Comparison of Two Different Suture Materials for Transvaginal Sacrospinous Fixation of the Vault: A Prospective Randomized Trial

Abstract

Objective: The aim of this study was to compare the efficacy of polyglactin-910 (Vicryl) and polydioxanone (PDS II) sutures for sacrospinous fixation (SSF) in patients with uterovaginal prolapse (pelvic organ prolapse quantification [POP-Q] stage 2 or higher) in terms of postoperative recovery, complications, recurrence of prolapse, and quality of life (QoL). Design/Methods: Patients were randomized into two groups and all patients underwent transvaginal SSF routinely with polyglactin or with PDS II suture irrespective of whether hysterectomy and/or pelvic-floor reconstruction were combined or not. The patients were followed-up for at least till 2 years postoperatively. Cases were excluded if they were lost to follow-up for 2 years after being operated on. Results: There were 80 patients in group 1 and 82 patients in group 2 with uterovaginal prolapse of POP-Q grade 2 or higher. The majority (70/80 in group 1 and 71/82 in group 2) of the cases underwent vaginal hysterectomy (VH) with pelvic floor-repair (PFR) along with SSF. There was no significant difference between the groups in terms of short- or long-term morbidity. The mean follow-up period was 28 months and 95% of these patients reported improved QoL in both groups. Five patients developed asymptomatic cystocoeles in group 1 and 4 developed this condition in group 2. Enterocoeles were detected in 2 cases each in both of the groups. The objective cure rates were 91.25% and 92.68% in the groups, respectively. Conclusions: Extensive data exist regarding SSF, but the search for ideal suture material is still ongoing. The polyglactin suture is equally efficacious, compared to the polydioxanone suture, for decreasing the incidence of future vault prolapse with comparable suture related complications. (J GYNECOL SURG 29:281)

Introduction

Pelvic organ prolapse (POP) is a health problem that may affect up to 40% of parous women over age 50.¹ The lifetime risk of undergoing surgery to manage POP is ∼11%, and 30% of these women will require reoperation for prolapse recurrence.² The risk increases with the number of vaginal births and is higher in older and obese women. Significant negative effects on a woman's quality of life (QoL), ranging from physical discomfort, to psychologic and sexual complaints, to occupational and social limitations are inevitable in POP. Moreover, increased life expectancy during the past few decades is likely to result in increasing numbers of women presenting with POP and consequently with postsurgical vault prolapse. Surgical management becomes rather challenging owing to coexistent multiple support defects. Isolated defects in the anterior or posterior compartments without apical defects may be few. Adequate suspension of the apex plays a pivotal role in prolapse repair according to many experts. Several procedures have been described for repair of apical prolapse, but a paucity of high-quality data exist regarding which procedure for apical prolapse will have optimal durability and provide patient safety. Sacrospinous fixation (SSF) has been extensively studied, and is a highly effective and well-tolerated surgical treatment for uterine or vaginal-vault prolapse.^3–7 Long-term support of the vaginal apex after SSF has been reported to be 81%–100%.^8–10 Procedures, such as abdominal sacral colpopexy, are associated with lower rates of apical prolapse and dyspareunia than SSF has, but these benefits come at the cost of a longer operating time, a longer time to return to daily activities, and an increased cost of therapy.¹¹ Researchers have found a 2%–13% rate of recurrent vault prolapse. However, the issue of a standardized surgical procedure that improves the outcome with fewer complications still remains an area for research. The pelvic organ prolapse quantification (POP-Q) system is a reliable, reproducible and specific method to measure the pelvic organ support quantitatively.^12,13 The aim of this study was to compare the efficacy of polyglactin 910 and polydioxanone sutures for treating uterovaginal prolapse (POP-Q stage 2 or higher) in terms of success rate (conversely, also recurrence in the anterior or posterior compartments), postoperative recovery, immediate and late complications, hospital stay, and general QoL.

