Pelvic organ prolapse (POP) is a global health condition affecting many women regardless of social economic status.1  While there are many surgical options available to correct POP, for correction of apical prolapse the sacrospinous ligament fixation (SSLF) and the uterosacral ligament suspension (USLS) still remain the most commonly performed vaginal procedures worldwide.  Since both of these procedures are performed vaginally they are relatively low-risk and generally determined to be effective.2  Both procedures correct apical prolapse and both are associated with particular types of complications. We hypothesize that the SSLF will have a greater number of perioperative complications and more recurrences in the anterior compartment. Thus, we primarily aimed to assess perioperative complications amongst all patients undergoing either SSLF or USLS and compare these between both procedures.  A secondary aim was to assess the incidence of reoperation within one year following the initial surgery.

Retrospective study of patients undergoing apical suspension with either SSLF or USLS. Institutional Review Board (IRB) was obtained. Cases were initially retrieved from a dedicated database and further retrieval of data was from clinical and hospital electronic health records (EHR). Between June 2011 and June 2016, 167 patients underwent either SSLF or USLS with or without vaginal hysterectomy for uterovaginal or post-hysterectomy vaginal vault/cuff prolapse respectively.  Inclusion consisted of cases having had a SSLF or USLS with hysterectomy or without if done for correction of post hysterectomy vaginal vault prolapse.  Exclusion criteria included all other types and routes of suspension as well as all uterine sparing procedures.  Prolapse was assessed utilizing the POPQ system.  Preoperative data as well as intraoperative and postoperative data were reviewed.  Patients missing either preoperative or postoperative POPQ points, pertinent intraoperative or follow-up information were also excluded. Failure was defined as any prolapse beyond the hymen, subjective complaining of a bulge or need for additional treatment for prolapse in any compartment or other surgery within the first year following surgery. Intraoperative and postoperative complications were assessed. EBL ≥ 500 ml was considered significant.  Terminology conforms to the ICS terminology report and all prolapse was assessed using the POPQ system.  SAS 9.4 (SAS Institute, Inc.; Cary, NO) was used for all statistical analyses. Statistical significance was determined at a p-value of 0.05.

Overall 159 (95%) patients were included in the final analysis, 2 excluded for missing postoperative data points and 6 for undergoing uterine preservation surgery (4 from SSLF group and 2 from the USLS group).  The final cohort for comparison consisted of 102 SSLF and 57 USLS.  The mean age for the entire cohort was 62.5  9.1 years old, median parity 2 (Range 0-7) and mean BMI 28.6  4.1 kg/m2.  The patients in the SSLF group were older (p=0.05) than those in the USLS group [mean, SD; 64.47.3 versus 60.87.1 years old respectively]. Parity and BMI were not different. There was no significant difference in preoperative or postoperative POPQ point C value between the two groups [preoperative mean, SD: -1.85.8 vs. -0.44.6 and postoperative -8.71.1 vs. -8.90.4, respectively for SSLF and USLS]. There were no difference in complications between the two groups Table 1. The mean±SD EBL for the SSLF and USLS were not significantly different [179.5±157.9 ml vs. 164.0±103.6 ml, respectively]. Overall only 3 (1.9%) patients underwent a reoperation within the first 12 months following surgery [1 (0.9%) in the SSLF group and 2 (3.5%) in the USLS group, a midurethral sling revision in each and a prolapse surgery in the latter]. Overall the 
mean POPQ point C was significantly improved (p<0.001) for the entire cohort from a preoperative mean -0.55.4 to a postoperative value of -8.90.9.  This improvement was significant within each the SSLF and USLS groups, but not different between the two groups.

There was no significant difference in complications between SSLF and USLS procedures. Most initially perceived ureteral obstructions were from pre-existing kidney disease (atrophic kidney and staghorn calculi). The overall reoperation rate at 12 months was low and mostly stemming from voiding dysfunction.

Both the SSLF and USLS are effective operations to correct apical prolapse with similar number of complications.  Choice of operation depends on concomitant defects, need for hysterectomy and surgeon preference.3

Slieker-ten Hove MC, Pool-Goudzwaard AL, et al. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:1037-45.
Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. Lancet 2007;369:1022-1038.
Jelovsek JE, Barber MD, Brubaker L, Norton P, et al. Effect of uterosacral ligament suspension vs sacrospinous ligament fixation with or without perioperative behavioral therapy for pelvic organ vaginal prolapse on surgical outcome and prolapse symptoms at 5 years in the OPTIMAL randomized clinical trial. JAMA 2018;319(15):1554-1565.