To compare minimally invasive sacrocolpo(hystero)pexy (MISCP) and Sacrospinous Ligament Fixation (SSLF) in terms of success, complications, and perioperative outcomes.

This multicenter retrospective study was approved by the local ethics committee. A total of 303 patients with Baden–Walker grade 3 or 4 apical pelvic organ prolapse who underwent surgical treatment at five tertiary referral centers were assessed. Of these, 207 patients who underwent MISCP (RSC or LSC) and had sufficient follow-up data were included in the study.  The criteria for failure after surgical correction included the occurrence of Baden-Walker grade 2 or greater prolapse, the requirement for reoperation or pessary insertion, and the persistence of bulging symptoms. Postoperative complications were classified according to the Clavien–Dindo classification system. Surgical success and the development of de novo urinary incontinence were evaluated during follow-up.
Continuous variables were expressed as median and interquartile range (IQR) and compared using the Mann–Whitney U test. Categorical variables were presented as number and percentage (%) and compared using the chi-square test or Fisher’s exact test, as appropriate.
Subgroup analyses were performed according to age (<65 vs. ≥65 years) and body mass index (BMI <30 vs. ≥30 kg/m²). A p-value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS software (IBM Corp., Armonk, NY, USA).

A total of 207 patients were included (MISCP:n=132, SSLF:n=75). Patients in the MISCP group were significantly older (p=0.001) and had lower ASA scores compared to the SSLF group (p=0.001). Symptom duration was longer in the MISCP group (p=0.005), and parity was slightly higher (p=0.002). Previous hysterectomy and prior mid-urethral sling (MUS) surgery were significantly more frequent in the SSLF group (p<0.001).

Perioperative outcomes showed that operation time was significantly longer in the MISCP group (p<0.001), and hospital stay was also longer (p<0.001). Estimated blood loss was higher in the MISCP group (median 100 vs. 50 ml, p<0.001). Despite these differences, overall success rates were comparable between groups (90.9% vs. 93.3%, p=0.541).

De novo urinary incontinence differed significantly between groups (p=0.004), with a higher rate of urge incontinence in the SSLF group. Follow-up duration was slightly longer in the MISCP group (p=0.006). 

Complication rates, including Clavien–Dindo grade 1–3 events, were similar between groups, with no statistically significant differences. Major complications such as bladder, bowel, mesh-related, or ureteral injuries were rare in both groups. 

Subgroup analyses according to age (<65 vs. ≥65 years) and BMI (<30 vs. ≥30 kg/m²) showed no significant differences in success rates between MISCP and SSLF. Similarly, within-group analyses demonstrated that neither age nor BMI significantly affected surgical success.

Although there are studies in the literature that compare the MISCP and SSLF, there is no distinct consensus on this issue. Each technique has its own set of advantages and disadvantages. The current study which contains real-world data showed that in patients with apical prolapse who have a higher ASA score and a history of abdominal hysterectomy, similar successful outcomes can be achieved with vaginal SSLF, and offers shorter operation and hospital stays with less risk of bleeding.

ASC is considered the gold standard method for apical prolapse repair, and, its high success rate and long-term durability have been demonstrated in various studies. Nevertheless, due to the extended duration of operation and hospitalization, and higher complication rates, MISCP techniques have emerged to overcome this issues. On the other hand vaginal SSLF method offers comperable success rates in apical prolapse. Both MISCP and SSLF can be performed in the treatment of apical prolapse. The selection of procedure must take into account the patient characteistics, complication rates, duration of the operation and hospital stay, blood loss, and the surgeon's expertise.