Risk factors for ureteral occlusion during transvaginal uterosacral ligament suspension

Outcomes of uterosacral ligaments suspension for uterovaginal prolapse native-tissue repair: Over 1000-patient single-center study

INTRODUCTION AND HYPOTHESIS

Surgical repair is the mainstay of genital prolapse management. Among native-tissue apical procedures, high uterosacral ligaments suspension is considered a valid and effective option for central compartment repair. In this study, we aimed to evaluate the effectiveness, complications rate, and functional results of high USL suspension as a primary prolapse repair technique in a large cohort of patients.

METHODS

Patients who underwent vaginal hysterectomy followed by high uterosacral ligaments suspension for POP between January 2008 and December 2020 were retrospectively analyzed. Questionnaires and clinical interviews were preoperatively performed to assess symptoms and severity of urinary, bowel, and sexual dysfunctions. After surgical procedure, diagnostic cystoscopy was performed to evaluate ureteral patency. Postoperative data, objective, and subjective cure rate were then noted at the follow-up evaluation.

RESULTS

A total of 1099 patients underwent high uterosacral ligaments suspension. The total complication rate was 3.4 % and recurrence in any of the vaginal compartments was 12.4 %. Reoperation for symptomatic prolapse recurrence or pessary treatment was required in 9 women (0.9 %). In the evaluation of postoperative questionnaires, functional outcomes analysis revealed a significant improvement (p < 0.05) in terms of stress urinary incontinence, urge urinary incontinence, voiding symptoms, constipation, and dyspareunia after prolapse repair.

CONCLUSION

Uterosacral ligament suspension is a safe and effective procedure for primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and the reoperation rate for recurrence was below 1%.

Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy

STUDY OBJECTIVE

To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair.

DESIGN

A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome.

SETTING

Tertiary center for urogynecology.

PATIENTS

Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse.

INTERVENTIONS

Comparison analysis of estimated long-term costs was performed.

MEASUREMENTS AND MAIN RESULTS

Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse.

CONCLUSION

The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

The EnPlace® sacrospinous ligament fixation-A novel minimally invasive transvaginal procedure for apical pelvic organ prolapse repair: Safety and short-term outcome results

OBJECTIVE

The EnPlace® device is a novel minimally invasive tool allowing transvaginal sacrospinous ligament (SSL) fixation of apical pelvic organ prolapse (POP). The study aimed to investigate the safety and short-term efficacy of the EnPlace® SSL fixation for significant apical POP repair.

METHODS

A retrospective cohort study of 123 consecutive patients (mean age 64.4 ± 11.1 years) with stage III or IV apical POP who underwent SSL fixation by the EnPlace® device. Safety and 6-month outcome results were analyzed and compared between 91 (74%) patients with uterine prolapse versus 32 (26%) patients with vaginal vault prolapse.

RESULTS

There were no intraoperative or early postoperative complications. The mean (± standard deviation) duration of surgery was 30 ± 6.9 min and mean blood loss was 30.5 ± 18.5 mL. The average position of point C by POP-Quantification measurements before surgery and at 6 months postoperatively was 4.5 ± 2.8 cm and -3.1 ± 3.3 cm, respectively. Of 91 patients with preoperative uterine prolapse, eight (8.8%) patients developed a recurrent uterine prolapse within 6 months postoperatively. Of 32 patients with preoperative vault prolapse, two patients (6.3%) had recurrent vault prolapse.

CONCLUSION

Short-term outcome results of EnPlace® SSL fixation suggest that it is a safe and effective minimally invasive transvaginal procedure for significant apical POP repair.

Bilateral medial sacrospinous ligament suture for apical suspension through natural spaces: A single-center study with low perioperative complications

