Study design, materials and methods
Retrospective relational analytical study including patients who had undergone pelvic organ prolapse surgery during December 2015 and December 2018 with a diagnosis of symptomatic genital prolapse and a desire for reconstructive surgery with uterine conservation. Demographic data, clinical and surgical history were obtained from the hospital electronic medical record. The inclusion criteria were stage III and IV pelvic organ prolapse quantification (POPQ) with apical involvement, normal transvaginal ultrasound, normal cervical exfoliative cytology with no previous preinvasive disease, absence of postmenopausal bleeding and normal preoperative tests. The patients were evaluated by the surgical team and it has been decided to perform anterior approach when the anterior defect was predominant or posterior when the involvement of the posterior compartment was greater than or equal to a POPQ stage II and according to the availability of equipment in the hospital. Anchoring devices (Capio TM and AnchorSure) were used for anterior sacrospinous ligament fixation, and posterior approach was performed under direct vision of the ligament with prolene sutures. Unilateral or bilateral fixations were performed depending on the opportunity of access to the sacrospinous ligament. Two groups were established for comparison, anterior sacrospinous (n=56) and posterior sacrospinous (n=61). Sociodemographic characteristics, POPQ, operating time, concomitance of repairs of other compartments and anti-incontinence surgery (retropubic/Transobturator), significant bleeding over 100 cc, viscera lesions and complications related to instruments and surgical supplies were evaluated. Postoperative complications were evaluated in the first ambulatory control performed between 7 and 15 days after surgery and the presence of buttock pain, urinary retention defined as the need for a urinary catheter for more than 24 hours or the presence of symptoms of voiding dysfunction and urinary tract infection diagnosed with urine culture was evaluated. Data were analyzed with descriptive statistics, qualitative variables with Chi-square or Fisher test according to expected frequencies, and Mann Whitey test to compare medians and anova.
Data from 117 patients were analyzed. The anterior sacrospinous group was made of 56 patients and the posterior sacrospinous group was made up of 61 patients. The average age of the cohort was 64.82 (SD 7.51). The mean age of the anterior sacrospinous group was 65.78 and the mean age of the posterior sacrospinous group was 63.87 years (p=0.13). The average parity was 3.67 (SD 1.48), for the anterior sacrospinous group it was 3.77 and for the posterior group it was 3.56 (p=0.54). The average Ba point was +3.4 (SD 1.98), the average Ba in anterior sacrospinous was +3.17 and in posterior sacrospinous was +3.63 (p=0.5). The average C point was +0.5 (SD 3.58), the average C in anterior sacrospinous was -0.08 and in posterior sacrospinous was +0.9 (p=0.18). The average operating time was 91.3 minutes (SD 23.57), the average operating time for the anterior sacrospinous was 88.6 minutes and for the posterior sacrospinous was 93.8 minutes (p=0.13). Fifty-two percent of the surgeries were accompanied by mediouretral sling (transobturator or retropubic). 12% of the patients presented bleeding greater than 100 cc, with no significant differences between the approach routes (p=0.459). Other intraoperative complications occurred in 7.7% of the patients, with no significant differences between the two groups (p=0.735). During the first control that was performed between 7 and 15 post-operative days, buttock pain was present in 15.7% of the patients, with no significant differences between the two groups (p=0.26). The presence of urinary tract infection occurred in 9.6% of patients, with no significant differences between the two groups (p=0.156). Urinary retention was present in 14.6% of patients; in the anterior sacrospinous group it was 23.3% and in the posterior sacrospinous group it was 6.5%, this difference being significant (p=0.02).
Interpretation of results
Uterine preservation surgery has shown in recent years an effectiveness very similar to that involving hysterectomy, although with better operating time and less rate of associated complications. There is no clear evidence of advantages between sacrospinous approach routes in terms of outcomes, complications and safety. The patient cohort in this study does not differ significantly in age, parity and diagnosis. It is also demonstrated that there are no differences in surgical time, bleeding and other intraoperative complications. There is also no difference between the presence of buttock pain and urinary tract infection. It was demonstrated that there is a difference in the presence of urinary retention between both groups, being greater in the anterior approach of sacrospinous. We infer that this is due to the dissection of the perivesical space, the consequent inflammation and possible hematoma formation that might influence the appearance of urinary retention symptoms. The strength of this study lies in the sample size of patients, as well as in the analysis of immediate perioperative complications. The weakness of this study lies in the short follow-up of the patients and the absence of evaluation of other factors. It is necessary to extend the follow-up time as well as to improve the registration of the patients.