Uterosacral Suspension Research Articles

Conventional vaginal approach vs. transvaginal natural orifice transluminal endoscopic surgery for treating apical prolapse, a randomized controlled study

ObjectiveVaginal hysterectomy combined with uterosacral suspension (USLS) is a technique for treating pelvic organ prolapse. Vaginal natural orifice transluminal endoscopic surgery (vNOTES) has been described as an alternative minimal invasive approachfor treating various gynecological and non-gynecological pathologies. The aim was to compare the surgical time between conventional vaginal hysterectomy combined with USLS and vNOTES hysterectomy combined with USLS. Study designMulti-center randomized controlled trial performed 2019–2021 at Rambam Health Care Campus (Israel) and Imelda Hospital (Belgium). Thirty women underwent vNOTES procedures and 30 women underwent conventional vaginal procedures. The primary outcome was total surgical time. Secondary outcomes included hysterectomy time, USLS time, intraoperative bleeding, length of hospitalization, pain during the first 24 h postoperative, the need of analgesia, intraoperative and postoperative adverse events, and patient-reported outcomes questionnaires. Parametric statistical methods were used to analyze the data. ResultsCompared to conventional vaginal procedures, vNOTES procedures were shorter in total surgical time (77 vs. 93 min, p = 0.004), hysterectomy time (26 vs 33 min, p < 0.001), and USLS time (20 vs 26 min. p = 0.02). Blood loss was higher in conventional vaginal compared to vNOTES surgery, as reflected by the mean blood loss estimate (143 vs 60 ml. p < 0.001) and the delta-hemoglobin (pre-operation minus the post-operation hemoglobin level (1.8 vs 1.2 ml/dL, p = 0.01). There was no difference between the groups regarding analgesics used, postoperative pain, surgical objective outcomes, and scores on patient-reported outcomes questionnaires. Adverse events were significantly more frequent in the conventional vaginal group than in the vNOTES group (p < 0.001 for intraoperative events and p = 0.05 for events that occurred in the follow-up time interval). ConclusionvNOTES hysterectomy with USLS has lower surgical times than conventional vaginal hysterectomy with USLS, lower blood loss and less adverse events. Other surgical objective and subjective outcomes were similar between the approaches.

Bilateral Sacrospinous Vaginal Vault Fixation With Synthetic Mesh Arms: A Novel Technique

Sacrospinous ligament suspension is used for suspension of apical prolapse; however, it has a high rate of recurrence compared with sacrocolpopexy, and a high rate of pain compared with uterosacral suspension. We developed a novel surgical procedure of bilateral sacrospinous vaginal vault fixation with synthetic mesh arms. We previously demonstrated its safety, and in Supplementary video 1, we describe a step-by-step surgical approach that could be replicated. This technique restores support, creating an anatomically correct midline configuration of the vaginal axis with minimal tension. A randomized controlled trial is underway to examine durability of mesh versus suture techniques for sacrospinous ligament suspension.

How Old Is Too Old? Outcomes of Prolapse Native-Tissue Repair through Uterosacral Suspension in Octogenarians.

Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients. We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively. Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients.

The influence of the combined impairments and apical mesh surgery on the biomechanical behavior of the pelvic floor system.

Objective: The prolapse mechanism of multifactorial impairment of the female pelvic floor system and the mechanics of the pelvic floor after apical suspension surgery are not yet understood, so we developed biomechanical models of the pelvic floor for the normal physiological state (0°) and 90° pathological state. Methods: Under different types and levels of the impairments and uterosacral suspensions, the possible changes in the morphometric characteristics and the mechanical characteristics of suspension and support functions were simulated based on the biomechanical models of the pelvic floor. Results: After the combined impairments, the descending displacement of the pelvic floor cervix and the stress and displacement of the perineal body reached maximum values. After surgical mesh implantation, the stresses of the normal pelvic floor were concentrated on the uterine fundus, cervix, and top of the bladder and the stresses of the 90° pathological state pelvic floor were concentrated on the uterine fundus, uterine body, cervix, middle of the posterior vaginal wall, and bottom of the perineal body. Conclusion: After the combined impairments, the biomechanical support of the bladder and sacrococcyx in the anterior (0°) and 90° pathological state pelvic floor system is diminished, the anterior vaginal wall dislodges from the external vaginal opening, and the posterior vaginal wall forms "kneeling" profiles. The pelvic floor system may evolve with a tendency toward the cervical prolapse with anterior and posterior vaginal wall prolapse and eventually prolapse. After surgical mesh implantation, the cervical position can be better restored; however, the load of combined impairment of the pelvic floor is mainly borne by the surgical mesh suspension, the biomechanical support function of pelvic floor organs and sacrococcyx was not repaired by the physiological structure, and the results of uterosacral suspension alone may be poor.

