Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery

ABSTRACT Although hysterectomy is traditionally performed at the time of pelvic organ prolapse repair for apical prolapse, women are increasingly interested in uterine preservation during pelvic organ prolapse surgical management. Approximately 36% to 60% of women indicate interest in uterine preservation, assuming equal efficacy. This has led to more uterus-preserving prolapse repairs (hysteropexy) being performed. After the removal of mesh products from the US market in 2019, transvaginal native tissue techniques are commonly used for hysteropexy. This study aimed to compare 6-week and 1-year anatomical failure rates between vaginal uterosacral ligament hysteropexy and sacrospinous ligament hysteropexy. Secondary outcomes included retreatment for prolapse, symptoms of recurrent prolapse, and perioperative adverse event rates in these 2 groups. This was a multicenter retrospective cohort study of patients undergoing vaginal uterosacral hysteropexy (USHP) or sacrospinous hysteropexy (SSHP) with a urogynecologist between January 1, 2015 and December 31, 2019. The pool of patient data was extrapolated from 4 geographically unique urban locations. Patient identification took place via querying the respective electronic medical records for the current procedural terminology codes of extraperitoneal colpopexy (57,282, SSHP) and intraperitoneal colpopexy (57,283, USHP). These operative reports underwent review in order to confirm that each patient had a uterus at time of surgery, underwent either USHP or SSHP, and did not undergo concurrent hysterectomy. Exclusion criteria included patients undergoing different types of uterine-preserving procedures or patients with less than 6 weeks of follow-up. The study included 147 patients undergoing SSHP and 114 having USHP over 5 years at the 4 clinical sites. The study population included mostly nonsmoking (179, 68.6%), White (224, 85.5%) patients with no history of pelvic surgery (142, 54.4%), and a mean Charleston Comorbidity Index score of 2. Overall, USHP patients exhibited a higher likelihood to undergo concurrent anterior repair, posterior repair, and incontinence procedures. The follow-up rate was 95% at 6 postoperative weeks with 4 anatomic failures. Not all patients had formal prolapse quantitation examinations recorded. However, only 32% (83/261) of patients were available for follow-up at 1 year after surgery when 10 patients met criteria for anatomic failure. Notably, although there was no statistically significant difference between failure rates for SSHP and USHP at either time point, there were roughly 3 times as many failures for USHP compared with SSHP, despite the SSHP representing a larger portion of the total cohort. At 1 year, however, 26 patients had undergone retreatment for prolapse, with 12 undergoing hysterectomy (11 due to prolapse, 1 due to colorectal cancer debulking). Of those undergoing hysterectomy, 10 were from the SSHP cohort, whereas 1 was from the USHP cohort. The 1 year anatomic outcomes presumably included prolapse assessments after these salvage surgeries. One year after vaginal native tissue hysteropexy, only 1 in 3 patients were available for follow-up, but this limited cohort demonstrated that no differences for prolapse recurrence between SSHP and UHSP. Adverse events incidence rates were low, with only 5% of patients undergoing subsequent hysterectomy for prolapse. Any next step in research should include more rigorous prospective trials.