Patient Impression of Improvement 1 year After Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Pelvic Organ Prolapse Stage 2 or Higher

INTRODUCTION AND HYPOTHESIS

Patient-reported outcomes are relevant outcomes in studies on pelvic organ prolapse (POP) surgery, as anatomical recurrence alone does not have a significant correlation with perceived improvement. In the present study, the patient's impression of improvement after 1 year is studied after vaginal hysterectomy (VH) versus sacrospinous hysteropexy (SSH) in large cohorts from daily clinical practice. We hypothesize that there is no difference between the groups.

METHODS

This is a secondary analysis on prospectively collected data in a multicenter cohort of patients who underwent VH or SSH for symptomatic POP. All patients had a POP-Q stage ≥ 2 in at least one compartment at baseline and were treated with VH or SSH between 2002 and 2019. The primary outcome was the patient-reported score on the patient global impression of improvement index (PGI-I) 1 year after surgery. The secondary outcome was a composite outcome of surgical success, defined as the absence of recurrent POP beyond the hymen with bothersome bulge symptoms and/or repeat surgery.

RESULTS

A total of 378 women (196 VH and 182 SSH) were included. The median score on the PGI-I did not differ between VH and SSH. At 1 year post-operatively, 77 women after VH (73%) and 77 women after SSH (75%) considered their condition (very) much improved (p = 0.86). There was no difference in composite outcome of surgical success (126 out of 137 women [92%] after VH, 118 out of 125 women [94%] after SSH; p = 0.44).

CONCLUSIONS

Our study shows that there was no difference in the type of surgery, VH or SSH, with regard to the patient's impression of improvement 1 year postoperatively in a large cohort from daily clinical practice.

Anterior sacrospinous ligament fixation by the vaginal route in ten steps

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery. Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences. The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure. In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.

Concomitant pericervical reconstruction with sacrospinous hysteropexy: Anatomical and functional results

OBJECTIVE

Pericervical ring reconstruction through restoration of pubocervical and rectovaginal fascia is performed concomitantly with sacrospinous hysteropexy as a transvaginal native tissue procedure for vaginal apical prolapse. The main goal of this study was to assess subjective and objective outcomes of sacrospinous hysteropexy and additional pericervical ring reconstruction.

MATERIALS AND METHODS

We conducted a prospective and observational study. All participants underwent sacrospinous hysteropexy and pericervical ring reconstruction and perineorrhaphy. Surgical complications, anatomical and functional efficacy were assessed.

RESULTS

108 cases were included in this study. The mean follow-up timeframe was 18.62 ± 1.22 months (minimum 12 and maximum 26 months). All parameters of subjective outcomes were improved significantly. The overall anatomic success rate was 92.59%. Mean operation time was 50.64 ± 20.8 min. No major intraoperative or postoperative complications were found. There was no statistically significant difference in demographic characteristics including age, BMI, gravidity, medical comorbidities, menopausal status, sexual activity, pretreatment prolapse severity scores between subjects with failure, and good anatomical outcome. Recurrence was mostly observed in patients with higher prolapse stages of anterior and apical compartments. Baseline POP-Q parameters Ba, C, D were significantly higher in cases with failure.

CONCLUSION

Our study disclosed sustainable anatomic and subjective outcomes of modified sacrospinous hysteropexy by means of additional pericervical ring reconstruction.

Laparoscopic sacrohysteropexy versus vaginal sacrospinous hysteropexy as treatment for uterine descent: comparison of long-term outcomes

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a frequent occurring health issue, especially concerning elderly women. The objective of this study is to examine the long-term outcomes of laparoscopic sacrohysteropexy (LSH) and vaginal sacrospinous hysteropexy (SSHP) for treatment of uterine prolapse.

METHODS

A retrospective study of patients who underwent a LSH or SSHP. Validated questionnaires and an outpatient examination visit were used to investigate the effects of both surgical treatments. The primary outcome was the composite outcome of success for the apical compartment, defined as no recurrence of uterine prolapse (POP-Q measurement C ≤ 0), no subjective recurrence of POP, and/or not requiring therapy for recurrent prolapse. Secondary outcomes were peri- and postoperative data, anatomical failure, prolapse beyond hymen, subjective outcomes, and disease-specific quality of life.

RESULTS

We included 105 patients, 53 in the LSH group and 52 in the SSHP group. The overall response rate of the questionnaires was 83% (n = 87) after a mean follow-up time of 4.5 years (54.2 months; 95% CI 44.8-64.2 months) in the LSH group and 2.5 years (30.1 months; 95% CI 29.3-31.5 months) in the SSHP group. There were no clinically relevant differences between the study groups in composite outcome of success (p = 0.073), anatomical failure of the apical compartment (p = 0.711), vaginal bulge symptoms for which patients consulted professionals (p = 0.126), and patient satisfaction (p = 0.741). The operative time was longer in the LSH group (117 min; interquartile range (IQR) 110-123) compared to the SSHP group (67 minutes; IQR 60-73) (p < 0.001). The duration of hospital stay was also longer in the LSH group (4 days) than in the SSHP group (3 days) (p = 0.006).

