Vaginal Uterosacral Ligament Suspension Research Articles

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.

Absorbable versus Permanent Suture for Vaginal Uterosacral Ligament Suspension for Treatment of Apical Prolapse

The aim of this study was to compare surgical outcomes in women undergoing vaginal uterosacral ligament suspension using permanent as opposed to absorbable sutures. We also aimed to assess for specific risk factors for suture complications. Retrospective cohort study. Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center. Women with apical prolapse who underwent vaginal hysterectomy with uterosacral ligament suspension during the study period. none. A total of 197 women were included in the study. Of them, 118 (59.9%) underwent the procedure using a permanent suture and 79 (40.1%) using an absorbable suture. Women in the permanent suture group were less sexually active and had less prolapse of point C on pre-operative exam. With regard to intra-operative and postoperative data, women in the permanent suture group had increased frequency of concomitant procedures, regional anesthesia, surgical time, duration of hospital stay, and change in hemoglobin. Clinical, anatomical, and composite success did not differ between groups. Patient satisfaction recorded using the Patient Global of Improvement Questionnaire was similar as well. Women in the permanent suture group had a higher frequency of suture exposure compared with the absorbable suture group (9.3% vs 0.0%, p=.006). In order to assess for risk factors leading to suture complications, a comparison was performed between women who had suture exposure or granulation tissue and those who did not. Increasing parity by 1 increased the odds of having suture exposure or granulation tissue by a factor of approximately 1.2 (adjusted odds ratio=1.24; Confidence interval, 1.05-1.47). Women with stage IV prolapse had 3.4 times the odds of suture complication compared with women with stage III prolapse (adjusted odds ratio=3.4; Confidence interval, 1.1-10.6). Use of an absorbable suture affords comparable success and lower frequency of suture exposure compared with permanent sutures in women undergoing vaginal uterosacral ligament suspension for treatment of apical prolapse.

Simulation of vaginal uterosacral ligament suspension damage, mimicking a mesh-augmented apical prolapse repair.

Synthetic implants were used for repair of anterior compartment prolapses, which can be caused by direct trauma resulting in damaged pelvic structures. The mechanical properties of these implants may cause complications, namely erosion of the mesh through the vagina. In this study, we evaluated, by modeling, the behavior of implants, during Valsalva maneuver, used to replace damaged uterosacral ligaments (USLs), mimicking a sacrocolpopexy repair. For this purpose, two synthetic implants (A®, for prolapse repair and B®, for Hernia repair) were uniaxially tested, and the mechanical properties obtained were incorporated in the computational models of the implants. The computational model for the implant was incorporated into the model of the female pelvic cavity, in order to mimic the USLs after its total rupture and with 90% and 50% impairment. The total rupture and impairments of the USLs, caused a variation of the supero-inferior displacement and displacement magnitude of the vagina, with higher values for the total rupture. With total rupture of the USLs, when compared to healthy USLs, supero-inferior displacement and displacement magnitude of the vagina increased by 4.98 mm (7.69 mm vs 12.67 mm) and 6.62 mm (9.38 mm vs 16.00 mm), respectively. After implantation (A® and B®) a reduction of the supero-inferior displacements of the anterior vaginal wall occurred, to values found in the case of the model without any impairment or rupture of the ligaments. The simulation was able to mimic the biomechanical response of the USLs, in response to different implants stiffnesses, which can be used in the development of novel meshes.

Comparison of laparoscopic high and vaginal uterosacral ligament suspension in the management of apical prolapse

Comparison of laparoscopic high and vaginal uterosacral ligament suspension in the management of apical prolapse

Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse

ObjectiveThe objective of this study was to compare surgical and short-term postoperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) uterosacral ligament suspension (USLS) surgery. Study designA retrospective cohort study was conducted on 135 patients who underwent hysterectomy with USLS via CV (n = 70) or via vNOTES (n = 65). Patients’ baseline characteristics, surgical characteristics, and surgical outcomes were retrieved. The primary outcome was total operative time. Secondary outcomes include intra- and post-operative complications. ResultsSalpingectomy was performed in all vNOTES procedures and in only 27 % of conventional vaginal procedures (p < 0.005). Compared to the conventional vaginal procedures (n = 65), the vNOTES (n = 70) showed lower mean operative time and mean anesthesia time (101.4 ± 22.3 vs 125.5 ± 27.6 min and 141.4 ± 29.6 vs. 174.0 ± 32.9 min, respectively); and slightly longer median hospital stay (3 [range 2−4] vs. 2 [range 2−4] days, p < 0.05). Compared to women who underwent conventional vaginal hysterectomy with USLS, women who underwent vNOTES hysterectomy with USLS had lower incidences of intraoperative complications (6% vs. 18 %, p < 0.05) and intraoperative ureteral obstruction (0% vs. 8%, p < 0.05); and less estimated blood loss (58 ± 68 ml vs. 143 ± 87 ml, p < 0.05). ConclusionvNOTES hysterectomy with USLS is associated with reduced incidence of intraoperative complications, shorter surgical and anesthesia time, and slightly longer hospital stay, compared to the traditional vaginal surgical approach. Post-operative complications during hospital stay were similar and infrequent following the two procedures.

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women

To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse. Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction. Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ). Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options. The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire). This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The search included multiple terms for apical POP surgical procedures, approaches, and complications. We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension. We included randomized controlled trials and prospective or retrospective comparative studies. We limited language of publication to English and French and accessibility to full text. A systematic review and meta-analysis was performed. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP. All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified.

Suture Complication Rates and Surgical Outcomes According to the Nonabsorbable Suture Materials Used in Vaginal Uterosacral Ligament Suspension: Polyester versus Polypropylene

To evaluate suture complication rates and surgical outcomes according to the nonabsorbable suture materials used in vaginal uterosacral ligament suspension (USLS) surgery. Multifilament polyester (polyethylene terephthalate [PET]) and monofilament polypropylene (PP) sutures were compared. Retrospective cohort study. Single teaching hospital. Total of 229 patients who underwent transvaginal USLS and completed a 1-year follow-up. Use of PET and PP sutures for transvaginal USLS procedures. PP sutures were used in 149 patients, and PET sutures were used in 80 patients. The suture-related complication rates, including granulation tissue and suture erosion at the vaginal apex, were significantly higher in the PET suture group than in the PP suture group (46.3% vs 20.1%, p <.01). However, there was no significant difference in the rates of surgical failure (defined as the presence of vaginal bulging symptoms, apical descent ≥ half of the total vaginal length, anterior or posterior vaginal wall descent beyond the hymen, or retreatment for prolapse) between the 2 groups (p = .84). Compared with the use of multifilament PET sutures, the use of monofilament PP sutures in transvaginal USLS may reduce suture-related complications without increasing surgical failure rates.

Transvaginal Natural Orifice Transluminal Endoscopic (vNOTES) Versus Conventional Vaginal Uterosacral Ligament Suspension

Study Objective To study the pre- and post-operative outcomes of vNOTES versus vaginal uterosacral ligament suspension for apical compartment prolapse. Design Retrospective cohort study. Setting Academic affiliated community hospital. Patients or Participants Women with apical compartment prolapse who underwent vaginal uterosacral ligament suspension (USLS) procedure from January 2014 to February 2020. Interventions Uterosacral ligament suspension via vNOTES versus conventional vaginal approach. Measurements and Main Results Patients' baseline characteristics, surgical characteristics, and surgical outcomes were retrieved from patients' electronic file. Of the 135 women underwent USLS, 65 women underwent conventional vaginal procedure while 70 women underwent vNOTES surgery. Higher incidence of intra-operative complications was observed in women that underwent vaginal USLS vs vNOTES USLS (14% vs. 6%, p With regards to surgical outcomes, the vNOTES USLS group demonstrated a reduced operative time (125.5±27.6 vs. 101.4±22.3, p Conclusion vNOTES USLS is associated with reduced incidence of intra-operative complications, shorter surgical and anesthesia time, and slightly longer hospital stays compared to the traditional vaginal surgical approach. There was no statistically significant difference in the rate of post-operative complications during hospital stay between the vNOTES and the traditional vaginal USLS.

