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Original articles

Ultrasonic uterine volume and menopausal status as risk factors for uterine prolapse after sacrospinous hysteropexy

Ragab, Wael S.

Author Information
Evidence Based Women's Health Journal: August 2014 - Volume 4 - Issue 3 - p 159-163
doi: 10.1097/01.EBX.0000452878.67388.d7
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Pelvic organ prolapse is a common health problem affecting up to 40% of parous women over 50 years of age 1. From population-based studies it has been estimated that one in 10 women would have undergone pelvic surgery by the age of 80, and 29% will require a second operation because of recurrence 2. The sacrospinous ligament fixation of the vaginal vault was first described by Richter in 1968 3 for the treatment of vaginal vault prolapse and was associated with a success rate of 96.4% with regard to apical support. Richardson et al. 4 were the first to report about sacrospinous hysteropexy in young women with uterine descent. Since then, many studies have evaluated the apical anatomical cure rates for sacrospinous hysteropexy. The success rates in these studies ranged from 85 to 100%. However, no study has compared the recurrence rate between patients on the basis of their menopausal status.

Pelvic organ prolapse is related to weakness in the supporting connective tissue of the pelvic structures that leads to the development of uterine descent secondary to conditions related to high intra-abdominal pressure (physical labor, chronic lung disease, chronic staining, and pelvic–abdominal masses) 5. Moreover, ultrasonic uterine volume calculation has been used for the estimation of uterine weight 6. Therefore, in this study, the author postulates that increased uterine volume would be a risk factor for recurrent uterine prolapse after sacrospinous hysteropexy.

This study compares 1-year anatomical outcome of sacrospinous hysteropexy between premenopausal and postmenopausal patients. Also, data on complications and hospital stay are presented. Moreover, the effect of increased uterine volume has been investigated as a risk factor for uterine prolapse after sacrospinous hysteropexy.

Patients and methods

Thirty premenopausal and 30 postmenopausal patients were included in this study, which took place at Fayoum University Teaching Hospital, Egypt, during the period from February 2009 to October 2013. The criterion for entry into the study was the presence of a uterine descent stage 2–4 on gynecological examination with Valsava manoeuvre, according to the classification of the International Continence Society 7. After repositioning the uterus to its place with a tenaculum, uterine volume was calculated ultrasonographically. The volume was calculated using the prolate ellipsoid formula of 4/3×π×L/2×W/2×AP/2 6. When this formula is simplified, calculation of uterine volume in cm3 is made by multiplying the length by breadth in AP dimension by 0.542.

Other selection criteria were absence of medical history of pelvic surgery, a normal cervical cytology, normal uterus and ovaries on ultrasound examination, and normal menstrual bleeding pattern (if premenopausal). Baseline characteristics were collected. Participants were counseled about the long duration of follow-up of the study. In addition, the risks associated with uterus preservation were clearly mentioned for the postmenopausal group. Written informed consent was obtained before the surgery. All patients were advised to abstain from heavy physical work for a minimal period of 6 weeks postoperatively. After surgery, patients visited the hospital at 6 weeks, 6 months, and 12 months for gynecological examination. A prolapse stage 2–4 of the apical, anterior, and posterior compartments after sacrospinous hysteropexy on gynecological examination 1 year after surgery was considered a recurrence. Secondary outcomes were operative complications and hospital stay.

Statistical analysis was performed using statistical package for social sciences for Windows version 18.0 (SPSS Inc., Chicago, Illinois, USA). Data were presented as mean and SD for numeric variables and as number and percentage for categorical variables.

Individual associations between demographic and clinical characteristics of the patients were evaluated by Student’s t-test for continuous variables and by the χ2-test for categorical variables. Binary logistic regression analysis was performed to calculate the predictive accuracy of numeric variables on the recurrence of uterine descent. A receiver operating characteristic curve was calculated for each of the recurrence cases of uterine descent (independent variable) and for uterine volume (dependent variable). If the parameter was capable of predicting recurrence (area under the curve>50%, P<0.05), the best cutoff value was selected.

