Uterosacral Ligament Vault Suspension Research Articles

Risk of ureteric injury during ipsilateral uterosacral ligament vault suspension with intra-operative cystoscopy

Background: Post hysterectomy vaginal vault prolapse (PHVVP) occurs in up to 40% of women following hysterectomy. Many authorities recommend a procedure such as uterosacral ligament vault suspension (ULVS) is performed alongside hysterectomy to prevent future PHVVP. However, there is a concern that ULVS increases the risk of ureteric injury. The incidence of ureteric injury during ULVS is unknown but may be underestimated by studies which do not employ a reliable technique to detect ureteric complications. Here we present a large case series detailing outcomes from transvaginal ULVS.

49: Incidence and risk factors for transient ureteral obstruction at the time of uterosacral ligament vault suspension

The objective of this study is to determine risk factors for transient ureteral obstruction at the time of transvaginal uterosacral ligament vault suspension. This was a retrospective chart review with a nested case-control analysis. Patients were included if they underwent transvaginal uterosacral ligament vault suspension (CPT code 57283) at the time of hysterectomy for uterovaginal prolapse. One of 5 FPMRS surgeons performed all of the procedures between December 2007 and December 2012. Once patients were identified, perioperative data were collected. For the retrospective cohort study, the incidence of intraoperative and delayed ureteral injury for all patients was described. Delayed ureteral injury was defined as those with a negative cystoscopy (presence of bilateral ureteral efflux) at the time of surgery who then developed postoperative pyelonephritis, hydronephrosis, and/or acute renal failure immediately after the index surgery. For the nested case-control analysis, cases were defined as patients with transient ureteral obstruction at the time of surgery. Controls were defined as those who did not have a transient ureteral obstruction. Cases and controls were matched 1:4 by date of surgery. During the study period, 551 patients underwent uterosacral ligament vault suspension. Of these patients, 527 (95.6%) had a negative cystoscopy, with 2 (0.38% [95% CI 0.09-1.31]) patients experiencing a delayed ureteral injury. Twenty-four (4.4% [95% CI 2.94-6.40]) patients had a ureteral obstruction on cystoscopy. Obstruction was determined to be a result of the uterosacral vault suspension in 19 (79.2%) cases and the anterior repair in 2 (8.3%) of cases, while the etiology of obstruction was unclear in 3 (12.5%) cases. Resuspension of the vaginal vault once obstruction was resolved was performed in 12 (54.6%) cases. The 24 cases of transient ureteral obstruction were matched to 96 controls. Cases were significantly older (65 vs 58 years, p=0.008), and had lower BMI (26.2 vs 28.9 kg/m2, p=0.03) when compared to controls. The right ureter was more commonly obstructed than the left (47.8% vs. 39.1%). There were otherwise no other differences between the groups. On logistic regression, increased age remained associated with a transient ureteral obstruction (adj OR 1.06, 95% CI 1.02-1.11, p=0.004) and a higher BMI had lower odds of ureteral obstruction (adj OR 0.89, 95% CI 0.79-0.98, p=0.015). In this retrospective study, the incidence of transient ureteral obstruction after uterosacral ligament vault suspension was 4.4%. The incidence of delayed ureteral injury was 0.38%. Older age was associated with higher odds of obstruction while a higher BMI was protective.

Long-term outcomes of modified high uterosacral ligament vault suspension (HUSLS) at vaginal hysterectomy

The aim of this study was to prospectively evaluate long-term outcomes of a modified high uterosacral ligament suspension (HUSLS) at vaginal hysterectomy for pelvic organ prolapse (POP). POP was assessed 5 years postoperatively in 42 women who underwent vaginal hysterectomy and HUSLS for POP. Bladder, bowel, sexual function and quality of life (QoL) were evaluated. Preoperatively, 27/42 women had at least BW grade 2 uterine prolapse. At a mean follow-up period of 59.4 months (range: 40-79 months), two women had undergone surgical intervention for vault prolapse, 33 had no vault prolapse and six grade 1 vault prolapse. One woman declined vaginal examination. Twenty women were sexually active and 18 completed the PISQ-31. The mean total score for all domains was 91/125. On QoL assessments high scores were noted in all domains. Modified HUSLS at vaginal hysterectomy is associated with satisfactory long-term objective and subjective outcomes, sexual function and quality of life scores.

