ABSTRACT
Objective:
To demonstrate our transvaginal high uterosacral ligament (HUL) hysteropexy technique as an alternative mesh-free uterine-preserving pelvic organ prolapse (POP) repair approach and present our institutional outcomes. Concurrent hysterectomy with POP repair is controversial as uterine-preserving techniques may beneficially allow fertility, body image and sexual function preservation (11. Milani R, Frigerio M, Manodoro S, Cola A, Spelzini F. Transvaginal uterosacral ligament hysteropexy: a retrospective feasibility study. Int Urogynecol J. 2017; 28:73-6., 22. Costantini E, Porena M, Lazzeri M, Mearini L, Bini V, Zucchi A. Changes in female sexual function after pelvic organ prolapse repair: role of hysterectomy. Int Urogynecol J. 2013;24:1481-7.).
Materials and Methods:
This video illustrates a step-by-step sequence of our HUL hysteropexy technique in a symptomatic Stage III POP patient. Retrospective single-institution, single-surgeon analysis of patients treated by either HUL hysteropexy or hysterectomy with HUL suspension for symptomatic prolapse was performed with minimum 2 years of follow-up. Patient demographics, operative characteristics, pre and post-operative POP-Q evaluation, American Urological Association Symptom scores (AUASS) and post-operative Pelvic Floor Distress Inventory (PFDI-20) were compared.
Results:
Surgery time was 3 hours 24 minutes. No immediate/early complications were noted, with successful repair on follow-up. Outcomes of 18 patients (10 HUL hysteropexy, 8 hysterectomy and HUL suspension) were assessed (Supplemental Table SUPPLEMENTAL TABLE Table 1 Comparison of outcomes of women undergoing high uterosacral ligament hysteropexy versus hysterectomy and high uterosacral ligament suspension for pelvic organ prolapse repair. High Uterosacral Ligament Hysteropexy High Uterosacral Ligament Suspension with Hysterectomy p-value Number 10 8 Mean Age (years)a 69.1±14.18 65±13.00 0.562 Mean BMI (kg/m2)*a 25.81±4.48 35.84±6.72 0.008 Median Parity 3 3 Race Caucasian: 11 Caucasian: 6 African American: 3 African American: 4 Other: 3 Preop POP-Q Stage Stage 2: 30% Stage 2: 25% 0.306 Stage 3: 50% Stage 3: 75% Stage 4: 20% Stage 4: 0 AUASS Pre-opa 19.9±6.06 14.5±9.15 0.230 AUASS Post-opa 11.13±9.38 13.00±6.24 0.453 Operative Time (minutes)*a 190.40±41.89 279.13±39.01 0.0021 EBL (mL)*a 57.50±29.08 205.00±94.38 0.00086 Mean Follow-up (months) 33.25 36.71 0.410 Post-op PopQ stage (at 2 years in pts not requiring reoperation) Stage 0: 0% Stage 0: 0% 0.282 Stage 1: 12.5% Stage 1: 50% Stage 2: 87.5% Stage 2: 50% Stage 3+4: 0% Stage 3+4: 0% Post-op PFDI-20 (at 2 years in pts not requiring reoperation)a 18.50±17.61 26.93±16.16 0.483 BMI = Body Mass Index; EBL = Estimated Blood Loss; AUASS = American Urological Association; POPQ = Pelvic Organ Prolapse Quantification; PFDI = Pelvic Floor Distress Inventory. * statistically significant difference a Mean +/- Standard Deviation ). The only baseline difference was a lower body mass index in the HUL hysteropexy cohort (25.8 vs. 35.8kg/m2, p=0.008). In the HUL hysteropexy cohort, blood loss (mean: 58 vs. 205ml, p=0.00086) and operative time (190.4 vs. 279.1minutes, p=0.0021) were significantly reduced. There was no difference in post-operative AUASS, POP-Q or PFDI-20 at 2 years.
Conclusion:
We present our HUL hysteropexy technique. Although limited by sample size and retrospective design, resulted in significantly reduced blood loss and operative time with comparable post-operative 2 year outcomes to non-uterine-preserving techniques. In our opinion, HUL hysteropexy is a safe, durable POP management option for women without significant endometrial pathology risk factors.