At the Scrub Sink: Uterosacral Ligament Suspension.

Uterosacral ligament suspension for repair of prolapse has some challenges, such as visualization in the vagina, choice of suture, and avoidance of dangers such as ureteral kinking. This editorial offers some tips for performing a uterosacral suspension that are commonly discussed "at the scrub sink" before a case.

The effect of hysteropreservation versus hysterectomy on the outcome of laparoscopic uterosacral suspension in pelvic organ prolapse surgery

ObjectivesThis study compares the recurrence rate, complication rate and subjective satisfaction with laparoscopic uterosacral suspension with or without hysterectomy. Study designThis retrospective cohort study included 105 patients between June 2014 and December 2019. Recurrent pelvic organ prolapse was defined as any prolapse to or beyond the hymen with straining or needing retreatment. Student's t-test, the Mann–Whitney U test, the chi square test or Fisher's exact test, multivariate Cox proportional hazards regression and Kaplan–Meier survival analysis were used for the data analysis. Main outcome measuresWhether the durability of laparoscopic uterosacral suspension surgery is affected by uterine preservation. Results60 patients underwent laparoscopic uterosacral suspension with concomitant hysterectomy (Hysterectomy group), and 45 underwent laparoscopic uterosacral hysteropexy (Hysteropexy group). The median (interquartile range) duration of follow-up for all 105 patients was 31 (22.5–47.5) months. The results of multivariate Cox proportional hazards regression showed that no difference was found in the risk of overall recurrence between the hysterectomy and hysteropexy groups (25 % vs. 22 %; HR, 0.37; 95 % CI, 0.14–1.00). Kaplan–Meier survival analysis also demonstrated that there were no significant differences in the overall rates of recurrent prolapse between the two groups (P = 0.30). In addition, the subjective success rates were high in both groups (82 %). ConclusionsOur study demonstrated equally satisfactory objective and subjective long-term outcomes after laparoscopic uterosacral suspension with or without hysterectomy. Laparoscopic uterosacral hysteropexy can be safely and effectively offered to patients with pelvic organ prolapse who wish to preserve their uterus and do not have contraindications.

Robotic Nerve Sparing Uterosacral Ligament Suspension

<h3>Study Objective</h3> To demonstrate a technique for robotic assisted nerve sparing uterosacral ligament suspension. <h3>Design</h3> Description and demonstration of a novel surgical technique. <h3>Setting</h3> Tertiary care academic center. <h3>Patients or Participants</h3> A 49-year-old woman, who presented with AUB -A, pelvic pain, and vaginal bulge, was diagnosed with stage 2 pelvic organ prolapse, adenomyosis and endometriosis. <h3>Interventions</h3> Robotic assisted hysterectomy and excision of endometriosis for treatment of her pelvic pain and AUB. Robotic approach was recommended for prolapse repair due to the other underlying conditions; however, decision was made to perform uterosacral suspension over mesh augmentation. Mobilization of the ureter and dissection of the inferior hypogastric nerve was performed. Suspension of the vaginal cuff was performed using barbed sutures. A total of 6 suspension sutures were placed incorporating the uterosacral ligaments to the anterior and posterior vaginal cuff. Obliteration of the enterocele was performed using this method. Care was taken not to include the inferior hypogastric nerve in these suspension sutures performing a nerve sparing uterosacral ligament suspension. <h3>Measurements and Main Results</h3> At 6 weeks, patient suffered no perioperative complications and had excellent apical suspension. Continued follow-up is ongoing. <h3>Conclusion</h3> Identification and avoidance of the inferior hypogastric nerve while performing uterosacral ligament suspension is a safe, feasible procedure and may prevent morbidities.

Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension

Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery in the Vaginal hysterectomy with Native Tissue Vault Suspension vs Sacrospinous Hysteropexy with Graft Suspension (Study for Uterine Prolapse Procedures Randomized Trial) trial, sacrospinous hysteropexy with graft (hysteropexy) resulted in a lower composite surgical failure rate than vaginal hysterectomy with uterosacral suspension over 5 years. This study aimed to identify factors associated with the rate of surgical failure over 5 years among women undergoing sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral suspension for uterovaginal prolapse. This planned secondary analysis of a comparative effectiveness trial of 2 transvaginal apical suspensions (NCT01802281) defined surgical failure as either retreatment of prolapse, recurrence of prolapse beyond the hymen, or bothersome prolapse symptoms. Baseline clinical and sociodemographic factors for eligible participants receiving the randomized surgery (N=173) were compared across categories of failure (≤1 year, >1 year, and no failure) with rank-based tests. Factors with adequate prevalence and clinical relevance were assessed for minimally adjusted bivariate associations using piecewise exponential survival models adjusting for randomized apical repair and clinical site. The multivariable model included factors with bivariate P<.2, additional clinically important variables, apical repair, and clinical site. Backward selection determined final retained risk factors (P<.1) with statistical significance evaluated by Bonferroni correction (P<.005). Final factors were assessed for interaction with type of apical repair at P<.1. Association is presented by adjusted hazard ratios and further illustrated by categorization of risk factors. In the final multivariable model, body mass index (increase of 5 kg/m2: adjusted hazard ratio, 1.7; 95% confidence interval, 1.3-2.2; P<.001) and duration of prolapse symptoms (increase of 1 year: adjusted hazard ratio, 1.1; 95% confidence interval, 1.0-1.1; P<.005) were associated with composite surgical failure, where rates of failure were 2.9 and 1.8 times higher in women with obesity and women who are overweight than women who have normal weight and women who are underweight (95% confidence intervals, 1.5-5.8 and 0.9-3.5) and 3.0 times higher in women experiencing >5 years prolapse symptoms than women experiencing ≤5 years prolapse symptoms (95% confidence interval, 1.8-5.0). Sacrospinous hysteropexy with graft had a lower rate of failure than hysterectomy with uterosacral suspension (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-1.0; P=.05). The interaction between symptom duration and apical repair (P=.07) indicated that failure was less likely after hysteropexy than hysterectomy for those with ≤5 years symptom duration (adjusted hazard ratio, 0.5; 95% confidence interval, 0.2-0.9), but not for those with >5 years symptom duration (adjusted hazard ratio, 1.0; 95% confidence interval 0.5-2.1). Obesity and duration of prolapse symptoms have been determined as risk factors associated with surgical failure over 5 years from transvaginal prolapse repair, regardless of approach. Providers and patients should consider these modifiable risk factors when discussing treatment plans for bothersome prolapse.

Incidence and Risk Factors for Genitourinary Tract Injury Within 1 Year After Surgery for Pelvic Organ Prolapse.

