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Uterine-Sparing Prolapse Surgery: Techniques & Technologies

Author Olivia Reid covers Uterine-Sparing Prolapse Surgery: Techniques & Technologies on BackTable OBGYN

Olivia Reid • Apr 2, 2024 • 37 hits

A critical challenge of uterine-sparing prolapse surgery is preventing recurrence and reoperation. Recent clinical data has shed light on the importance of adopting the right surgical approaches, and new technologies have emerged with the potential to help operators achieve consistent outcomes. Dr. Olivia Chang and Dr. Suzette Sutherland share the specifics of their uterine-sparing prolapse surgery techniques, covering specific strategies to reduce recurrence and which tools to use in specific clinical scenarios.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

•Specialized approaches tailored to specific compartments in prolapse surgery are crucial for reducing recurrence rates and optimizing outcomes.

•Recent advancements in accessing the sacrospinous ligament through novel technologies offer more minimally invasive options (e.g. Anchorsure, Saffron, and EnPlace) for gynecological procedures.

•The selection of either permanent or delayed absorbable sutures in uterine-sparing prolapse repair involves considerations of procedural ease, granulation tissue concerns, and the operational requirements of devices.

•Precise suture placement is essential in bilateral suspensions to prevent asymmetrical tension and potential recurrence, particularly given the limited space within the vaginal vault.

Uterine-Sparing Prolapse Surgery: Techniques & Technologies

Table of Contents

(1) Strategies for Reducing Recurrence Rates in Uterine-Sparing Prolapse Surgery

(2) Innovations in Sacrospinous Ligament Access: Devices & Techniques

(3) Suture Placement in Uterine-Sparing Prolapse Repair

Strategies for Reducing Recurrence Rates in Uterine-Sparing Prolapse Surgery

Since recurrence rates in prolapse surgery vary depending on the specific compartment operated on, it is crucial to employ specialized methods for each compartment and monitor recurrence patterns diligently. The importance of this approach was underscored by findings from the SAVE U trial, which revealed a higher reoperation rate when the anterior compartment was initially involved in the prolapse. This accentuates the necessity of addressing the anterior compartment concurrently with apical repair to mitigate the risk of recurrence. Dr. Chang suggests adopting an anterior approach to the sacrospinous ligament in cases of advanced anterior prolapse to enhance compartment elevation and optimize surgical outcomes. Although the posterior approach is commonly favored when the posterior compartment is the primary site of prolapse, Dr. Sutherland emphasizes the continued importance of addressing the anterior compartment simultaneously due to its susceptibility to prolapse recurrence.

[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.

Listen to the Full Podcast

Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang on the BackTable OBGYN Podcast)
Ep 32 Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse with Dr. Olivia Chang
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Innovations in Sacrospinous Ligament Access: Devices & Techniques

Through novel technologies in recent years, significant advancements in accessing the sacrospinous ligament have been made. Historically, ligature carriers like Miya hooks and Deschamps allowed for needle insertion into the sacrospinous ligament, followed by threading. However, the invasiveness of this method led to the development of Capio by Boston Scientific, the most traditional suture-capturing device used by practitioners.

While Capio remains functional, the demand for more minimally invasive options has driven the creation of Anchorsure. This instrument deploys an anchor through a tube, enabling direct, effective, and durable suture placement through the sacrospinous ligament, enhancing support for the vaginal apex. Shortly after, Saffron was developed, allowing direct palpation of the ligament before anchor placement, thus improving precision. EnPlace, the latest technology, anchors transvaginally, eliminating the need to open the perirectal or perivesical space, making it the least invasive option.

In the operating room, practitioner familiarity, comfort, and the goal of reducing tissue destruction and postoperative pain are pivotal factors. Dr. Chang emphasizes that procedural outcomes improve when doctors are comfortable with their chosen device, regardless of its specific pros and cons. Dr. Sutherland concurs, noting that these advancements have led to decreased tissue destruction and postoperative pain overall due to their minimally invasive nature.

[Dr. Suzette Sutherland]

What products are available or what means are available today to access the sacrospinous ligament, as an example? There are a number of products that are on the market now that make it easier to access this. Do you have experience with these? I don't know if you're able to list them just for our listeners.

[Dr. Olivia Chang]
Of course. The most traditional suture-capturing device has been Capio. There's been different ligature carriers. Going back historically, we first started with ligature carriers, and there's the Miya hooks and the Deschamps that allows you to place a needle through the sacrospinous ligament and then pass the needle through. From there on, there was the Capio suture capturing device by Boston Scientific.

