Transvaginal Sacrospinous Ligament Fixation: Revisited in Modern Gynecology

INTRODUCTION

Pelvic organ prolapse (POP) is a common complaint in women causing varying degrees of discomfort and hampering the quality of life.^1,2 The lifetime risk of surgery for pelvic prolapse in women is 7%. Clarks et al. found that 12% undergo second surgery within 6 years,³ and Denman et al. found the recurrence rate was 17% at 10 years.⁴ The ultimate aim of any pelvicorgan prolapse surgery is to reestablish the normal anatomy and minimize the symptoms. MRI determines that the normal position of vaginal apex is approximately 5 cm inferior to second sacral vertebral body and 5 cm medial to the ipsilateral spine. Sacrospinous ligament fixation (SSLF) reconstructs this anatomy and suspends the vaginal apex over the levator plate.

Modern gynecologists have concentrated on the various defects in the endopelvic fascia as a cause of POP and attempts at selective treatment for these defects. With the advent of various graft materials like mesh, these procedures started gaining popularity. But owing to recent U.S FDA warnings about mesh-related complications,^5,6 here is an attempt to reconsider the modern role of SSLF, a traditional vaginal procedure in today’s era.

Delancey divided the supports of vagina in three levels. The level I defects are apical defects. The sacrospinous ligament suspension seek to restore the level I vaginal support.⁷ Ultimate treatment for the stage III and the stage IV uterine prolapse is considered as the Mayo Wards operation (vaginal hysterectomy). This study is focused to consider sacrospinous ligament fixation simultaneously during the Mayo Wards operation to prevent vault prolapse in future.

MATERIALS AND METHODS

A total of 106 patients (aged between 40 years and 70 years) were included in our study. The study period was from January 2016 to October 2017. This study is a retrospective observational study carried out at Smt. Kashibai Navale Medical College and General Hospital, Pune. Pelvic organ prolapse quantification (POP-Q) staging was carried out in all patients before the surgery.

RESULTS

In the present study, there were 106 patients, 18 with vault prolapse and 88 patients with III or IV degree uterine prolapse (Tables 1 to 3).

The average age of the patients was 53 years (range 40–70 years).

Some patients also underwent other procedures.

There were no serious complications of the procedure. Maximum (20%) number of patients complained of postoperative pain lasting for six weeks. Only one (0.94%) patient had rectal injury, one (0.94%) patient had serious hemorrhage requiring blood transfusion, and one (0.94%) patient had abscess. None of the patients complained of recurrence of prolapse.

DISCUSSION

The upper third of the vagina (Delancey’s biomechanical level I) is suspended from the pelvic walls by vertical fibers of the paracolpium, which is a continuation of the cardinal ligament. The sacrospinous ligament suspension seeks to restore the level I vaginal support.⁷ The true incidence of vaginal vault prolapsed following hysterectomy is approximately 0.5%.⁸ Numerous techniques for correction of vault prolapsed have been described.⁹ Transvaginal SSLF avoids the potential complications of laparotomy and general anesthesia, resulting in fewer complications and less postoperative pain, decreased blood loss, and greater cost-effectiveness.¹⁰ As a vaginal procedure, sacrospinous ligament suspension enables concurrent management of anterior and posterior vaginal wall prolapse, which is present in no less than two-thirds of cases with total prolapse.⁷ Sedera¹¹ was the first to use the sacrospinous ligament as a secure point of attachment for patients with vaginal vault and uterine prolapse as early as 1958. Richter¹² popularized the procedure in Europe in 1968, and by 1971, Randall and Nichols¹³ introduced the technique to the United States. Sacrospinous ligament fixation (SSF) keeps the vaginal axis in the midline and enables adjustment of the vaginal length.

In our study, at 6 weeks of duration, none of the patients had recurrence of prolapse. At the end of follow-up of 6 months, only one patient had recurrence of stage II prolapse according to POP-Q staging and nine had stage I prolapse.

In our study, only one woman had cystocele as recurrence which did not require any surgical intervention. The rates of anatomic failure in published studies vary significantly. Beer and Kuhn reviewed the literature and found that the failure rates ranged from 3 to 37%.¹⁴ The disparity in outcome led to a systematic review to explain the differences in failure rates. Failure rates were higher in the anterior compartment repair and lower in the posterior and apical compartments repair. A meta-analysis demonstrates that uterosacral ligament suspension is a highly effective procedure in reestablishing apical vaginal support. A successful anatomic result, defined as support of POP-Q stage 0 (“optimal”) or stage I (“satisfactory”), was reported in 98% of women. All studies, which met the inclusion criteria, were consistent in demonstrating this beneficial effect.¹⁵ In the present study, only one woman had a mild cystocele recurrence, which did not require any reoperation. Most common complications were postoperative gluteal pain 20%, which lasted for almost 6 weeks. In a study by Nicholas,¹³ damage to the femoral and sciatic nerves were reported in 1.8%, gluteal pain, bladder pain, or unclassified pain in 0.8%, and with the development of vaginal adhesions or rectovaginal fistula in 0.5% of patients, respectively.¹³ Sciatic neuralgia was observed in 1.8% comparable to study by Nicholas.¹³ Febrile morbidity arising due to fever was seen in 15%, abscess 0.94%, and hemorrhage requiring transfusion in 0.94% of patients. Urinary tract infections occurred in three (2.8%) patients which was comparable to the study by Gupta et al.¹⁶ The urinary tract infections were successfully treated by oral antibiotics. In a study by Pasley,¹⁷ 94% of the patients who underwent sacrospinous suspension for uterovaginal prolapse and vaginal vault prolapse had no persistence or recurrence of vaginal vault prolapse 6–83 months after the procedure.¹⁷ This is similar to the cases in the present study. In our study, junior residents and assistant professors have done maximum number of cases, with minimum instrumentation (only two Sims speculum) and a mean operative time of 20–25 minutes. Our patients had the lowest complication rates compared to previous studies, which could be due to small sample size. Further studies are required with large sample size.

CONCLUSION

In conclusion, transvaginal sacrospinous colpopexy is a simple, easy, and safe procedure that can be effectively taught at various teaching organizations and can be performed together with vaginal hysterectomy and vault prolapse.

REFERENCES

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