Materials and Methods

Procedures

This study was performed from January 2007 to August 2010. The technique¹¹ and protocol of the study design was approved by the institutional ethical committee and informed consent was obtained from the patients before the intervention. The study involved 180 women who had POP (POP-Q stage 2 or higher) with or without coughing or a Valsalva maneuver. The patients were allocated into two groups following a computer-generated random number table. The surgical technique, as described by Hardiman and Drutz,¹⁴ was followed. A double-ply, number 1 polyglactin-910 suture (Vicryl, J359H, Johnson & Johnson™) was used to fix the vault with the sacrospinous ligament in group 1 and a double ply, number 1, polydioxanone suture (PDS II, Z359T, Johnson & Johnson™) was used for group 2. All surgeries were performed by two senior gynecologists in both groups to exclude interobserver bias. The dissection to the ischial spine was done through an incision in the midline posterior vaginal wall, and the pararectal space was dissected bluntly to the lateral pelvic wall. Each suture was loaded in a Deschamps ligature carrier and passed 2 cm medial through the right sacrospinous liagment. Stitches were then passed through the vault, and closure of the colpoperineorrhaphy was performed. Finally, the fixation sutures were firmly tied without leaving any suture bridge.

The patients were followed-up after 1 month, 3 months, 12 months, and 24 months postoperatively (Fig. 1). During each follow-up visit, patients were asked if they had any urinary and bowel complaints, pain, or abnormal vaginal bleeding. Patients who did not attend the follow-up clinic visits for at least 24 months postoperatively were excluded from the study.

FIG. 1.

Study profile. PDS II is a type of suture. POP-Q, pelvic organ prolapse quantification, SSF, sacrospinous fixation; USG, ultrasound (gynecologic).

Outcome measures

The primary outcome measure was success rate (i.e., recurrence in the form of symptomatic or asymptomatic prolapse stage 2 or more [leading part of the prolapse is ≥−1cm to the level of the hymen) in the middle compartment (Point C/distal edge of the cervix or vaginal cuff/apex in cases of hysterectomy] and/or need for reoperation within 2 years of follow-up. Each patient's clinical parameters were evaluated during each postoperative check-up.

Secondary outcome measures were immediate and late complications, hospital stays, postoperative recovery, subjective outcome, and improvement in general and disease-specific QoL.

Statistical analysis

Sample size was calculated for the primary outcome measure (i.e., the success rate of the procedure). A minimum of 90 subjects in each group was calculated, assuming a power of 0.8 (β=80% and α=0.05) at a 95% significance level (p-value 0.05), to detect a difference of 15% in the success rate between the two groups, assuming at least an average success rate of 80%^8–10 and a dropout rate of 15%.

Characteristics of the patients were summarized, using descriptive statistics for continuous variables (mean, median, and standard deviation as appropriate) and compared using Student's t-tests. Categorical data were summarized as count and in-frequency distribution and evaluated using McNemar's exact test. Data were analyzed using the statistical package Epi Info Statcalc, version 6 (Centers for Disease Control and Prevention, Atlanta, GA). The p-value was established at ≤0.05 as statistically significant.

Results

Ten cases in group 1 and 8 cases in group 2 were excluded from the study, as these subjects did not return for follow-up during the stipulated time period of 24 months (Figs. 1 and 2). Both the groups were comparable in terms of demographic and preoperative variables (Table 1). Seventy-three women in group 1 and 70 in group 2 were postmenopausal. Seven cases in group 1 and 8 cases in group 2 (including a total of 11 cases of symptomatic vault prolapse to or beyond the hymenal level) had prior histories of surgery (abdominal/vaginal hysterectomy with/without repair of pelvic floor; Table 1).

FIG. 2.

Time-dependent survival probability for Group 1 and Group 2 in terms of success rate.

Table 1.

Demographic Characteristics of Study Population (N for Groups 1+2=162)

Variable	Group 1	Group 2	p-Value
Age (mean ± SD)	49.5±10.6	48.2±10.9	0.44
Parity (mean ± SD)	3.1±0.9	3.2±0.96	0.49
Duration of disease (mean ± SD)	3.7±1.6	3.9±1.8	0.45
BMI (kg/m²; mean ± SD)	21.8±2.7	22.5±3.1	0.12
Hospital days (mean ± SD)	5.5±2.3	5.5±2.5	0.99

