Vaginal Sacrospinous Ligament Fixation: Outcomes of Absorbable Compared to Permanent Suture

Abstract

Introduction:

Suture type is thought to influence prolapse recurrence following sacrospinous ligament fixation (SSLF), but comparative data between absorbable and permanent suture remains sparse. This study aimed to compare prolapse recurrence rates after SSLF using absorbable versus permanent suture, hypothesizing no difference in outcomes.

Materials and Methods:

We conducted a retrospective cohort study of women who underwent vaginal SSLF from January 2017 to June 2021 at a single institution. We compared two groups: (1) absorbable suspension suture (Maxon or polydiaxanone) (2) permanent suspension suture (prolene). Our primary outcome was composite prolapse recurrence, defined as (1) anatomical failure (recurrent prolapse in any compartment past the hymen) and/or (2) retreatment for prolapse with either surgery or pessary at the most recent pelvic exam.

Results:

Our cohort was composed of 152 women, of whom 47.4% (n = 72) underwent SSLF with only delayed absorbable suture and 80 (52.6%) with permanent suture. Overall, there were no differences between the two groups in composite prolapse recurrence (11.1% vs. 22.5%, p = 0.06), anatomical failure (6.9% vs. 16.3%, p = 0.08), or retreatment (4.2% vs. 5.0%, p = 0.82) at a median of 217.5 days of follow-up. There was no difference in postoperative complications between groups (32.4% vs. 33.8%, p = 0.86). When adjusting for differential characteristics, hazard ratios of composite prolapse recurrence were similar between suture groups (adjusted hazard ratio: 0.52; confidence interval [CI]: 0.18–1.49; p = 0.22).

Conclusions:

Vaginal SSLF with delayed absorbable suture demonstrates similar durability to permanent suture in terms of prolapse recurrence.

Keywords

pelvic organ prolapse sacrospinous ligament fixation prolapse recurrence suture type absorbable suture permanent suture

Introduction

Symptomatic pelvic organ prolapse (POP) affects approximately 3% of women in the United States, and approximately 200,000 women have surgery for correction of POP symptoms annually.^1,2 Common surgical options for apical vaginal suspension are sacrospinous ligament fixation (SSLF), uterosacral ligament suspension (USLS), and sacrocolpopexy.

SSLF is an extraperitoneal native tissue apical suspension procedure. It was first described in 1958 and was popularized in the 1970s after a case series showed successful apical support.^3,4 No standardized guidelines exist for the choice of suture type for this procedure. Traditionally, permanent sutures of different varieties, often combined with absorbable sutures, have been utilized, but recently, there has been a push toward the use of absorbable sutures only. This is because permanent sutures may be associated with more complications, including suture erosion, vaginal bleeding, and bothersome vaginal discharge.⁵ In some studies using permanent suture, suture removal was required in up to 25% of patients due to bleeding or discharge.^5,6 There is a paucity of research comparing success rates between SSLF with permanent versus absorbable suture. Notably, a recent study comparing permanent with absorbable sutures for USLS found comparable success rates between the two groups.⁷

The objective of this study was to compare the risk of prolapse recurrence after vaginal SSLF without mesh augmentation in patients who received delayed absorbable versus permanent suture. We hypothesized that there would be no difference in prolapse recurrence based on suture type used during SSLF.

Materials and Methods

We performed a retrospective cohort study of women who underwent vaginal SSLF for either uterovaginal or vaginal vault prolapse from January 2017 to June 2021 at a single academic medical center by 10 reconstructive pelvic surgeons. After institutional review board approval (IRB, #21110069), subjects were identified by current procedural terminology code for SSLF (57282). Subjects with uteri underwent either concomitant vaginal hysterectomy or sacrospinous hysteropexy. Subjects without any postoperative exam or POP-Q exam data were excluded. Subjects were also excluded if they underwent sacrospinous hysteropexy with mesh augmentation.

