Sacrospinous fixation versus uterosacral ligament suspension in managing apical prolapse

Purpose To compare and assess the safety of two mesh-free surgical techniques in managing apical pelvic organ prolapse (POP); robot assisted/laparoscopic uterosacral ligament suspension (USLS) and vaginal sacrospinous ligament fixation (SSLF). Methods We performed a retrospective review of 116 women with apical POP who underwent USLS (n = 61) or SSLF (n = 55) by a single surgeon. Demographic data including age, parity, previous POP surgery was recorded. A pre-operative pelvic floor questionnaire was used to identify prevalence of bladder, bowel and vaginal symptoms. POP Quantification system (POP-Q) scores were recorded at surgery and at post-operative reviews. The absolute change in POP-Q scores were recorded as objective measures of pelvic floor support. Other post-operative metrics used include the presence of vaginal bulge, need for repeat POP surgery (re-operation) and subjective improvement in symptoms based on a patient-reported outcome measures survey. Post-operative adverse events were recorded using the Clavien-Dindo grading scale. Multivariable logistical regression analysis was performed to predict factors for failure, re-operation and adverse events. Results Baseline demographics were similar. Mean post-operative follow-up time was 24 months (USLS) and 18.5 months (SSLF). The difference in post-operative C point was not significant (USLS: median - 8 (IQR 2), SSLF: median - 7 cm (IQR 2)). Procedure success rates (post-operative C point < 0) were not different (USLS 90.2%, SSLF 92.5%). Re-operation rates for apical recurrence were similar between groups (SSLF 1.9%, USLS 6.6%). Univariate analysis for re-operation found that age, parity, and surgery type were not predictors of re-operation. The most common post-operative adverse event was urinary tract infection (USLS 10.2%, SSLF 10.5%). Conclusion Robot assisted/laparoscopic uterosacral ligament suspension and vaginal sacrospinous ligament fixation are safe and effective mesh-free techniques for management of apical pelvic organ prolapse based on objective improvements in POP-Q score and patient-reported outcome measures.