Sacrospinous ligament fixation (SSLF) is one of the most used native tissue approaches for apical suspension with a high rate of perioperative complications. This study aimed to review cases undergoing a modified SSLF and assess its perioperative adverse events. It was a retrospective study of 168 consecutive patients undergoing modified transvaginal SSLF at a single tertiary center from 2017 to 2021. The sutures were placed on the sacrospinous ligament (SSL) approaching the sacrum through natural spaces under direct vision. Moreover, it was performed bilaterally. Patient demographics and perioperative complications were reviewed. The median age was 65 years, and 85.7% (144/168) had stage III-IV prolapse. Among the 168 patients undergoing this modified SSLF, 161 were for uterovaginal prolapse, and seven were for posthysterectomy vaginal vault prolapse. 83.9% (135/161) patients were concomitant with hysterectomy, and 70.2% (118/168) were with anteroposterior colporrhaphy. The median operation time was 82 min (interquartile range [IQR], 61-100 min), and the median intraoperative blood loss was 50 ml (IQR, 30-50 ml). Two cases had pelvic hematoma, and both were cured after expectant treatment. No patient required a homologous blood transfusion, and none complained about buttock or lower limb pain 2 weeks postoperatively. Nor did injury of the ureters, bladder, or rectum occur intraoperatively. This modified transvaginal SSLF procedure was safe and had no severe perioperative complications.

Minimally invasive meshless and minimal dissection ligament fixation system for apical organ prolapse procedures: A 4-year prospective follow up study

OBJECTIVE

EnPlace™ (formerly named NeuGuide™) is a minimally invasive meshless anchoring system for pelvic organ prolapse (POP) repair designed to provide centro-apical pelvic floor support. We present a 4-year prospective follow up evaluation of this repair system.

METHODS

This was a single-center longitudinal prospective study of women with advanced POP who underwent pelvic floor apical repair using EnPlace™ with at least 4 years of follow-up. The primary outcome was surgical success defined as anatomical success, no symptoms of vaginal bulging and no need for re-treatment. A standardized validated questionnaire to assess symptom burden was used.

RESULTS

Fifteen women were enrolled in the study. Two patients were lost to follow-up. The median follow-up was 51 months (range 42-57) with a surgical success rate of 92.3%. One patient (7.7%) reported symptoms of vaginal vault prolapse and underwent a repeated prolapse surgery. Using the UDI-6 questionnaire, an improvement in all domains was seen.

CONCLUSION

The 4-year prospective follow up suggests that apical repair using the EnPlace™ device may be considered safe and effective for sacrospinous ligament fixation with a sustainable long-term success. This procedure is a minimally invasive meshless addition to pelvic surgeon's armamentarium.

Risk factors for ureteral obstruction and the diagnostic value of the "cysto-under-tension" technique at the time of uterosacral colpopexy

INTRODUCTION AND HYPOTHESIS

The objective is to determine the incidence of ureteral obstruction and delayed ureteral injury and to identify risk factors for ureteral obstruction following uterosacral colpopexy. The secondary objective is to evaluate the diagnostic value of the "cysto-under-tension" technique, when a cystoscopy is performed prior to vaginal cuff closure with the uterosacral sutures on tension.

METHODS

This was a retrospective review of patients undergoing uterosacral ligament colpopexy between 2007 and 2012 with a nested case-control analysis. Patients with documented ureteral obstruction on cystoscopy or a delayed ureteral injury were identified. Cases were defined as patients with a ureteral obstruction on cystoscopy and controls as those who did not; a multivariable regression analysis was performed.

RESULTS

A total of 551 patients underwent uterosacral ligament colpopexy. Twenty-four (4.3% [95% CI = 2.94-6.40]) patients had a ureteral obstruction on cystoscopy, and two (0.4% [95% CI = 0.09-1.31]) patients experienced a delayed ureteral injury. The "cysto-under-tension" technique was used in 40 (7.3%) cases, with a sensitivity of 50.0% (CI = 1.26-98.74) and specificity of 97.4% (CI = 86.2-99.9) to detect ureteral obstruction. On logistic regression for the case-control analysis, increased age remained associated with increased odds of ureteral obstruction (adjOR 1.06, 95% CI = 1.02-1.11) and a higher BMI had lower odds (adjOR 0.89, 95% CI = 0.79-0.98).

CONCLUSIONS

In this large cohort study, older age was associated with higher odds of obstruction at the time of colpopexy while a higher BMI might have been protective. The "cysto-under-tension" technique overall may not be that useful in detecting ureteral obstructions but has high negative predictive value.

Long-term efficacy of transvaginal high uterosacral ligament suspension for middle-compartment defect-based pelvic organ prolapse

BACKGROUND

We aim to assess the long-term efficacy of transvaginal high uterosacral ligament suspension (HUS) procedure for middle compartment defect-based pelvic organ prolapse (POP).