The rate of genitourinary tract injury (GUTI) following pelvic organ prolapse (POP) surgery is presently ill-defined and based on relatively small trials with short follow-up time. Given the potential for higher risk of injury with POP, a better understanding of this type of injury is important for patient counseling. The objective of this study was to identify the incidence and risk factors of GUTI related to POP surgery. Women undergoing POP surgery between 2010 and 2019 were identified using Current Procedural Terminology codes in the Premier Healthcare Database. The primary outcome was GUTI, defined as bladder or ureteral injury, and vesicovaginal or ureterovaginal fistula within 1 year of surgery. Genitourinary tract injury was identified using International Classification of Diseases and Current Procedural Terminology codes. Patients were divided into those with and without GUTI. Differences between groups were evaluated using the Student t test, Wilcoxon rank-sum test, and Fisher exact test as appropriate. Multivariable logistic regression was used to evaluate the independent predictors of GUTI. One hundred thirty-nine thousand one hundred fifty-eight surgical procedures for POP were captured between 2010 and 2019. The rate of GUTI was 1.10%: 0.48% bladder, 0.64% ureteral injuries, and 0.01% fistulas. The most significant variables associated with any GUTI were as follows: adhesiolysis (adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.07-6.51), blood transfusion (aOR, 3.67; 95% CI, 1.34-10.04), and low-volume surgeons (<12 cases per year) (aOR, 1.68; 95% CI, 1.60-1.77), nonurologic or gynecologic surgeon specialty (aOR, 1.62; 95% CI, 1.49-2.00), and uterosacral suspension (aOR, 1.30; 95% CI, 1.13-1.49). The rate of GUTI following POP surgery is lower than has previously been reported. Surgeon experience and specialty and surgical approach may affect GUTI incidence.

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

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.

Selective suture removal for the management of buttock pain after uterosacral ligaments suspension.

Selective suture removal for the management of buttock pain after uterosacral ligaments suspension.

Management of Pelvic Organ Prolapse in the Adult Congenital Genitourinary Patient

To assess and present our experience with the management and outcomes of female pelvic organ prolapse in the adult congenital genitourinary patient population. Retrospective review of our adult congenital GU patients with spina bifida with a documented Pelvic Organ Prolapse Quantification exam (POP-Q) from 2006 - 2021 was undertaken. Spina bifida lesion level, bladder management method, prolapse stage and component, and obstetric history were reviewed. Outcomes of treated patients are from most recent follow up. 37 congenital GU patients were identified. 26 (70%) were nulliparous with many showing advanced prolapse, defined as stage 2 or greater. By POP-Q, only 22% were stage 0, indicating no prolapse. 68% had advanced prolapse, with one case of complete procidentia despite no pregnancy history. The dominant prolapse compartment in advanced prolapse patients regardless of parity was apical, or cervical (47%). 16 had symptomatic prolapse, most with vaginal bulge or noticing bulge with catheterization. 6 patients underwent surgery with 2 vaginal hysterectomy and uterosacral suspensions and 1 sacrocolpopexy with mesh. Due to elongated cervix with protrusion, 3 patients underwent cervical shortening as their primary prolapse intervention. 4 of the patients saw a decrease in POP-Q score post-operatively with 2 patients still pending follow-up. Congenital GU patients may have more advanced prolapse at younger ages and nulliparity and are frequently apical dominant. A variety of surgical options can provide meaningful improvement in the symptomatic patient.

Perioperative Use of Pain Medications in Vaginal Versus Laparoscopic Pelvic Organ Prolapse Surgery

<h3>Study Objective</h3> To determine if the use of perioperative pain medications differs between vaginal versus laparoscopic surgery in women with pelvic organ prolapse. <h3>Design</h3> We compared the consumption of various pain medications (opioids, intravenous and local anesthetics, non-steroidals, acetaminophen and gabapentin) between vaginal hysterectomy with uterosacral suspension and laparoscopic supracervical hysterectomy with sacrocolpopexy during intraoperative and immediate postoperative period. <h3>Setting</h3> Tertiary care hospital within the US. <h3>Patients or Participants</h3> Women undergoing surgery for pelvic organ prolapse. <h3>Interventions</h3> Retrospective chart review. <h3>Measurements and Main Results</h3> A total of 195 women who underwent pelvic organ reconstructive surgery were included in the study, with 98 in the vaginal and 97 in the laparoscopic group. Duration of surgery was significantly shorter in the laparoscopy (versus vaginal) group (98 vs. 190 minutes, p<0.001), with less blood loss (30 vs. 100ml, p<0.001), and shorter hospital stay (7.05 vs. 20.8 hours, p<0.001). Intraoperative opioid use was similar between the groups (25 MME, p = 0.34). However, women in the laparoscopy group received significantly more intravenous and local anesthesia than in the vaginal group (lidocaine: 60 vs 40mg; bupivacaine 49.6 vs. 20 ml, respectively, p<0.001). Postoperatively, women in the vaginal group required almost twice as many narcotics as those in the laparoscopy group (MME=28 vs. 15, p<0.001). Postoperatively, the groups did not vary in term of ketorolac, ibuprofen, or gabapentin use. After controlling for covariates, postoperative opioid and acetaminophen use were no longer significantly different between the vaginal and laparoscopic groups; however, recovery time was the most significant confounder accounting for the difference across all types of pain medications used, p<0.001. <h3>Conclusion</h3> Women undergoing prolapse repair regardless of route require similar amount of opioid intraoperatively, but differ in use in the postoperative period. Use of non-opioid pain medication were similar between the groups was comparable.

