Results
Table
1 shows the characteristics of the 72 women. The fast majority had a combination of sacrospinous hysteropexy with an anterior colporrhaphy (87.5%). Five women (6.9%) had a sacrospinous hysteropexy of a stage 1 uterine descent. In these women, the surgeon decided to perform a sacrospinous hysteropexy during surgery because the uterine descent under anaesthesia was stage 2. The mean follow-up time was 12.7 months (median 11 months).
Table 1
Patient characteristics
Age (years)a
| 57.2 (11.9) |
Surgery for prolapse in medical history | 3 (4.2) |
Surgery for urinary incontinence in medical history | 4 (5.6) |
Urinary incontinence before surgeryb
| 40 (55.6) |
Urge incontinence | 9 (12.5) |
Stress incontinence | 21 (29.2) |
Combination stress and urge incontinence | 10 (13.9) |
Gynecological examination before surgery |
Descensus uteri stage 2 or more | 67 (93.2) |
Cystoceles stage 2 or more | 57 (79.2) |
Rectoceles stage 2 or more | 19 (26.4) |
Enterocele | 1 (1.4) |
Surgery |
Sacrospinous hysteropexy | 8 (11.1) |
Sacrospinous hysteropexy + anterior colporrhaphy | 54 (75) |
Sacrospinous hysteropexy + anterior and posterior colporrhaphy | 9 (12.5) |
Sacrospinous hysteropexy + posterior colporrhaphy | 1 (1.4) |
Additional TVT | 15 (20.8) |
Hospital stay (days)c
| 3.5 (1–8) |
Follow-up in monthsc
| 12.7 (3–33) |
Perioperative and postoperative complications are shown in Table
2. One woman needed repeated surgery for postoperative bleeding a couple of hours after the primary procedure. Total blood loss was estimated at 400 cc. There were no incidental bladder or rectal injuries. Of the 20 women (27.8%) who had urinary retention over 100 ml after removal of the indwelling bladder catheter, five women (6.9%) needed intermittent self-catheterisation more than 2 weeks after surgery. However, at 4 weeks, no women had significant urinary retention. This complication only occurred in women who underwent an anterior colporrhaphy. Seven women with cystitis received antibiotics and made an uneventful recovery. Five women (6.9%) developed right-sided buttock pain which persisted longer than 2 weeks. It resolved spontaneously within 6 weeks. No removal of the sacrospinal suture was required.
Table 2
Complications related to surgery
Complications during surgery | 0 (0) |
Complications after surgery | 32 (44.4) |
Second surgery because of bleeding | 1 (1.4) |
Buttock pain | 13 (18.1) |
Buttock pain <2 weeks | 8 (11.1) |
Buttock pain >2 weeks | 5 (6.9) |
Vaginal hematoma | 2 (2.8) |
Urinary tract infection | 7 (9.7) |
Retention bladder | 20 (27.8) |
Bladder catheterisation <2 weeks | 15 (20.8) |
Bladder catheterisation >2 weeks | 5 (6.9) |
Vaginal adhesion | 3 (4.2) |
During the follow-up period, a total of 16 women (22.2%) had a recurrent prolapse of one of the compartments. Five women (6.9%) had a recurrent prolapse of the uterus (four women stage 2, one woman stage 3). Ten women (13.9%) had a cystocele stage 2 or more (eight women stage 2, two women stage 3) and two women (2.8%) had a prolapse of the posterior compartment stage 2. All the women with a recurrent cystocele had had surgery of the anterior compartment combined with the hysteropexy, so there were no de novo cystoceles. The two women with a recurrent rectocele did not have surgery of the posterior compartment combined with the sacrospinous hysteropexy, so these can be considered as de novo rectoceles.
Table
3 shows the results of the UDI, DDI and IIQ domain scores before and after surgery. On all urogenital domains, there was significant improvement as well as on all quality of life domains. Symptoms on domain constipation and obstructive defecation also improved significantly. Large effect sizes were found on domain pain (effect size = 0.92) and genital prolapse (effect size = 2.0) of the UDI. The domain physical functioning and emotional health of the IIQ also showed a large effect size (0.82 and 0.79, respectively).
