Comparison of safety and long-term efficacy of anterior and posterior sacrospinous ligament fixation using EnPlace device for apical pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse is a common condition in older women and can substantially impair quality of life. Sacrospinous ligament fixation (SSLF) is a common procedure performed to treat apical prolapse. Variations of the procedure exist; however, it remains unclear whether there is any difference in efficacy between anterior and posterior SSLF.

MATERIALS AND METHODS: This retrospective comparative cohort study included patients with apical prolapse who underwent anterior or posterior SSLF using a minimally invasive EnPlace® technique. The primary outcome was composite long-term failure, defined as either patient-reported symptoms suggestive of recurrent prolapse or repeat apical prolapse surgery during follow-up. Secondary outcomes included long-term satisfaction, severity of recurrent prolapse symptoms, overall repeat prolapse surgery, repeat apical prolapse surgery, repeat colporrhaphy, short-term satisfaction, and short-term POP-Q measurements at 1 and 4 months.

RESULTS: Two hundred and ten patients were included in the study: 99 underwent posterior SSLF and 111 underwent anterior SSLF. Baseline characteristics were similar between the groups. SSLF performed via the anterior approach had a shorter operative time (22.6 ± 4.61 min vs. 24.4 ± 6.52 min, p = 0.039), and no significant surgical complications were noted in either group. Satisfaction was similar at 1 month, whereas anterior SSLF was associated with higher 4-month satisfaction and better short-term POP-Q support. Composite long-term failure occurred in 41.4% of women in the posterior group and 25.5% in the anterior group (p = 0.014). Although anterior SSLF was associated with lower odds of composite failure in univariable analysis, surgical approach was not associated with composite failure after adjustment for follow-up duration and baseline clinical factors (adjusted OR 0.90, 95% CI 0.42-1.89; p = 0.773). Overall, repeat prolapse surgery was numerically more frequent after posterior SSLF, whereas the difference in repeat apical prolapse surgery was similar between groups.

CONCLUSION: Anterior SSLF was associated with better short-term anatomical outcomes and higher short-term satisfaction. At long-term follow-up, surgical approach was not independently associated with composite failure after adjustment for follow-up duration and baseline clinical factors. These findings suggest comparable long-term outcomes between the two approaches but should be interpreted cautiously because the study was not powered to establish equivalence between approaches.