Type of presentation	Group 1 (%)	Group 2 (%)	p-Value
Uterine prolapse with cystocoele & rectocoele	66 (82.5)	66 (80.4)	0.74
Vault prolapse	5 (6.2)	6 (7.3)	0.8
Cystocele & rectocele	9 (11.2)	10 (12.1)	0.85

Previous surgery	Group 1 (%)	Group 2 (%)	p-Value
Fothergill's	2 (2.5)	2 (2.4)	0.98
TAH & BSO	2 (2.5)	3 (3.6)	0.66
VH	1 (1.2)	2 (2.4)	0.57
VH & PFR	2 (2.5)	1 (1.2)	0.54

BMI, body mass index; SD, standard deviation; TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; VH, vaginal hysterectomy; PFR, pelvic-floor repair.

Blood loss was proportional to the duration and nature of surgery, and there was no significant difference the groups (Table 2). The majority (87.5% in group 1 versus 86.5% in group 2) of the patients underwent vaginal hysterectomy, anterior colporrhaphy, and posterior colpoperineorrhaphy along with SSF. SSF was combined with anterior and posterior repair in 5 cases in both groups, as the patients were young and did not opt for hysterectomy.

Table 2.

Type of Operation Combined with SSF and Perioperative Details

Operation	Group 1 (n=80)	Group 2 (n=82)	p-Value
VH+AC+PC	70 (87.5)	71 (86.5)	0.86
AC+PC	5 (6.2)	5 (6.1)	0.96
Vault repair	5 (7.1)	6 (8.1)	0.78

Variable	Group 1	Group 2	p (95% CI)
Operating time in min (Mean ± SD)	90±25	87±28	0.47 (−5.24 to 11.23)
Blood loss in mL (Mean ± SD)	228±39	226±32	0.72 (−9.05 to 13.05)

SSF, sacrospinous fixation; VH, vaginal hysterectomy; AC, anterior colporrhaphy; PC, posterior colpoperineorrhaphy; CI, confidence interval; min, minutes, SD, standard deviation.

The perioperative complication (Table 3) most commonly encountered was hemorrhage (7.5% of group 1 versus 6.09% of group 2), which was managed by blood transfusion and pressure packing of the vagina immediately after the operation in the patients in both groups. Mild-to-moderate gluteal pain (5% versus 3.65%) responded well to analgesics for 3–7 days and resolved within 3 months. Persistent gluteal pain for more than a year was encountered in 3 cases in group 2 and in 1 case in group 1. Sutures were not detectable at this stage of follow-up. Persistent vaginal bleeding was noted in a total of 9 cases (5% in group 1 versus 6.09% in group 2). In 5 cases, granulation tissue had to be managed with silver-nitrate application. Others resolved spontaneously over time. Five patients in group 1 and 4 patients in group 2 developed postoperative cystocoeles (grade 2), which were mostly asymptomatic. The incidence of enterocoele was 2 in each group. Recurrence either in the anterior or posterior compartment did not require reoperation within the follow-up period. Postoperative urinary complaints of either stress or urge incontinence were comparable in both groups.

Table 3.

Operative Complications

Type of complication	Group 1 n (%)	Group 2 n (%)	p-Value	Risk ratio (95% CI)
Immediate
Hemorrhage requiring BT	6 (7.5)	5 (6.1)	0.72	1.23 (0.39–1.13)
Mild–moderate gluteal pain	4 (5)	3 (3.6)	0.67	1.37 (0.31–5.9)
Late
Vaginal bleeding (granulation tissue formation)	4 (5)	5 (6.1)	0.76	0.82 (0.23–2.9)
Stress urinary incontinence	3 (3.7)	4 (4.8)	0.72	0.77 (0.18–3.3)
Urge urinary incontinence	2 (2.5)	2 (2.4)	0.98	1.02 (0.15–7.1)
Cystocoele	5 (6.2)	4 (4.8)	0.70	1.28 (0.35–4.6)
Enterocoele	2 (2.5)	2 (2.4)	0.98	1.02 (0.15–7.1)
Persistent gluteal pain	1 (1.2)	3 (3.6)	0.32	0.34 (0.03–3.2)

BT, blood transfusion; CI, confidence interval.

