in a follow-up review (more than one year later). Genital prolapse was evaluated qualitatively in stages and quantitatively in centimeters. Prolapse stage < 2 was considered to be the cure criterion. Statistical analysis was performed using the Wilcoxon test (paired samples) to compare the points and stages of prolapse before and after surgery. Evaluation of the vaginal vault after one year revealed that 95% of subjects were in stage zero and that 5% were in stage 1. For cystocele, 50% were in stage 1, 10% were in stage 0 (cured) and 40% were in stage 2. For rectocele, three women were in stage 1 (15%), one was in stage 2 (5%) and 16 had no further prolapse. The most frequent complication was pain in the right buttock, with remission of symptoms in all three cases three months after surgery. In this retrospective study, the surgical correction of vault prolapse using a sacrospinous ligament fixation technique associated with anterior colporrhaphy proved effective in resolving genital prolapse. Despite the low complication rates, there was a high rate of cystocele, which may be caused by posterior vaginal shifting due to either the technique or an overvaluation by the POP-Q system.

Prevention, Recognition, and Management of Complications Associated with Sacrospinous Colpopexy

The purpose of this video is to describe the anatomy surrounding the sacrospinous ligament and highlight techniques to prevent and manage potential complications associated with sacrospinous colpopexy. Sacrospinous colpopexy is a commonly performed procedure for vaginal apex prolapse. We present a video that contains a detailed description of the anatomic structures surrounding the sacrospinous ligament. A brief overview of the surgical techniques for performing a sacrospinous colpopexy are included. Lastly, we review the known complications of sacrospinous colpopexy and discuss potential management strategies. Reconstructive pelvic surgeons should have an extensive knowledge of the anatomy surrounding the sacrospinous ligament. By understanding these anatomical relationships, the pelvic surgeon will then be able to prevent and manage potential complications associated with sacrospinous colpopexy.

Posterior repair quantification (PR-Q) using key anatomical indicators (KAI): preliminary report.

Posterior vaginal compartment repairs (PR) have traditionally involved a subjective approach. We aim to quantify such repairs using key anatomical indicators (KAI). At 50 consecutive PRs: perineal gap (PG); posterior vaginal vault descent (PVVD); mid-vaginal laxity (MVL-vault undisplaced/displaced); and recto-vaginal fascial laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded. A mean preoperative PG of 2.5 cm was reduced to 0.0 cm postoperatively by excision (100 % cases) with an average increase of 21.6 % in total vaginal length over that if the repair was commenced at the hymen. There was an average reduction of 25.0 % in the genital hiatus (GH). Mean PVVD was 5.3 cm overall; 6.4 cm for 31 out of 50 (62 %) undergoing sacrospinous colpopexy; 3.5 cm for 19 out of 50 (38 %) with no ligamentous vault fixation. An approximate "cut-off" for PVVD of 5 cm may assist with the differentiation of cases where vault fixation may be desirable. Up to 52 % (1.4/2.7 cm) of preoperative MVL displacement was due to vaginal vault descent. The MVL undisplaced (mean 1.3 cm) may better guide vaginal mucosal trimming. RVFL averaged just 0.8 cm with 22 out of 50 (44 %) RVFL being 0.5 cm or less, and not requiring any RVF plicatory sutures. It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL, and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal mucosa, and recto-vaginal space respectively.

Comparison of vaginal mesh repair with sacrospinous vaginal colpopexy in the management of vaginal vault prolapse after hysterectomy in patients with levator ani avulsion: a randomized controlled trial