Total Vaginal Hysterectomy With Uterosacral Ligament Suspension Compared With Supracervical Hysterectomy With Sacrocervicopexy for Uterovaginal Prolapse.

To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse. We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension. The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P<.001) and less than 1 year for both groups. The uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426], P=.02) and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426], P=.02). The uterosacral group demonstrated a shorter time to prolapse recurrence on multivariable Cox regression (hazard ratio 3.14, 95% CI 1.90-5.16). There were 14 (3.3%) mesh complications in the sacrocervicopexy group. Overall reoperation was similar between groups (4.8% [11/228] vs 3.8% [16/426], P=.51). Total vaginal hysterectomy with uterosacral ligament suspension was associated with higher rate of, and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy.

Back to the future: vaginal hysterectomy and Campbell uterosacral ligaments suspension for urogenital prolapse.

To evaluate vaginal hysterectomy (VH) associated with vaginal native tissue repair (VNTR) using Campbell uterosacral ligament suspension (C-USLS) for the treatment of predominant uterine prolapse associated with cystocele. We conducted a retrospective monocentric study including patients who underwent VH and C-USLS, without concomitant mesh, for primary urogenital prolapse between January 2011 and June 2018. We evaluated the anterior and apical prolapse recurrence rate, using a composite criterion (symptomatic, asymptomatic recurrence, POP-Q stage ≥ 2). We analyzed 2-year recurrence-free survival using the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify variables associated with recurrence. Secondary outcomes included postoperative complications, lower urinary tract symptoms (LUTS) and sexual satisfaction. Ninety-four patients were included. Eighty-three (88.3%) and 65 (69.1%) patients had stage ≥ 3 uterine prolapse and cystocele, respectively. Mean follow-up was 36months. Prolapse recurrence rate was 21.3% including 3.2% of cystocele. Two-year recurrence-free survival was 80%. Age, body mass index, POP-Q stage and associated surgical procedure were not significantly associated with recurrence. Early complications were reported for 20 patients (21.2%), mostly grade ≤ 2 (95%). De novo LUTS were reported in 11 cases (11.7%). Preoperative stress urinary incontinence and urgency were cured for 12 (80%) and 29 (80.6%) patients, respectively. Sexual satisfaction rate for patients with preoperative sexual activity was 95.8%. C-USLS following VH as primary treatment for predominant uterine prolapse with associated cystocele is a safe procedure with satisfying mid-term functional results. This VNTR could be an alternative in light of the worldwide market withdrawal of actual vaginal mesh.

Changes in Sexual Activity and Function After Pelvic Organ Prolapse Surgery: A Systematic Review.