Satisfaction and Regret Following Uterosacral Ligament Suspension and Sacrocolpopexy: A Prospective Multicenter Analysis From the Fellows’ Pelvic Research Network

The primary objective was to compare levels of satisfaction, regret, and Patient Global Impression of Improvement (PGI-I) scores between women who underwent vaginal uterosacral ligament suspension (USLS) and minimally invasive sacrocolpopexy (SCP). Secondary objectives were to identify which preoperative counseling resources were most useful. This was a multicenter, retrospective cohort study through the Fellows' Pelvic Research Network that included women who underwent a USLS or SCP between January 2013 and January 2016 with 1-year follow-up. Women completed the Decision Regret Scale for Pelvic Floor Disorders, Satisfaction with Decision Scale for Pelvic Floor Disorders, and PGI-I. Data were also collected on usefulness of various educational preoperative resources. A total of 175/367 (47.6%) women participated; 45 (25.7%) and 130 (74.3%) in the USLS and SCP groups, respectively. Mean Decision Scale for Pelvic Floor Disorders scores were 4.6 ± 0.8 and 4.5 ± 0.7 (P = 0.30) in the USLS and SCP groups, respectively, indicating a high level of satisfaction with surgical decision. The mean Decision Regret Scale for Pelvic Floor Disorders score was 1.5 ± 0.8 in USLS and 1.6 ± 0.8 in SCP (P = 0.53). The SCP group had higher PGI-I scores (1.7 ± 1.4 vs 2.0 ± 1.3, P = 0.02), indicating lower perceived postoperative improvement. Most women (151 [86.3%] of 175) reported that verbal counseling was sufficient and would not have found additional resources helpful. Women have high satisfaction and low regret with their decision to pursue surgical correction with USLS or SCP. Most are satisfied with only verbal preoperative counseling.

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Uterosacral Ligament

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension. Stepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage. An academic tertiary referral center. The ethics committee ruled that approval was not required for this study. A 53-year-old woman. vNOTES hysterectomy and apical suspension to the uterosacral ligament. A 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA). vNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.

Retrospective Cohort Study on the Perioperative Risk Factors for Transient Voiding Dysfunction After Apical Prolapse Repair.

The primary aim was to compare the incidence of transient voiding dysfunction (TVD) between vaginal uterosacral ligament suspension, sacrospinous ligament fixation, and robotic sacrocolpopexy. Secondarily, we identified risk factors for TVD and associated postoperative complications. This was a retrospective cohort study of women who underwent apical repair at 1 institution. Data were collected from electronic medical records and were presented as means (SD) or numbers (percent) as appropriate. Univariate and multivariate analyses were performed to identify risk factors for TVD and its associated postoperative complications. Three hundred sixty women were included in analysis. Two hundred nineteen (60.8%) passed their voiding trial and 141 (39.2%) experienced TVD. The TVD group demonstrated a higher age, age-adjusted Charlson Comorbidity Index score, and preoperative postvoid residual (all P < 0.05). Univariate analysis demonstrated higher rates of TVD in the vaginal uterosacral ligament suspension and sacrospinous ligament fixation groups compared with the robotic sacrocolpopexy group (P = 0.012). Transient voiding dysfunction occurred more frequently with a concomitant anti-incontinence procedure, anterior repair, and/or posterior repair (all P < 0.05). In multivariate analysis, only an anti-incontinence procedure and concomitant anterior repair were independently associated with a risk of TVD (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.37-3.62, and OR, 2.20; CI, 1.14-4.27, respectively). Transient voiding dysfunction was associated with a culture-proven urinary tract infection within 6 weeks (OR, 3.2; CI, 1.3-8.55). There was no difference in TVD between types of apical repair. Concomitant anti-incontinence procedure and anterior repair were associated with TVD. Women with TVD have an increased risk of postoperative urinary tract infections.

Anterior Wall Success at 1 Year After Vaginal Uterosacral Ligament Suspension and Sacral Colpopexy.