CONCLUSIONS

LSH and SSHP seem to be equally effective after long-term follow-up in treating uterine prolapse in terms of objective and subjective recurrence.

Complications and objective outcomes of uterine preserving surgeries for the repair of pelvic organ prolapse versus procedures removing the Uterus, a systematic review

BACKGROUND

Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data.

METHODS

We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis.

RESULTS

Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD =  - 0.159 days, 95% CI [-0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD =  - 0.339, 95% CI [-0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD =  - 1.191 h, 95% CI [-1.836, -0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]).

CONCLUSION

We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.

Sacrospinous hysteropexy with an autologous rectus fascia sling for treatment of advanced apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

There is a great interest in avoiding mesh usage in vaginal surgeries. We propose using the autologous rectus fascia to repair apical vaginal prolapse in a similar way it has been successfully used in urinary stress incontinence surgery. This study aims to demonstrate the technique of sacrospinous hysteropexy using autologous rectus fascia for apical pelvic organ prolapse (POP) treatment.

METHODS

We present a video of a 63-year-old female with stage IV pelvic organ prolapse and urinary obstruction. A rectus fascia sling of approximately 90 × 10 mm was harvested through a Pfannenstiel incision. It was used in vaginal surgery to suspend the cervix and fix the apical POP.

RESULTS

The patient resumed her usual activities after 1 week and waited 2 months to resume physical activities and sexual intercourse. She is satisfied at 6 months follow-up, without complications or prolapse recurrence.

CONCLUSION

The sacrospinous hysteropexy using autologous rectus fascia is a feasible technique with excellent results and low risk of complication. Further studies are required to compare POP repair using autologous rectus fascia and polypropylene meshes.

Short-term outcomes of sacrospinous hysteropexy through an anterior approach

INTRODUCTION AND HYPOTHESIS

The posterior approach to sacrospinous hysteropexy has been well studied but little is known about the anterior approach. This study assessed the efficacy and complications of an anterior approach to sacrospinous hysteropexy compared to hysterectomy with apical repair. We hypothesized that anterior sacrospinous hysteropexy has similar efficacy and fewer complications.

METHODS

This retrospective cohort study compared patients who underwent native-tissue anterior sacrospinous hysteropexy (cases) with those who underwent hysterectomy with apical repair (controls). Composite success was defined as (1) leading edge of prolapse not beyond the hymen and apex not descended > 1/3 total vaginal length; (2) no vaginal bulge symptoms; (3) no prolapse retreatment. Descriptive and bivariate statistics were performed as well as a Cox regression analysis for time to failure.

RESULTS

Fifty cases and 97 controls were compared. The median follow-up time was 7.6 months. Operative time was shorter in the hysteropexy group (110.7 vs. 155.9 min, p < 0.001). The composite success was 92% for both cases and controls (p = 1.000) with no difference in time to surgical failure (p = 0.183). There were no serious intraoperative complications in the hysteropexy group and six in the control group (3 transfusions, 1 conversion to laparotomy, 1 ureteral injury, 1 cystotomy; p = 0.101). There was no difference in the number of postoperative complications (22.0% vs. 30.9%, p = 0.203).

CONCLUSIONS

For primary uterine prolapse, anterior sacrospinous hysteropexy has similar short-term efficacy compared to hysterectomy with apical repair with shorter operative time and a trend towards fewer serious complications.

Native tissue sacrospinous hysteropexy from an anterior approach

AIM OF THE VIDEO

The goal of urogynecologic surgeons is to pair patients with the most appropriate and effective surgery. Sacrospinous hysteropexy has become an increasingly utilized surgical option for uterovaginal prolapse repair. The primary aim of this video is to highlight the role that sacrospinous hysteropexy can have in prolapse repair and to demonstrate an anterior approach for this procedure.

METHODS

We performed a literature review to provide general information on the efficacy, risks, and comparative benefits of sacrospinous hysteropexy. Our video demonstrates the key steps in performing a sacrospinous hysteropexy procedure from an anterior approach including method of dissection, suture fixation to the sacrospinous ligament, and cervical suspension.

RESULTS

Sacrospinous hysteropexy has generally been found to be an effective option for uterovaginal prolapse repair in properly selected patients. The demonstrated approach integrates sacrospinous ligament fixation with an anterior colporrhaphy.

CONCLUSIONS

Data and experience to date on sacrospinous hysteropexy are largely based on a posterior approach for access to the sacrospinous ligament. This surgical video demonstrates an anterior approach to sacrospinous hysteropexy that is not well characterized in the literature.

Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study)

BACKGROUND

Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed.

METHODS

The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%.

DISCUSSION

This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed.

TRIAL REGISTRATION

Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.

Trends in apical prolapse surgery between 2010 and 2016 in Denmark

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is a common diagnosis. Today there is no consensus on the ideal operation technique for apical prolapse. Vaginal hysterectomy with suspension of the vaginal cuff is the most frequently used, but the popularity of uterus-preserving techniques is increasing. The aim of this study was to describe trends in surgical techniques used to treat primary apical prolapse in Danish hospitals.

