Bilateral minimal tension sacrospinous fixation in pelvic organ prolapse: an observational study

Mobility analysis of a posterior sacrospinous fixation using a finite element model of the pelvic system

INTRODUCTION AND HYPOTHESIS

In order to improve the knowledge POP physiopathology and POP repair, a generic biomechanical model of the female pelvic system has been developed. In the literature, no study has currently evaluated apical prolapse repair by posterior sacrospinous ligament fixation using a generic model nor a patient-specific model that personalize the management of POP and predict surgical outcomes based on the patient's pre-operative Magnetic Resonance Imaging. The aim of our study was to analyze the influence of a right and/or left sacrospinous ligament fixation and the distance between the anchorage area and the ischial spine on the pelvic organ mobility using a generic and a patient-specific Finite Element model (FEM) of the female pelvic system during posterior sacrospinous ligament fixation (SSF).

METHODS

Firstly, we used a generic 3D FEM of the female pelvic system previously made by our team that allowed us to simulate the mobility of the pelvic system. To create a patient-specific 3D FEM of the female pelvic system, we used a preoperative dynamic pelvic MRI of a 68 years old woman with a symptomatic stage III apical prolapse and cystocele. With these 2 models, a SSF was simulated. A right and/or left SSF and different distances between the anchorage area and the ischial spine (1 cm, 2 cm and 3 cm.) were compared. Outcomes measures were the pelvic organ displacement using the pubococcygeal line during maximal strain: Ba point for the most posterior and inferior aspect of the bladder base, C point the cervix's or the vaginal apex and Bp point for the anterior aspect of the anorectal junction.

RESULTS

Overall, pelvic organ mobility decreased regardless of surgical technique and model. According to the generic model, C point was displaced by 14.1 mm and 11.5 mm, Ba point by 12.7 mm, and 12 mm and Bp point by 10.6 mm and 9.9 mm after left and bilateral posterior SSF, respectively. C point was displaced by 15.4 mm and 11.6 mm and Ba point by 12.5 mm and 13.1mm when the suture on the sacrospinous ligament was performed at 1 cm and 3 cm from the ischial spine respectively (bilateral posterior SSF configuration). According to the patient-specific model, the displacement of Ba point could not be analyzed because of a significative and asymmetric organ displacement of the bladder. C point was displaced by 4.74 mm and 2.12 mm, and Bp point by 5.30 mm and 3.24 mm after left and bilateral posterior SSF respectively. C point was displaced by 4.80 mm and 4.85 mm and Bp point by 5.35 mm and 5.38 mm when the suture on the left sacrospinous ligament was performed at 1 cm and 3 cm from the ischial spine, respectively.

CONCLUSION

According to the generic model from our study, the apex appeared to be less mobile in bilateral SSF. The anchorage area on the sacrospinous ligament seems to have little effect on the pelvic organ mobilities.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04551859.

Bilateral posterior Richter sacrospinous fixation with native tissue: anatomical and functional results and quality of life assessment over 10 years

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition that affects 50% of women who have given birth in their lifetime. With stop of vaginal mesh sale in 2019, the sacrospinous fixation technique according to Richter with native tissue has seen its incidence tripled in 15 years. Classically, sacrospinous fixation according to Richter is performed unilaterally, however its unilateral or bilateral character is controversial. Objective of this work is to evaluate the efficacy and safety of bilateral sacrospinous fixation according to Richter by the posterior approach with native tissue (SSB).

METHODS

We performed a retrospective single-center study. From March 12, 2010 to March 23, 2020, all first-time operated patients who underwent SSB in CHU Strasbourg gynecological surgery unit for symptomatic POP management were included. The main endpoint of our work is the anatomical and functional success rate at 12 and 24 months. The secondary judgment criteria of our work were based on the postoperative evaluation of patient's quality of life according to the PFDI-20 score as well as the rate of postoperative complications.

RESULTS

77 patients were included in our work. The anatomical success rate at 12 months is 94% and 81% at 24 months regardless of the compartment affected. The functional success rate is 94% at 12 months and 82% at 24 months. Quality of life evaluation through the PFDI-20 scale revealed a clear improvement in the symptomatology related to POP: 127/300 +/- 27.3. preoperatively and 59.8 ± 14.7 postoperatively.