The primary objective was to evaluate 1-year anterior wall anatomic success rates for vaginal uterosacral ligament suspension (USLS) and minimally invasive sacral colpopexy (SCP) using delayed-absorbable suture. Secondary objectives included assessment of apical success, mesh or suture exposure, and postoperative quality of life (QoL) measures 12 months after surgery. This was a retrospective cohort study including women who underwent a hysterectomy with concomitant USLS or SCP with delayed-absorbable suture from January 2011 to December 2015 with 1-year follow-up. Successful anterior vaginal wall support was defined as Ba of less than 0. Successful apical support was defined as no apical descent (point C) greater than one half of the total vaginal length. In addition, 1-year QoL questionnaires were measured postoperatively. A total of 282 women were identified. Sixty-two women (31 vaginal USLS and 31 SCP) met inclusion criteria. Demographics were similar between groups except for a higher body mass index in the USLS group (27.5 ± 5.6 kg/m vs 24.1 ± 3.3 kg/m, P < 0.05). Preoperative POP-Q was mostly stage II and III. At 1-year, anatomic success rates for the anterior compartment were 66.7% versus 90.3% for USLS and SCP groups, respectively (P = 0.02). There was no significant difference in apical success (P = 1.00) or QoL scores between groups at 1 year. Anatomic success rates at 1 year using delayed-absorbable suture were better for SCP when using the anterior wall as a measure of success, but there were no significant differences in apical success rates, mesh or suture exposure, and QoL measures between groups.

01: Minimally invasive sacrocolpopexy versus vaginal uterosacral ligament suspension: Comparing anatomic outcomes at 1 year

Our aim was to compare anatomic outcomes 1-year after surgery between patients who underwent minimally invasive sacrocolopopexy (MISC) (laparoscopic or robotic) with synthetic mesh to those who underwent vaginal uterosacral suspension (USLS) for management of apical prolapse. Secondary outcomes included comparing intra and postoperative complications. This was a multi-center, retrospective cohort study through the Fellows Pelvic Research Network. Patients with prolapse who underwent apical suspension with USLS or MISC from January 2013 to January 2016 with at least 1-year postoperative anatomic data were included. Patients with prior apical repairs, prior vaginal repair with biologic/synthetic graft, or history of connective tissue disorders were excluded. Eligible patients were identified using current procedural terminology codes. Relevant pre, intra, and postoperative data were abstracted from medical records. Prolapse recurrence beyond the hymen and/or POPQ stage 2 or higher were identified at 1-year postoperatively. Categorical data were compared using chi-square and Fisher’s exact tests, and continuous data were compared using the Wilcoxon rank sum test. During the study period, 311 patients underwent MISC (159 laparoscopic and 152 robotic) and 129 patients underwent USLS. They all had 1-year POPQ data available. The proportion of patients in MISC and USLS group were similar with respect to stage of prolapse (47.3% vs. 44.2% with stage 2 and 47.9% vs. 46.5% with stage 3). The median (interquartile range) preoperative apical point C was higher in the MISC group at -2.5 (-4.0, 1.0) than in the USLS group at 0.0 (-4.0, 2.5). The anterior and posterior walls were similar: Aa/Ba at 1.0 (0.0, 2.0) and Ap/Bp at -1.0 (-2.0, 0.0). Intra and perioperative complications such as blood loss (P < 0.0001), conversion to laparotomy (P = 0.002), urinary dysfunction (P = 0.02), and fever (P = 0.007) were higher in the USLS group, but operative time was longer in MISC group (P = 0.002). Three patients in the MISC group had mesh erosion and 5 patients in the USLS group had suture erosions. Postoperative pelvic pain, dyspareunia, voiding and bowel dysfunction were comparable in the two groups. At 1-year postoperatively, 50 patients (38.8%) in the USLS group had apical descent beyond the hymen compared to 77 (24.8%) patients in the MISC group (P = 0.003). Recurrence in the anterior compartment beyond the hymen was also higher in the USLS versus MISC group: 29 (22.5%) vs 19 (6.1%) patients (P < 0.0001), respectively. Posterior compartment recurrences were comparable: 5 (3.9%) versus 16 (5.1%) patients in the USLS versus MISC group (P = 0.57), respectively. At 1-year postoperatively, stage 2 prolapse or greater were noted in 69 (45.7%) patients in the USLS group versus 108 (34.7%) patients in the MISC group. While MISC had longer operative times and risk of mesh erosion, anterior and apical compartment prolapse recurrence rates were lower at 1 year compared to USLS. Future studies comparing bothersome bulge symptoms and need for repeat surgery or pessary placement are currently underway to better assess both symptomatic and anatomic failure within 1-year from initial prolapse surgery.

