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Outcomes of transvaginal high uterosacral vault suspension for apical prolapse repair: A comparative study between unilateral and bilateral fixation
IUGA Academy. Hengrasmee P. Jun 30, 2018; 213066
Topic: Pelvic Organ Prolapse
Dr. Pattaya Hengrasmee
Dr. Pattaya Hengrasmee

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Outcomes of transvaginal high uterosacral vault suspension for apical prolapse repair: A comparative study between unilateral and bilateral fixation

Hengrasmee, P1; Anukunwattaka, S1; Asumpinwong, C1; Leerasiri, MD., P1

1: Faculty of Medicine, Siriraj Hospital, Mahidol University

Introduction: The concept of POP repair in accordance with DeLancey’s theory is to correct all anatomical defects by repairing endopelvic fascia and re-suspending apical portion to uterosacral-cardinal ligament complex. With passage of sutures bilaterally through uterosacral ligaments near level of ischial spine, vaginal cuff can be securely supported without vaginal axis distortion, making this procedure applicable to all types of vaginal prolapse repair. However, the drawback of this procedure is possibility of ureteral kinking leading to subsequent removal of suspensory sutures which may affect effectiveness and successful outcome of the repair.

Objective: To evaluate outcomes of transvaginal high uterosacral vault suspension for apical prolapse repair by comparing between unilateral and bilateral fixation in terms of success rate, recurrence rate, and perioperative complications.

Methods: This is a retrospective cohort study of patients undergoing transvaginal high uterosacral vault suspension for severe POP between July 2009 and December 2016. Prolapse severity and location were identified according to POP-Q system. Vaginal hysterectomy was performed in all patients with uterovaginal prolapse. High uterosacral vault suspension was performed by passing suspensory sutures between vaginal cuff and ipsilateral uterosacral ligament at the level of ischial spine intraperitoneally. For those with vaginal vault prolapse, the procedure was carried out retroperitoneally. Suspensory suture on the affected side was removed if ureteric patency could not be confirmed during cystoscopy. Demographic data and peri-operative outcomes were recorded. At each follow-up visit, reassessment of symptom and POP-Q measurements were performed. POP-Q measurements were demonstrated using independent and paired Student’s t test. P-value <0.05 indicated statistical significance. Objective cure was defined as prolapse at or above hymen, and subjective cure determined as resolution of prolapse sensation.

Results: Of 117 women undergoing uterosacral vault suspension, 15.4% were post-hysterectomy patients. Mean age was 66.55±9.41 years and mean BMI was 24.96±3.62 kg/m2. Unilateral suspension was carried out in one-fifth of patients. Regarding baseline characteristics, there were no significant differences when compared between two groups. No significant differences were found regarding pre- and post-operative POP location and severity. 90% were diagnosed with advanced stage prolapse. Mean operative time for all carried out procedures was 141.79±34.08 minutes and mean blood loss was 150.51±111.65 ml. There were no significant differences between two groups regarding adds-on procedures, operative time, blood loss, and perioperative complications. Ureteric obstruction occurred in only 1 patient requiring double-J stent insertion and removal of one suspensory suture. Mean follow-up time was 27.3 months. Significant improvement in clinical symptoms and POP-Q measurements were demonstrated from early postoperative period up to 7 years. Objective cure was 88.9%, whereas overall subjective cure was 94.9%. When evaluating only outcome of apical prolapse repair, very high success rates were demonstrated (objective 96.6% and subjective 97.4%). No significant differences were found when compared between unilateral and bilateral vault suspension.

Conclusions: High uterosacral vault suspension is a very effective repair procedure with low morbidity. Although there is disadvantage of ureteral kinking causing subsequent removal of one of the suspensory sutures, surgical outcomes of unilateral uterosacral is still comparable to the standard bilateral fixation.

Disclosure:

Work supported by industry: no.

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