Heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse: a systematic review

Abstract

Objective: To explore why failure rates vary so much between published reports of sacrospinous ligament fixation to correct pelvic organ prolapse and what the potential sources of heterogeneity may be.

Data sources: MEDLINE was queried for studies between 1966 and 2005 that included the term "sacrospinous."

Methods of study selection: One-hundred eighty-seven studies were reviewed. Studies were selected if they 1) involved a surgical procedure performed unilaterally with a posterior or apical vaginal incision and approach to the ligament; 2) reported objective outcomes with a classification system (Baden-Walker, pelvic organ prolapse quantification) over a defined follow-up period; and 3) were published in English, French, or German. Random effects meta-analyses were conducted for both objective and subjective measures of failure.

Tabulation, integration, and results: Seventeen cohorts met the selection criteria, and the Baden-Walker vaginal profile or a close variation suitable for meta-analysis was used in 10 of them. Variability in failure rates was observed depending on site of and grade of vaginal support (P<.05). The anterior compartment was the most common site of failure for any given grade. This was most striking when the criterion for failure was grade 1 (40.1% anterior, 11.0% apical, 18.2% posterior) or grade 2 prolapse (21.3% anterior, 7.2% apical, 6.3% posterior). Areas of vaginal support were more equally affected when the criterion for failure was grade 3 prolapse (3.7% anterior, 2.7% apical, 2.3% posterior). Among cohorts using grade 2 prolapse as the criterion for objective failure, the pooled measure of failure to relieve symptoms was 10.3% (95% confidence interval 4.4-16.2%) and to provide patient satisfaction was 13.0% (95% confidence interval 7.4-18.6%).

Conclusion: The variation in published failure rates after sacrospinous ligament fixation is, in part, accounted for by differences in how anatomical outcomes are evaluated and which compartment of vaginal support is being considered. Failure rates are highest in the anterior compartment.