Laparoscopic High Uterosacral Ligament Suspension vs. Laparoscopic Sacral Colpopexy for Pelvic Organ Prolapse: A Case-Control Study

Abstract

IntroductionLaparoscopic sacral colpopexy is the gold standard technique for apical prolapse correction but it is a technically challenging procedure with rare but severe morbidity. Laparoscopic high uterosacral ligament suspension could be a valid technically easier alternative using native tissue.Material and MethodsIn the period from 2015 to 2018, 600 women were submitted to laparoscopic sacral colpopexy while 150 to laparoscopic high uterosacral ligament suspension in three Italian urogynecology referral centers. We enrolled women with apical prolapse stage ≥2 alone or multicompartment descensus. To reduce allocation bias, we performed a propensity matched analysis. Women undergoing laparoscopic high uterosacral ligament suspension surgery were matched 1:2 to women undergoing laparoscopic sacral colpopexy. The cumulative proportion of relapse-free women in time was analyzed by the Kaplan–Meier method. The primary objective of this multicenter case-control retrospective study was to compare the recurrence rate while the secondary objectives were to compare feasibility, safety, and efficacy of laparoscopic sacral colpopexy and laparoscopic high uterosacral ligament suspension in surgical treatment of pelvic organ prolapse.ResultsThree hundred and nine women were enrolled (103 laparoscopic high uterosacral ligament suspension; 206 laparoscopic sacral colpopexy). Median operatory time was significantly shorter in the laparoscopic high uterosacral ligament suspension group (P = 0.0001). No statistically significative difference was found in terms of estimated blood loss, admission time, intraoperative, and major early postoperative complications, postoperative pelvic pain, dyspareunia and de novo stress urinary incontinence. Surgical approach was the only independent risk factor for prolapse recurrence (RR = 6.013 [2.965–12.193], P = 0.0001). The objective cure rate was higher in the laparoscopic sacral colpopexy group (93.7 vs. 68%, 193/206 vs. 70/103, P = 0.0001) with a highly reduced risk of recurrence (RR = 5.430 [1.660–17.765]). Median follow up was 22 months.ConclusionBoth techniques are safe, feasible, and effective. Laparoscopic sacral colpopexy remains the best choice in treatment of multicompartment and advanced pelvic organ prolapse while laparoscopic high uterosacral ligament suspension could be appropriate for moderate and isolated apical prolapse when laparoscopic sacral colpopexy is not suitable for the patient or to prevent prolapse in women at high risk at the time of the hysterectomy.

The effectiveness and safety of laparoscopic uterosacral ligament suspension: A systematic review and meta‐analysis

“…All studies only included patients with symptomatic POP requiring apical surgical treatment. Eight studies only included women with apical prolapse ≥ POP‐Q stage 2 (C at −1 or more) 19,20,22,26–28,30,31 . Other studies also included women with apical POP‐Q stage 1, but with a prolapse ≥ stage 2 in a different compartment 21,23–25,30 .…”

“…Ten studies used nonabsorbable sutures (mostly Ethibond or Goretex size 0 or 1 19–26,30,31 ). Three studies used absorbable sutures 27–29 . Nine studies described peritoneal releasing incisions or ureterolysis to avoid ureteral kinking 19–23,25,28,29,31 ; for eight of these, this was the standard in all LUSLS procedures, and in one study only if necessary 22 .…”

“…The median/mean follow‐up time ranged from 3 to 38 months. Nine studies had a median/mean follow‐up period of at least 12 months 20,22–26,28,29,31 . The remaining studies had a follow‐up of 11 months, 30 7 months 19,21 and 3 months, respectively 27 .…”

“…An overview of outcomes per study is displayed in Table S1. Objective outcomes were based on a postoperative POP‐Q < stage 2 in 10 studies 20,22–30 . Seven studies reported POP‐Q point C (cm) pre‐ and postoperatively 20,21,24,25,27,29,30 .…”

“…Subjective outcome was measured with a validated questionnaire (PGI‐I) in three studies 25,27,28 . Five studies 19–22,24 defined subjective success as relief of prolapse symptoms (unvalidated).…”