Sacrospinous Ligament Suspension Research Articles

Three-year outcomes of a randomized clinical trial of perioperative vaginal estrogen as adjunct to native tissue vaginal apical prolapse repair

As the muscular and connective tissue components of the vagina are estrogen responsive, clinicians may recommend vaginal estrogen to optimize tissues preoperatively and as a possible means to reduce prolapse recurrence, but long-term effects of perioperative intravaginal estrogen on surgical prolapse management are uncertain. This study aimed to compare the efficacy of perioperative vaginal estrogen vs placebo cream in reducing composite surgical treatment failure 36 months after native tissue transvaginal prolapse repair. This was an extended follow-up of a randomized superiority trial conducted at 3 tertiary US sites. Postmenopausal patients with bothersome anterior or apical vaginal prolapse were randomized 1:1 to 1-g conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally twice weekly for ≥5 weeks preoperatively and continued twice weekly for 12 months postoperatively. All participants underwent vaginal hysterectomy (if the uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The primary report's outcome was time to failure by 12 months postoperatively, defined by a composite outcome of objective prolapse of the anterior or posterior walls beyond the hymen or the vaginal apex descending below one-third the total vaginal length, subjective bulge symptoms, and/or retreatment. After 12 months, participants could choose to use-or not use-vaginal estrogen for atrophy symptom bother. The secondary outcomes included Pelvic Organ Prolapse Quantification points, subjective prolapse symptom severity using the Patient Global Impression of Severity and the Patient Global Impression of Improvement, and prolapse-specific subscales of the 20-Item Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire-Short Form 7. Data were analyzed as intent to treat and "per protocol" (ie, ≥50% of expected cream use per medication diary). Of 206 postmenopausal patients, 199 were randomized, and 186 underwent surgery. Moreover, 164 postmenopausal patients (88.2%) provided 36-month data. The mean age was 65.0 years (standard deviation, 6.7). The characteristics were similar at baseline between the groups. Composite surgical failure rates were not significantly different between the estrogen group and the placebo group through 36 months, with model-estimated failure rates of 32.6% (95% confidence interval, 21.6%-42.0%) and 26.8% (95% confidence interval, 15.8%-36.3%), respectively (adjusted hazard ratio, 1.55; 95% confidence interval, 0.90-2.66; P=.11). The results were similar for the per-protocol analysis. Objective failures were more common than subjective failures, combined objective and subjective failures, or retreatment. Using the Patient Global Impression of Improvement, 75 of 80 estrogen participants (94%) and 72 of 76 placebo participants (95%) providing 36-month data reported that they were much or very much better 36 months after surgery (P>.99). These data included reports from 51 of 55 "surgical failures." Pelvic Organ Prolapse Quantification measurements, Patient Global Impression of Severity scores, and prolapse subscale scores of the 20-Item Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire-Short Form 7 all significantly improved for both the estrogen and placebo groups from baseline to 36 months postoperatively without differences between the groups. Of the 160 participants providing data on vaginal estrogen usage at 36 months postoperatively, 40 of 82 participants (49%) originally assigned to the estrogen group were using prescribed vaginal estrogen, and 47 of 78 participants (60%) assigned to the placebo group were using vaginal estrogen (P=.15). Adjunctive perioperative vaginal estrogen applied ≥5 weeks preoperatively and 12 months postoperatively did not improve surgical success rates 36 months after uterosacral or sacrospinous ligament suspension prolapse repair. Patient perception of improvement remained very high at 36 months.

Characteristics Associated With Surgical Failure After Native Tissue Apical Prolapse Repair.

To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair. This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosacral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with P <.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model. One hundred eighty-six participants underwent surgery; 183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.86-0.98, P =.016). Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair. ClinicalTrials.gov , NCT02431897.

Nerve relationships to the sacrospinous ligament: application to suspension procedures and transgluteal approaches for nerve repair and tumor removal with three case illustrations.