CONCLUSION

Bilateral sacrospinous fixation according to Richter by posterior approach with native tissue is a safe and effective surgical technique allowing a clear improvement in patients quality of life.

Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To explore how permanent compared with absorbable suture affects anatomic success in native tissue vaginal suspension (uterosacral ligament suspension and sacrospinous ligament suspension) and sacrocolpopexy with mesh.

DATA SOURCES

MEDLINE, EMBASE, and ClinicalTrials.gov were searched through March 29, 2022.

METHODS OF STUDY SELECTION

Our population included women undergoing apical prolapse surgery (uterosacral ligament suspension and sacrospinous ligament suspension and abdominal sacrocolpopexy). Our intervention was permanent suture for apical prolapse surgery, and our comparator was absorbable suture. We determined a single anatomic success proportion per study. Adverse events collected included suture and mesh exposure, surgery for suture and mesh complication, dyspareunia, and granulation tissue. Abstracts were doubly screened, full-text articles were doubly screened, and accepted articles were doubly extracted. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. In single-arm studies using either permanent or absorbable suture, random effects meta-analyses of pooled proportions were used to assess anatomic success. In comparative studies investigating both suture types, random effects meta-analyses of pooled risk ratios were used.

TABULATION, INTEGRATION, AND RESULTS

Of 4,658 abstracts screened, 398 full-text articles were assessed and 63 studies were included (24 vaginal suspension [13 uterosacral ligament suspension and 11 sacrospinous ligament suspension] and 39 sacrocolpopexy). At 2-year follow-up, there was no difference in permanent compared with absorbable suture in uterosacral ligament suspension and sacrospinous ligament suspension (proportional anatomic success rate 88% [95% CI 0.81-0.93] vs 88% [95% CI 0.82-0.92]). Similarly, at 18-month follow-up, there was no difference in permanent compared with absorbable suture in sacrocolpopexy (proportional anatomic success rate 92% [95% CI 0.88-0.95] vs 96% [95% CI 0.92-0.99]). On meta-analysis, there was no difference in relative risk (RR) of success for permanent compared with absorbable suture for uterosacral ligament suspension and sacrospinous ligament suspension (RR 1.11, 95% CI 0.93-1.33) or sacrocolpopexy (RR 1.00, 95% CI0.98-1.03).

CONCLUSION

Success rates were similarly high for absorbable and permanent suture after uterosacral ligament suspension, sacrospinous ligament suspension, and sacrocolpopexy, with medium-term follow-up.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021265848.

Native-tissue pelvic organ prolapse (POP) repair with perineorrhaphy for level III support results in reduced genital hiatus size and improved quality of life in sexually active and inactive patients

INTRODUCTION AND HYPOTHESIS

Recent findings address the importance of Level III defects with increased genital hiatus being associated with pelvic organ prolapse (POP), correlated with Level I defects and strongly related to POP recurrence. We hypothesised that concomitant perineorrhaphy in POP repair reduces genital hiatus (gh) and increases perineal body (pb), that gh would be larger with number of vaginal deliveries and that patients' QOL was not different comparing sexually active vs inactive patients with overall judgement of cure comparable to the literature at evaluation.

METHODS

Retrospective observational study including consecutive patients with indications for posterior repair and Level III support between 2016 and 2018. Concomitant perineorrhaphy was indicated due to complaints of wide introitus or genital hiatus of ≥ 3.5 cm. Primary objective was to compare pre- and postoperative gh and pb according to POP-Q. Secondary objectives were preoperative gh and pb values by parity, POMs obtained with P-QOL/D comparing sexually active vs inactive patients, and subjective judgement of cure according to EGGS system.

RESULTS

In n = 121 patients, mean gh value was reduced postoperatively by 29.5 % (31 ± 6 vs 44 ± 10 mm, p < 0.001), mean pb value increased by 25.5 % (47 ± 8 vs 35 ± 8 mm, p < 0.001). Influence of parity on preoperative gh (p = 0.020), but not pb values (p = 0.119) was observed. All P-QOL/D domain scores improved significantly postoperatively without differences seen in sexually active vs inactive patients. EGGS responses indicated partial/full goal achievement in 90 % and cure in 87 %.

