IS THE HIGH UTEROSACRAL LIGAMENTSUSPENSION SUBSEQUENT TO VAGINAL HYSTERECTOMY SUPERIOR TO ASIMPLIFIED MCCALL PROCEDURE IN PATIENTS WITH PELVIC ORGAN PROLAPSE?
R. LITJENS, O. RIJSDIJK, G.LINK;
Department of Obstetrics & Gynecology, Pelvic CareCentre Maastricht, Maastricht Univ. Med. Ctr., Maastricht,Netherlands.
Introduction: Despite increasein popularity of uterus preserving techniques, vaginal hysterectomy(VH) is still a common option in the treatment of pelvic organprolapse (POP). Sufficient suspension of the vaginal vault isimportant in preventing vaginal apex prolapse. For vault anchoringthe McCall culdoplasty is widely used. However, recently the highuterosacral ligament suspension (HUSLS) has been recommended becauseof an excellent restoration of the vaginal length (1).
Objective:The aim of this retrospective chart review study was to compare thevault attachment after VH by means of a simplified McCall procedure(SMCP) with an extended attachment by means of the HUSLStechnique.
Methods: In 41 patients, aged between 39 and 78years, a VH was done because of uterovaginal prolapse POP-Q stage II(n = 15) and III (n = 26). In 28 cases a SMCP procedure of thevaginal vault was done. This is a modified McCall culdoplasty. Afterhysterectomy the peritoneal cavity was entered by two long Breiskyspecula. In between, the uterosacral ligament was exposed andidentified as a prominent peritoneal plication. Each vaginal cornerwas connected with the ligament 2 to 3 cm above the peritoneal marginusing one absorbable 1-0 suture. In 13 patients the vaginal vault wasanchored by the HUSLS technique placing two PDS 2-0 sutures as highas possible through the ligaments on each side. After gently tying ofall PDS sutures, ureteral patency was verified by chromocystoscopy.The anatomical repair by the two techniques was compared. In severalcases sexual behavior and discomfort was assessed by a standardizedquestionnaire. Data analysis was done using nonparametric tests andby linear regression.
Results: The distribution of POP-Qstages shifted significantly to lower stages after surgery (table 1).In 6 patient’s reoperations were performed. One patient in the SMCPgroup received a transobturator tape. In two cases, a primary and arecurrent cystocele were corrected by anterior wall repair, eachcombined with sacrospinous ligament suspension. Two recurrentprolapses of the vaginal apex (4,9%), one in the SMCP group (C +3 cm)and one in the HUSLS group (C -2 cm) were repaired by sacrospinousligament suspension and laparoscopic sacral colpopexy 10 and 19months after the primary interventions, respectively. One HUSLSprocedure was complicated by a unilateral ureteral obstruction: thesuspension sutures were removed on that side.Age, BMI and concurrentanterior and posterior wall repair did not differ between the groups.However, a higher BMI was associated with an enlargement of tvl,postoperatively (r = 0,43, n = 40, 2α < 0,01). Mean follow up inthe HUSLS group was 10 ½ month shorter.C ranged between -4 cm to +5cm before surgery and between -10 cm to +3 cm after surgery (n = 41,p < 0,001). The mean inward shift of point C was 6,7 ± 2,9 cm. Nodifferences were detected in patients treated by SMCP compared topatients treated by HUSLS (table 2). However, in contrast to thepreoperative data diminishing values of C after surgery weresignificantly related to an increase of tvl (r = 0,47, n = 40, 2α <0,01).Available questionnaires after surgery did not prove anyfrustration concerning sexual life in half of all patients (13/24),irrespective of being sexually active. Eight out of 29 patientsreported to have no intercourse anymore. Dyspareunia was reported byfour patients. No significant differences were detected between thegroups (table 3).No correlation was found between the postoperativevalues of C and tvl and the frequency of intercourse. However, it diddecrease with increasing age (r = 0,48, n = 25, 2α <0,05).
Conclusions: After hysterectomy, the vaginal vaultcan be sufficiently suspended by SMCP using only one suture on eachcorner. Notably due to the significant shorter follow up, the HUSLSprocedure does not provide any superior benefit to the anatomicalrestoration but enhances the risk of ureteral injury (2). The levelof POP repair has no impact on sexual function. Sexual activity ispreferably associated with age.
Table1. Distribution of POP-Q stages in the total group.
Table2. POP-Q data.
Cbefore surgery (cm)
Cafter surgery (cm)
*p < 0,01 concerning the values after surgery compared to thevalues before surgery
Table3. Data of sexual domain.