Transvaginal suspension procedures often use the sacrospinous ligament (SSL), which attaches onto the ischial spine (IS). However, nerve-related sequelae (e.g., sciatic nerve injury) following such procedures have been reported. Therefore, the current anatomical study was performed to better understand these relationships. Additionally, three case illustrations of patients with injury to the sciatic nerve following sacrospinous ligament suspension procedures are included to exemplify the significance of a thorough knowledge of this anatomy. In 20 human adult cadavers (40 sides), a gluteal dissection was performed to expose the IS and SSL and regional nerves near the greater sciatic foramen. Measurements between the IS and SSL were made between these structures and surrounding nerves. The average distance between the IS and sciatic nerve was 1.4cm. From this bony part, the average distance to the S1 and S2 ventral rami was 3.1cm and 1.9cm, respectively. From the IS to the lumbosacral trunk, pudendal nerve, nerve to obturator internus, and superior gluteal nerve, the mean distance was 4cm, 0.5cm, 0.7cm, and 4.5cm, respectively. From the SSL to the lumbosacral trunk, S1 ventral ramus, and S2 ventral ramus, there was an average distance of 4.2cm, 1.6cm, and 0.8cm, respectively. Statistically, in females, the distances from the IS and SSL to the sciatic nerve, lumbosacral trunk, superior gluteal nerve, and S1 and S2 ventral rami were shorter when compared to males. An improved understanding of the relationship between the SSL and IS and nerves near the greater sciatic foramen can lead to fewer intraoperative complications during approaches to various peripheral nerves in this region. Lastly, these relationships might help better understand the nerve injuries following pelvic suspension procedures that use the SSL.

Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis.

To explore how permanent compared with absorbable suture affects anatomic success in native tissue vaginal suspension (uterosacral ligament suspension and sacrospinous ligament suspension) and sacrocolpopexy with mesh. MEDLINE, EMBASE, and ClinicalTrials.gov were searched through March 29, 2022. Our population included women undergoing apical prolapse surgery (uterosacral ligament suspension and sacrospinous ligament suspension and abdominal sacrocolpopexy). Our intervention was permanent suture for apical prolapse surgery, and our comparator was absorbable suture. We determined a single anatomic success proportion per study. Adverse events collected included suture and mesh exposure, surgery for suture and mesh complication, dyspareunia, and granulation tissue. Abstracts were doubly screened, full-text articles were doubly screened, and accepted articles were doubly extracted. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. In single-arm studies using either permanent or absorbable suture, random effects meta-analyses of pooled proportions were used to assess anatomic success. In comparative studies investigating both suture types, random effects meta-analyses of pooled risk ratios were used. Of 4,658 abstracts screened, 398 full-text articles were assessed and 63 studies were included (24 vaginal suspension [13 uterosacral ligament suspension and 11 sacrospinous ligament suspension] and 39 sacrocolpopexy). At 2-year follow-up, there was no difference in permanent compared with absorbable suture in uterosacral ligament suspension and sacrospinous ligament suspension (proportional anatomic success rate 88% [95% CI 0.81-0.93] vs 88% [95% CI 0.82-0.92]). Similarly, at 18-month follow-up, there was no difference in permanent compared with absorbable suture in sacrocolpopexy (proportional anatomic success rate 92% [95% CI 0.88-0.95] vs 96% [95% CI 0.92-0.99]). On meta-analysis, there was no difference in relative risk (RR) of success for permanent compared with absorbable suture for uterosacral ligament suspension and sacrospinous ligament suspension (RR 1.11, 95% CI 0.93-1.33) or sacrocolpopexy (RR 1.00, 95% CI0.98-1.03). Success rates were similarly high for absorbable and permanent suture after uterosacral ligament suspension, sacrospinous ligament suspension, and sacrocolpopexy, with medium-term follow-up. PROSPERO, CRD42021265848.

Comparison of High Uterosacral and Sacrospinous Ligament Suspension Surgeries for the Treatment of Pelvic Organ Prolapse in Women.