CONCLUSIONS

In the study cohort, perineorrhaphy as concomitant in POP repair led to Level III support reflected by decreased genital hiatus size. Functional QOL was improved regardless of sexual activity status and the majority of patients reported partial or full cure.

Bilateral Sacrospinous Hysteropexy Versus Bilateral Sacrospinous Ligament Fixation with Vaginal Hysterectomy for Apical Uterovaginal Prolapse

Purpose

The aim of this retrospective study was to compare the anatomical and functional outcomes between bilateral sacrospinous hysteropexy (BSHP) and bilateral sacrospinous ligament fixation with vaginal hysterectomy (BSLF/VH) in women with apical-predominant uterovaginal prolapse.

Methods

Clinical data from patients with symptomatic Pelvic Organ Prolapse-Quantification (POP-Q) stage 2 or higher uterovaginal prolapse who underwent either BSHP (48 patients) or BSLF/VH (69 patients) between January 2014 and December 2018 were reviewed retrospectively. The primary outcome was the subjective satisfaction rate evaluated by Patient Global Impression of Improvement, and the secondary outcomes included objective anatomical success rates, impact on disease-specific quality of life evaluated by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, Pelvic Floor Distress Inventory-Short Form 20, and Pelvic Floor Impact Questionnaire 7, and surgical complications.

Results

After a median follow-up of 35 months (range, 25–58 months), all patients in both groups demonstrated significant postoperative improvements in anatomical and functional outcomes (P<0.001). There were no significant differences in postoperative subjective and objective results, sexual satisfaction outcomes, or disease-specific quality of life between the BSHP and BSLF/VH groups, and similar incidence rates of intraoperative and postoperative complications were also recorded.

Conclusions

The uterus-sparing BSHP procedure yielded noninferior anatomical and functional outcomes compared to the BSLF/VH procedure and could be adopted as an alternative to conventional hysterectomy-based native-tissue repair modalities for symptomatic apical-predominant uterovaginal prolapse.

Safety and efficiency of modified sacrospinous ligament fixation for apical prolapse: Long-term studies and outcomes

OBJECTIVE

To explore the safety and efficiency of modified sacrospinous ligament fixation (MSSF) for apical prolapse.

METHODS

A retrospective cohort study. Patients diagnosed with apical prolapse from 2014 to 2019 were recruited and divided into three groups: sacrospinous ligament fixation (SSF), MSSF, and laparoscopic sacral hysteropexy (LSH). All surgical characteristics were obtained and information concerning complications was collected and compared among these three groups.

RESULTS

A total of 710 patients were included: 108 in the SSF group, 260 in the LSH group, and 342 in the MSSF group. The MSSF and SSF groups took less surgical time (P < 0.001) and had shorter hospital stays (P < 0.001). All three methods can significantly change prolapses to point C on the POP quantification score (P < 0.001). Prevalence of vaginal and pelvic pain after surgery was higher in the SSF group (8/108; 7.41%) (P = 0.028), and urinary incontinence was higher in the LSH group (22/260; 8.46%) (P = 0.010). In the LSH group more patients experienced constipation and dyschezia after surgery (prevalence 18/260; 6.92%; P = 0.048). Recurrence of pelvic organ prolapse in the MSSF group (15/324; 4.39%) and LSH group (12/260; 4.62%) was much lower than in the SSF group (16/108; 14.81%) (P < 0.001).

CONCLUSION

The efficacy of MSSF is commendable with low recurrence of POP and few complications in long-term follow up.

Anatomical and functional outcomes after hysterectomy and bilateral sacrospinous ligament fixation for stage IV uterovaginal prolapse: a prospective case series

Background

Aim of this study is to examine pelvic floor symptoms, anatomical results and patients’ satisfaction after sacrospinous vaginal fixation for stage 4 pelvic organ prolapse.

Methods

All patients with stage 4 pelvic organ prolapse were treated with vaginal hysterectomy, native tissue cystocele and rectocele repair and bilateral sacrospinous vaginal fixation. Anatomical and functional outcomes according to the POPq classification system and the German version of the Australian pelvic floor questionnaire were assessed. Changes between baseline, first follow-up and second follow-up were assessed by the paired Wilcoxon rank test using R, version 3.5.1.

