Laparoscopic uterosacral ligament suspension: a comprehensive, systematic literature review

Outcome of Laparoscopic Versus Vaginal High Uterosacral Ligament Vault Suspension at the Time of Hysterectomy

INTRODUCTION AND HYPOTHESIS

High uterosacral ligament suspension (HUSLS) can be used to treat apical pelvic organ prolapse (POP). This can be performed both vaginally and laparoscopically. Data comparing the two suspension procedures remain limited. The aim of this study is to compare the effectiveness and safety of vaginal HUSLS and laparoscopic HUSLS at the time of hysterectomy.

METHODS

This is a retrospective cohort study of women who underwent hysterectomy between 2019 and 2021 at a tertiary urogynaecology unit. Either vaginal or laparoscopic hysterectomy was performed, followed by vaginal or laparoscopic HUSLS respectively. Women were followed up at 6 weeks, and at 6 and 12 months postoperatively. The primary outcome was symptomatic recurrence of vaginal bulge symptoms. Secondary outcomes were anatomical recurrence, re-treatment and safety.

RESULTS

A total of 111 women met the inclusion criteria. Twelve were excluded, leaving 99 for analysis. HUSLS was performed vaginally in 47 and laparoscopically in 52 women. There was no significant difference in demographics between the groups. At 12 months, 92% in the vaginal group and 48% of the laparoscopic group reported no symptoms of prolapse, 67% vs 36% had no anatomical recurrence and 0% vs 34% had re-treatment respectively. Logistic regression (adjusting for age, BMI, menopausal status, preoperative stage apical prolapse, procedure type) demonstrated that the laparoscopic route was the only variable associated with recurrent prolapse at or beyond the hymen and symptomatic prolapse at 12 months.

CONCLUSIONS

Symptomatic and anatomical recurrent POP was associated with this technique of laparoscopic HUSLS. Further research should consider prospective evaluation of these or modified techniques.

Two-Year Follow-Up on Surgical Outcomes of vNOTES High Uterosacral Ligament Suspension for the Prophylaxis and Treatment of Pelvic Organ Prolapse: A Multicenter Prospective Cohort Study

STUDY OBJECTIVE

We aimed to evaluate the medium-term outcomes of high uterosacral ligament suspension (HUSLS) with vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) in patients either having pelvic organ prolapse or undergoing routine prophylaxis to prevent posthysterectomy vaginal vault prolapse.

DESIGN

Multicenter prospective cohort study.

SETTING

Three tertiary care hospitals.

PATIENTS

Patients who received vNOTES-HUSLS between January 1, 2021, and January 1, 2023, were included in the study.

INTERVENTIONS

vNOTES-HUSLS.

MEASUREMENTS AND MAIN RESULTS

The data collected included surgery duration, intraoperative and postoperative complications, postoperative visual analog scores, and Female Sexual Function Index pain subdomain scores. The changes in prolapse levels were measured using modified Pelvic Organ Prolapse Quantifications System scores, including the C, Ba, and Bp scores recorded before surgery and during the postoperative follow-up examination. Patient satisfaction was assessed using the Patient Global Impression of Improvement questionnaire. The final analysis included 55 women. Of these, vNOTES-HUSLS was performed in 43 patients (78.2%) to treat apical prolapse, whereas the remaining 12 patients (21.8%) underwent prophylaxis after hysterectomy to prevent vaginal vault prolapse. The median follow-up period was 23.5 months, with a range of 12 to 37 months. Ba, C, and Bp points significantly improved in patients who underwent surgery for prolapse (p <.001). There was no recurrence in the apical compartment after vNOTES-HUSLS for both performed prophylactic and treatment purposes after hysterectomy. Two patients (3.6%) were diagnosed as having stage 3 anterior compartment prolapse. The overall vNOTES-HUSLS success rate was 96.4% at approximately 2-year follow-up. Bladder injury was detected as an intraoperative complication in 1 patient (1.8%). The overall satisfaction rate was 98.1% at the final follow-up.

CONCLUSION

vNOTES-HUSLS was effective in the treatment and prophylaxis of apical prolapse, demonstrating high anatomic success rates. The procedure demonstrated a low complication rate, with intraoperative and postoperative complications each observed in 1.8% of patients (n = 1).

Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) in Urogynecological Surgery: A Systematic Review

Background: Minimally invasive surgery could improve cosmetic outcomes and reduce the risks of surgical injury with less postoperative pain and a quicker patient's discharge. Recently, transvaginal natural orifice transluminal endoscopic surgery (vNOTES) has been introduced in urogynecology with exciting results. Evidence Acquisition: After PROSPERO registration (n°CRD42023406815), we performed a comprehensive literature search on Pubmed, Embase, and Cochrane CENTRAL, including peer-reviewed studies evaluating transvaginal natural orifice transluminal endoscopic surgery. No limits on time or type of study were applied. Evidence synthesis: Overall, 12 manuscripts were included in the analysis. Seven studies evaluated uterosacral ligament suspension, four studies evaluated sacral colpopexy, three evaluated sacrospinous ligament suspension, and one study evaluated lateral suspension. Overall success rates were high (>90%); however, definitions of success were heterogeneous. In terms of complication, most of the studies reported low-grade complications (Clavien-Dindo I and II); only two patients needed mesh removal because of mesh exposure. The risk of bias of the trials was rated in the medium to high-risk category. Conclusions: The present review highlights important initial results for vNOTES. Future randomized clinical trials are needed to better define its role in the management of urogynecological procedures.