Pelvic floor disorders include urinary incontinence, fecal incontinence, and pelvic floor prolapse, which are common complaints in women. Patients that suffer from uterine prolapse could benefit from surgical procedures that stabilize pelvic ligaments. Here, we aimed to compare the high uterosacral and sacrospinous ligament suspension surgeries. This clinical trial was performed in 2019-2021 on 64 women with uterine prolapse. Demographic data of the patients, including age, body mass index (BMI), past medical diseases, history of delivery, type of delivery, and duration of hospitalization, were collected. We assessed their urinary symptoms, prolapse degree, and sexual symptoms using the Female Sexual Function Index (FSFI) and Pelvic Floor Disability Index (PFDI-20) questionnaires before surgical interventions. Patients were divided into two groups undergoing high uterosacral and sacrospinous ligament suspension. They were followed up 6 and 12 months after surgeries. Patients treated with sacrospinous ligament suspension had higher frequencies of surgical complications (P = 0.039), and the most common complication was low back pain (15.6%). The uterine prolapse andC point degree improved significantly in all cases after 6 and 12 months (P < 0.001). The Pelvic Organ Prolapse Quantifications System (POP-Q) scores improved significantly in both groups 6 and 12 months after surgery (P < 0.001), and patients who underwent sacrospinous ligament suspension had significantly lower pain intensity compared to the other group (P = 0.003). FSFI scores improved significantly in patients treated in both groups (P < 0.001). Both high uterosacral and sacrospinous ligament suspension techniques significantly improved pain, uterine prolapse, and C point degree.

8097 How Do You Do It? a Survey on the Preferences of Surgeons Regarding Uterosacral Ligament Suspension (USLS) Technique

<h3>Study Objective</h3> To describe the practice patterns and techniques for performing uterosacral ligament suspension (USLS) for the treatment of apical prolapse. <h3>Design</h3> Web-based survey performed from October 2021 to April 2022. Study was IRB exempt. Data was collected in RedCap. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> Members of AUGS, IUGA, AAGL, and UGSA. <h3>Interventions</h3> A 31-item, deidentified questionnaire. <h3>Measurements and Main Results</h3> We received a total of 595 responses, mostly from the United States (40.7%) and Australia (7.9%). Most of the respondents were Obstetrics and Gynecology and FPMRS specialists (67.9%), followed by general Obstetrics and Gynecology (16.8%) and MIGS (8.4%). Most surgeons were more than 20 years in practice (33.9%) and 49% perform >100 surgeries/year with a mean of 67.7% of cases being for apical support procedures. USLS is the most common apical support surgery taught during their fellowship (44.4%), followed by sacrospinous ligament suspension - SSLS (35.8%) and sacrocolpopexy - SCP (19.9%). Regarding preferences, USLS is performed by 46.3% of respondents >40% of the time for apical support, while 29.1% and 20.1% perform SSLS and SCP, respectively. Vaginal route (72.8% > 60% time) and ipsilateral (64.3%) high USLS technique were the most common route and technique performed. When placing sutures vaginally, 32.3% of respondents used delayed absorbable suture, followed by 24.3% absorbable sutures. Two sutures were the most common choice for ipsilateral or midline USLS plication. There was even distribution between placing sutures at the level of the ischial spine (46.6%) or above the level of the ischial spine (36.4%). A third of surgeons that perform lap/robotic/open USLS perform a relaxing peritoneal incision. Eighteen percent of surgeons routinely identify the inferior hypogastric plexus. Routine cystoscopy is performed by 65.2% and 73.2% of surgeons that perform, respectively, lap/robotic/open and vaginal USLS. <h3>Conclusion</h3> There is significant heterogeneity in the techniques to perform a uterosacral ligament suspension for apical prolapse. Standardization is recommended for future surgical studies.

Predictors of persistent overactive bladder following surgery for advanced pelvic organ prolapse.

