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Restoring Genital Hiatus to Normative Values After Apical Suspension Alone Versus With Level 3 Support Procedures

Carter-Brooks, Charelle M., MD*; Lowder, Jerry L., MD, MSc; Du, Angela L., BS; Lavelle, Erin S., MD*; Giugale, Lauren E., MD*; Shepherd, Jonathan P., MD, MSc§

Female Pelvic Medicine & Reconstructive Surgery: May/June 2019 - Volume 25 - Issue 3 - p 226–230
doi: 10.1097/SPV.0000000000000528
Original Articles

Objective The aim of the study was to evaluate postoperative genital hiatus after apical suspension procedures without a level 3 support procedure (L3SP), posterior repair, and perineorrhaphy, compared with normative-value genital hiatus of 3.4 cm.

Methods This an analysis of a pre-existing retrospectively collected database that included all minimally invasive sacrocolpopexies and uterosacral ligament suspensions performed at a tertiary medical center from January 2009 to August 2015.

Results We identified 1006 surgical cases: 160 (15.9%) apical suspensions with L3SPs and 846 (84.1%) without. Mean (SD) age was 59 (9) years and body mass index was 27.6 (4.7) kg/m2. Women were mainly white (97.4%) with stage III prolapse (67.8%). Those who underwent L3SPs were more likely to be premenopausal and undergo hysterectomy and USLS.

Baseline genital hiatus was similar with and without L3SPs (4.8 [1.2] cm vs 4.6 [1.1] cm, P = 0.096). Postoperative genital hiatus was reduced beyond normative (3.4 cm) after apical suspension without (3.0 [0.7] cm, P < 0.001) and with (2.8 [0.9] cm, P < 0.001) L3SPs. Postoperative genital hiatus after L3SPs was similar to those without (2.8 [0.9] cm vs 3.0 [0.7] cm, P = 0.06). We found that change in genital hiatus was greater, by 0.7 cm, when L3SP was performed versus not performed (2.3 [1.2] cm vs 1.6 [1.1] cm, P < 0.001).

Conclusions Level 3 support procedures may be unnecessary to restore genital hiatus to normal at time of apical suspension procedures and should be reserved for select patients.

Level 3 support procedures may be unnecessary to restore genital hiatus to normal at time of apical suspension procedures.

From the *Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Division of Urogynecology and Reconstructive Surgery, Magee-Womens Hospital of UPMC, Pittsburgh, PA;

Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO;

University of Pittsburgh, School of Medicine, Pittsburgh, PA; and

§Department of Obstetrics and Gynecology, St. Francis Hospital and Medical Center, Hartford, CT.

Correspondence: Charelle M. Carter-Brooks, MD, 300 Halket St, Suite 2323, Pittsburgh, PA. E-mail:

The authors have declared they have no conflicts of interest.

The abstract was presented at the American Urogynecologic Society Scientific Meeting September 27–October 1, 2016, in Denver, CO.

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