To compare the efficacy of two standard surgical procedures for post-hysterectomy vaginal vault prolapse in patients with levator ani avulsion. This was a single-center, randomized interventional trial, of two standard surgical procedures for post-hysterectomy vaginal vault prolapse: Prolift Total vs unilateral vaginal sacrospinous colpopexy with native tissue vaginal repair (sacrospinous fixation, SSF), during the period from 2008 to 2011. Entry criteria included at least two-compartment prolapse, as well as complete unilateral or bilateral levator ani avulsion injury. The primary outcome was anatomical failure based on clinical and ultrasound assessment. Failure was defined clinically, according to the Pelvic Organ Prolapse Quantification system, as Ba, C or Bp at the hymen or below, and on translabial ultrasound as bladder descent to 10 mm or more below the lower margin of the symphysis pubis on maximum Valsalva maneuver. Secondary outcomes were evaluation of continence, sexual function and prolapse symptoms based on validated questionnaires. During the study period, 142 patients who were post-hysterectomy underwent surgery for prolapse in our unit; 72 of these were diagnosed with an avulsion injury and were offered participation in the study. Seventy patients were randomized into two groups: 36 in the Prolift group and 34 in the SSF group. On clinical examination at 1-year follow-up, we observed one (3%) case of anatomical failure in the Prolift group and 22 (65%) in the SSF group (P < 0.001). Using ultrasound criteria, there was one (2.8%) failure in the Prolift group compared with 21 (61.8%) in the SSF group (P < 0.001). The postoperative POPDI (Pelvic Organ Prolapse Distress Inventory) score for subjective outcome was 15.3 in the Prolift group vs 21.7 in the SSF group (P = 0.16). In patients with prolapse after hysterectomy and levator ani avulsion injury, SSF has a higher anatomical failure rate than does the Prolift Total procedure at 1-year follow-up.

The Outcome of Transvaginal Sacrospinous Colpopexy : King Hussein Medical Center Short Term Experience

Results: The diagnosis of patients whom were operated included uterine prolpse in 23(72%) patients and vaginal vault prolapse in 9 (28%) patients. The operation was successful in 97% of the patients. During follow-up period, the operation was complicated with urinary tract infection in 3 (9%) patients and 2(6%) patients with low back pain. We had not encountered any intra-operative complications in relation to the procedure. Conclusion: The success rate for vaginal sacrospinous colpopexy operation was 97% in our series with minimal perioperative complications. It may be concluded that vaginal sacrospinous colpopexy may be safely combined with other vaginal surgeries for patients with uterovaginal prolapse.

Apical prolapse

The aim was to review the safety and efficacy of pelvic organ prolapse surgery for vaginal apical prolapse. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials (RCT) or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Abdominal sacral colpopexy (ASC) has a higher success rate than sacrospinous colpopexy with less SUI and postoperative dyspareunia for vault prolapse. ASC had greater morbidity including operating time, inpatient stay, slower return to activities of daily living and higher cost (grade A). ASC has the lowest inpatient costs compared with laparoscopic sacral colpopexy (LSC) and robotic sacral colpopexy (RSC). LSC has lower inpatient costs than RSC (grade B).In single RCTs the RSC had longer operating time than both ASC and LSC (grade B). In small trials objective outcomes appear similar although postoperative pain was greater in RSC. LSC is as effective as ASC with reduced blood loss and admission time (grade C). The data relating to operating time are conflicting. ASC performed with polypropylene mesh has superior outcomes to fascia lata (level I), porcine dermis and small intestine submucosa (level 3; grade B). In a single RCT, LSC had a superior objective and subjective success rate and lower reoperation rate compared with polypropylene transvaginal mesh for vault prolapse (grade B).Level 3 evidence suggests that vaginal uterosacral ligament suspension, McCall culdoplasty, iliococcygeus fixation and colpocleisis are relatively safe and effective interventions (grade C). Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse. Polypropylene mesh is the preferred graft at ASC. Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy.

Where to for pelvic organ prolapse treatment after the FDA pronouncements? Comment