Reliable risk factors for persistent urgency following pelvic organ prolapse (POP) surgery are still unclear. We aimed to identify preoperative parameters related to persistent postoperative urgency in a cohort of women following surgery for POP stage 3-4 with concomitant overactive bladder (OAB). In this retrospective analysis, women with POP stage 3-4 and OAB who underwent POP repair during November 2012-December 2020 were included. Preoperative evaluation included history, Pelvic Organ Prolapse Quantification (POP-Q), multi-channel urodynamic studies and Pelvic Floor Distress Inventory (PFDI-20). Surgical procedures included: anterior and posterior colporrhaphy, sacrospinous ligament suspension, anterior vaginal wall mesh repair and robotic-assisted laparoscopic sacrocolpopexy. At the 12-month follow-up, urogynecological history, POP-Q evaluation, cough stress test and the PFDI-20 questionnaire were repeated. One hundred seventy-three patients were included in the analysis. Resolution of urgency was observed in 56% of women. Variables associated with persistent postoperative urgency included body mass index (BMI) (27 kg/m2 vs 25.7 kg/m2, p = 0.04), preoperative increased daytime frequency (46.39% vs 61.84%, p = 0.05), urgency urinary incontinence (UUI) (51.46% vs 80.26%, p = 0.0001), detrusor overactivity (DO) (40.2% vs 61.84%, p = 0.009) and lower maximum flow rate on UDS (13.9 ml/s vs 15 ml/s, p = 0.04). Multivariate analysis confirmed preoperative DO (OR: 12.2 [95% CI: 1.4-16.6]; p = 0.01), preoperative UUI (OR 3.8 [95% CI: 1.3-11.0]; p = 0.008) and BMI > 25 kg/m2 (OR 1.8 [95% CI: 1.1-7.2]; p = 0.04) as predictive factor for persistent urgency. In women with advanced POP and OAB, being overweight, preoperative UUI and DO are related to persistent postoperative urgency. These findings will guide our future preoperative counseling and reinforce the role of UDS in POP management.

Single-port laparoscopic sacrospinous ligament suspension via the natural vaginal cavity (SvNOTES) for pelvic prolapse: The first feasibility study.

ObjectiveThis study aims to investigate the feasibility and short-term efficacy of single-port laparoscopic-assisted transvaginal natural cavity endoscopic sacrospinous ligament suspensions (SvNOTES).MethodsA total of 30 patients diagnosed with anterior or/and middle pelvic organ prolapse Stages III and IV underwent natural vaginal cavity (SvNOTES), and 30 patients who underwent conventional sacrospinous ligament (SSLF) were used as a control group. The operation time, blood loss, postoperative POP-Q score, length of hospital stay, and complications were compared between the two groups.ResultsThe operation time for SvNOTE was (60 ± 13) min, which was longer than (30 ± 15) min for SSLF (P = 0.04). However, the bleeding amount in SvNOTE was 29.44 ± 2.56, significantly lower than that in the SSLF group (80 ± 10; P = 0.02), and the postoperative hospital stay in the SvNOTE group was (4 ± 2) days, longer than (3 ± 1) days in SSLF (P = 0.02). However, there were no intraoperative complications in the SvNOTE group, whereas one ureteral injury occurred in the SSLF group; in addition, the postoperative POP-Q score was significantly better in the SvNOTE group than that in the SSLF group with increasing time (P < 0.001).ConclusionCompared with SSLF, single-port laparoscopic sacrospinous ligament suspension via the natural vaginal cavity is visualized, greatly improving the success rate of sacrospinous ligament fixation, with less blood loss and fewer complications, arguably a safer and minimally invasive surgical approach.

Perioperative and Long-Term Anatomical and Subjective Outcomes of Laparoscopic Pectopexy and Sacrospinous Ligament Suspension for POP-Q Stages II-IV Apical Prolapse.

The aim of this paper was to analyze perioperative and long-term outcomes in 114 women undergoing surgery for POP-Q ≥ 2 apical prolapse: sacrospinous ligament colpo/hysteropexy (SSLF/SSHP)—61; laparoscopic pectopexy (LP)—53. Validated questionnaires (PGI-I, ISI, #35 EPIQ, PFIQ-7, PFDI-20) were completed at baseline and follow-up. POP-Q stages II, III and IV were diagnosed in 1 (0.9%), 84 (73.7%) and 29 (25.4%) patients, respectively. Mean operative time and hospital stay were 151.8 ± 36.2 min/2.6 ± 1.1 days for LP and 69 ± 20.4 min (p < 0.001)/2.7 ± 1.0 days for SSLF. Severe intraoperative complications occurred in two (1.8%) patients. Mean follow-up was 26.9 ± 12 and 37.3 ± 17.5 months for LP and SSLF, respectively. At follow-up, significant improvement for all POP-Q points was observed in both groups (p < 0.001). Shortening of total vaginal length was found in both groups, but predominantly in SSLF patients (p = 0.01). The sensation of vaginal bulge (EPIQ) was reduced, and total PFDI-20 and PFIQ-7 scores improved (p < 0.04) in both groups. Subjective success was reported by 40 (75.5%) LP and 44 (72.1%) SSLF patients. ISI detected no deterioration in urinary incontinence. PGI-I, PFDI-20, #35 EPIQ, PFIQ-7 and ISI did not differ between the groups. In conclusion both, SSLF and LP for apical prolapse generate good anatomical and subjective outcomes, with protective effect on the anterior compartment observed for LP.