Results

20 patients were included in the study. Scores in all four domains of the pelvic floor symptom questionnaire (bladder, bowel, prolapse, sexual function) were significantly improved at 6 and 12-months follow-up. One patient presented with a symptomatic stage 3 cystocele that needed a second surgical intervention and two patients needed surgery due to a de novo stress urinary incontinence. There were no perioperative adverse events and all patients reported full satisfaction after surgery.

Conclusions

The vaginal approach with hysterectomy, native tissue repair and bilateral sacrospinous vaginal fixation seems to be a safe and effective method for the treatment of advanced stage POP, offering excellent relief in all pelvic floor symptoms.

Trial registration

ClinicalTrials.gov (NCT 02998216), December 20th, 2016.

Prospectively registered.

Prolapse Repair Using Non-synthetic Material: What is the Current Standard?

PURPOSE OF REVIEW

Due to recent concerns over the use of synthetic mesh in pelvic floor reconstructive surgery, there has been a renewed interest in the utilization of non-synthetic repairs for pelvic organ prolapse. The purpose of this review is to review the current literature regarding pelvic organ prolapse repairs performed without the utilization of synthetic mesh.

RECENT FINDINGS

Native tissue repairs provide a durable surgical option for pelvic organ prolapse. Based on recent findings of recently performed randomized clinical trials with long-term follow-up, transvaginal native tissue repair continues to play a role in the management of pelvic organ prolapse without the added risk associated with synthetic mesh. In 2019, the FDA called for manufacturers of synthetic mesh for transvaginal mesh to stop selling and distributing their products in the USA. Native tissue and non-synthetic pelvic organ prolapse repairs provide an efficacious alternative without the added risk inherent to the utilization of transvaginal mesh. A recent, multicenter, randomized clinical trial demonstrated no clear advantage to the utilization of synthetic mesh. Furthermore, transvaginal native tissue repairs have demonstrated good long-term efficacy, particularly when anatomic success is not the sole metric used to define surgical success.

A Posterior Approach to Laparoscopic Sacrospinous Ligament Suspension

Background and Objectives:

Laparoscopic sacrospinous ligament suspension, as commonly performed, is associated with extensive stripping, high risk of intraoperative bleeding, and prolonged operative time. We explore the safety and feasibility of posterior laparoscopic approach sacrospinous ligament suspension (LPASLS) in the treatment of pelvic organ prolapse (POP).

Methods:

We retrospectively analyzed the clinical data of 9 patients with symptomatic POP treated intraoperatively with LPASLS at the Women's and Children's Health Centre, The Third Affiliated Hospital of Chongqing Medical University, between November 2016 and July 2017. Regular follow-up was performed at 1, 3, and 6 months after the operation. Subjective cure was considered as the absence of any postoperative subjective symptoms, and objective cure was considered as a postoperative POP-Q grade of 0.

Results:

All operations were completed successfully. The operative time ranged from 90 to 140 (mean, 117.78 ± 20.01) minutes, and the mean suspension time was about 30 minutes. The intraoperative estimated blood loss ranged from 30 to 100 (range, 54.9 ± 24.2) mL, and pelvic vascular injury occurred in 1 patient. Postoperative sacrococcygeal pain occurred in 5 patients, and Visual Analog Scale scores ranged from 3 to 4 (mean, 3.4 ± 0.5). The symptom disappeared without any treatment after 3–4 d. Patients were followed up for 3–10 (mean, 6.3 ± 2.1) months, and the subjective and objective cure rates were both 100%.

Conclusion:

LPASLS is safe and feasible and may be considered as an alternative approach to traditional laparoscopic sacrospinous ligament suspension.

Ablative dual-phase Erbium:YAG laser treatment of atrophy-related vaginal symptoms in post-menopausal breast cancer survivors omitting hormonal treatment

PURPOSE

First evaluation of dual-phase vaginal Er:YAG laser to omit hormonal treatment for atrophy-related symptoms in post-menopausal breast cancer survivors following prolapse surgery.