The exposure of interest was suture type at the time of SSLF. We divided the cohort into two groups: (1) absorbable suture only (Maxon or polydiaxanone) and (2) permanent suture (Prolene) (including if used in combination with absorbable suture). The choice of suture used for a unilateral SSLF was based on the attending surgeon’s preference. SSLF was performed either by direct visualization of the ligament or with a suture capturing device. Of the 10 surgeons, 3 exclusively used permanent suture, 2 exclusively used delayed-absorbable suture, and 5 used a combination of both permanent and delayed-absorbable suture. Few surgeons exclusively used permanent sutures therefore, for analysis purposes, we combined the groups using only permanent sutures with those using a combination of permanent and absorbable sutures.

Our primary outcome was composite prolapse recurrence at the most recent follow-up. Prolapse recurrence was defined as (1) anatomical recurrence (recurrent prolapse in any compartment past the hymen) and/or (2) retreatment of prolapse with either pessary or surgery. Secondary outcomes included postoperative complications related to SSLF, including postoperative urinary tract infection (UTI), wound infection, pain, granulation tissue, suture exposure, nerve injury, reoperation requiring suture removal, ileus, or SBO. Postoperative UTI was defined as symptoms of bacterial cystitis up to 6 weeks postoperatively that were either culture-proven or resulted in empirical treatment with antibiotics.

We reviewed medical records to collect the following variables: demographics, medical and surgical histories, concurrent surgical procedures at the time of SSLF, suture material and number of sutures used for SSLF, intraoperative complications (bladder or bowel injury) and postoperative complications, Pelvic Organ Prolapse Quantification (POP-Q) examinations, and length of follow-up. POP-Q exam data from the electronic medical record (EMR) were collected from their preoperative visit, the first postoperative appointment, and for the most recent follow-up appointment that was documented in the EMR as of January 2023.

Data analysis was performed with SPSS Version 28.0 (IBM) and Stata SE (College Station, Tx). Continuous variables were analyzed using the Student’s t test or Mann–Whitney U test as appropriate, and categorical variables were analyzed using Pearson’s chi-squared test. Log-rank tests were used to compare composite prolapse recurrence between the two groups. Adjusted Cox proportional hazards regression models examined associations between suture group and composite prolapse recurrence, controlling for advanced preoperative prolapse, concomitant anterior and sacrospinous suture number, which we described as a binary variable (>2 sutures total or ≤2 sutures total). Clinically relevant variables with a p-value ≤0.2 were identified, and a backwards selection process was then used for the final model in the adjusted Cox hazards model.

Results

We identified 152 women who underwent vaginal SSLF during the study period. The cohort of women was predominantly White race (n = 132, 90.8%) with a mean (standard deviation) age of 65 (8.9) years and a BMI of 28.5 (5.6) kg/m². Advanced prolapse, defined as stage 3 or higher by POP-Q criteria, was observed in 106 patients (69.7%) across the cohort. This was significantly more common in the permanent suture group compared to the delayed absorbable group.

In this study population, 72 (47.4%) women underwent SSLF with only delayed absorbable suture, and 80 (52.6%) women underwent SSLF with either only permanent suture or permanent suture in combination with delayed absorbable suture. In the absorbable suture group, 9 (12.5%) women received only polydioxanone (PDS) suture and 63 (87.5%) women received only polyglyconate (Maxon) suture. In the permanent suture group, patients received either only polypropylene (prolene) suture (n = 39, 48.8%) or a combination of polypropylene and PDS suture (n = 41, 51.2%).

Baseline characteristics in our two cohorts are summarized in Table 1. There were no differences in concomitant procedures or hysteropexies. The most common concomitant procedures were as follows: posterior repair/perineorrhaphy (n = 125, 82%), anterior repair (n = 85, 56%), and midurethral sling (n = 8, 5%). A total of 23 (15.0%) women underwent hysteropexy. Compared to the delayed-absorbable suture group, the permanent suture cohort was more likely to have advanced prolapse prior to surgery (81.3% vs. 56.9%, p < 0.01), have greater than two SSLF sutures placed (81.6% vs. 54.2%, p < 0.01) and less likely to have a concomitant anterior repair (42.5% vs. 71.8%, p < 0.01). Additionally, the median follow-up duration was significantly longer in the permanent suture group (366 days vs. 133 days, p < 0.01). No other differences in baseline characteristics were observed. Postoperative outcomes were similar between groups, with no significant differences in complication rates, including UTIs, wound infections, pain, suture exposure, ileus, or small bowel obstruction.