Urinary basement membrane graft-augmented sacrospinous ligament suspension: a description of technique and short-term outcomes.

Since the discontinuation of manufacture and distribution of surgical mesh for transvaginal prolapse repair, the use of biologic grafts for transvaginal apical suspension has gained renewed attention. However, there is no FDA-approved device and minimal published data describing such an approach. The objective of this video is to describe a technique and to present limited short-term outcomes utilizing a porcine urinary basement membrane (UBM) graft to perform an augmented bilateral sacrospinous ligament suspension (SSLS). We present a step-by-step overview of our technique to perform an augmented SSLS with off-label utilization of a 7- × 10-cm porcine UBM graft. We demonstrate graft shaping and application during transvaginal repair along with data describing perioperative outcomes associated with a series of 25 cases performed at our institution using the technique described. No perioperative complications related to the graft were observed in our cohort. The most common postoperative concern was buttock pain, which spontaneously resolved within 6 months. Two individuals (8%) developed recurrent prolapse within 1 year of surgery. The UBM-augmented apical suspension allows for reinforced transvaginal prolapse repair without the use of permanent mesh material. We have observed good clinical success in our application of this technique, but dedicated research assessing long-term outcomes compared with a native tissue repair is needed.

Deep Pelvic Side Wall Anatomy: A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area

Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy [1-3]. Case presentation with showing anatomic structures in detail. Tertiary academic teaching hospital. A 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension 9 years ago presented with fever and was found to have bacteremia. Abdomen and pelvic magnetic resonance imaging showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections.Transgluteal drain placed with cultures growing Streptococcus constellatus and Gemella morbillorum. Blood cultures grew same bacteria. She was started on vancomycin, cefepime, and metronidazole and was transitioned to ceftriaxone with a plan for 6-week antibiotic course. Her blood sugar levels were well controlled during hospitalization with baseline insulin and moderate sliding scale. Physical therapy started preoperative and continued postoperative. She was managed with an interdisciplinary team of gynecologists, urogynecologists, orthopedic doctors, neurosurgeons, nutritionists, infectious disease doctors, endocrinologists, hematologists, rehabilitation specialists, and physical therapists. This video showcases laparoscopic resection of sacrospinous fistula tract. Postoperative pathology result showed squamous mucosa, submucosa, and deep soft tissue with a submucosal abscess surrounded by fibrosis, consistent with a fistula tract. Preoperative planning is of paramount importance in cases with multiple comorbidities. Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection. Knowing the precise anatomy of critical structures close to the area of interest is crucial.

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

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)

An Unusual Complication of Gluteal Fistula after Sacrospinous Ligament Suspension: A Case Report

Background: Sacrospinous ligament suspension (SSLS), also referred to as sacrospinous ligament fixation, is a well-established transvaginal procedure performed to treat apical prolapse. Serious complications are uncommon following SSLS, and mild infectious complications, such as cystitis, are most common. In this report, we present an uncommon case of gluteal fistula as a complication of this procedure. Case: A multiparous 48-year-old with a history of vaginal hysterectomy with bilateral salpingectomy, anterior and posterior colporrhaphy, and sacrospinous ligament suspension presented one year later with multiple emergency department visits for gluteal abscesses and continuous right gluteal drainage. MRI confirmed a gluteal fistula extending from the sacrum to the right gluteal fold and right piriformis muscle, thought to be caused by retained suture. The patient subsequently underwent an exam under anesthesia in which the reproduction of the vaginal dissection performed to place the SSLS sutures and probing of the fistula failed to expose any suture. The fistula was copiously irrigated with antibiotic solution, and on a 2-week postoperative visit, the fistula was noted to be completely healed. Conclusion: This is a rare case of gluteal fistula as a complication of SSLS procedure. In this case, the suspected retained suture causing the fistula was not identified; however, the fistula was still able to heal

