Sacrospinous ligament fixation (SSLF) is defined as suspension of the vaginal apex to the sacrospinous ligament (SSL). If the patient has a previous hysterectomy, the vaginal cuff is attached to the SSL. If the uterus is present, it is usually suspended to the SSL, a procedure sometimes called sacrospinous hysteropexy. 1 With the aim to diminish the morbidity associated with the dissection needed to visualize the SSL, some devices have been developed to facilitate the suture placement. 2   Despite the efficacy rates are quite decent with the classical approach, grafts have been used to increase the strength of the fixation with the aim to improve surgical outcomes.  We included a variation of the standard SSLF technique in which we use a polypropylene sling to suspend the vaginal apex with or without a uterus in place with the objective to restore the anatomy with minimal deviation of the vaginal axis, recreating the normal anatomic support and limiting the use of mesh material to minimize mesh related complications. In the present study, we aim to describe the objective and subjective cure rates of a commercially available fixation anchoring system using two different approaches for SSLF, the classical stitch approach and the sling suspension.

We performed a retrospective analysis of prospectively collected data on patients with symptomatic apical pelvic organ prolapse who underwent SSLF using a commercially available fixation system (Anchorsure/Surelift link ® Neomedic – Figure 1).  Data was collected between January 2011 and December 2023.  Women who had symptomatic apical prolapse and undergoing sacrospinous ligament fixation were included.  Exclusion criteria were previous pelvic radiotherapy and neurological disease. 

Demographic variables as well as relevant medical history were recorded. Patients were evaluated preoperatively with vaginal examination that included assessment of prolapse using Pelvic Organ Prolapse Quantification (POP-Q) System3 and urodynamics. Intraoperative parameters such as concurrent procedures, bleeding, surgical time, and complications were obtained according to the medical record. Concomitant procedures performed included anterior colporrhaphy, posterior colporrhaphy, perineoplasty and mid-urethral slings. Postoperative pain, hospital stay and first month complications were also registered. The follow-up included POP-Q assessment, symptomatic prolapse evaluation and cough stress test.  The POP-Q assessment was carried out by clinical examination performed by the same evaluator who made the initial evaluation.  All the procedures were performed under general or regional anesthesia by one surgeon. 

The primary outcomes for objective cure were defined as reduction of the apical compartment to ≤ 1 stage assessed by the POP-Q system and subjective cure defined as patient's absence of vaginal bulge sensation or visualization of the prolapse inquired at medical checkups. Complications were reported using the Clavien-Dindo classification. 

A descriptive analysis of all the variables was carried out. For quantitative variables, the Kolmogorov-Smirnov normality test was applied to define distribution; the corresponding central tendency and dispersion measures were reported. Logistic regression analysis was carried out to determine the association of treatment failure with other variables, using both objective cure and subjective cure as dependent variable. All analyses were conducted using STATA/SE 18.0

A total of 100 patients were included. Sociodemographic characteristics are described in Table 1. The mean age of patients was 67.7 ± 7 years, 44% (n=44) had a history of hysterectomy and most of them had post-menopausal status (85%). Multi-compartment prolapse also was found in most of the patients (Table 1).  Stage 3 and 4 apical prolapse was found in 97.9% of the cases. Occult urinary incontinence was found in 24% (n=24) of the cases . Table 2 shows intraoperative characteristics and postoperative outcomes.  Simultaneous management of stress urinary incontinence was carried out in 59 subjects (59%) using a mid-urethral sling.  Thirty-two patients required a perineoplasty to diminish the size of the genital hiatus. The mean surgical time was 69 minutes [IQR 58-91] with a mean hospitalization time of 24 hours [IQR 22.6 - 27.15].   The most frequent complication during the first postoperative month was urinary tract infection in 2 cases and urinary retention in 1 case. Pain evaluation was reported to be none or mild in 90% of the cases.  Follow-up was 25 months [IQR 11.5 - 46.5]. Global subjective cure rate was achieved in 89 (89%) subjects and subjective cure was reached by 92 (92%). Re-intervention for recurrent symptomatic prolapse was needed in 3.49% of patients during follow-up. Table 3 describes bivariate analysis for treatment failure.  Vaginal delivery was the only associated factor with a treatment failure (OR 1.43; 95% IC: 1.01 - 2.02).   Apical sling was not associated with treatment failure (OR 2.62, 95% IC 0.66 - 10.3). Neither Hysterectomy nor high BMI weres associated with treatment failu re.  In the same way, the severity of POP was not a predictor of failure.

The present study suggests that the fixation of the sacrospinous ligament is a safe and effective technique with functional results maintained over time.

Mid-term objective and subjective cure rates of SSLF are high either using the classical approach or using a reinforcing apical sling.  Long term follow-up will determine if the difference in reintervention rates favors the use of an apical sling.

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