85: Vaginal versus laparoscopic uterosacral ligament suspension: Does approach matter?

The primary aim of this study is to compare the 6 month anatomic outcomes in women who underwent vaginal uterosacral ligament suspension (vUSLS) with women who had a laparoscopic uterosacral suspension (lUSLS). Secondarily, we compared perioperative complications between both approaches. IRB approval was obtained to conduct this retrospective cohort study of women who underwent a vUSLS or lUSLS at a single institution between January 1, 2013 and December 2015. The primary outcomes were the POPQ C and Aa points 6 months after surgery. Patient demographics, preoperative POPQ exams, baseline PFDI scores, surgical data, postoperative voiding function and postoperative POPQ examination were recorded from the electronic medical record. During the 3-year study period, 96 women underwent uterosacral apical suspension. Four had incomplete records and were excluded. Of the remaining 92 women, 64 (70%) underwent a vUSLS and 28 (30%) underwent a lUSLS. The mean age was lower in the lUSLS group compared to the vUSLS group (48.9 ± 13.3 years vs 61.4 ± 12.2 years, respectively, p = < 0.0001). More women in the lUSLS group were African American than in the vUSLS group (50% vs 23%, respectively, p = 0.039). Those in the lUSLS group had a lower comorbidity burden as measured by the age-adjusted Charlson Comorbidity Index (ACCI 1.68 ± 1.47 vs 3.25 ± 1.75, p < 0.0001). The average BMI in this study was 29.6 ± 6.52kg/m2, with no statistical difference between the 2 groups (p = 0.29). There was no significant difference in preoperative POPQ point C and TVL between the groups (p = 0.34 and 0.64, respectively). The lUSLS group had a lower POPQ Aa compared to the vUSLS group (-0.09 ± 1.19 vs 0.83 ± 1.77, respectively, p = 0.13). The average PFDI-20 score was 108.49 ± 51.51 and was similar between groups (p = 0.07). There were no significant differences in postoperative voiding dysfunction or other postoperative complications (p = 0.11 and 0.42, respectively). At 6 months, all women had point C ≤ -TVL/2. Multivariate linear regression models were developed to control for potential confounders, including operative approach of USLS. After controlling for age, parity, BMI, preop TVL and C points, concomitant procedures, and hysterectomy, the lUSLS group had a statistically more proximal C point at six months compared to vUSLS (p = 0.01). In a separate model controlling for preoperative Aa, point Aa was not significantly different at 6 months regardless of the USLS approach. Although operative times were similar among surgical groups, EBL was significantly lower in the lUSLS group compared to vUSLS (121.43 ± 75.68ml vs 184 ± 103.81ml, respectively, p = 0.002). After controlling for hysterectomy, concomitant procedures, operative time, and ACCI, EBL remained significantly lower in the lUSLS group (p = 0.001). This study suggests that lUSLS may be associated with an improved postoperative apical point C at 6 months. EBL was significantly higher in the vUSLS group, but there were no other differences in postoperative complications. A larger prospective study is needed to determine if lUSLS is associated with improved postoperative subjective and anatomical outcomes.

Recurrence of vaginal prolapse after total vaginal hysterectomy with concurrent vaginal uterosacral ligament suspension: comparison between normal-weight and overweight women