Comparison of the Functional and Anatomical Outcomes of Abdominal Sacrocolpopexy and Vaginal Sacrospinous Ligament Suspension for the Treatment of Apical Prolapse

Comparison of the Functional and Anatomical Outcomes of Abdominal Sacrocolpopexy and Vaginal Sacrospinous Ligament Suspension for the Treatment of Apical Prolapse

Deep Pelvic Side Wall Anatomy; A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area

<h3>Study Objective</h3> Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy. <h3>Design</h3> Case presentation. <h3>Setting</h3> Tertiary medical center. <h3>Patients or Participants</h3> 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension nine years ago, presented with fever and found to have bacteremia. Abdominal and pelvic MRI showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. <h3>Interventions</h3> Laparoscopic resection of sacrospinous fistula tract. <h3>Measurements and Main Results</h3> The patient showed significant improvement in her symptoms with resolution of low back pain, vaginal discharge and bleeding. <h3>Conclusion</h3> Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection.

Randomized Clinical Trial of Gabapentin Versus Placebo for Pain After Sacrospinous Ligament Fixation

Given the risk of postoperative pain and specifically neuropathic gluteal pain after a sacrospinous ligament suspension, we conducted a randomized trial to compare a 2-week course of gabapentin versus placebo on postoperative pain after a sacrospinous ligament fixation. This double-blinded, randomized, placebo-controlled trial compared 2 weeks of gabapentin (300 mg nightly for 3 days and then 300 mg twice a day for 11 days) versus identical-appearing placebo after a sacrospinous ligament fixation procedure. The primary outcome was participant-reported average pain during normal activity in the past 24 hours (score 0-10 on the validated Surgical Pain Scale) assessed on postoperative day (POD) 7. We also assessed average pain at rest and gluteal (buttocks) pain (score 0-10). We needed 17 participants per group to detect a 2.5-point difference in Surgical Pain Scale score with an SD of 2.6 (α = 0.05; power, 80%). The final intention-to-treat analysis compared 19 (49%) in the gabapentin group versus 20 (51%) in the placebo group. Between the gabapentin and placebo groups, average pain (2.0 ± 2.0 vs 3.4 ± 2.8, P = 0.09, respectively) and gluteal pain (2.1 ± 2.0 vs 3.4 ± 2.4, P = 0.09) during normal activity on POD 7 were not significantly different. However, average pain at rest on POD 7 was lower with gabapentin (1.6 ± 1.5 vs 3.2 ± 2.6, P = 0.04). Although a 2-week course of gabapentin did not significantly decrease overall pain with normal activity after a sacrospinous ligament fixation procedure, pain at rest was lower with gabapentin compared with placebo.

Pelvic Organ Prolapse IV: Surgical Options

Pelvic organ prolapse is a common gynecologic condition, with increasing number of women electing for surgical intervention over conservative management with pessaries and pelvic floor physical therapy. Over the past decade, minimally invasive techniques using laparoscopic and vaginal approaches have largely replaced open abdominal surgery. However, this time period has also seen the challenges and limitations of using synthetic mesh materials in urogynecologic procedures. This publication provides a background for the most common and successful surgical techniques to treat pelvic organ prolapse and briefly reviews key anatomy and surgical steps. This review contains 3 figures, 3 tables, and 101 references. Key words: anterior colporrhaphy, colpocleisis, hysteropexy, mesh, pelvic organ prolapse, perineorrhaphy, posterior colporrhaphy, sacrocervicopexy, sacrocolpopexy, sacrospinous ligament suspension, uterosacral ligament suspension

Sacrospinous ligament suspension and uterosacral ligament suspension in the treatment of apical prolapse

: In pelvic organ prolapse, anatomical defects may occur in either the anterior, posterior, or apical vaginal compartment. The apex must be evaluated correctly. Often, defects will occur in more the one compartment with apical defects contributing primarily to the descent of the anterior or posterior vaginal wall. If the vaginal apex, defined as either the cervix or vaginal cuff after total hysterectomy, is displaced downward, it is referred to as apical prolapse and must be addressed. Apical prolapse procedures may be performed via native tissue repair or with the use of mesh augmentation. Sacrospinous ligament suspension and uterosacral ligament suspension are common native tissue repairs, traditionally performed vaginally to re-support the apex. The uterosacral ligament suspension may also be performed laparoscopically. We review the pathophysiology, clinical presentation, evaluation, pre-operative considerations, surgical techniques, complications, and outcomes of these procedures. Both sacrospinous ligament suspension and uterosacral ligament suspension are equally effective with few complications and adverse events. The risks and benefits of each procedure must be considered along with shared patient and physician decision making. Sacrospinous ligament suspension has a higher risk of persistent neurologic pain while uterosacral ligament suspension has a higher risk of ureteral obstruction.

