SACROSPINOUS LIGAMENT FIXATION FORHYSTEROPEXY: DOES CONCOMITANT ANTERIOR AND POSTERIOR FIXATION IMPROVESURGICAL OUTCOME?
T. LO1, W. HSIEH 2,J. YANG 3, M. UY-PATRIMONIO 4, Y. LIN 5;
1Chang Gung Mem. Hosp., Keelung, Taiwan, 2ChangGung Mem. Hosp. Linkou Med. Ctr., Taoyuan, Taiwan, 3XiamenChang Gung Mem. Hosp., Xiamen, China, 4Dr. Pablo O. TorreMem. Hosp., Talisay City, Philippines, 5Obstetrics andgynecology, Chang Gung Mem. Hosp., Tao-Yuan, Taiwan.
Introduction: Uterinepreservation in uterine prolapse is an option for young patients.There are many procedures designed for uterine preservation, one ofwhich is sacrospinous hysteropexy (SSH).
Objective: Our aimis to compare the 3-year outcome of SSH with anchorage in theposterior cervix alone or both anterior and posteriorcervix.
Methods: 75 patients who undergone SSH betweenMarch 2008 and August 2013. Women who had POP > stage 3,symptomatic and requested for uterine preservation were included.Exclusion criteria were those who had previous pelvic surgery, unfitfor surgery. Group 1 was 35 patients who underwent SSF forhysteropexy at posterior cervix (SSH-p) between March 2008 and June2011, and group 2 was 35 patients between June 2010 and August 2013who did SSF for hysteropexy at anterior and posterior cervix(SSH-ap). Five were excluded due to incomplete data. Concurrentprocedures done were anterior colporrhaphy, posterior colporrhaphy,trachelectomy and mid-urethra sling (MUS) surgery. All patients wereasked to complete a 72-hr voiding diary and IIQ-7, UDI-6, POPDI-6,PISQ-12 as part of subjective evaluation. Objective evaluationincluded a POP quantification system (POP-Q) staging and 2 additionalmeasurements of anterior fornix (Ca, the distance betweenexternal urethral meatus to anterior fornix with a negative orpositive number showing it was proximal or distal to the externalurethral meatus respectively) and cervical diameter (Cx).Follow-ups were done at 1-week, 1-month, 3-months, 6-months, 1-yearand annually thereafter. A 3 year outcome was used forcomparison.
Results: The mean age of patients was 46.0±17.1years old, median parity was 2.2±1.4, mean BMI 23.6±2.4 kg/m2.About 32.9% of patients were postmenopausal. There was no significantdifference in BMI, parity, operating time, intraoperative blood lossand hospital stay between the two groups. Some women had concurrentsurgeries performed 17 had MUS and 19 had trachelectomy. There wereno major complications noted, but only minor complication ofpostoperative pain. For the postoperative POP-Q 9 measurements withthe addition of anterior fornix (Ca) and cervical diameter (Cx), itshowed a significant difference in the postoperative measurements onthe point Ba, C (anterior cervical lip) and Ca. The post-operativemeasurement of the points Ba, C and Ca in SSH-p were -1.5±0.8,-6.3±1.0 and -6.8±1.1 cm while in SSH-ap were -1.9±0.6, -7.9±1.1and -8.3±1.1 cm respectively (p=0.001, p=0.012 and p=0.022). Thecorrection difference on point Ba, C and Ca from pre-operative topost-operative measurements in SSH-p were 5.4±1.7, 10.9±2.2 and11.2±2.2 while in SSH-ap were 5.9±1.5, 12.8±2.4 and 13.0±2.4,which had shown a statistically difference p=0.014, p=0.001 andp=0.001, respectively. Other measurements (Aa, Ap, Bp, D, Gh, Pb, Tvland Cx) had no significant differences between groups. We furtheranalyzed on Cx measurement between patients with objective failureand success. The pre-operative and post-operative Cx were 3.3±0.6vs. 2.7±0.5 and 3.2±0.5 vs.2.6±0.5, for objective failure andsuccess which had shown a statistically p<0.001 and p<0.001,respectively. At 3-year follow-up, objective and subjective curerates for overall compartments for all patients who had SSF were78.6% (55/70) and 84.3% (59/70), respectively. In comparing the SSH-pwith the SSH-ap group, there were significantly higher subjectivecure rates in the latter 74.3% versus 94.4%. (p=0.023), butthe overall objective cure rates were not (74.3% versus 82.9%,p=0.073). On the specific compartment cure rates, there was asignificant difference on the apical compartment between the twogroups where the SSH-p group had 77.1% cure rate while the SSH a-pgroup had a 94.3% cure rate (p=0.042). The rest of thecompartments were not significant. Although, there was no significantdifference on the objective cure on the anterior compartment betweengroups, the point Ba and Ca at post-operative measurement has shown abetter outcome at SSH-ap group.
Conclusions: Anchorage ofthe anterior cervix and vaginal wall together with the usualposterior anchorage yield better subjective outcome and apicalsuspension over posterior cervix and vaginal wall only at 3rdyear post-operatively. The cervix position affected the subjectiveoutcome as seen in points C and Ca.