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

Long-Term Outcomes Following Vaginal versus Laparoscopic Uterosacral Ligament Suspension

INTRODUCTION AND HYPOTHESIS

Long-term outcomes following vaginal (V-USLS) versus laparoscopic (L-USLS) uterosacral ligament suspension have not been reported in the literature. Our objective was to compare long-term outcomes following V-USLS versus L-USLS following hysterectomy.

METHODS

This was an ambispective cohort study at a single academic institution comparing patients who underwent a V-USLS following a vaginal hysterectomy or L-USLS following a laparoscopic hysterectomy from 2013 to 2018. The primary outcome was composite prolapse recurrence rate, combining subjective prolapse symptoms and objective failure, including prolapse beyond the hymen on pelvic organ prolapse quantification exam or retreatment. A power calculation determined 68 patients in each group would be required to detect a difference of 15% in recurrence rates. Statistical analysis was performed using Student' t-test, Wilcoxon rank sum test, chi-square test, or Fishers exact test, and multivariable logistic regression where appropriate.

RESULTS

Thirty-six patients in each group presented for a study visit. Preoperative POP-Q measurements were similar between groups. Surgical complication rates were low and similar between groups. Mean follow-up time was 6.8 years, similar between groups. V-USLS had higher rates of recurrent prolapse beyond the hymen on POP-Q (33.2% vs 11.1%, p = 0.016), retreatment (25.0% vs 2.8%, p = 0.006), and composite failure (47.2% vs 22.2%, p = 0.019). Subjective prolapse symptoms were similar between groups. V-USLS was associated with a higher risk of prolapse recurrence (aOR 1.73 (95%CI 1.13-5.78). Anterior prolapse (Aa) was associated with higher recurrence risk, with aOR 2.04 (95%CI 1.15-3.62) per every 1 cm, up to 3 cm beyond the hymen.

CONCLUSIONS

On the basis of these results, L-USLS appears to have a decreased association with recurrence compared to V-USLS. Conclusions are limited by a small sample size.

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.

Laparoscopic Shull Technique for Uterine Prolapse and Risk of Recurrences: A Retrospective Comparison with Vaginal Hysterectomy

INTRODUCTION AND HYPOTHESIS

The objective was to compare the vaginal and laparoscopic approaches with natural tissue vaginal repair of pelvic organ prolapse (POP) in terms of recurrence rate and complete remission rate (CRR) of symptoms.

MATERIALS AND METHODS

This retrospective cohort study analyzed women who underwent hysterectomy for uterine prolapse at two Italian hospitals between October 2021 and March 2023. Group A included 89 patients who received vaginal hysterectomy and colposuspension (VCH), whereas group B included 58 patients who underwent laparoscopic hysterectomy followed by laparoscopic colposuspension sec Shull (LPSS).

RESULTS

The study included 147 patients with comparable baseline characteristics regarding menopausal age and body mass index. Concerning preoperative data, it is worth mentioning that group A had a higher proportion of patients with more than two previous deliveries and, overall, more severe prolapse stages. Concerning postoperative results, the patients undergoing laparoscopic surgery had longer operation times than group A. Moreover, group B had a higher recurrence rate after surgery (5.6% vs 13%, p = 0.057). Kaplan-Meier analysis indicated a lower rate of prolapse-free patients over time in group B. Cox regression showed a higher hazard ratio for recurrence in the LCSS group than in the VCH group. Complete remission rates for urinary symptoms varied, with group B showing higher CRR for stress incontinence (33% vs 71%, p < 0.001).

CONCLUSION

Both VCH and LCSS are effective for POP treatment, with VCH showing better outcomes in terms of symptom remission and shorter operation times. At the same time, LCSS had better CRR for stress incontinence but a higher recurrence rate. Further high-quality prospective studies are needed to confirm these findings and determine the best surgical approach for POP.

Surgical outcomes of sacrospinous hysteropexy and hysteropreservation for pelvic organ prolapse: a systematic review of randomized controlled trials

Objective

In several randomized controlled trials (RCTs), sacrospinous hysteropexy and other forms of hysteropreservation have been compared. Nevertheless, there is no definitively best treatment. This study summarized RCT evidence for various uterine preservation surgical procedures.

Methods

From each database inception to August 2023, we searched PubMed, Embase, Cochrane Library, and Web of Science for eligible RCTs. A comparison was made between sacrospinous hysteropexy and other hysteropreservation, including vaginal and abdominal surgery. For categorical and continuous variables, relative risks (RRs) and mean differences (MDs) were calculated using random-effects models.