METHODS

We performed a retrospective review of 84 women with middle-compartment defect-based POP who underwent transvaginal HUS as the primary surgical treatment without mesh augmentation from January 2007 to January 2019. All 84 patients manifested ≥ grade-II middle-compartment defect-based POP. Follow-up visits were performed 2, 6 and 12 months after surgery and then annually, including questionnaires and clinical examination using pelvic organ prolapse quantitation system (POP-Q). Surgical success required to fulfill all three of these criteria: (I) anterior or posterior vaginal wall prolapsed the leading edge of 0 cm or less and apex of 1/2 total vaginal length or less; (II) the absence of POP symptoms as reported on the PFDI-20 question No. 3 ("do you usually have a bulge or something falling out that you can see or feel in your vaginal area?"); and (III) no prolapse re-operations or pessary use during the study period.

RESULTS

Of 84 women, 56 cases (66.7%, 56/84) were evaluated at a ≥5-year follow-up. The 5-year recurrence rates for patients with prolapse of either the anterior vaginal wall, vaginal vault, or posterior vaginal wall, or prolapses in multiple sites, were 7.1% (4/56), 0, 1.8% (1/56), and 3.6% (2/56), respectively. The surgery success rate was 87.5% (49/56). None of the recurrent women underwent retreatment. The satisfaction rate was 91.1% (51/56).

CONCLUSIONS

Transvaginal HUS without mesh augmentation is a safe and effective procedure in the surgical treatment of patients with middle-compartment defects. Anatomical, functional, and subjective outcomes were very satisfactory.

Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort of Absorbable and Permanent Suture Groups

OBJECTIVE

The aim of this study was to compare anatomic results after vaginal uterosacral ligament suspension with absorbable versus permanent suture.

METHODS

We performed a retrospective cohort study of women who underwent vaginal uterosacral ligament suspension, from 2006 to 2015. We compared 2 groups: (1) absorbable suspension suture and (2) permanent suspension suture (even if accompanied by absorbable suture). Our primary outcome was composite anatomic failure defined as (1) recurrent prolapse in any compartment past the hymen or (2) retreatment for prolapse. Continuous variables were analyzed using the Student t test or Mann-Whitney U test, and categorical variables were analyzed using χ or Fisher exact test. Multivariable logistic regression analysis was performed to control for confounders. P < 0.05 was considered significant.

RESULTS

Of the 242 patients with medium-term follow-up (3 months to 2 years after surgery), 188 underwent vaginal uterosacral ligament suspension with only absorbable suture, and 54 underwent suspension with permanent suture. Compared with the absorbable suture cohort, the permanent suture cohort was more likely to have had advanced preoperative prolapse (P = 0.01), less likely to have had a prior hysterectomy (P = 0.01), and less likely to have undergone a concomitant posterior colporrhaphy/perineoplasty (P < 0.01). Overall, there were no differences in composite anatomic failure between the absorbable and permanent suture groups (17.0% vs 20.4%, P = 0.41). In multivariable logistic regression analyses, when controlling for covariates, there remained no difference in composite anatomic failure between permanent and absorbable suture groups.

CONCLUSIONS

Completion of vaginal uterosacral ligament suspension using only absorbable suture affords similar anatomic outcomes in the medium term as compared with suspension with additional permanent suture.

Outcomes of Transvaginal High Uterosacral Ligaments Suspension: Over 500-Patient Single-Center Study

BACKGROUND

Uterosacral ligament (USL) suspension is a safe and effective procedure in terms of anatomical, functional, and subjective outcomes for primary surgical treatment of prolapse.

OBJECTIVES

There has been a renewed interest toward native tissue prolapse repair by vaginal route because of low cost and lack of mesh-related complications. Uterosacral ligaments are considered safe, effective, and durable as suspending structures for primary surgical repair of the apical compartment. Our aim was to evaluate complications, anatomical, functional and subjective outcomes of high USL suspension for primary prolapse repair.

METHODS

Data of patients who underwent vaginal hysterectomy followed by high USL suspension for pelvic organ prolapse were retrospectively analyzed. Operative data, as well as complications, were recorded. Anatomical recurrence was defined as descent of any compartment stage II or greater according to the Pelvic Organ Prolapse Quantification system. Functional outcomes focused on urinary, bowel, and sexual dysfunctions. International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, Wexner, and Patient Global Impression of Improvement questionnaires were collected.