The length of postoperative follow-up was at least 24 months. There was significant improvement of general and disease-specific QoL in 93.75% (77/80 in group 1 versus 75/82 in group 2) of the subjects. Five patients were not satisfied at the end of stipulated follow-up period (2 years)—2 because of persistent gluteal pain and the other 3 because of menopausal symptoms unrelated to the surgery—although the anatomical outcome was satisfactory in both cases (Fig. 2). The success rate in group 1 was 91.25% and was 92.68% in group 2.

Although 18 cases were excluded from this study, it is worth mentioning that, among these cases, 9 patients were followed for 12 months, 7 patients for 3 months, and the rest of the patients for 18 months. Almost all of these patients were symptom-free; 1 patient had urge incontinence at 3 months and the other had a grade 1 cystocoele at 12 months.

Discussion

As women live longer and healthier lives, pelvic-floor disorder continues as an important health and social issue. Management of pelvic-organ prolapse can be difficult because of the coexistence of different support defects. Various types of surgical approaches have been studied to address this bothersome condition. Although the true incidence of vault prolapse is unknown, some literature has estimated its incidence as 0.2%–1.0%.⁹ Nichols¹⁵ studied sacrospinous fixation for vault support in the late 1980s and found it to be an excellent procedure without jeopardizing vaginal length. Subsequently, SSF was used as a procedure for vaginal-vault prolapse only.¹⁰ Cruikshank and Cox¹⁶ stated that this procedure can also be used as a prophylaxis against posthysterectomy vault prolapse, especially in patients having loss of uterosacral–cardinal ligament complex noted at the time of hysterectomy. However Colombo and Milani¹⁷ did not recommend this procedure as a prophylactic measure with vaginal hysterectomy for prevention of vault prolapse, owing to increased blood loss in an SSF group. Compared to some other studies,^2,18,19 average blood loss was higher owing to the fact that vaginal hysterectomy was done in the majority (85.41%) of the cases along with pelvic-floor repair, requiring longer operative time. Injury to the vessels may occur from overzealous dissection or passage of a needle through the neurovascular bundle in the sacrospinous ligament. Pressure may work well for control of this type of hemorrhage.²⁰ Most of the intraoperative bleeding in the current study was managed by pressure packing. In the current study, the incidence of hemorrhage requiring blood transfusion was comparable to other studies.^2,19 SSF has been used over the years as an effective method for suspension of the vaginal vault, a but paucity of data exists regarding the ideal suture material for this widely practiced procedure. Historically, various types of sutures (permanent or delayed absorbable) have been used for this procedure (e.g., nylon, prolene, silk, polydiaxanone, or TiCron^tm). A recent review regarding the use of different sutures concluded that use of permanent sutures (either braided or monofilament) have a very high complication rate compared to delayed absorbable ones.^21,22 As such, the recurrence of prolapse is not related to the use of delayed absorbable, permanent monofilament or use of permanent braided sutures as noted in the available literature.^23–25 Both types of sutures were used (Vicryl and PDS), with fewer complications and a lower incidence of recurrence as concluded by Toglia and Fagan.²⁶ The sutures used in both groups were comparably efficacious in terms of recurrence and side-effects in the current study. Type of concomitant procedures had no impact on the development of suture-related complications as shown in the current study.²¹

Concern regarding a higher incidence of postoperative cystocoele caused by damage of the pudendal nerve has been reported in some studies.¹⁸ Some researchers argue in favor of iliococcygeus fixation, showing a higher success rate and a lower incidence of cystocoele formation.^27,28 However, iliococcygeus fixation might contribute to stress in the anterior vaginal wall, as it this procedure is usually performed bilaterally. SSF has a comparable success rate to iliococcygeus suspension, but patients' satisfaction is higher after SSF.¹⁸ According to Morgan et al., failure rates after SSF are, in part, accounted for by differences in how anatomical outcomes are evaluated and which compartment of vaginal support is being considered.⁵ Failure rate after SSF is highest in the anterior compartment.⁵ Nine cases of asymptomatic cystocoele (5 in group 1 versus 4 in group 2) were recorded in the current study, which is comparable to the studies related to iliococcygeus fixation.^27,28 A study by Smilen et al.²⁹ concluded that SSF did not increase the risk of postoperative cystocoele formation independently, compared with other vaginal reconstructive procedures performed without SSF. In addition, in the current study, 4 cases of enterocoeles were detected during follow-up.

