Permanent Versus Delayed-absorbable Monofilament Suture for Vaginal Graft Attachment During Minimally-invasive Total Hysterectomy and Sacrocolpopexy: A Randomized Clinical Trial

Symptomatic pelvic organ prolapse is common and 13%1 to 19%2,3 of women undergo surgical repair. Reconstructive pelvic surgery is broadly divided into procedures that rely on existing native tissue versus the use of graft augmentation, either with synthetic or biologic materials. Native tissue vaginal repair, while associated with the lowest rate of surgical complications,4 has a high rate of recurrent prolapse. A recent randomized trial of uterosacral versus sacrospinous ligament fixation for POP demonstrated a 30% recurrence rate at 2 years.3

Abdominal sacrocolpopexy (SCP) is considered to be the most durable operation for advanced pelvic organ prolapse with reoperation rates of less than 5%.5-7 Minimally-invasive techniques of SCP, such as robotic-assistance, are associated with improved recovery times and less cost than abdominal SCP without a demonstrable difference in efficacy.8,9 While traditionally reserved for women with vaginal vault prolapse, SCP is increasingly considered as a primary surgical option for women who present with uterovaginal prolapse in an attempt to improve longer-term surgical outcomes. The optimal management of the uterus and cervix in these cases is unclear.

Rationale for total versus supracervical hysterectomy with concomitant SCP

While supracervical hysterectomy and concomitant SCP are associated with lower rates of mesh exposure,10-12 potential negative consequences of a supracervical hysterectomy include morcellation of unanticipated uterine malignancy,13 cervical stump prolapse/elongation, cyclic vaginal bleeding, and reduced anterior vaginal support (Myers EM, Matthews et al., in press). When conducting a supracervical hysterectomy, power morcellators are the most common method used to extract the amputated uterine corpus. The potential risks of power morcellation were recently highlighted by the FDA safety notification which focused on the potential to disseminate fragments of an undiagnosed uterine leiomyosarcoma throughout the abdomen, which negatively impacts prognosis (http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm). With these recent developments the focus has shifted towards performing total hysterectomy for delivery of an intact specimen through the vagina.

Vaginal mesh exposure has been a problematic complication with both abdominal SCP and minimally invasive SCP. Widely disparate rates of mesh exposure ranging from 0%14 to 27%15 have been reported. A systematic review of ASCP outcomes in 2004 reported an overall rate of 3.4%,6 and a recent meta-analysis of robotic-assisted SCP reported an overall rate of 2%.16 Some consistent risk factors for mesh exposure are non-Type 1 polypropylene mesh (knitted, small-pore mesh materials) and smoking.17,18 Some studies have identified total hysterectomy as a significant risk factor. In an evaluation of patients enrolled in the CARE trial, 6% had evidence of mesh exposure at 2 years, with concomitant hysterectomy presenting almost a 5-fold increased risk.18 The rate at 6 years rose to 10.5%. 5 More than 50% of subjects in this trial, however, had a non-Type 1 polypropylene mesh. Akyol et al. demonstrated a 2-fold increased risk (12%)19 and Bensinger et al. a 7-fold increased risk (8.2%)20 of concomitant total hysterectomy. In contrast, 4 retrospective studies in which Type1 polypropylene mesh was used revealed no increased risk of mesh erosion with concomitant total hysterectomy.14,21-23 These widely discrepant rates of mesh exposure may be related to surgical technique, graft material and/or suture materials used for mesh attachment.