High uterosacral ligament hysteropexy for the management of pelvic organ prolapse

Objective: To demonstrate our transvaginal high uterosacral ligament (HUL) hysteropexy technique as an alternative mesh-free uterine-preserving pelvic organ prolapse (POP) repair approach and present our institutional outcomes. Concurrent hysterectomy with POP repair is controversial as uterine-preserving techniques may beneficially allow fertility, body image and sexual function preservation (1, 2). Materials and Methods: This video illustrates a step-by-step sequence of our HUL hysteropexy technique in a symptomatic Stage III POP patient. Retrospective single-institution, single-surgeon analysis of patients treated by either HUL hysteropexy or hysterectomy with HUL suspension for symptomatic prolapse was performed with minimum 2 years of follow-up. Patient demographics, operative characteristics, pre and post-operative POP-Q evaluation, American Urological Association Symptom scores (AUASS) and post-operative Pelvic Floor Distress Inventory (PFDI-20) were compared. Results: Surgery time was 3 hours 24 minutes. No immediate/early complications were noted, with successful repair on follow-up. Outcomes of 18 patients (10 HUL hysteropexy, 8 hysterectomy and HUL suspension) were assessed (Supplemental Table). The only baseline difference was a lower body mass index in the HUL hysteropexy cohort (25.8 vs. 35.8kg/m(2), p=0.008). In the HUL hysteropexy cohort, blood loss (mean: 58 vs. 205ml, p=0.00086) and operative time (190.4 vs. 279.1minutes, p=0.0021) were significantly reduced. There was no difference in post-operative AUASS, POP-Q or PFDI20 at 2 years. Conclusion: We present our HUL hysteropexy technique. Although limited by sample size and retrospective design, resulted in significantly reduced blood loss and operative time with comparable post-operative 2 year outcomes to nonuterine-preserving techniques. In our opinion, HUL hysteropexy is a safe, durable POP management option for women without significant endometrial pathology risk factors.