Functional and anatomic comparison of 2 versus 3 suture placement for uterosacral ligament suspension: a cadaver study

OBJECTIVE: The objective of the study was to compare the vaginal apex pullout distance using 2 vs 3 suspension sutures during transvaginal uterosacral ligament suspension (USLS) and to describe relationships to ipsilateral ureter and nerve structures. STUDY DESIGN: Eight fresh-frozen female cadavers were studied. After hysterectomy, a transvaginal USLS was performed with placement of 3 suspension sutures per side. The 2 most distal sutures on each ligament were tied. A screw-and-washer attachment was secured in the middle of the vaginal cuff and tied to a pulley system with surgical filament. Distal traction was applied with sequentially increasing weight loads. Distal migration of the vaginal apex from baseline with each weight load was recorded. The most proximal suspension suture was tied and the procedure repeated. Horizontal distances between each USLS suture to the ipsilateral ureter were measured. Three discrete points were marked on sacral nerves S1-S3, and the shortest distance between each point and each ipsilateral USLS suture was measured. Descriptive statistics and repeated-measures analysis of variance were performed. RESULTS: Application of each load resulted in greater migration distances for the 2 suture configuration when compared with 3 sutures (P < .05). Differences were greatest for the 3 kg load (mean +/- SEM, 2.0 +/- 0.2 vs 1.5 +/- 0.1 cm, respectively). Distances to ipsilateral ureter between the 2 most cranial sutures were comparable (P > .05). The most cranial USLS suture was closest to sacral nerves S1-S3. CONCLUSION: In this cadaveric study, 3 USLS sutures provided more support to the vaginal apex than 2 sutures, although the absolute difference may not be clinically significant. The most cranial suture had the smallest distances to sacral nerves S1-S3.