Several surgical methods have been described to prevent recurrent prolapse after pelvic organ prolapse (POP) surgery. Among them are the high intraperitoneal uterosacral ligament vault suspension (IPUSL) and the Modified McCall culdoplasty, which has been modified by the senior author. However, some national guidelines have suggested that a prophylactic sacrospinous suspension fixation (SSF) should be used at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse (1). Our objective was to evaluate the long-term results of the modified high McCall culdoplasty (group A) versus IPUSL (group B) at time of hysterectomy in women presented with stage 3-4 uterine prolapse.

A longitudinal retrospective comparative clinical study conducted at a tertiary urogynaecology centre. Initial evaluation and follow-up were done by using standardised questionnaires and examination by POP-Q or Baden – Walker system pre-and post-operatively. All modified McCall were done by the same surgeon, and the IPUSL were done by 2 other surgeons, or under their direct supervision. Comparison tests used were Chu square test and Fisher exact tests as applicable. There is a dearth of comparative trials in this area however using a 5% difference in primary outcomes and using a previously published study as index literature we obtained a sample size of 120 in each arm for a power of 80% and alpha 0.05.  P<0.05 was considered as statistically significant.

A total of 176 (group A) versus 132 (group B) cases met the inclusion criteria. Mean follow-up was 19.35 (+22.9) vs. 21.28 (+18.1) months (p=0.426). Patients demographic and clinical data are presented in table 1. Overall, group A had less anatomical recurrences (14% vs. 40%, p<0.0001). However, site specific and recurrences at the vault were low in both groups (Table 2).  Of all recurrences, 6 cases (3%) vs. 5 (4%) (p=1) were symptomatic and required further surgery.

Both modified McCall technique and intraperitoneal uterosacral ligament vault suspension for vault suspension at the time of hysterectomy for advanced pelvic organ prolapse has a good long-term success rate without the need for sacrospinous suspension fixation. Although the intraperitoneal uterosacral ligament vault suspension group had a more anatomical failure, the site-specific recurrences and the need for re-operation was low and equal in both groups. A future large randomized controlled trial is warranted.

Either modified McCall or intraperitoneal uterosacral ligament vault suspension techniques should be considered for vault suspension and prevention of post-hysterectomy vault prolapse at the time of repair for advanced uterine prolapse.

Post-Hysterectomy Vaginal Vault Prolapse (Green-top Guideline No. 46) Published: 24/07/2015