Laparoscopic Versus Vaginal Uterosacral Ligament Suspension in Women With Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of the Literature

OBJECTIVE

Uterosacral ligament suspension (USLS) is one of the most frequently used operations for the restoration of apical support in women with uterovaginal prolapse. However, existing studies are inconclusive as to whether and which surgical access route is superior. The aim of the present meta-analysis is tentatively to compare the efficiency and the postoperative complications of laparoscopic USLS (L-USLS) and vaginal USLS (V-USLS), highlighting that current evidence remains inconclusive regarding the superiority of either surgical access route.

DATA SOURCES

We performed a systematic literature review of 5 major databases (Medline, Scopus, Google Scholar Cochrane Central Register of Controlled Trials and Clinicaltrials.gov) from inception till April 2023.

METHODS OF STUDY SELECTION

No language restrictions were applied. All comparative studies that compared L-USLS and V-USLS for the management of women with uterovaginal prolapse were included.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 retrospective cohort studies on 856 patients were extracted and analyzed. The methodological quality of the included studies was assessed using the risk of bias in nonrandomized studies of interventions tool and ranged between moderate to serious. The pooled results suggest that L-USLS was associated with a potentially decreased incidence of ureteral compromise (odds ratio [OR], 0.19; 95% confidence interval [CI] 0.04-0.89; p = .04) and seemingly lower objective (OR 0.47; 95% CI 0.23-0.97; p = .04) and subjective recurrence rates (OR 0.46; 95% CI 0.23-0.92; p = .03). There were no significant differences between the rates of postoperative pain from USLS sutures, postoperative pelvic hematomas, the suture exposure/granulation tissue formation, and the prolapse recurrence retreatment among the 2 groups.

CONCLUSION

The present meta-analysis indicates that L-USLS is possibly associated with significantly fewer ureteral compromise rates and decreased subjective and objective recurrences rates compared to V-USLS. Nevertheless, given the limitations in data quality and heterogeneity of the included studies, these findings should be interpreted with caution. Large-scale randomized studies are essential to more definitively determine the relative merits of the laparoscopic versus vaginal approach.

Meta-analysis of the efficacy of laparoscopic uterosacral ligament suspension in patients with pelvic organ prolapse

OBJECTIVE

This study aimed to evaluate the efficacy of laparoscopic uterosacral ligament suspension (LUSLS) for pelvic organ prolapse (POP) using a meta-analysis method.

METHODS

All articles about LUSLS published in English from Jan. 2010 to Jan. 2020 were retrieved using a computer from search engines, including PubMed, EMbase, Cochrane Library, CNKI, Wanfang, VIP, and Chinese Medical Journals. Meta-analysis was performed by two evaluators using RevMan 5.3 software according to the inclusion criteria.

RESULTS

A total of five studies were finally included, with 361 LUSLS cases and 361 control cases. LUSLS group showed a shorter operation duration (SMD-1.96; 95% CI = -3.90- -0.03; P = 0.05), more POP-quantification system (Q) (I) (SMD1.64; 95% CI = 1.05-2.56; P = 0.03), than the control group, with significant differences. There was no difference in the complication incidence, hospital stay, POP-Q>=II between the 2 groups (P > 0.05).

CONCLUSION

LUSLS was a safe and effective treatment for POP. Patients had higher postoperative satisfaction, shorter operation duration and satisfactory outcome. More high-quality randomized controlled trials are required in the future to make the results of the meta-analysis more accurate.

Laparoscopic uterosacral ligament suspension: a systematic review and meta-analysis of safety and durability

Introduction

Pelvic organ prolapse (POP) is a widespread condition affecting from 40% to 60% of women. Reconstructive vaginal surgeries are the most commonly performed procedures to treat POP. Among those, uterosacral ligament suspension (USLS), which is usually performed transvaginally, preserves pelvic statics and dynamics and appears to be an effective method. Laparoscopic USLS is a valid alternative to vaginal approach, and the aim of our review is to confirm its safety and feasibility and to compare clinical outcomes among the procedures.

Materials and methods

Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed and Scopus databases in December 2022. We made no restriction on the publication year nor on the country. Data about POP-Q recurrence rate (RR), intraoperative and postoperative complications (graded according to Clavien-Dindo classification), readmission rate, and reoperation rate were collected and analyzed. We used comparative studies for meta-analysis.

Results

A total of nine studies fulfilled inclusion criteria: two articles were non-comparative retrospective observational studies, three more articles were comparative studies where laparoscopic USLS was confronted with other surgical techniques (only data of laparoscopic USLS were analyzed), and four were comparative retrospective cohort studies between laparoscopic and vaginal USLS procedures. The comparative studies were enrolled in meta-analysis. Patients were analyzed concerning perioperative risks and the risk of recurrence. The meta-analysis highlighted that there was no clear inferiority of one technique over the other.

Discussion

Laparoscopic USLS is a technique with a low complication rate and low recurrence rate. Indeed, laparoscopic procedure allows better identification of anatomical landmarks and access to retroperitoneum. Moreover, efficacy over time and durability of Laparoscopic (LPS) USLS was also observed. However, these data should be weighed in light of the length of follow-up, which was in a very short range. Further, focused and prospective studies will be necessary to confirm this finding.