Table 3
Urinary Distress Inventory (UDI), Defecatory Distress Inventory (DDI) and Incontinence Impact Questionnaire (IIQ)
UDI |
Urinary incontinence | 18.5 (24.2) | 10.5 (21.0) | 0.012 | 0.35 |
Overactive bladder | 29.5 (26.7) | 14.4 (18.6) | 0.000 | 0.66 |
Pain | 30.1 (26.7) | 9.5 (16.7) | 0.000 | 0.92 |
Obstructive micturition | 27.0 (28.3) | 10.8 (19.7) | 0.000 | 0.66 |
Genital prolapse | 56.6 (32.0) | 5.6 (17.4) | 0.000 | 2.0 |
DDI |
Constipation | 11.9 (18.8) | 6.3 (9.8) | 0.021 | 0.37 |
Obstructive defecation | 13.3 (19.7) | 8.3 (11.8) | 0.016 | 0.22 |
Pain | 4.5 (16.3) | 2.8 (8.3) | 0.498 | 0.13 |
Fecal incontinence | 8.6 (20.7) | 8.5 (14.4) | 0.955 | 0.01 |
IIQ |
Physical functioning | 26.0 (24.4) | 9.4 (15.1) | 0.000 | 0.82 |
Mobility | 25.0 (22.8) | 12.6 (18.4) | 0.000 | 0.60 |
Emotional health | 23.2 (23.3) | 8.0 (14.2) | 0.000 | 0.79 |
Social functioning | 14.8 (19.1) | 4.5 (11.8) | 0.000 | 0.65 |
Embarrassment | 11.2 (13.8) | 6.7 (11.1) | 0.013 | 0.41 |
In addition to the table we made a sub-analysis for the 15 women who had additional surgery for urinary incontinence (TVT). These women improved significantly on the urinary incontinence domain after surgery (mean score: 26.7→6.7, p = 0.009). This improvement was not significant for the women without TVT surgery (mean score: 16.4→11.5, p = 0.162). On the other hand, the women with TVT surgery did not improve significantly on the overactive bladder domain (mean score: 24.3→16.23, p = 0.079) where the group without TVT did (mean score: 30.8→14.3, p = 0.000).
Discussion
The objective of this study was to assess quality of life and urogenital and defecatory symptoms before and after sacrospinous hysteropexy. The results show that a sacrospinous hysteropexy significantly reduced all urogenital and several defecatory symptoms and significantly improved quality of life. Effect sizes were large on domain genital prolapse and pain (UDI), and on domain physical functioning and emotional health (IIQ). It also anatomically cured the uterine descent in 93.1% of women.
The sacrospinous ligament fixation was first described by Sederl (1958) [
19]. Later it became more popular by Richter and Albright [
20] (Europe) and Randall and Nichols [
21,
22] (USA). Several modifications of their techniques have been described since. The anatomical results of 2,256 women after a sacrospinous ligament fixation of the vaginal vault were recently reviewed [
1]. Objective cure rates varied between 67 and 96.8%, and subjective cure rates varied between 70 and 98%. Our findings are in line with these results, although the review focused on the sacrospinous fixation of a vault prolapse. Subjective outcomes are underreported in most studies on the sacrospinous ligament fixation. We have shown prospectively that bladder and bowel function improves significantly after a sacrospinous hysteropexy.
There are a variety of reasons why women want to preserve their uterus. Among those reasons are: keeping their fertility, personal identity, but also the possibility that this kind of surgery might reduce operation time, estimated blood loss and postoperative recovery time [
4,
23]. There are signs that removing the uterus may increase the risk of pelvic neuropathy, new onset urinary incontinence, bladder dysfunction and prolapse [
24,
25,
26]. Several studies on the sacrospinous hysteropexy, as a technique in which the uterus is preserved, are available [
3‐
6,
8‐
10,
27]. Among these studies, three were of prospective design [
6,
8,
27], five were of retrospective design [
3‐
5,
9,
10] and there was one case report [
28]. One report described a different surgical technique and therefore cannot be compared with our study [
2]. One study assessed risk factors for failure of sacrospinous hysteropexy [
29] and another study only assessed sexual functioning after sacrospinous hysteropexy [
30]. Anatomic success rates in these studies varied between 74 and 93.5%, which is comparable with our results. The main problems when comparing studies on the sacrospinous ligament fixation were recently debated by Morgan et al. [
11]. They showed that there is a variety in definition of failure of sacrospinous ligament fixation due to differences in how anatomical outcomes are evaluated and which compartment of the vagina is considered. In our group, recurrent postoperative cystoceles, stage 2 or higher, were seen in 10 women (13.9%). This percentage is slightly lower than the 21.3% reported in the recent review [
11]. However, our follow-up in the current study was relatively short and some recurrences may not have been detected in this timeframe.
