One hundred eighteen patients were included in our study; 96 underwent vaginal uterosacral ligament suspension (VUSLS), and 22 patients underwent laparoscopic uterosacral ligament suspension (LUSLS) at the time of vaginal hysterectomy (). Overall mean age was 57.3 (SE 12.1) years old, without significant differences between groups. Our population was predominantly white (96.5%) and postmenopausal (66.2%). Prior surgery for prolapse was reported in 9.4% of VUSLS (9 of 96) patients and 9.1% (2/22) of LUSLS patients. Mean preoperative POP-Q measurements were similar in the 2 groups ().
Demographics and Preoperative Clinical Characteristics
Concurrent procedures for prolapse and stress urinary incontinence were performed as appropriate in 92% (92/96) and 95.5% (21/22) of the VUSLS and LUSLS cases, respectively (). The surgical approach to correction of the anterior compartment defects was different between the 2 groups, with LUSLS patients more commonly undergoing laparoscopic paravaginal defect repair (p < 0.001). Concurrent incontinence procedures were performed in 54.4% (63/118) of patients overall, without significant differences between groups; patients also underwent rectocele repair at similar rates between the 2 groups (p = 0.48).
Concurrent Surgical Procedures Performed at the Time of Vaginal Hysterectomy
Ureteral compromise was identified during intraoperative cystoscopy in 4 (4.2%) cases in the vaginal group; no ureteral compromise was observed in the laparoscopic group (p = 0.33). Additionally, 1 patient in the VUSLS group had vault suspension sutures removed and replaced intraoperatively due to suture placement in the rectum, detected on digital rectal examination. No patients in the LUSLS group required suture revision (p = 0.27). In 1 patient undergoing VUSLS, ureteral compromise continued despite intraoperative ureteral stent placement and release of vault suspension sutures. Hydronephrosis was seen on computed tomography in the immediate postoperative period but had resolved 4 weeks following surgery. The etiology of the ureteral compromise was unclear in this patient; either surgical compromise or long-standing pelvic organ prolapse may have caused this transient condition. Mean estimated blood loss was greater for the VUSLS group (362 ± 21.3 mL vs. 222 ± 17.3 mL, p = 0.003).
Overall, immediate postoperative complications were few (). One patient from each group required reoperation within the first 30 days postoperatively: 1 VUSLS patient required revision of tension-free vaginal tape, while 1 LUSLS patient underwent diagnostic laparoscopy for persistent constipation and painful defecation; vault suspension sutures were not considered causative. There was a nonsignificant trend toward higher urinary retention rates (defined as requirement of catheter bladder drainage for >48 hours after surgery) among patients in the VUSLS group (29.8% vs. 4.6%, p = 0.07). Fourteen (14.6%) VUSLS patients and 2 (9.1%) LUSLS patients experienced pelvic and/or leg pain that was considered to be neuropathic in origin and related to the procedure during the postoperative period. This pain resolved with conservative treatment in 12 of the 14 VUSLS patients (78.6%) and both LUSLS patients (100%). The 2 VUSLS patients who did not respond to conservative therapy were treated with amitriptyline and/or referred for neurologic evaluation. Granulation tissue requiring silver nitrate application beyond 90 days after surgery occurred in 15.8% of patients in the VUSLS group and none in the laparoscopic group (p = 0.046).
Perioperative Data and Immediate Postoperative Period (First 90 Days After Surgery)
Mean follow-up time in the vaginal group was 8.8 (±0.7) months and 10.8 (±1.36) months in the laparoscopic group. Although statistical significance was not observed, trends toward lower apical failure rates (6.3% vs. 0%), recurrent symptomatic vault prolapse requiring an intervention (10% vs. 0%) and any symptomatic prolapse recurrence requiring an intervention (12.5% vs. 4.6%) were observed in the laparoscopic group (p > 0.05 for all). Three of the 6 patients (50%) in the vaginal group with apical failures had received permanent sutures for the vault suspension. Vaginal vault support (mean postoperative POP-Q point C) was statistically significantly higher in the laparoscopic group (−7.0 vs. −5.9 for LUSLS and VUSLS, respectively; p = 0.04); other mean postoperative POP-Q measurements were similar between groups ().
Mean Postperative POP-Q Values
Mean change in individual patients’ preoperative and postoperative POP-Q values was calculated in both the VUSLS and LUSLS groups (paired t test) and found to be non-significant (p > 0.05 for all). Among patients with preoperative anterior defects (greater than or equal to stage II), recurrent anterior prolapse was detected in 28.7% and 9.5% of patients in VUSLS and LUSLS groups, respectively (p = 0.07). Recurrent anterior prolapse requiring repeat surgery was encountered in 5.5% vs. 0% of the VUSLS and LUSLS groups, respectively ().
Recurrence of posterior compartment prolapse (POP-Q stage II or greater) was observed in 6 of 48 (12.5%) patients in the VUSLS group and 1 of 10 (10%) patients in the LUSLS group; 5 patients (10.4%) in the VUSLS vs. 0 patients in the LUSLS group underwent additional surgery for correction of symptomatic posterior compartment prolapse (p = 0.25). Among patients without preoperative posterior defects, de novo posterior compartment defects (POP-Q Stage II or greater) were detected in 3/48 (6.25%) and 1/12 (8.5%) of VUSLS and LUSLS patients, respectively (p = 0.98); 1 patient in each group elected to undergo additional surgery for this condition (p = 0.40).