METHODS

Patients with a history of breast cancer at the time of surgery for pelvic organ prolapse were offered non-hormonal vaginal Er:YAG laser treatment when complaining of atrophy-related genitourinary syndrome of menopause. A single 10-min course of dual-phase protocol of pulsed Er:YAG laser (2940 nm, fractional ablative and thermal mode, fluence according to tissue thickness). Follow-up included subjective satisfaction, vaginal pH, vaginal health index (VHI), and complications after 6 weeks.

RESULTS

A total of 16 breast cancer survivors (age 71 years, SD 7) had been seeking treatment for pelvic floor symptoms related to vaginal atrophy at follow-up visits after prolapse surgery. All ablative vaginal Er:YAG laser outpatient procedures were successfully completed, all patients returned to daily activities without a need for analgetic medication. Evaluation was performed after 8.3 (SD 2.5) weeks. Pre-laser VHI scored 16 (SD 4.6) and post-laser VHI 20 (SD 3) with p = 0.01. Patients were satisfied in 94% (n = 15) regarding symptom relief.

CONCLUSIONS

Breast cancer survivors with atrophy-related complaints after pelvic floor surgery may benefit from vaginal application of this innovative dual protocol of Er:YAG laser technology as a non-hormonal treatment approach.

Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse

OBJECTIVE

To define and classify cervical elongation, to compare uterine measurements after prolapse hysterectomy with a non-prolapse control group, and to associate stage of prolapse and degree of cervical elongation.

STUDY DESIGN

This was a single-centre retrospective case-control study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. Data were collected from patients with and without pelvic organ prolapse (POP) who underwent laparoscopically assisted vaginal hysterectomy. Post-hysterectomy uterine cervical elongation was examined using the corpus/cervix ratio (CCR), calculated from measurements taken on photographs. Cervical elongation was classified as physiological (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5).

RESULTS

Cervical elongation was detected in 288/295 (97.6%) patients in the prolapse group (grade I, 44/288 [15.2%]; grade II, 212 [73.6%]; grade III, 32 [11.1%]). Mean CCR was greater among those with stage II/III than among those with stage IV prolapse (1.0±0.4 vs. 0.8±0.2; p<0.001). Grades of cervical elongation and prolapse stages were associated (p<0.001). Grade I cervical elongation was detected in 26/69 (37.6%), grade II in 5/69, and grade III in 0/69 patients of the control group. Cervical elongation was found more often in the prolapse group compared to the control group (p<0.001). Mean total uterine length did not differ between the prolapse and control groups (8.0±1.6 vs. 8.2±1.3cm), but mean calculated cervical length was greater in the prolapse group than in the control group (4.4±1.1 vs. 3.1+0.8cm; p<0.001).

CONCLUSIONS

Uterine cervical elongation is found in patients undergoing hysterectomy for pelvic organ prolapse. Cervical elongation grades and prolapse stages are correlated. Defining uterine cervical elongation based on corpus/cervix ratio with grades I-III could be a valuable basic tool for further research.

A new reusable suturing device for vaginal sacrospinous fixation: feasibility and safety study

OBJECTIVE

We sought to evaluate the feasibility and safety of SeraPro(®) (Serag-Wiessner, Germany), an innovative reusable suturing device for vaginal sacrospinous ligament fixation.

STUDY DESIGN

We reviewed the electronic files of all women who underwent vaginal sacrospinous ligament fixation with SeraPro(®) for apical pelvic floor prolapse, with or without mesh implant, performed between April 2013 and September 2013. Preoperative demographic, clinical, operative and postoperative data were analyzed. The women were interviewed and examined before the procedure, at one month postoperatively and tele-interviewed again after three months.

RESULTS

Overall, 88 women were included in the study. Fifty-three patients (60.2%) had additional anterior mesh placement, 42 (47.7%) had posterior mesh, and 16 (18.2%) had both anterior and posterior mesh insertion. Five patients (5.7%) had no mesh implant. Sixteen patients (18.2%) had an additional mid-urethral sling for the treatment of stress urinary incontinence. No significant technical difficulty was recorded at the procedures. None of the patients had significant long-term morbidity. The mean 3-month follow-up demonstrated significant anatomical and functional improvement.

CONCLUSIONS

The SeraPro(®) reusable suturing device is a feasible and safe tool for sacrospinous ligament fixation during vaginal pelvic floor reconstruction.