Expert Commentary

Which vaginal procedure is best for uterine prolapse?

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Sacrospinous hysteropexy and vaginal hysterectomy with uterosacral ligament suspension were found to be comparable at 12 months after surgery in this large randomized trial involving 208 women with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery.

Detollenaere R, den Boon J, Stekelburg J, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with 
uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial. BMJ. 2015;351(1):h3717.



More than one-third of women aged 45 years or older experience uterine prolapse, a condition that can impair physical, psychological, and sexual function. To compare vaginal vault suspension with hysterectomy, investigators at 4 large Dutch teaching hospitals from 2009 to 2012 randomly assigned women with uterine prolapse to sacrospinous hysteropexy (SSLF) or vaginal hysterectomy with uterosacral ligament suspension (ULS). The primary outcome was recurrent stage 2 or greater prolapse (within 1 cm or more of the hymenal ring) with bothersome bulge symptoms or repeat surgery for prolapse by 12 months follow-up.

Details of the trialOne hundred two women assigned to SSLF (median age, 62.7 years) and 100 assigned to hysterectomy with ULS (median age, 
61.9 years) were analyzed for the primary outcome. The patients ranged in age from 33 to 85 years.

Surgical failure rates and adverse events were similarMean hospital stay was 3 days in both groups and the occurrence of urinary retention was likewise similar (15% for SSLF and 11% for hysterectomy with ULS). At 
12 months, 0 and 4 women in the SSLF and hysterectomy with ULS groups, respectively, met the primary outcome. Study participants were considered a “surgical failure” if any type of prolapse with bothersome symptoms or repeat surgery or pessary use occurred. Failures occurred in approximately one-half of the women in both groups.

Rates of serious adverse events were low, and none were related to type of surgery. Nine women experienced buttock pain following SSLF hysteropexy, a known complication of this surgery. This pain resolved within 
6 weeks in 8 of these women. In the remaining woman, persistent pain led to release of the hysteropexy suture and vaginal hysterectomy 4 months after her initial procedure.

What this evidence means for practice

Advantages of hysterectomy at the time of vaginal vault suspension include prevention of endometrial and cervical cancers as well as elimination of uterine bleeding. However, data from published surveys indicate that many US women with prolapse prefer to avoid hysterectomy if effective alternate surgeries are available.1

In the previously published 2014 Barber and colleagues’ OPTIMAL trial,1,2 the efficacy of vaginal hysterectomy with either SSLF or USL was equivalent (63.1% versus 64.5%, respectively). The success rates are lower for both procedures in this trial by Detollenaere and colleagues.

Both SSLF and ULS may result in life-altering buttock or leg pain, necessitating removal of the offending sutures; however, the ULS procedure offers a more anatomically correct result. Although the short follow-up interval represents a limitation, these trial results suggest that sacrospinous fixation without hysterectomy represents a reasonable option for women with bothersome uterine prolapse who would like to avoid hysterectomy.
—Meadow M. Good, DO, and Andrew M. Kaunitz, MD

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