Severe postoperative gluteal pain that runs down the posterior surface of the right thigh may result from pudendal-nerve injury or entrapment. Some researchers suggest that muscular ischemia contributes to this type of buttock pain.¹⁸ In the current study, in patients presenting with late-onset vaginal bleeding, granulation tissue was found in 8 (3 in group1 versus 5 in group2). Immediate removal of the suture has been suggested by several researchers who did studies in which where permanent sutures were used.^11,21 Sutures were not visible at this stage of follow-up, and 5 cases resolved with application of silver nitrate. Patients may have transient, moderate-to-severe buttock pain on the side of the sacrospinous ligament suspension (10%–15%).²⁰ This is usually self-limiting and resolves within 2–3 months postoperatively as was also noted in the current study. Although there were 4 cases (1 in group 1 versus 3 in group 2) of persistent gluteal pain, this was not related to pudendal-nerve entrapment, thus, neither kinds of suture had to be removed. Complications such as ureteral entrapment^23,30 have also been reported in some studies but this was not seen in the current study's series.

Restoration of the vaginal apex remains the primary goal of this surgery. SSF is used to suspend the vagina to the sacrospinous ligament and brings the upper vagina over the levator plate. This procedure is generally done unilaterally, although bilateral performance of it has been described. The right sacrospinous ligament is commonly chosen, based on the hand dominance of the surgeon.²⁰ The overall results from sacrospinous ligament fixation has been good. Sze and Karman reviewed 1137 patients with 83% cure rate.³¹ In the current study, the cure rate in group 1 was 90% and was 91.89% in group 2.

Abdominal sacrocolpopexy can be performed as an alternative to SSF. The former procedure is associated with a better long-term result (a lower rate of recurrent vault prolapse and dyspareunia) but requires longer a hospital stay with potentially more postoperative morbidity and a longer learning curve for the surgeon, compared to SSF.^11,32 The trend toward a lower reoperation rate for prolapse following abdominal sacrocolpopexy was not statistically significant, compared to vaginal SSF.¹¹ However, vaginal SSF is quicker and less expensive to perform and provides patients with earlier return to daily activities.¹¹

Conclusions

Various surgical techniques have been used to suspend the vaginal vault. The experience—and, consequently, the bias of surgeons—have historically dictated the approaches and the types of suture material used during surgery. Techniques and approaches for SSF has changed over time, a but paucity of data exists regarding which suture material will yield a lower rate of complications. The current authors suggest that absorbable sutures, such as polyglactin 910 or PDS II, have comparable success profiles and fewer complications.

Footnotes

Disclosure Statement

The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article.

References

Slieker-ten Hove

, Pool-Goudzwaard

, Eijkemans

, Steegers-Theunissen

, Burger

, Vierhout

. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct, 2009, 20:1037.

Olsen

, Smith

, Bergstrom

, Colling

, Clark

. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol, 1997; 89:501.

Hefni

, El-Toukhy

, Bhaumik

, Katsimanis

. Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: An evolving concept. Am J Obstet Gynecol, 2003; 188:645.

Hefni

, El-Toukhy

. Long-term outcome of vaginal sacrospinous colpopexy for marked uterovaginal and vault prolapse. Eur J Obstet Gynecol Reprod Biol, 2006; 127:257.

Morgan

, Rogers

, Huebner

, Wei

, Delancy

. Heterogeneity in A systematic review. Obstet Gynecol, 2007; 109:1424.

Diwan

, Rardin

, Kohli

. Uterine preservation during surgery for uterovaginal prolapse: A review. Int Urogynecol J Pelvic Floor Dysfunct, 2004, 15:286.

Dietz

, de Jong

, Huisman

, Schraffordt Koops

, Heintz

, van der Vaart

. The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct, 2007; 18:1271.

Dietz

, Huisman

, de Jong

, Heintz

, van der Vaart

. Functional Int Urogynecol J Pelvic Floor Dysfunct, 2008; 19:747.