In the past five years or so, there has really been a great explosion of new products that allows for a more minimally invasive way of accessing and placing sutures through the sacrospinous ligament. One product is called Anchorsure. There is an anchor that is deployed through a tube that is connected to PS sutures or Prolene sutures that allows for a very effective and durable placement of an anchor through the sacrospinous ligament. Then, you can suspend the vaginal apex to these anchors.

There's also Saffron, which I think came out of the market in the past few months by Coloplast. It's most similar to a Capio, in my opinion. The difference is that rather than a suture that goes through the sacrospinous ligament, it's a little anchor that goes into the sacrospinous ligament. The difference is that you can directly palpate the sacrospinous ligament before placing the Saffron anchor onto.

EnPlace is another one. EnPlace is definitely the most unique compared to these other ones because you can actually place the anchor into the sacrospinous ligament transvaginally. What does that mean? That means you don't have to open up the perirectal space or the perivesical space to get to the sacrospinous ligament.

They all have their advantages. They all have their different techniques in order to use them. To date, there's really no head-to-head trials comparing these anchors capturing devices at least with regard to surgical outcomes. The only trial that I'm aware of was one that came out of Wake Forest that compared Capio to Anchorsure. Their primary outcome was to look at postoperative gluteal pain, and they didn't see a difference between these two types of modalities. In my opinion, it really comes down to what you're familiar and comfortable using and whichever modality that is, whichever product that is, you're going to get good results.

[Dr. Suzette Sutherland]
Yes. I think some of the movement to develop these products also is about being able to access the sacrospinous ligament with less dissection and doing it more by feel: feeling the ischial spine, feeling the sacrospinous ligament with your hands deep in the endopelvic space and then passing the device and feeling where it needs to go, especially those where there's an anchor, like the Anchorsure, the Saffron, but even with the Capio device.

Whereas, before these devices, you were incumbent on being able to look at the sacrospinous ligament and get back there with a suture or the Miya hook, you mentioned, to make sure you are getting into that sacrospinous ligament. In order to get back there and see very well, there's quite a dissection that needs to happen, and with people holding retractors in order to get back there and see maybe even a headlight. These tools have really helped us to access where we need to be without doing such a big dissection, which limits tissue destruction back there, limits bleeding, and then hopefully post-op pain, which I think is what we are also seeing. That's been helpful. I don't know if there's one that you use predominantly that you feel you're most comfortable with.

[Dr. Olivia Chang]
I have explored all of these products in simulation settings. I've stuck with Capio because that's just the product that I feel most comfortable with. The other reason I favor the Capio is because I can take out the sutures. That's something that is important, that if I don't like the placement, that I have the ability to remove it entirely and replace it.

[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.

Suture Placement in Uterine-Sparing Prolapse Repair

When selecting the appropriate suture for uterine-sparing prolapse repair, there's significant discussion about the disparities between permanent and delayed absorbable sutures. Based on current short-term data, there appears to be minimal distinction between the two types of sutures. However, Dr. Chang leans towards delayed absorbable sutures for suspensions due to their perceived procedural advantages. These benefits stem from the decreased likelihood of granulation tissues and suture tails, both critical for successful suspensions. Nevertheless, absorbable sutures cannot always be utilized; the EnPlace device necessitates the use of permanent sutures for uterine suspension due to its operational requirements.

To mitigate asymmetrical tension and potential recurrence in bilateral suspensions, precise suture placement is essential, regardless of the chosen suture type. The restricted space within the vaginal vault often increases the difficulty of achieving symmetrical tension distribution, underscoring the importance of meticulous physician technique. As interest grows in uterine-sparing procedures within the gynecological field, Drs. Chang and Sutherland advocate for more comprehensive clinical trials with extended post-procedure follow-up periods for patients.

[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.

Podcast Contributors

Dr. Olivia Chang discusses Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse on the BackTable 32 Podcast

Dr. Olivia Chang

Dr. Olivia Chang is an assistant professor of clinical urology and the chief of female urology, pelvic reconstructive surgery and voiding dysfunction in the department of Urology at UC-Irvine in California.

Dr. Suzette Sutherland discusses Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse on the BackTable 32 Podcast

Dr. Suzette Sutherland

Dr. Suzette Sutherland is the director of female urology with UW Medicine in Seattle, Washington.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 13). Ep. 32 – Hysteropexy vs Hysterectomy for Pelvic Organ Prolapse [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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