Obesity is one of the most important risk factors for the development and progression of the pelvic organ prolapse. However, data regarding whether obesity is a risk factor for recurrence after pelvic organ prolapse surgery are controversial. The aim of this study was to estimate the risk of recurrent prolapse in any vaginal compartment after total vaginal hysterectomy with concurrent uterosacral ligament vaginal vault suspension among normal-weight women compared with either overweight or obese women. This is a 5-year retrospective cohort study of women who underwent total vaginal hysterectomy with concurrent vaginal uterosacral ligament suspension at one referral center for pelvic organ prolapse in Italy from January 2010 to January 2015. All women who underwent total vaginal hysterectomy with concurrent uterosacral ligament suspension were included in the analysis. Laparoscopic approach was excluded. Women were classified according to the body mass index of 2 groups: (1) normal weight (body mass index, 18.5-24.9 kg/m2) and (2) either overweight (body mass index, 25.0-29.9 kg/m2) or obese (body mass index, ≥30.0 kg/m2). The primary outcome was the incidence of recurrent prolapse in any vaginal compartment (anterior, posterior, or apical). Recurrent prolapse was defined as prolapse extending beyond the hymen with straining (pelvic organ prolapse quantification points Ba, C, Bp ≥0) or repeat treatment for prolapse with either pessary or surgery. Uterosacral ligament suspensions were performed with a vaginal approach with the use of sutures placed in the intermediate uterosacral ligament, at or above the ischial spine, and affixed to the vaginal apex. Delayed absorbable sutures were used, with 2 sutures per side. Three hundred sixty women who underwent total vaginal hysterectomy with concurrent uterosacral ligament suspension with at least 6 months of follow up after surgery were included in the study. The overall incidence of recurrent prolapse in any vaginal compartment was 19.7% (71/360 women). The risk of recurrent prolapse in any vaginal compartment (ie, primary outcome) was similar in the normal-weight compared with the overweight or obese group (16.7% vs 21.3%; P=.30). Women in the normal-weight group had a lower risk of recurrent anterior vaginal prolapse (10.8% vs 20.0%; adjusted odds ratio, 0.49; 95% confidence interval, 0.25-0.94) and of multiple compartment prolapse (8.3% vs 14.6%; adjusted odds ratio, 0.53; 95% confidence interval, 0.31-0.83). After total vaginal hysterectomy with concurrent uterosacral ligament suspension, the risk of recurrent vaginal prolapse was 20% based on a composite outcome definition of any anatomic prolapse beyond the hymen or pessary or repeat surgery. The most common site of recurrence was the anterior compartment. The risk of recurrent surgery was 10%. Our study showed that women with normal-weight had similar risk of recurrent prolapse compared with the overweight or obese group. In subgroup analyses, women with normal-weight had one-half the odds of recurrent anterior vaginal wall prolapse compared with those who were overweight or obese.

Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort.

The aim of this study was to evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). This is a retrospective cohort study comparing all women who underwent laparoscopic and vaginal USLSs at 2 institutions (part of a single training program with procedures performed by 11 fellowship-trained Female Pelvic Medicine and Reconstructive Surgery gynecologic surgeons) between January 2008 and June 2013. A total of 208 patients in the study underwent a USLS, 148 in the laparoscopic group and 60 in the vaginal group. At baseline, there were statistically significant differences between the groups in mean age (50.4 vs 55.3 years, P = 0.008), parity (2.44 vs 2.77, P = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively; P = 0.042).There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.0% vs 10.0%, respectively; P < 0.001). In an analysis evaluating only those ureteral compromises requiring stent placement, the higher rate of ureteral compromise in the vaginal group persisted despite exclusion of those cases requiring only suture removal and replacement (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; P = 0.023).There was a lower median blood loss in the laparoscopic group (137.5 vs 200.0 mL, respectively; P = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; P = 0.025). There were no other significant differences in postoperative complications between the 2 groups. We found a lower rate of ureteral compromise in the laparoscopic approach to USLS compared with the traditional vaginal approach.

Apical prolapse repair: weighing the risks and benefits.

This article reviews the current literature regarding surgical repair of vaginal apical prolapse and discusses the risks and benefits of various surgical approaches. Vaginal uterosacral ligament suspension has similar anatomic and subjective outcomes to sacrospinous ligament fixation at 1 year. Native tissue vaginal repairs offer decreased morbidity compared with mesh-augmented sacrocolpopexy; however, sacrocolpopexy has greater anatomic success. Minimally invasive sacrocolpopexy appears to be equivalent to open abdominal sacrocolpopexy. Native tissue repairs and transvaginal mesh kits support the vaginal apex with similar results; however, long-term follow-up is needed. Robotic and laparoscopic sacrocolpopexy are equally effective in restoring the vaginal apex. Surgical restoration of the vaginal apex can be accomplished via a variety of approaches and techniques. When deciding on the proper surgical intervention, the surgeon must carefully calculate the risks and benefits of each procedure while incorporating the patient's individual medical and surgical risk factors. Lastly, a discussion regarding the patient's overall goals of care is paramount to the decision-making process.