Table 1.

Demographics and Intraoperative Characteristics of Study Group

	Delayed absorbable (n = 72)	Permanent only/combination (n = 80)	p-value
Baseline demographics
Age, years	66.3 (61.0, 73.5)	63.8 (59.5, 70.5)	0.47
Race			0.09
White	62 (86.1)	76 (95.0)
Black	7 (9.9)	4 (5.0)
Other	3 (4.2)	0 (0.0)
BMI, kg/m	27 (25.0, 30.5)	27 (25.0, 31.0)	0.91
Hypertension	33 (45.8)	39 (48.8)	0.72
Diabetes Mellitus	7 (15.2)	6 (9.5)	0.30
Tobacco use	7 (9.7)	7 (8.8)	0.97
Prior hysterectomy	51 (70.8)	54 (67.5)	0.66
Prior prolapse repair	9 (12.5)	10 (12.5)	1.00
Advanced prolapse	41 (56.9)	65 (81.3)	0.001
POPQ
Ba	1.0 (−0.5, 3.0)	2.0 (0.0, 3.0)	0.22
Bp	−1.0 (−2.0, 0.5)	0.0 (−2.0, 2.0)	0.30
C	−4.0 (−5.0, −1.0)	−3.0 (−4.5, 2.5)	0.03
GH	4.0 (3.5, 5.0)	4.5 (4.0, 5.5)	0.12
Intraoperative characteristics
Hysterectomy	11 (15.3)	16 (20.0)	0.45
Hysteropexy	10 (13.9)	13 (16.3)	0.69
Concomitant anterior repair	51 (71.8)	34 (42.5)	<0.001
Concomitant posterior repair and/or perineorrhaphy	59 (83.1)	66 (82.5)	0.92
Concomitant mid-urethral sling	5 (7.0)	3 (3.8)	0.37
Bladder injury	0 (0.0)	0 (0.0)
Bowel injury	1 (1.4%)	0 (0.0)	0.29
No. of SSLF sutures			<0.001
≤2	33 (45.8)	14 (18.4)
>2	39 (54.2)	62 (81.6)
Follow-up (days)	133 (55.5, 366.5)	366 (135.5, 920.5)	<0.001

Advanced prolapse defined as ≥ stage 3 pelvic organ prolapse on POPQ exam.

Data presented as either n (%), mean ± SD, median (interquartile range).

Student t test for continuous variables, chi-square test for proportions and Mann–Whitney U for ordinal variables.

The significance of the p-value is represented in bold data.

BMI, body mass index; SSLF, sacrospinous ligament fixation.

Composite prolapse recurrence was identified in 26 (17.1%) women at a median follow-up time of 217.5 days (IQR: 95.5, 524.5). Of those with recurrence, 2 (7.7%) underwent repeat surgery (Table 2). There were no significant differences in composite recurrence, anatomical recurrence, or retreatment between our groups based on suture type. There were no overall differences between survival curves of the two suture groups with the log-rank test (p = 0.44, see Fig. 1). Potential confounders between suture groups were adjusted for using adjusted Cox proportional hazards regression models, controlling for advanced preoperative prolapse, concomitant anterior colporrhaphy, baseline genital hiatus (GH) measurement, and sacrospinous suture number. Baseline GH measurement was associated with a higher hazard ratio (HR) of prolapse recurrence with an adjusted HR of 1.74 (95% CI: 1.28–2.39; p < 0.01). Otherwise, the HR of composite prolapse recurrence was similar between suture groups (adjusted HR: 0.52; confidence interval [CI]: 0.18–1.49; p = 0.22). Additionally, there was no significant difference in the HR for concomitant anterior colporrhaphy (adjusted HR: 0.52; CI: 0.21–1.31; p = 0.16), advanced baseline prolapse (adjusted HR: 0.84; CI: 0.27–2.6; p = 0.76), or the number of sutures (adjusted HR: 0.67; CI: 0.26–1.71; p = 0.40).