Sze

, Karram

. Transvaginal repair of vault prolapse: A review. Obstet Gynecol, 1997; 89:466.

10.

Morley

, DeLancey

. Sacrospinous ligament fixation for eversion of the vagina with cystocoele. Am J Obstet Gynecol, 1988; 158:872.

11.

Maher

, Feiner

, Baessler

, Glazener

CMA

. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev, 2010; 4:CD004014.

12.

Bump

, Mattiasson

, Bo

, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol, 1996; 175:10.

13.

Hall

, Theofrastous

, Cundiff

, Harris

, Hamilton

, Swift

, Bump

. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol, 1996; 175:1467.

14.

Hardiman

, Drutz

. Sacrospinous vault suspension and abdominal colposacropexy: Success rates and complications. Am J Obstet Gynecol, 1996; 175:612.

15.

Nichols

. Sacrospinous fixation for massive eversion of vagina. Am J Obstet Gynecol, 1982; 142:901.

16.

Cruikshank

, Cox

. Sacrospinous ligament fixation at the time of transvaginal hysterectomy. Am J Obstet Gynecol, 1990; 162:1611.

17.

Colombo

, Milani

. Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse. Am J Obstet Gynecol, 1998; 179:13.

18.

Maher

, Murray

, Carey

, Dwyer

, Ugoni

. Illiococcygeus or sacrospinous fixation for virginal vault prolapse. Obstet Gynecol, 2001:98:40.

19.

Alladhin

, Herd

, Reid

. Twenty-five sacrospinous ligament fixation procedures in a district general hospital: Our experience. J Obstet Gynaecol, 2005; 25:361.

20.

John

, Howard

III . Surgery for correction of defects in pelvic support and pelvic fistulas. In: Rock

, Thompson

, eds. Te Linde's Operative Gynecology, 8th ed., Philadelphia: Linppincott-Raven, 1997:1017.

21.

Yazdany

, Yip

, Bhatia

, Nguyen

. Suture complications in a teaching institution among patients undergoing uterosacral ligament suspension with permanent braided suture. Int Urogynecol J, 2010; 21:813.

22.

Luck

, Galvin

, Theofrastous

. Suture erosion and wound dehiscence with permanent absorbable suture in reconstructive posterior vaginal surgery. Am J Obstet Gynecol, 2005; 192; 1626.

23.

Barber

, Viso

, Weidner

, Amundsen

, Bump

. Bilateral uterosacral ligament vaginal vault suspension with site specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol, 2000; 183; 1402.

24.

Jenkins

II . Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse. Am J Obstet Gynecol, 1997; 177; 1337.

25.

Silva

, Pauls

, Segal

, Rooney

, Kleeman

, Karram

. Uterosacral ligament vault suspension: Five year outcomes. Obstet Gynecol, 2006; 108:255.

26.

Toglia

, Fagan

. Suture erosion rates and long term surgical outcomes in patients undergoing sacrospinous ligament suspension with braided polyester suture. Am J Obstet Gynecol, 2008; 198; 600.e1.

27.

Shull

, Capen

, Riggs

, Kuehl

. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: An effective method of cuff suspension. Am J Obstet Gynecol, 1993; 168; 1669.

28.

Meeks

, Washburne

, McGehee

, Wiser

. Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Am J Obstet Gynecol, 1994; 171; 1444.

29.

Smilen

, Saini

, Wallach

, Porges

. The risk of cystocoele after sacrospinous fixation. Am J Obstet Gynecol, 1998; 179; 1465.

30.

Aronson

, Aronson

, Howard

, Morse

, Baker

, Young

. Low risk of ureteral obstruction with “deep” (dorsal/posterior) uterosacral ligament suture placement for transvaginal apical suspension. Am J Obstet Gynecol, 2005; 192; 1530.

31.

Sze

, Miklos

, Partoll

, Roat

, Karram

. Sacrospinous ligament fixation with transvaginal needle suspension for advanced pelvic organ prolapse and stress incontinence. J Obstet Gynecol, 1997; 89:94.

32.

Benson

, Laucente

, McClellan

. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defect: A prospective randomizes study with long-term outcome evaluation. Am J Obstet Gynecol, 1996; 175:1418.