Long-term Outcomes Following Vaginal versus Laparoscopic Uterosacral Ligament Suspension

Objectives: To compare long-term outcomes following vaginal (V-USLS) versus laparoscopic (L-USLS) uterosacral ligament suspension following hysterectomy.

Methods: This was an ambispective cohort study at a single academic institution comparing patients who underwent a V-USLS following a vaginal hysterectomy or L-USLS following a laparoscopic hysterectomy. The primary outcome was rate of prolapse recurrence, defined as a composite failure rate combining subjective prolapse symptoms (answering yes to question 3 on the PFDI-20), and objective failure including prolapse beyond the hymen on pelvic organ prolapse quantification (POP-Q) exam or retreatment with surgery or pessary. Secondary outcomes included comparison of urge and stress incontinence and sexual function. Patients who underwent V- or L-USLS with concomitant hysterectomy between 2013-2019 were identified from the electronic medical record (EMR) using CPT codes. V-USLS was performed using six 0 delayed absorbable monofilament sutures placed in the bilateral uterosacral ligaments, three on each side. L-USLS was performed using two 0 delayed absorbable monofilament or nonabsorbable braided polyester sutures that were passed through the uterosacral ligament three times from proximal to distal, one on each side. Recruited patients underwent a POP-Q exam and completed validated questionnaires (PFDI-20 and PISQ-12). Demographics and information related to the index surgery was collected from the EMR. Statistical analysis was performed using Student’ t-test, Wilcoxon Rank Sum test, chi-square test, or Fishers exact test where appropriate. Multivariable logistic regression was performed to identify risk factors related to prolapse recurrence.

Results: 71 patients presented for a study visit, 35 in the V-USLS group and 36 in the L-USLS group. V-USLS patients were older (57.1 vs 47.1 years, p< 0.001) and were more likely to be menopausal (68.6% vs 25.0%, p=0.003) and have urge incontinence (74.2% vs 27.8%, p=0.001) preoperatively. L-USLS patients were more likely to smoke tobacco (44.4% vs 20.0%, p=0.03). Preoperative POP-Q measurements were similar between groups. Operative time was longer for L-USLS (147.8 vs 108.3 min, p< 0.001). Surgical complication rates were low and similar between groups. Follow-up time was similar between groups with an overall mean follow-up time of 352.7 weeks. V-USLS patients had higher rates of recurrent prolapse beyond the hymen on POP-Q (34.2% vs 11.1%, p=0.016), retreatment (25.7% vs 2.8%, p=0.006), and composite failure (48.5% vs 22.2%, p=0.019). Subjective prolapse symptoms and PFDI-20 and PISQ-12 scores were similar between groups. On logistic regression, V-USLS was associated with a higher risk of prolapse recurrence (aOR 1.73 (95%CI 1.13-5.78). Baseline anterior prolapse (point Aa) was associated with higher recurrence risk, with aOR 2.04 (95%CI 1.15-3.62) per every one centimeter, up to three centimeters beyond the hymen.

Conclusions: Based on these results, L-USLS appears to have a decreased association with failure compared to V-USLS. A randomized controlled trial is needed to better evaluate the difference between these procedures.