Total Vaginal Hysterectomy With Uterosacral Ligament Suspension Compared With Supracervical Hysterectomy With Sacrocervicopexy for Uterovaginal Prolapse

Options for women with uterovaginal prolapse who desire hysterectomy and reconstructive repair include native tissue or mesh-based repairs. The benefit of a mesh sacrocolpopexy as the initial surgical approach for uterovaginal pelvic organ prolapse (POP) is unclear. A prior meta-analysis demonstrated that although mesh sacrocolpopexy was more durable anatomically for prolapse repair than native tissue repair, reoperation rates between the groups were similar. A frequently used treatment for uterovaginal POP native tissue repair is total vaginal hysterectomy with uterosacral ligament suspension. For mesh repair, laparoscopic supracervical hysterectomy with mesh sacrocervicopexy is often used. Data comparing these 2 treatments are sparse. The aim of this retrospective cohort study was to compare uterosacral ligament suspension and laparoscopic supracervical hysterectomy with mesh sacrocervicopexy as primary treatment of anatomic uterovaginal prolapse recurrence after total vaginal hysterectomy. The study was conducted at a large academic center from 2009 to 2019. Participants were women undergoing either a total vaginal hysterectomy with uterosacral ligament suspension, or a laparoscopic or robotic-assisted supracervical hysterectomy with mesh sacrocervicopexy, and for whom a postoperative Pelvic Organ Prolapse Quantification examination was documented. Composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery) was the primary outcome. The secondary outcomes evaluated included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. Propensity scoring was performed with a 2:1 ratio of sacrocervicopexy to uterosacral suspension. Of a cohort of 654 patients, 228 (34.9%) underwent uterosacral suspension, and 426 (65.1%) underwent sacrocervicopexy. Median follow-up was less than 1 year for both groups: 230 days after supracervical hysterectomy with mesh sacrocervicopexy and 126 days after total vaginal hysterectomy with uterosacral ligament suspension (P < 0.001). Compared with the sacrocervicopexy group, the uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426] and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426]; P < 0.02 for both comparisons). Multivariable Cox regression showed that the time to prolapse recurrence was shorter with the uterosacral group; the hazard ratio was 3.14, with a 95% confidence interval of 1.90 to 5.16. The sacrocervicopexy group had 14 mesh complications (3.3%); all were vaginal exposure. Reoperation rates were similar in the uterosacral and sacrocervicopexy groups (4.8% [11/228] vs 3.8% [16/426], P = 0.51). These data show that total vaginal hysterectomy with uterosacral ligament suspension demonstrated higher rate of and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy. Both these treatments are acceptable options for the primary treatment of uterovaginal prolapse in women undergoing hysterectomy and reconstructive surgery.