Preliminary Outcomes of an Innovative Approach to Transvaginal Graft Augmentation for Pelvic Organ Prolapse in the “Post-Mesh Era”

Study Objective The objective of this study is to report the early outcomes of a novel transvaginal reconstructive repair of pelvic organ prolapse (POP) augmented with a “Y-shaped” biologic graft (Axis Dermis). Design Retrospective Cohort Study Setting Urogynecology academic private practice in central Pennsylvania Patients or Participants 36 women who underwent transvaginal pelvic reconstructive surgery with augmentation using Axisтм Dermis graft combined with SSL fixation using polypropylene suture for symptomatic Stage 2 prolapse or higher between April 2019 and October 2019 Interventions All patients underwent transvaginal pelvic reconstructive surgery employing a “Y-shaped” Axisтм Dermis graft reinforced with bilateral permanent (polypropylene) suture suspension to the sacrospinous ligament (SSL). Measurements and Main Results Primary outcome was success of surgery, defined by both subjective and objective results up to 6 months post-operatively. Subjectively, as the resolution of bothersome pelvic prolapse related symptoms as indicated by either negative answers to post-op Pelvic Organ Prolapse Distress Inventory 6 or on follow-up telephone interview. Objectively, as a POP-Q Stage ≤ 1. Secondary outcomes were complications, retreatment, and reoperation. The average patient age and BMI was 69.8 years and 27.9 kg/m2, respectively. The average parity was 2.5. The proportion of women with the pre-op diagnosis of uterovaginal prolapse versus post-hysterectomy vaginal vault prolapse was 72.3% and 27.7%, respectively. The subjective and objective cure rate at 6 months was 97.3% and 94.5%, respectively. There were no major complications. There was one retreatment (with a pessary) at 6 weeks postoperatively. One patient was taken for reoperation for ureteral stent placement after post-op transient ureteral dysfunction. Conclusion In this small cohort, a unique technique for transvaginal pelvic reconstruction using biologic graft augmentation combined with permanent suture (polypropylene) SSL suspension has good short-term cure rates for pelvic organ prolapse, without safety concerns. A larger, longitudinal study is planned to investigate long-term success, cost, and efficacy.

Do Women Who Self-report More Exercise Have Increased Rates of Symptomatic Stress Urinary Incontinence After Midurethral Slings?

There is a paucity of data on postoperative exercise and how it relates to surgical failure, specifically after midurethral sling (MUS) surgery. We aimed to assess if women with higher self-reported activity levels as measured by strenuous exercise are more likely to experience stress urinary incontinence (SUI) symptoms after MUS than women with lower self-reported activity. This is a secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss: the OPTIMAL Trial, a randomized trial comparing sacrospinous ligament suspension versus uterosacral ligament suspension, both with concomitant retropubic MUS. Participants completed a validated assessment of activity preoperatively and postoperatively. Women in the upper quartile for strenuous exercise (≥90 minutes per week) were compared with the remaining participants. Symptomatic SUI was defined as retreatment or reoperation for SUI and/or any positive response to Pelvic Floor Disorders Inventory stress incontinence questions 20 to 22. A total of 351 participants in the OPTIMAL study received MUS along with their prolapse repair and had postoperative exercise and Pelvic Floor Disorders Inventory data. At 2 years, 87 (29%) of 305 exercised strenuously for at least 90 minutes per week, and 63 (23%) of 277 experienced SUI. Women who were less active at 2 years were significantly more likely to experience SUI than women who were more active (26.6% vs 12.8%, P = 0.0138). In this study, symptomatic SUI occurred more frequently in women with lower self-reported exercise levels 2 years after MUS surgery.