We aimed to systematically review the literature to describe sexual activity and function before and after prolapse surgery. We searched MEDLINE, EMBASE, and ClinicalTrials.gov databases from inception to April 2018. Prospective, comparative studies of reconstructive pelvic organ prolapse (POP) surgeries that reported sexual function outcomes were included. Studies were extracted for population characteristics, sexual function outcomes, and methodologic quality. Data collected included baseline and postoperative sexual activity, dyspareunia, and validated sexual function questionnaire scores. Change in validated scores were used to categorize overall sexual function as improved, unchanged, or worsened after surgery. The search revealed 3,124 abstracts and identified 74 articles representing 67 original studies. The overall quality of evidence was moderate to high. Studies reporting postoperative results found higher rates of sexual activity than studies reporting preoperative sexual activity in all POP surgeries except sacrospinous suspension, transvaginal mesh, and sacrocolpopexy. The prevalence of dyspareunia decreased after all prolapse surgery types. The risk of de novo dyspareunia ranged from 0% to 9% for all POP surgeries except posterior repair, which lacked sufficient data. Overall sexual function based on PISQ-12 (Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-12) scores improved for mixed native tissue repairs, anterior repairs, uterosacral suspensions, sacrospinous suspensions, and sacrocolpopexy; scores were similar for posterior repairs, transvaginal mesh, and biologic grafts. Sexual function did not worsen after any POP surgeries. Sexual function improves or remains unchanged after all types of reconstructive POP surgeries and does not worsen for any surgery type. Prevalence of total dyspareunia was lower after all POP surgery types, and de novo dyspareunia was low ranging 0-9%. This information can help surgeons counsel patients preoperatively. PROSPERO, CRD42019124308.

Vaginal intraperitoneal versus extraperitoneal uterosacral ligament vault suspensions: a comparison of a standard and novel approach

Uterosacral ligament suspension surgery is commonly utilized to correct post-hysterectomy vaginal vault prolapse (VVP). Vaginal intraperitoneal uterosacral vault suspension (IUSVS) is a viable option, but intraperitoneal access can be challenging. An alternative approach is an extraperitoneal uterosacral vault suspension (EUSVS). The aim of our study was to compare surgical outcomes of IUSVS and EUSVS in patients with post-hysterectomy VVP. Retrospective cohort study of women who underwent treatment of post-hysterectomy VVP with an IUSVS and EUSVS from May 2016 to January 2019 at our institution. The primary outcome was surgical success that was assessed by a composite outcome for surgical failure, defined as ANY of the following: (1) apical descent > 1/3 of the TVL or anterior or posterior vaginal wall beyond the hymen, (2) retreatment of prolapse, or (3) bothersome vaginal bulge symptoms with a positive response to either of two questions on the PFDI questionnaire. Secondary outcomes included EBL, operative time, duration of hospitalization, and perioperative complications. Two-sample t-tests and chi-square tests were used for the bivariate analysis. Eighty patients were included (36 IUSVS and 44 EUSVS) with a mean follow-up of 7months. For our primary outcome, there was no difference in surgical success (IUSVS group 72.22% vs. EUSVS group 81.82%, p = 0.307). Operative time, duration of hospitalization, and EBL were significantly less in the EUSVS group than in the IUSVS group. EUSVS demonstrated similar short-term success compared to IUSVS for post-hysterectomy VVP, with shorter operative time, EBL, and length of stay.

Apical suspension is underutilized for repair of stage IV pelvic organ prolapse: an analysis of national practice patterns in the United States.

Support of the vaginal apex is paramount for a durable repair of pelvic organ prolapse (POP). Our aim is to assess national utilization of apical suspension procedures for the surgical treatment of complete POP. We hypothesize that there might be a high rate of apical suspension with advanced prolapse. The 2006-2016 National Surgical Quality Improvement Program database was queried for a primary postoperative diagnosis of complete POP. The primary outcome was type of repair. Secondary outcomes included patient characteristics associated with apical suspension or colpocleisis. Procedures were delineated using CPT codes. Chi-squared and multivariate logistic regression analyses were used to evaluate factors associated with repair type. A total of 2,784 women underwent surgery for complete POP with a mean age of 64.6± 11.0years. Overall, 1,300 (46.7%) patients underwent apical suspension: 487 sacrocolpopexies (17.5%), 428 extraperitoneal suspensions (15.4%), and 391 uterosacral suspensions (14.0%). 5.2% (144) underwent colpocleisis, and 47.5% (1,332) of women had a concurrent hysterectomy (CH). With CH, 38.6% (502) had apical suspension or colpocleisis versus 69.5% (940) of post-hysterectomy cases. On logistic regression, CH was inversely associated with apical suspension (adjusted odds ratio [aOR] 0.37, CI 0.32-0.44, p < 0.001). Colpocleisis was associated with older age (aOR 4.9 per 10years, CI 3.8-6.3, p < 0.001), post-hysterectomy surgery (aOR 0.23, CI 0.1-0.4, p < 0.001 for CH), and higher comorbidity index (OR 1.7, CI 1.1-2.6, p = 0.009). Complication rates are similar with and without apical suspension (8.2% versus 7.0%, p = 0.269). During surgery for complete POP, an apical suspension procedure is performed in 46.7% of patients and is more common post-hysterectomy.

