Uterine-Sparing Prolapse Surgery: Techniques & Technologies

[Dr. Suzette Sutherland]
I wanted to move back for one second about recurrence rates after prolapse. In the SAVE U Trial, as well as in a number of other trials, they do talk about recurrence of prolapse, but we know today one person's prolapse isn't another person's prolapse. We need to look at what compartment is prolapsing, what compartment did we operate in, and is that the part that is re-prolapsing, so i.e. our intervention wasn't good enough? Or is that compartment okay and it's a different compartment, and maybe it wasn't addressed at the time, or our intervention made it weaker?

They did see this in the SAVE U Trial specifically, as well as some other trials, that there was a reoperation rate, but predominantly in the anterior compartment. Can you speak to that? How often do you feel like there is some attention paid surgically to the anterior compartment at the same time as the apical repair?

[Dr. Olivia Chang]
Yes, the anterior compartment is tricky. It's tricky. It's the most common site of recurrence for any type of prolapse surgery, no matter what the index procedure is. You're absolutely right. We really have to address the anterior compartment at the time of apical repair. I do find that, in my personal experience, for patients with advanced anterior prolapse, so somebody with a Stage 3 cystocele, for example. These patients, I routinely offer a sacrospinous ligament hysteropexy, but what I would modify is that I would perform an anterior approach to the sacrospinous ligament. In my experience, this allows for a better elevation of the anterior compartment, and just ultimately a better suspension at the end of the surgery. In doing so, if you do an anterior approach, you're addressing both the anterior compartment and the apical compartment through the same incision.

[Dr. Suzette Sutherland]
Then, I guess along those same lines, when might it be advantageous to do a posterior approach?

[Dr. Olivia Chang]
In my practice, I would do a posterior approach if the predominant or the leading edge of the prolapse is the posterior compartment. Say somebody comes in with a big Stage 3 rectocele, and in that, I would prefer a posterior reproach because it's the most accessible way to get the sacrospinous ligament. However, going back to your point earlier, even if I'm doing a posterior approach, I am still going to address that anterior compartment because the data shows that's the most likely site for the prolapse to recur.

[Dr. Suzette Sutherland]
Yes, that's a really good point because the others have an anchor, and you may be able to slip the suture out of the anchor, such as in the Saffron device, but the anchor stays behind unless you're able to really pull on it hard, but then it might cause a little bit of tissue destruction in that process, so that's a really good point to make.

This is getting a little bit into the weeds, but for our listeners who are interested in doing these procedures, do you recommend using a permanent suture when you're doing a hysteropexy as opposed to maybe a delayed absorbable for when the uterus isn't in place in doing an apical repair? What do you generally do?

[Dr. Olivia Chang]
Great question, Suzette. I know you and I have talked about this a lot offline because we don't have concrete data for hysteropexy. A lot of the data that we're using to apply to this question is extrapolations for prolapse repairs at the time of hysterectomy. If you look at the optimal trial, which was a trial comparing uterosacral ligament suspension to sacrospinous ligament suspension, all of their suspensions utilize both delayed absorbable sutures with permanent sutures at the time of suspension.

Since then, there's been many studies that have come out that have asked that specific question, is there a difference between using permanent versus delayed absorbable? My interpretation of the data is that there is no difference, whether it is delayed absorbable versus permanent. I actually do favor the delayed absorbable sutures for the suspension because then you don't have to worry about the granulation tissues or the Prolene suture tails poking through, and you don't have to bury the knot as you're tying it.

The only exception to this is really when you're using the EnPlace because the EnPlace does rely on using permanent sutures to suspend the uterus. If you do use the EnPlace product, that is one place where you should not be using delayed absorbable sutures.

[Dr. Suzette Sutherland]
Here's another thought there too, is when you are, especially doing a hysteropexy versus without the uterus in place, pulling the uterus and/or the apex all the way up to the sacrospinous ligament or leaving a bit of a suture bridge, as we say, in my experience with a hysteropexy, especially if it's going to be a bilateral suspension repair, that pulling it all the way up to the sacrospinous ligament oftentimes, it doesn't quite reach right or left. It pulls it one side versus the other, and a bit of a suture bridge ends up being there, or you don't want to pull it up quite that high, in any case, depending on how you got your anchors in there. Leaving a little bit of a suture bridge has been advantageous, but in that, using a permanent suture rather than delayed absorbable.

I think that is also some of the thought process behind what's going on with the EnPlace device. As opposed to doing a unilateral suspension procedure just off to one side and then being able to pull it up a little bit further, pull it to that sacrospinous ligament, and then maybe being able to use delayed absorbable. Can you comment on what of what I just said resonates with you versus if you see it in a different way?

[Dr. Olivia Chang]
That's a great point. When you're doing bilaterals, it is challenging because you only have so much space in the vaginal vault. If you're trying to pull it up to both sacrospinous ligaments, the fear is that if it doesn't reach, and if it doesn't reach, it might not scar into place, if you're using delayed absorbable sutures. I agree with you 100% that if you don't anticipate that the vaginal vault will reach both sacrospinous ligaments, it is a good idea to use permanent sutures in that situation. However, if you're doing the unilateral suspension, you should be able to reach that sacrospinous ligament. If that's the case, I do recommend a delayed absorbable suture.

[Dr. Suzette Sutherland]
You're doing predominantly unilateral with a hysteropexy or bilateral?

[Dr. Olivia Chang]
I almost exclusively only do unilateral suspensions. Because I favor using delayed absorbable sutures, it's more important to me to make sure the vaginal vault is really right at the sacrospinous ligament, rather than utilizing or relying on suture bridges to suspend the vaginal vault. Again, I think that's a great question that really warrants more attention with even some retrospective studies to better understand. Now, with EnPlace coming out, I think that is an arena where we'll start to get data where we can understand whether delayed absorbable unilateral suspension is just as good as bilateral suspension but with the suture bridge.

[Dr. Suzette Sutherland]
Yes. You mentioned a few studies already that have taken place, but again, just to bring home that point, you're making comparisons between permanent versus delayed absorbable, unilateral versus bilateral, so on and so forth. They're all great studies that just don't go out long enough. The data is immature, and so it goes out to a year, maybe three. That's not really long enough to tell the story because we're making choices about what we do for this prolapse repair with longevity in mind, and longevity is much longer than three, even five years, I would argue. All of our studies should be going out for 10 plus years if we can. Of course, it takes money to do studies. That's often the limiting factor, unfortunately.

[Dr. Olivia Chang]
Yes, I tell my patients that too. I tell them that keeping the uterus in at the time of prolapse repair is possible. The current data shows not a significant difference in outcomes. I tell them that the data is immature, but I tell them that there's nothing glaring in the current data that would make me advise them against it. I'm very transparent with my patients about this. Like I said, many of my patients have gravitated towards hysteropexy because of less downtime, because of the shorter operative time, and the less amount of bleeding.

[Dr. Suzette Sutherland]
I think it's important to disclose to patients what's in the literature, but also it's important to notice what your experience has been. Longer-term experience just because our experience didn't get published, so to speak, it wasn't part of a trial, but as an example, I've been doing hysteropexies for well over 10 years, more like 15 years. What I can say is those patients I've had an opportunity to be able to follow up on, they're doing quite well. We do think that, this is why we focus on this, there's longevity involved as long as they're done well.