High uterosacral ligament vault suspension at vaginal hysterectomy: Objective and subjective outcomes of a modified technique

To evaluate the outcomes of a modified high uterosacral ligament suspension (HUSLS) performed at vaginal hysterectomy for uterine prolapse. Prolapse was assessed pre- and postoperatively in 53 consecutive women, using Baden-Walker Halfway and Pelvic Organ Prolapse Quantification systems. Sexually active women completed the Prolapse and Incontinence Sexual Function Questionnaire at follow up. The technique involves placement of one HUSLS suture on each side without a fascial reconstruction. Preoperatively, 37 (66%) women had at least Grade 2 prolapse of the cervix. At mean follow-up of 15 months, 45 (85%) had no vault prolapse and 7 (13%) had Grade 1 prolapse. Nineteen (36%) women were sexually active at follow up and completed the Prolapse and Incontinence Sexual Function Questionnaire. Mean scores for pain, vaginal tightness, partner perception of tightness and vaginal length were 2.8, 3.2, 4.0, and 3.8 respectively, indicating excellent function. We report excellent objective, subjective and sexual function outcomes following this modified HUSLS.

Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations

With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios. Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option. As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.

Outcomes Data Show Durability of Uterosacral Ligament Vault Suspension

Outcomes Data Show Durability of Uterosacral Ligament Vault Suspension

Paper 7: Uterosacral Ligament Vault Suspension: Five-Year Outcomes

Paper 7: Uterosacral Ligament Vault Suspension: Five-Year Outcomes

Laparoscopic repair of vaginal vault prolapse.

Currently, the two laparoscopic techniques available and described in the literature for the treatment of vaginal vault prolapse are uterosacral ligament vault suspension and sacrocolpopexy. These two techniques are opposing each other fundamentally. While the first is reconstructive, the second is essentially palliative. In both methods the surgeon starts with the identification and dissection of the pubocervical and rectovaginal fascia. In the first technique however, the new vaginal vault, made by re approximation of the two fasciae, is attached to the uterosacral complex, while in the second one, each fascia is suspended from the sacral promontorium, using a mesh. In review of the existing literature, it seems that the palliative surgical approach is more successful in the long term, giving a cure rate of approximately 92%, probably as it involves using mesh instead of the native tissue. In this article we discuss the laparoscopic techniques available currently, analyse their results, discuss their differences and compare them with other non-laparoscopic techniques. Finally, we discuss the different options described, and offer some guidelines for the future of laparoscopic treatment of pelvic prolapse.

What's new in prolapse surgery?

There are very many types of operation for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task when selecting the most appropriate procedure(s) for an individual patient. Currently, the lifetime risk of undergoing prolapse or continence surgery in France is one in 11; up to 30% of patients will require repeat prolapse surgery, and 10% will require repeat continence surgery. Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for a definitive surgical cure. This review looks at the etiology, presentation and current surgical management of genital prolapse in females. There are three primary routes of access in reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) for the repair of anterior, superior and posterior defects; the choice often depends on the surgeon's experience. Of the abdominal repairs, abdominal sacrocolpopexy with mesh remains the 'gold standard'; the retropubic paravaginal repair and laparoscopic techniques have not gained widespread acceptance. The laparoscopic approach appears to be the least utilized, because of the great degree of technical difficulty associated with laparoscopic suturing. Of the vaginal restorative procedures, uterosacral ligament vault suspension and iliococcygeous and sacrospinous fixation have their proponents. However, there is increasing interest in the use of biological prostheses (allografts/xenografts) and synthetic absorbable meshes. Randomized controlled trials are required to evaluate the role of surgical procedures in reconstructive surgery, to determine which type of prosthesis is most suitable.

Surgical management of the apical vaginal defect.

To review the etiology, presentation, imaging techniques and current surgical management of the apical vaginal defect. Urologists are increasingly managing urinary incontinence and prolapse of the anterior and posterior compartment but most refer the management of the apical defect to gynecologists. A variety of abdominal and vaginal repairs are commonly utilized to repair the apical defect, often based on the surgeon's preference. Of the abdominal repairs, abdominal sacral colpopexy with mesh remains the gold standard. Laparoscopic techniques, although feasible, have not gained widespread acceptance. Of the vaginal restorative procedures there are proponents for uterosacral ligament vault suspension, iliococcygeus and sacrospinous ligament fixation. The uterosacral ligament vault suspension is the most anatomic of the repairs and hence least likely to create a predisposition to future anterior or posterior vaginal wall defects or compromise vaginal function. In rare instances where restorative procedures are discouraged and sexual function is no longer desired, obliterative procedures, which are better tolerated, may be more appropriate. The best approach for restoration of vaginal apical support remains controversial with abdominal and vaginal routes commonly utilized. A single approach or procedure based on the surgeon's preference is not always optimal. Procedure selection should be individualized based on the patient's age, comorbidities, prior surgical history and level of physical and sexual activity. The transvaginal uterosacral ligament vaginal vault suspension is increasingly our procedure of choice for management of the apical defect due to its versatility, reduced postoperative morbidity and excellent short-term results.