Dear Editor, With great interest I read the recently published article in the International Urogynecology Journal from Van Geelen and Dwyer titled “Where to for pelvic organ prolapse treatment after the FDA pronouncements?” [1]. One of the issues the authors try to address is the ongoing debate on the optimal approach for apical prolapse repair. They state that there is level I evidence that abdominal sacrocolpopexy (ASC), either by laparotomy or laparoscopy or with the aid of a robotic device, is more effective and durable in correcting anterior and apical anatomy than the vaginal approach using sacrospinous colpopexy. As a reference, they use an article byMaher et al. published in 2004 [2]. In this article, ASC is compared with vaginal sacrospinous colpopexy in 95 women. The objective success rate was 76 % in the abdominal group and 69 % in the vaginal group (P=0.48). The abdominal approach was associated with a longer operating time, a slower return to activities of daily living, and a greater cost than the sacrospinous colpopexy (P<0.01). Both surgeries significantly improved the patient’s quality of life (P<0.05). The subjective success rate was 94% in the abdominal and 91 % in the vaginal group (P=0.19). This level I evidence does not support the above-mentioned statement of the authors that ASC is more effective than vaginal sacrospinous colpopexy. On the contrary, it shows that there is no significant difference in terms of objective and subjective cure rate between ASC and vaginal sacrospinous colpopexy. Also, it does not justify the extrapolation of ASC data by laparotomy to other techniques, such as laparoscopy or robotassisted laparoscopy. In this light, the recently published article by Nygaard et al. is also very interesting [3]. These authors temper the general feeling that ASC is superior in terms of durability. By year 7, the estimated probability of composite (symptomatic or anatomic) pelvic organ prolapse failure after abdominal sacrocolpopexy was 0.48 when combined with a Burch urethropexy and 0.34 without a Burch urethropexy.

Where to for pelvic organ prolapse treatment after the FDA pronouncements? Reply to Pelikan

Dear Editor, We thank Dr. Pelikan [1] for his interest and comments regarding our review article on the treatment of pelvic organ prolapse (POP) after the US Food and Drug Administration (FDA) pronouncements [2]. The author rightly observes that the study by Maher et al. [3] does not support the statement that abdominal sacral colpopexy (ASC) is more effective than vaginal sacrospinous colpopexy (VSC). Indeed, in their randomized controlled trial (RCT) study comparing ASC and VSC, they conclude that both procedures are highly effective for treating vaginal vault prolapse. There were no differences in subjective and objective success rates between the two groups after 2 years follow-up. The International Consultation on Incontinence (ICI) committee reviewed surgery for POP [4] and identified three RCTs designed to compare vaginal and abdominal routes for surgical correction, including Maher et al.’s study [3]. The results are summarized in a Cochrane review byMaher et al. [5] in which they state that these trials provide level I evidence that the overall outcome (including quality of life) is similar between abdominal and vaginal approaches but that sacrospinousbased vaginal procedures have higher anterior and apical anatomical and dyspareunia recurrence rates than ASC. This is somewhat offset by the higher short-term morbidity of open abdominal sacrocolpopexy [4]. Therefore we should have referred to reference 10 instead of reference 14 in our manuscript to support the statement of higher apical success of ASC. A recently published study by Nygaard et al. on the longterm (7 years) outcomes following ASC for POP, with or without Burch urethropexy, reported increasing failure rates after 7 years, which emphazises the need for RCTs with longterm follow-up [6].

Vaginal Hysterectomy and Sacrospinous Colpopexy for Uterovaginal Prolapse : Anatomical and Functional Outcomes = استئصال الرحم بطريق المهبل و تثبيت المهبل للرباط العجزي الشوكي في حالات تدلي الرحم المهبلي : النتائج التشريحية و الوظيفية

Objective: The surgical management of pelvic organ prolapse requires a combination of techniques. This study evaluated the anatomical outcomes, functional outcomes and complications of vaginal hysterectomy and sacrospinous colpopexy in women with uterovaginal prolapse. Methods: We retrospectively evaluated 85 women who underwent vaginal hysterectomy and sacrospinous colpopexy over a period of 3 years. The primary outcome measures included anatomical outcome success rates (as assessed by pelvic organ prolapse quantification, POP-Q), pelvic floor function outcomes and complication rates. Results: At a mean follow-up duration of 35 months (range: 12-60), the overall objective success (for all compartments) was 81% (69/85), while the objective success rates for the anterior, posterior and apical compartments were 82% (70/85), 89% (76/85) and 92% (78/85). Respectively, there were no stage 3 or 4 recurrences at any site. Overactive bladder (OAB) symptoms improved significantly following the surgery, while new-onset stress urinary incontinence occurred in 5 patients. There was no significant change in sexual activity or dyspareunia. Surgical complications were minor. Conclusions: The combination of vaginal hysterectomy and sacrospinous colpopexy for the treatment of uterovaginal prolapse is reasonably effective in restoring pelvic anatomy and results in favourable pelvic function with an acceptable complication rate.