Surgical procedures

All sacrospinous hysteropexy procedures were performed by the author using a Miya hook needle (CooperSurgical Inc., Trumbull, Connecticut, USA). Sacrospinous hysteropexy was combined with posterior colpoperinorrhaphy and in some cases with an anterior colporrhaphy (fascia plication), both with absorbable Vicryl 2–0 interrupted sutures. All procedures were performed under general or spinal anesthesia according to the preference of the patient and the anesthesiologist. All women received perioperative antibiotics and thrombosis prophylaxis. Postoperatively, an indwelling bladder catheter was placed in all women and removed 24 h after surgery.

The sacrospinous hysteropexy was performed unilaterally to the right ligament. The posterior vaginal wall was opened to its apex. An ipsilateral triangular incision into the skin was made at the perineum. The rectovaginal space was dissected to the level of the ischial spine. The right hand index finger was placed on the lower border of the ischial spine. The right hand third finger felt the top of the sacrospinous ligament. The Miya hook needle was used to put 2 sutures (PDS1) into the ligament, 2–3 cm medial to the ischial spine. The hook was pushed with the third finger to enter the sacrospinous ligament and then the tissue was pushed down to expose the Miya needle tip between the index and third fingers. The assistant held the Miya hook in closed position. The rectum was then retracted using a Breisky-Navratil retractor (Novo Surgical Inc., Illinois, USA). A notched speculum was placed into the base of the needle. With the aid of a nerve hook, the threads of the suture were retrieved. The hook was then opened and withdrawn between the index and third fingers. The two ends of the PDS suture were brought through the apex of the incision. Using a separate needle, one was fixed by grasping a loop and running a suture around twice. A 0.5 cm depth was taken through the posterior side of the cervix in the midline. The mobile suture was on top. After posterior colpoperineorrhaphy the cervix was fixed in position by pulling on the mobile PDS, with the other fixed. This produces a pulley effect and the cervix was closely allied to the sacrospinous ligament.


Sixty patients were enrolled in this study. All patients underwent unilateral sacrospinous hysteropexy using a Miya hook needle. Two premenopausal and two postmenopausal patients did not attend follow-up assessment 1 year after the surgery. The remaining 56 patients were evaluated for apical, anterior, and posterior compartment recurrences according to the classification of the International Continence Society 7. The descriptive statistics of included women are shown in Table 1.

Table 1:
Descriptive statistics of the included women

Table 2 shows a comparison between premenopausal and postmenopausal women regarding recurrence of uterine prolapse after 1 year. In general, the recurrence rate of uterine prolapse (stage 2–4) was 17.9%. Eight premenopausal patients (28.6%) had recurrent uterine descent compared with only two postmenopausal women (7.1%). The recurrence rate of cystocele ranged from 40 to 55.6%, whereas the recurrence rate of rectocele ranged between 14 and 17.6%, with no significant statistical differences between the two groups.

Table 2:
Comparison between premenopausal and postmenopausal women regarding recurrence of uterine prolapse, cystocele, and rectocele after 1 year

Bladder injury occurred in neither group; no blood transfusions or intensive care admissions were needed. Only one premenopausal patient suffered a rectal injury, which was repaired in the same sitting. Eight patients in both groups (14.3%) complained of buttocks pain, which resolved within 2 weeks of the operation. Postoperative infection in the form of vaginal discharge and urinary tract infection occurred in 10 patients (17.9%) and were treated by appropriate antibiotics. As regards the mean hospital stay, there was no statistical difference between the two groups (Table 3).

Table 3:
Complications of surgery and mean hospital stay in both groups

Table 4 shows the impact of age, BMI, and uterine volume on the recurrence rate of uterine prolapse after 1 year of surgery. There was a binary logistic regression effect of uterine volume, age, and BMI on the recurrence of uterine descent, and a significant effect of uterine volume on the recurrence rate of uterine prolapse, with increased recurrence rate with larger uterine volume, with odds ratio of recurrence of 3.989 indicating a four-fold increase in recurrence rate with large uterine volume (P<0.05). In contrast, both age and BMI had no impact on recurrence rate (P>0.05). Moreover, as seen in Fig. 1, there was a high sensitivity of uterine volume as a prognostic factor for recurrence of uterine descent, with an area under the curve of 0.841 and a P value of 0.001. Assuming equal importance for both sensitivity and specificity, the recurrence rate of uterine descent was more likely to occur when uterine volume was greater than or equal to 352 cm3.