Results

We reviewed a total 1,398 studies and ultimately included five RCTs that met all inclusion criteria. These five studies included a total of 1,372 uterine POP cases all of whom received transvaginal surgery and had a follow-up period for assessment of recurrence from 12 months to 5 years. There were no significant differences between sacrospinous hysteropexy and other hysteropreservation for the incidences of recurrence (RR,1.24; 95% CI, 0.58 to 2.63; p = 0.58) or hematoma (RR,0.70; 95% CI, 0.17 to 2.92; p = 0.62). Moreover, neither sacrospinous hysteropexy nor hysteropreservation had any significant effect on the risk of mesh exposure (RR,0.34; 95% CI, 0.03 to 4.31; p = 0.41), dyspareunia (RR,0.45; 95% CI, 0.13 to1.6; p = 0.22), urinary tract infection (RR,0.66; 95% CI, 0.38 to 1.15; p = 0.15), bothersome bulge symptoms (RR,0.03; 95% CI, -0.02 to 0.08; p = 0.24), operative time (MD, -4.53; 95% CI, -12.08 to 3.01; p = 0.24), and blood loss (MD, -25.69; 95% CI, -62.28 to 10.91; p = 0.17). However, sacrospinous hysteropexy was associated with a lower probability of pain (RR,4.8; 95% CI, 0.79 to 29.26; p = 0.09) compared with other hysteropreservation.

Conclusion

There was no difference between sacrospinous hysteropexy and hysteropreservation in terms of recurrence, hematoma, mesh exposure, dyspareunia, urinary tract infection, bothersome bulge symptoms, operative time, pain, and blood loss.

Systematic Review Registration

PROSPERO [CRD42023470025].

Multicentric data analysis of the learning curve for laparoscopic Shull's repair of pelvic floor defects

Introduction

Pelvic organs prolapse remains a significant health concern affecting millions of women worldwide. The use of native tissues to suspend the apex has acquired relevance in urogynecologic surgery. One of the most commonly used procedures performed without mesh is the technique described by Shull, consisting of suturing the vaginal apex to the uterosacral ligaments. The objective of the study is to evaluate the learning curve of laparoscopic Shull's repair for the correction of pelvic floor defects, including the surgery time and surgical outcomes.

Materials and methods

This is a retrospective study conducted at the Policlinico G. Martino, University of Messina, Messina, Italy, and Policlinico Vanvitelli, Vanvitelli University, Naples, Italy. All patients affected by grade I-IV POP, consisting of apical prolapse with or without cystocele, and who underwent laparoscopic Shull's technique for prolapse correction were enrolled. The endpoints to estimate the learning curve for the procedure were the percentage of laparoscopic procedures completed, operative time, and the early complication rate.

Results

A total of 31 laparoscopic Shull repairs were collected for the study. To evaluate the learning curve of the technique, we divided the 31 cases into three different groups: Procedures 0-10; 11-20; 21-31. The parameter for evaluating technique learning was the operative time. Group 21-31 demonstrated an operative time of 97 min (SD 20), compared with 121 min (SD 23) in group 0-10 and 120 min (SD 13) in group 11-20. A comparison of these means through ANOVA showed a p-value of 0.01 for the entire system, and 0.95 for the comparison between 0 and 10 and 11-20, 0.04 for 0-10 vs. 21-31, and 0.02 between 11 and 20 and 21-31.

Conclusions

The rate of surgical improvement in terms of time became effective after an average of 20 procedures. However, the improvement seems to be effective case by case for surgeons skilled in basic endoscopy.

Frequency of cul-de-sac obliteration in surgery for pelvic organ prolapse: a retrospective analysis

INTRODUCTION AND HYPOTHESIS

We aimed to clarify the frequency of cul-de-sac obliteration in patients undergoing POP surgery.

METHODS

We retrospectively reviewed patients who underwent laparoscopic POP surgery at our hospital between April 2017 and September 2021.

RESULTS

In total, 191 cases were included in the analysis. Ten patients (5.2%) had cul-de-sac obliteration. No difference in age (73 years vs. 72 years, P = 0.99), parity (2 vs. 2, P = 0.64), or body mass index (BMI) (25.7 kg/m2 vs. 24.7 kg/m2, P = 0.34) was observed between the cul-de-sac obliteration and normal groups. No significant differences were observed in the rate of previous abdominal surgery (50.0% vs. 32.6%, P = 0.46), rate of POP - quantification system (POP-Q) ≥ 2 posterior prolapse (40.0% vs. 46.4%, P = 0.98), and effect of defecation symptoms on the prolapse quality of life (p-QOL) score (vaginal bulge emptying bowels: 2.5 vs. 3.5, P = 0.15; empty bowel feeling: 3 vs. 3, P = 0.72, constipation: 3.5 vs. 3, P = 0.58; straining to open bowels: 3.5 vs. 3, P = 0.82; empty bowels with fingers: 1 vs. 1, P = 0.55) between the cul-de-sac obliteration and normal groups. Multivariate analysis of risk factors for the cul-de-sac obliteration was performed for age, number of births, previous abdominal surgery, and presence of rectocele; however no significant risk factors were extracted.

CONCLUSION

Predicting cul-de-sac obliteration preoperatively in patients undergoing POP surgery based on age, number of previous surgeries, previous abdominal surgeries, rectocele, and defecation symptoms is difficult.