FIG. 1.

Kaplan–Meier Curve: Time to prolapse recurrence by suture strategy. Delayed absorbable sutures (blue) had no significant difference in prolapse recurrence in comparison to permanent sutures or a combination of permanent and absorbable sutures (log rank p = 0.44).

Table 2.

Pelvic Organ Prolapse Outcomes

	Delayed absorbable (n = 72)	Permanent only/combination (n = 80)	p-value
Composite prolapse recurrence	8 (11.1)	18 (22.5)	0.06
Anatomical recurrence	5 (6.9)	13 (16.3)	0.08
Anterior	4 (5.6)	11 (13.8)	0.09
Posterior	1 (1.4)	1 (1.3)	0.94
Apical	0 (0.0)	1 (1.3)	0.34
Retreatment for POP	3 (4.2)	4 (5.0)	0.82
Pessary	1 (1.4)	4 (5.0)	0.22
Repeat Surgery	2 (2.8)	0 (0.0)	0.78
POPQ
Ba	−2.0 (−3.0, −1.5)	−2.0 (−2.5, 0.0)	0.01
Bp	−3.0 (−3.0, −2.5)	−3.0 (−3.0, −2.0)	0.07
C	−7.0 (−8.0, −6.0)	−6.5 (−7.5, −5.5)	0.04
TVL	8.0 (7.0, 9.0)	7.5 (7.0, 8.5)	0.11
Postoperative complications^a	23 (32.4)	27 (33.8)	0.86
Urinary tract infection	4 (5.6)	5 (6.3)	0.86
Wound infection	0 (0.0)	3 (3.8)	0.10
Pain	15 (20.8)	15 (18.8)	0.75
Suture exposure	1 (1.4)	0 (0.0)	0.29
Ileus/SBO	0 (0.0)	0 (0.0)
Other^b	6 (8.3)	10 (12.5)	0.40

Data presented as n (%) or median (interquartile range).

Chi-square test for proportions and Mann–Whitney U for ordinal variables.

Could have more than one complication.

Other complications included granulation tissue, nerve injury and suture removal.

Discussion

In this retrospective cohort study, there were no differences in rate of prolapse recurrence in women who underwent vaginal SSLF with delayed absorbable versus permanent sutures. The prolapse recurrence rate was 17% using our composite anatomical outcome definition. We found that a larger baseline GH measurement was associated with an increased hazard ratio of POP recurrence even when controlling for baseline POPQ stage. Importantly, after adjusting for confounding variables such as baseline prolapse severity, number of sutures placed, GH size, and anterior colporrhaphy, suture type remained unassociated with composite recurrence (aHR: 0.52, 95% CI: 0.18–1.49; p = 0.22). In the literature, variable recurrence rates are reported, ranging from 3% to 37% for an objective definition of recurrence, but recurrence rates as high as 70.3% have also been reported after 5-year follow-up.^8,9 Our study used an objective definition of recurrence, which included prolapse in any compartment past the hymen and/or recurrent prolapse that required re-treatment. Using this definition, we found comparable medium-term recurrence rates to what is currently published in the literature.^8,10–12 We noted re-treatment rates with either surgery or pessary of 4.2% in the delayed absorbable suture group and 5% in the permanent suture group. These rates are similar to what is reported in the literature, with reported retreatment rates ranging from 2% to 15%.^9,10,12,13

While our study noted similar complications rates between our delayed-absorbable suture cohort and the permanent suture cohort, including rates of suture exposure during the follow-up period, a prospective cohort study by Hamdy et al. reported high complication rates when SSLF is performed with permanent suture, with suture-related complications (most commonly vaginal discharge and pain) in 55% of patients.⁶ These complications required suture removal in 25% of patients.⁶ In contrast, studies performed with Vicryl and PDS sutures report suture-related complication rates of 5–6.1%.¹⁴