Ureteral Compromise and Suture Exposure in Laparoscopic versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort

To evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). A secondary objective is to evaluate if vaginal suture exposure is significantly different between these groups. This is a retrospective cohort study comparing women who underwent laparoscopic and vaginal USLS at two institutions from a single training program with procedures performed by 11 fellowship-trained urogynecologic surgeons from Jan 2008 to Jun 2013. A total of 208 patients underwent USLS - 148 laparoscopically and 60 vaginally. There were statistically significant differences between the groups in mean age (50.4 vs 55.3 yrs, p = 0.008), parity (2.44 vs 2.77, p = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively, p = 0.042). There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.% vs 10.0%, respectively; p < 0.001). If only ureteral compromises requiring stent placement were counted, the higher rate of ureteral compromise in the vaginal group persisted (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; p = 0.023). The type of suture used for the suspension was significantly different between the laparoscopic and vaginal groups. Permanent suture was used more frequently in the laparoscopic group (90.5% vs 66.7%, p < 0.001). Clinically significant suture exposure, requiring removal in either the office or the operating room, was significantly higher in the vaginal compared to the laparoscopic group (10.0% vs 1.4%, p = 0.008). Permanent suture was used in 100% of laparoscopic cases and 83.3% of vaginal cases that resulted in suture exposure. There was a lower median estimated blood loss in the laparoscopic group (137.5 mL vs 200.0 mL, respectively; p = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; p = 0.025). There were no other significant differences in post-operative complications. We found a lower rate of ureteral compromise and a lower rate of clinically significant vaginal suture exposure in the laparoscopic approach to USLS compared to the traditional vaginal approach.

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.

Long-term outcomes of the high vaginal uterosacral ligament suspension in treatment of the severe pelvic organ prolapse

To investigate the long-term objective and subjective outcomes of the transvaginal high uterosacral ligament suspension(HUS) in treatment of severe pelvic organ prolapse (POP) . From Jun. 2003 to Mar.2013, 136 patients with severe POP quantitation (POP-Q) stage III-IV underwent transvaginal hysterectomy and HUS operation in the First Affiliated Hospital, General Hospital of People's Liberation Army. And 125 patients (91.9%, 125/136) were followed up at a mean of 5.4 years (range of 4.2-9.2 years) . Anterior colporrhaphy (79.2%, 99/125), posterior colporrhaphy (64.0%, 80/125), the perineorrhaphy (96.0%, 120/125) and tension-free suburethral slings (37.6%, 47/125) were performed concurrently, in which 53 (65%, 53/81) patients with severe cystocele and 5 patients (15%, 5/34) with rectocele were augmented with mesh, respectively. Concurrent operation and complications were studied. The objective success of the operation was defined as the leading vaginal edge above hymen.Subjective results were obtained quality-of-life questionnaires, including pelvic floor distress inventory short form (PFDI-20) and pelvic floor impact questionnaire short form (PFIQ-7). The mean interval of following up was (5.4 ± 1.2) years.Four patients presented mild anterior vaginal wall prolapse, and the recurrence rate were 3.2% (4/125), but no reoperation and pessary treatment were needed. Therefore, the subjective and objective satisfaction rate was 94.4% (118/125) and 96.8% (121/125). The mean scores of PFDI-20 and PFIQ-7 at 5 years after the operations were 8, 7, significantly lower than 62, 64 (P < 0.01). There were 3 cases of ureter obstruction. Tension-free vaginal tape was performed on 47 cases with stress urinary incontinence (SUI) as indicated. The symptom of 2 patients was not improved significantly after the operation, but one was improved after 6 months. The rate of denovo SUI was in 2(1.6%, 2/125) patients, but no further treatment was needed. The transvaginal HUS was then conformed to be a safe, minimal traumatic, highly successful and durable procedure for severe POP, so it is worthy of being popularized for clinical application.