Table 4:
Impact of age, BMI, and uterine volume on the recurrence rate of uterine prolapse 1 year after surgery
Figure 1:
Receiver operator characteristic curve for uterine volume as a prognostic indicator for the recurrence rate of uterine descent. ROC, receiver operating characteristic curve.


In this study the recurrence rate for uterine prolapse after sacrospinous hysteropexy was 17.9%. In several retrospective and prospective studies it has been shown that sacrospinous fixation in case of uterine or vaginal vault prolapse is a safe and effective treatment 8–12. Two retrospective and one prospective study comparing vaginal hysterectomy with sacrospinous fixation demonstrated no significant difference in anatomical outcome 13–15. However, Dietz et al. 16 performed the only randomized study comparing both procedures. They found a higher rate of recurrence after 1 year in patients with sacrospinous fixation (27 vs. 3% recurrence in patients with vaginal hysterectomy). Moreover, in their study 90% of the patients in the sacrospinous hysteropexy group were menopausal. Our study shows different results, as the recurrence rate among postmenopausal women was only 7.1%. Also, Lin et al.17 described a correlation between a high rate (75%) of recurrent prolapse and a stage 3 or 4 prolapse preoperatively. In the current study, 100% of patients who underwent the procedure suffered a stage 3 or 4 uterine descent. This could have also influenced our recurrence rates. Perhaps until the results of the SAVE U trial are published the question about the precise efficacy of sacrospinous hysteropexy cannot be answered 18.

The recurrence rate of cystocele after sacrospinous hysteropexy in this study ranged from 40 to 55.6%. In a systematic review exploring the heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse, the anterior compartment was found to be the most common site of failure (40.1%) 9. Later on in the same year, in a study by Dietz et al.11, the recurrence rate of cystocele was 38%. The high rate of recurrence may be related to the result of the retroverted axis of the vagina after sacrospinous hysteropexy. This, being regarded as an overcorrection, is held responsible for the high rate of anterior compartment recurrence 19,20. However, in a study by Smilen et al.21, the sacrospinous hysteropexy did not independently increase the risk of recurrent cystocele as compared with other surgical techniques. The recurrence rate of rectocele in the current study was 15.8%. Similar results were shown by Meschia et al.22 and Paraiso et al.23 (15 and 13.6%, respectively).

There were no serious complications from sacrospinous hysteropexy in this study. In the literature, several complications of sacrospinous ligament fixation have been documented, especially buttocks pain. In the current study, buttocks pain occurred in 14.3% of women, which is comparable to the results of earlier studies 11,24. In all cases, buttocks pain resolved spontaneously within 15 days and responded well to analgesics. There was one rectal injury during the procedure (1.8%). This is also comparable to what was seen in other studies, in which rectal injury did not exceed 2% 25,26. The rate of infection in this study was higher than that reported by Hefni et al.8 and Lantzsch et al.27 (17.9 vs. 8.3 and 8%, respectively). Moreover, Nieminen et al.28 suggested that postoperative infection is an independent and most important individual risk factor underlying recurrence. This could also be another factor for the relative high recurrence in the current study.

Ultrasonic estimation of uterine volume has been used for estimation of uterine weight by Kung and Chang 6. They concluded a close and positive correlation between estimated uterine volume and actual uterine weight. Also, Shirlina and Shirish 29 studied the relationship between uterine volume and the feasibility of performing vaginal hysterectomy. They found that the feasibility of performing vaginal hysterectomy decreased with increasing uterine volume. Hence, in this study, the author postulated that increased uterine volume would be a risk factor for recurrent uterine prolapse after sacrospinous hysteropexy. Indeed, the results flow with this stream, as there is a four-fold increase in recurrence rate with large uterine volume. A cutoff value of 352 cm3 is associated with a greater chance of recurrence of uterine prolapse.


Although vaginal sacrospinous hysteropexy is an effective and safe method of surgical treatment for uterine prolapse, the success rate is higher among postmenopausal women. Further, the success rate is higher among those with lower ultrasonographically determined uterine volumes. Therefore, surgeons should consider these findings when deciding the treatment options for patients with uterine descent to optimize the outcome of surgery.


Conflicts of interest

There are no conflicts of interest.


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menopause; sacrospinous hysteropexy; uterine volume

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