. In a previous retrospective study on the anatomical outcome of the sacrospinous hysteropexy by our group, we found a higher rate of recurrent cystoceles stage 2 or higher (30%) [
9]. The follow-up period in this study was a mean of 23 months. The high rate of recurrent cystoceles may be related to the primary damage of neuromuscular support or may be the result of the retroverted axis of the vagina after sacrospinous hysteropexy. This last aspect, being regarded as an overcorrection, is held responsible for the high rate of cystoceles [
27,
31]. However, in a study by Smilen et al. [
32] the sacrospinous hysteropexy did not independently increase the risk of recurrent cystocele as compared to other surgical techniques.
Apart from true genital prolapse symptoms, urogenital symptoms and also bowel symptoms improved after the sacrospinous hysteropexy. Because the majority of women in our study had their sacrospinous hysteropexy combined with an anterior colporrhaphy, one may argue that it was this anterior repair that relieved symptoms, and not the sacrospinous hysteropexy. However, it was shown that pelvic organ prolapse and urogenital symptoms were only slightly correlated to the site and severity of the prolapse [
14]. This lack of a clear correlation between the site of the pelvic organ prolapse and symptomatology makes it very difficult in combination surgery to contribute functional improvement to a certain intervention. All we can conclude from our results is that surgical procedures that involve a sacrospinous hysteropexy show good functional outcome.
It was shown that overactive bladder symptoms disappear after anterior repair in 60–82% of women [
33]. We also found a marked improvement of overactive bladder symptoms after surgery in our group. However, this significant improvement was confined to the women who did not have a combined TVT procedure with their sacrospinous hysteropexy. Women who did have a TVT combined procedure experienced more bother on overactive bladder domain after surgery as compared to women without TVT surgery. This finding is consistent with literature on the TVT in which the development of overactive bladder symptoms after TVT surgery is reported to occur in up to 15% of women [
34].
We have to keep this in mind when placing a TVT (prophylactic) in case of occult stress incontinence. After sacrospinous hysteropexy, postoperative complications occur, but none of them was life threatening. Most complications were self-limiting. The majority of postoperative complications were related to the bladder function. These complications did not occur in women who only had a sacrospinous hysteropexy. Therefore, it is likely that complications related to the bladder are the consequence of additional surgery and not the result of sacrospinous hysteropexy. The prevalence of buttock pain is estimated at 10 to 15% [
35]. This pain can be explained by injury to surrounding nerves of the sacral plexus and branches of the pudendal nerve. In an anatomical study, the relationship of the pudendal nerve to the sacrospinous ligament was found to be variable (one branch of the pudendal nerve piercing through the ligament was found in 11%) [
36]. Barksdale et al. also showed that nerve tissue is present and widely distributed within the sacrospinous ligament [
37]. Therefore, although the placement of the suture two centimetres medial to the ischial spine protects against major nerve injuries, the complications of buttock pain cannot be prevented in all women. Fortunately, this buttock pain was shown to resolve spontaneously in most cases, as we also demonstrated in our series [
9].
The strength of our study is that we measured urogenital and defecatory symptoms and quality of life in a large group of women who underwent a sacrospinous hysteropexy, with a validated questionnaire before and after surgery. There are some potential drawbacks that need to be discussed. First, there might be an indication bias. In our country, a vaginal hysterectomy is the standard surgical technique for correcting a uterine descent. Therefore, women that came to our hospital may have chosen specifically for this operation. They might have had high expectations of this procedure which could have influenced their outcome with respect to quality of life. Second, in some patients, follow-up time was limited to 3 months. Possibly, some recurrences had not yet developed at that time. Third, the study was performed in a single university hospital. The sacrospinous ligament fixation has become rapidly popular in our center and is performed by two surgeons. They are highly trained in performing the procedure. This might have influenced the outcome. Fourth, we did not compare the sacrospinous hysteropexy with another surgical technique to correct a uterine descent. Therefore, we cannot conclude that the sacrospinous hysteropexy is superior to other procedures. However, it is a safe and effective operation for women who wish to preserve their uterus at time of genital prolapse surgery.