RESULTS

Data of 533 women were analyzed. Mean follow-up was 32 (SD, 19) months (dropout rate, 2.6%). Most frequent complication was ureteral kinking (2.6%). Total recurrence rate was 13.7%, with anterior compartment being the most frequent (9.4%), whereas reoperation for symptomatic prolapse recurrence was required in only 1% of patients. Improvement of urinary incontinence, voiding dysfunction, constipation, and dyspareunia was observed. Overall subjective satisfaction was high (Patient Global Impression of Improvement score, 1.3), ranging from "much improved" to "very much improved."

CONCLUSIONS

Uterosacral ligament suspension is a safe and effective procedure in primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and reoperation rate for recurrence was only 1%.

Safety and short term outcomes of a new truly minimallyinvasive mesh-less and dissection-less anchoring system for pelvic organ prolapse apical repair

OBJECTIVE

To evaluate the safety and short term outcomes of a new, truly minimallyinvasive, mesh-less and dissection-less anchoring system for pelvic floor apical repair.

METHODS

A prospective study was conducted using the NeuGuide™ device system for pelvic floor apical repair. The primary effectiveness outcome was centro-apical pelvic floor prolapse by POP-Q after six months. The primary safety outcome was intra-operative, immediate (first 48 h) post-operative complications and adverse effects after six months. A standardized questionnaire (UDI-6) to assess quality of life at entry and during follow-up visits was used. Patients' six months-follow-up and evaluation are reported.

RESULTS

The mean age of the study population (n=10) was 63.8±12.0 years. All patients had a previous prolapse surgery. Five had a previous hysterectomy and two had stress urinary incontinence symptoms. During surgery six patients had a concurrent colporrhaphy. There was no injury to the bladder, rectum, pudendal nerves, or major pelvic vessels and no febrile morbidity was recorded. At six months, no cases of centro-apical recurrence were noted. Patients were satisfied with the procedure and had favorable quality of life scores. Using the UDI-6 questionnaire an improvement, in all domains was seen. Moreover, although the sample size was small, the improvement in urge and overflow incontinence related domains were demonstrated to be statistically significant.

CONCLUSIONS

This new NeuGuide™ device allows rapid and safe introduction of a suspending suture through the sacrospinous ligament and makes sacrospinous ligament fixation easy to perform, while avoiding dissection and mesh complications.

Native tissue repair for central compartment prolapse: a narrative review

Central descent due to a level 1 defect is a main component in pelvic organ prolapse (POP) reconstructive surgery, whether for symptomatic apical prolapse or for the prolapse repair of other compartments. A recent growth in the rate of native tissue repair procedures for POP, following the US Food and Drug Administration (FDA) warnings regarding the safety and efficacy of synthetic meshes, requires a re-evaluation of these procedures. The safety, efficacy, and determination of the optimal surgical approach should be the center of attention. Functional outcome measures and patient-centered results have lately gained importance and received focus. A comprehensive literature review was performed to evaluate objective and subjective outcomes of apical prolapse native tissue repair, with a special focus on studies reporting impact on patients' functional outcomes, quality of life, and satisfaction. We performed a MEDLINE search for articles in the English language by using the following key words: apical prolapse, sacrospinous ligament fixation, uterosacral ligament suspension, sacral colpopexy, McCall culdoplasty, iliococcygeus vaginal fixation, and functional outcomes. We reviewed references as well. Despite a prominent shortage of studies reporting standardized prospective outcomes for native tissue repair interventions, we noted a high rate of safety and efficacy, with a low complication rate for most procedures and low recurrence or re-treatment rates. The objective and subjective results of different procedures are reviewed. Functional outcomes of native tissue repair procedures have not been studied sufficiently, though existing data present those procedures as favorable and not categorically inferior to sacrocolpopexy. Apical compartment prolapse repair using native tissue is not a compromise. Functional outcomes of native tissue repair procedures are favorable, have a high rate of success, improve women's quality of life (QoL), and result in high rates of patient satisfaction. This subject requires further long-term, standardized prospective studies following the International Continence Society/International Urogynecologists Association guidelines for surgical outcomes report, with the focus on patient-centered functional outcomes.