Since completing our study, a similar retrospective cohort study by Padoa et al. and a systematic review and meta-analysis evaluating absorbable versus permanent sutures in apical prolapse surgery have been published.^7,15 These studies yield findings consistent with ours, further reinforcing our conclusion that there is no significant difference in complications or prolapse recurrence between permanent and absorbable sutures in SSLF. These similar findings further support the conclusion that either suture type can be effectively used, providing practical guidance for surgical decision-making in apical prolapse repair.

Finally, we found that baseline GH measurements were associated with an increased aHR of 1.75 for prolapse recurrence, consistent with existing literature. Vaughan et al. reported a 15.8-fold higher recurrence risk in patients with a widened GH (>4 cm) preoperatively and at 6 weeks postoperatively compared to those with normal measurements.¹⁶ Stiff et al. also found that a GH >3.5 cm postoperatively increased prolapse recurrence odds (OR: 1.6 for anatomical failure, OR: 1.5 for surgical failure).¹⁷ These findings highlight the importance of considering GH size when counseling patients on recurrence risk and raise the question of whether surgical correction can reduce the risk. Vaught et al. noted that patients whose GH normalized by 6 weeks had a 4.4-fold lower recurrence risk than those with persistently wide hiatuses, suggesting potential benefits in correction, though further research is needed.¹⁶

While our objective was to compare prolapse recurrence between delayed absorbable and permanent sutures, it is important to note that patients who received a combination of permanent and absorbable sutures were grouped with those who received only permanent suture. As a result, the study did not directly compare patients treated exclusively with permanent sutures to those treated exclusively with absorbable suture. However, because the effects of permanent suture persist regardless of the addition of delayed absorbable suture and few surgeons used permanent sutures exclusively, we opted to combine these groups. Of note, the permanent suture group had a higher rate of advanced prolapse, suggesting a potential inherent bias in surgeon technique. Surgeons may have preferred permanent suture for patients at higher risk of surgical failure, while opting for absorbable sutures in other cases. After analysis, more than half of the surgeons (n = 6) consistently used one type of suture, suggesting that each surgeon’s preference for absorbable versus permanent sutures was relatively well-defined.

The strengths of our study include the collection of detailed preoperative and postoperative information, including serial postoperative anatomical data with POP-Q examination that provided objective data for the composite outcome. In addition, the study is unique, as it reflects real-world surgical variability with 10 reconstructive pelvic surgeons with differing preferences and technique, therefore enhancing generalizability. The decision on suture type used for the procedure was based on surgeon preference, which was consistent regardless of patient characteristics such as degree of prolapse.

The limitations of this study are its retrospective, single-institution design; lack of subjective measurements of prolapse symptoms (such as with the use of patient-reported survey measures); and the small patient cohort. We are also limited by a significantly shorter follow-up period for the delayed absorbable group, which can introduce bias or a difference in outcomes. To address this, we utilized an adjusted hazards model to compensate for the difference in follow-up time. In conclusion, in this cohort, vaginal SSLF with only absorbable suture affords similar anatomical outcomes in the medium term when compared to suspension with additional permanent suture.

Therefore, our findings suggest that permanent sutures, with their increased risk of suture-related complications, may not be necessary for durable SSLF. Longer-term and larger studies are needed to confirm these findings and evaluate the longevity of SSLF performed with only delayed absorbable sutures.

Authors’ Contributions

A.J.M.: Conceptualization, data curation, writing—original draft, reviewing, and editing. S.W.Z.: Data curation, writing—reviewing and editing. S.S.: Data curation, writing—original draft. M.F.A.: Supervision. M.S.B.: Conceptualization, data curation, writing—reviewing and editing.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Ethical/Institutional Review Board Approval

University of Pittsburgh IRB #21110069.

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