Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse,☆☆

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Abstract

OBJECTIVE: Our purpose was to compare anatomic and functional results of 2 procedures performed at vaginal hysterectomy for vaginal vault suspension in patients with advanced uterovaginal prolapse.

STUDY DESIGN: A retrospective case-control study was designed comparing 62 patients who underwent sacrospinous ligament fixation and 62 members of a matched control group who underwent modified McCall culdoplasty during vaginal hysterectomy and reconstructive pelvic surgery. The 62 pairs were matched for grade of uterine prolapse, age, parity, dystocia, menopause, body mass index, previous prolapse surgery, heavy work, constipation, and chronic cough.

RESULTS: Operative time and blood loss were significantly greater (P < .001) in the group with sacrospinous suspension. With a follow-up from 4 to 9 years, 17 (27%) patients receiving sacrospinous suspension had prolapse recurrence at any vaginal site compared with 9 (15%) patients receiving modified McCall culdoplasty (P = .14). Recurrent vault prolapse was recorded in 5 (8%) and 3 (5%) subjects, respectively (P = .72). Thirteen (21%) and 4 (6%) patients, respectively, had recurrent cystocele (matched odds ratio 4.1, 95% confidence interval 1.3 to 14.2, P = .04). No significative difference was observed in postoperative sexual function.

CONCLUSION: Sacrospinous ligament fixation is not recommended as a prophylactic measure at vaginal hysterectomy in patients with uterovaginal prolapse. (Am J Obstet Gynecol 1998;179:13-20.)

Section snippets

Material and methods

During the period from November 1987 through May 1993, 65 women admitted to our department for the correction of advanced uterovaginal prolapse underwent vaginal hysterectomy and reconstructive pelvic surgery, which included sacrospinous ligament fixation. Three patients were lost to follow-up and were thereafter excluded from this study, leaving 62 cases available for evaluation. A review was made of the computerized records of a further 317 women who underwent surgery with the same indication

Results

As would be expected from the selection process, no significant differences were seen between the 2 groups in the characteristics examined (Table I).

. Characteristics of patients used as match criteria

Empty CellSacrospinous ligament fixation (n = 62)Matched controls with modified McCall culdoplasty (n = 62)Statistical significance
Uterine prolapse (No.)
Grade 224 (39%)22 (36%)
Grade 338 (61%)40 (64%)P = .87*
Age (y)56.9 ± 7.8 (40–76)58.4 ± 8.7 (40–77)P = .31
Parity (median, range)2 (1–10)2 (1–12)P = .43

Comment

The use of sacrospinous suspension as a prophylactic measure in conjunction with vaginal hysterectomy is controversial, and no comparative study is available in the literature.2 We used an individually matched design to compare sacrospinous ligament fixation and modified McCall culdoplasty in women with advanced uterovaginal prolapse. Data were taken from a computerized data collection exercise that has taken place at our center since 1986 and was specifically instituted by the first author

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    Techniques described include McCall culdoplasty, sacrospinous ligament fixation, and Shull suspension.14–16 The modified McCall culdoplasty as described by Colombo and Milani16 has been shown to be superior to sacrospinous ligament fixation in reducing apical recurrence. The technique of McCall culdoplasty was first described by McCall in 1957 as a treatment for uterovaginal prolapse,17 with various subsequent modifications by other surgeons.

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    Despite its common use, the debate on its effectiveness in advanced stage prolapse still goes on. Several reports have described VH and cuff suspension as an insufficient procedure for advanced prolapse and have suggested that its use should be limited to mild to moderate prolapse [3,4,15]. However, recently Alas et al. assessed the success rates of VH&McCall in women with advanced and less severe uterine prolapse and found similar success and reoperation rates [16].

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From the Division of Gynecology, Department of Obstetrics and Gynecology, San Gerardo Hospital, Third Branch of the University of Milan.

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