Hysterectomy with uterosacral suspension or Uphold™ hysteropexy in women with apical prolapse: a parallel cohort study.

The aim was to compare objective and subjective cure rates between Uphold™ hysteropexy (HP) and vaginal hysterectomy (VH) with uterosacral suspension. A sample size of 49 in each arm would be required to detect a clinical difference of 20% between the groups. Owing to delayed recruitment, this originally planned randomised controlled trial was changed to a patient preference study after randomising initial 6 participants. Women with symptomatic stage ≥2 uterine descent wishing a surgical solution were included. Routine follow-up was scheduled at 6weeks, 6months, 12months, and annually thereafter. Primary outcome was absence of stage ≥2 apical prolapse. Secondary outcomes included a composite cure of no leading edge beyond the hymen, absence of bulge symptoms and no retreatment; patient-reported outcomes were based on quality-of-life questionnaires (PFDI-20, PFIQ-7, PISQ-12, PGI-I, EQ5D and a health score). We recruited 50 patients undergoing VH between 2011 and 2013 and 51 patients undergoing HP between 2011 and 2016. Participants were followed up for a median of 25months (23-96). Five women from the VH (10%) and 7 from the HP (14%) group were lost to follow-up. Combined anatomical and symptomatic outcomes were available for 41 (82%) VH and 39 (76%) in the HP group. There was no difference in objective apical outcomes; the incidence of stage 2 prolapse was 0% in the VH group and 2% in HP group (p= 0.50). We found no difference in the composite cure rate (78% VH vs 85% HP, 0.45) between the groups. There was no significant difference in surgical complications (p= 0.33), assessed using Clavien-Dindo classification. There was a 2% surgery rate for mesh exposure in the HP group. Uphold™ uterine suspension and VH appear to have similar objective and subjective cure at 25months, with no significant difference in surgical complications.

Dynamic magnetic resonance imaging to quantify pelvic organ mobility after treatment for uterine descent: differences between surgical procedures.

Pelvic organ mobility is defined as the displacement of pelvic organs between rest and maximal straining. We hypothesized that pelvic organ mobility after vaginal sacrospinous hysteropexy (SSHP) might be increased compared with other surgeries for uterine descent, which may contribute to the high occurrence of postoperative cystocele after this surgery. Pelvic organ mobility and the vaginal axes after SSHP are compared with other surgical procedures for uterine descent: vaginal hysterectomy with uterosacral suspension (VH) and laparoscopic sacrohysteropexy (LSH). In this prospective pilot study, 15 women were included (5 for each procedure). Six months postoperatively, POP-Q examination and dynamic MRI were performed and questionnaires were filled out regarding prolapse complaints. Pelvic organ mobility on MRI was defined as vertical displacement of pelvic organs at rest and maximal straining. The displacements and angles were measured using an image registration method. Furthermore, the angle of displacement of cervix/vaginal vault and vaginal axes were assessed. No anatomical recurrences of pelvic organ prolapse were found. No difference in pelvic organ mobility was demonstrated. After VH, a more posterior position of the upper vagina was found compared with SSHP and LSH. Based on these data, the higher recurrence risk in the anterior compartment after SSHP cannot be explained. Larger sample sizes, studying women with recurrence or de novo cystocele after SSHP or using an upright MRI scanner would be of interest to further assess the relationship between pelvic organ mobility and the occurrence of anterior vaginal wall prolapse.