UTEROSACRAL VAULT SUSPENSION AT TIME OF HYSTERCTOMY: COMPARISON OF LAPAROSCOPIC VS. VAGINAL APPROACH ON SURGICAL CASE TIME, LENGTH OF STAY AFTER SURGERY, AND POST-OPERATIVE URINARY RETENTION RATES.
HOULIHAN1, S. KIM-FINE 1, C. BIRCH 1, S. TANG 2, E. A. BRENNAND 1;
1Department of Obstetrics and Gynecology, Univ. of Calgary, Calgary, Canada, 2Alberta Hlth.Services, Calgary, Canada.
Introduction: At our institution, two approaches to uterosacral (US) vault suspension at time of hysterectomy are employed. Some surgeons prefer a vaginal approach, accessing the US ligaments through the vaginal cuff in a Mayo-McCall or Schull fashion after completion of vaginal hysterectomy (vaginal uterosacral ligament suspension:V-USLS)1. Others prefer to secure the uterosacral ligaments laparoscopically prior to initiation of VH (laparoscopic uterosacral ligament suspension: L-USLS), securing them to the vaginal cuff at conclusion of the hysterectomy. It is not known if one technique is superior to another in terms of length of surgical case time and post-operative length of stay (LOS), as well as post-operative urinary retention (UR). This information is important for resource planning in our single-payer universal health care system.
Objective: To characterize the mean/median case time for both surgical approaches, as well as mean/median LOS and rates of UR after surgery.
Methods: A database of all surgical cases from April 2015 - November 2016 was searched for cases involving both vaginal hysterectomy and US vault suspension, and the route of access to the US ligaments identified. Patient demographics such as age, BMI, ASA class, concomitant prolapse and adnexal procedures, LOS after surgery and post-operative UR were abstracted. Comparison between the two groups was performed appropriate by Mann Whitney U test and Chi-square.
Results: One hundred cases were identified during the study window. Sixty-six women had a vaginal US suspension and 34 women had a laparoscopic approach to US at time of their VH. Women undergoing vaginal approach to US were slightly older (60.8 (10.9) vs. 55.7 (12.7), p=0.039), but no differences existed in BMI (26.1 (7.2) vs 27.7 (7.3), p=0.200) or ASA class. Rates of completed adnexal surgery differed between the two approaches (65.2% vs 97.1%, p<0.001). Rates of concomitant anterior and posterior did not differ between the two groups. The average case times of the two approaches differed by <15 minutes: 139.7 (29.7) minutes for vaginal vs. 153.2 (26.5) (p=0.028) for laparoscopic approach. LOS after surgery did not differ between the groups, with median length of stay being 2 (1) days for both groups. No statistical difference was found in proportion of women immediately passing the post-operative bladder protocol (51.5% vs. 55.9%) and proportion of women discharged with on-going need for catheterization (28.8% vs. 14.7%).
Conclusions: Laparoscopically and vaginally approached uterosacral ligament vault suspension have similar case times and length of stay post-op. Our study was under powered to evaluate a statistical difference in post-operative UR, but a trend was observed in keeping with prior work which suggests rates may be higher with vaginal approach2. Rates of concomitant adnexal surgery are higher in the laparoscopic group. Given that there is increasing interest in opportunistic salpingectomy and salpingo-ophorectomy for ovarian cancer prevention, the difference in successful completion rates of adnexal procedures could play a role in the surgical decision making of which route to use. As it has yet to be determined what the gold standard is for primary prolapse surgery at time of hysterectomy, further research is needed. The information gathered from this work will be used to plan a prospective surgical trial not only to re-evaluate operative time and length of stay but also to determine complication and recurrence rates as well as the importance of opportunistic adnexal surgery to women undergoing pelvic reconstructive surgery. The balance of these will dictate which approach is superior.
References: 1. Int Urogynecol J. 2017;28(1):65-71. 2. J Reprod Med. 2009;54(5):273-280.