METHODS

Data were obtained from the Danish Urogynecological Database and included women with primary prolapse surgery in the apical compartment operated in Denmark 2010-2016. Public hospital departments were divided into three categories according to degree of urogynecological specialization: high level, moderate level, and no specialization.

RESULTS

The number of vaginal hysterectomies decreased and the number of uterus-preserving operations increased from 2010 to 2016. The proportion of uterus-preserving techniques versus vaginal hysterectomy differed substantially between different hospital types. At departments with high and moderate levels of specialization, uterus-preserving techniques increased during the period, accounting for nearly 90% and 40%, respectively, in 2016, while decreasing to < 35% for departments with no specialization. Three of the four departments with high-level specialization preferred the Manchester-Fothergill procedure, while one preferred sacrospinous hysteropexy. Only 2.3% of all procedures were performed at private hospitals.

CONCLUSIONS

The proportion of uterus-preserving techniques to treat apical prolapse increased from 2010 to 2016. However, there is a wide variation in practice at the different hospitals. An agreement on uterus-preserving techniques has not been reached.

Sacrospinous ligament fixation for hysteropexy: does concomitant anterior and posterior fixation improve surgical outcome?

INTRODUCTION AND HYPOTHESIS

Uterine preservation in uterine prolapse is an option for young patients. We hypothesized that sacrospinous hysteropexy (SSH) with anchorage to both the anterior and posterior cervix (SSH-ap) would have a better outcome than SSH with anchorage to the posterior cervix only (SSH-p).

METHODS

This was a retrospective study including 75 patients who underwent SSH at Chang Gung Memorial Hospital between March 2008 and August 2013. Five were excluded due to incomplete data. Of the remaining 70 patients, 35 underwent SSH-p between March 2008 and June 2011, and 35 underwent SSH-ap between June 2010 and August 2013. The primary outcome was the objective anatomical result, and a successful outcome was considered anatomical correction (POP-Q stage 1 or less) of anterior and apical prolapse. Subjective outcome was evaluated using the POPDI-6 questionnaire, and a patient response of "No or mild abdominal organ falling out sensation" together with "No or mild heaviness" was considered to indicate a successful outcome. Anterior fornix and cervical diameter measurements were included. The secondary outcome was quality of life according to the UDI-6, IIQ-7, POPDI-6, and PISQ-12 questionnaires. The 3-year outcome was used for comparison.

RESULTS

The subjective overall cure rates were significantly different between the SSH-p and SSH-ap groups (74.3% and 94.3%, respectively; p = 0.023). However, the objective overall cure rates were not significantly different (74.3% and 82.9%, respectively).

CONCLUSION

Anchorage of the anterior cervix and vaginal wall together with the usual posterior anchorage yield better subjective outcomes and apical suspension at 3 years after surgery than anchorage of the posterior cervix and vaginal wall only. The cervix position affected the subjective outcome. Concurrent trachelectomy did not affect the outcome.

Bladder function after sacrospinous hysteropexy and vaginal wall repair in women with uterovaginal prolapse

OBJECTIVE

To evaluate the impact of repair of uterovaginal prolapse using sacrospinous hysteropexy and vaginal wall repair on the bladder function.

STUDY DESIGN

The study was conducted at the urogynecology clinic of Suez Canal University Hospitals, Ismailia from January 2014 to March 2016. This study included women with a diagnosis of uterovaginal prolapse and wishing to preserve their uteri. Bladder function was evaluated through assessment of urological symptoms using a standardized questionnaire - the urogenital distress inventory (UDI-6) - in addition to urodynamic studies just before and six-months after the sacrospinous hysteropexy ± associated vaginal wall repair operation.

RESULTS

Twenty-seven patients completed the study with a mean age of 36.5 ± 4 years. Only 3 women had sacrospinous hysteropexy with no additional procedures. Other procedures included anterior colporrhaphy (12), posterior colporrhaphy (9) and perineorrhaphy (15). Based on UDI-6, there was no significant difference between the pre- and post-operative symptoms of stress urinary incontinence (SUI) [8/27 (29.6%) vs. 9/27 (33.3%) respectively; p value = 0.7]. The pre- and post-operative symptoms of urge urinary incontinence were also insignificantly different [13/27 (48.1%) vs. 15/27 (55.5%); p value = 0.5]. The total score of UDI-6 increased from 24.5 ± (14.2) to 32.8 ± (29.4) which was not statistically significant (p value = 0.12). Urodynamically, voiding dysfunction was found less frequently after the operation, however the difference was statistically insignificant [9/27 (33.3%) vs. 8/27 (29.6%); p value = 0.7].

CONCLUSION

Sacrospinous hysteropexy and associated vaginal wall repair do not affect the bladder function either subjectively or objectively.

Sacrospinous hysteropexy: review and meta-analysis of outcomes

INTRODUCTION

Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery.

METHODS

Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration's Review Manager software to perform meta-analysis of randomized controlled studies and observational studies.

RESULTS

Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n = 651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76-5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41-2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy.

CONCLUSION

Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.