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07: Uterosacral ligament suspension: A radiographic study of suture location in live subjects

      Objectives

      This study aimed to describe uterosacral ligament suspension (USLS) suture location relative to the surrounding anatomy in a living model using computed tomography (CT) imaging.

      Materials and Methods

      This was an Institutional Review Board-approved prospective descriptive study. Written informed consent was obtained from all patients. Women aged 18-85 undergoing pelvic reconstructive surgery to include vaginal hysterectomy with USLS were eligible. After completing the hysterectomy and tying each of the 4 uterosacral ligament suspension sutures (2 right, 2 left), a size “small” titanium vascular clip was applied to the base of the sutures. Computed tomography of the pelvis was performed on postoperative day one. Due to the inability of CT imaging to accurately characterize pelvic nerves, all patients completed preoperative and postoperative neurological questionnaires and physical examinations. A sample of 15 subjects was deemed appropriate for this pilot study.

      Results

      Seventeen subjects were enrolled: 2 excluded, 15 analyzed. The mean age of subjects was 58.1 years. The closest branch of the internal iliac complex was 2.5 (0.5) cm [mean (SD)] from the proximal suture on the right and 2.8 (0.7) cm on the left. The right ureter was 2.2 (0.5) cm from the right proximal suture and 2.2 (0.4) cm from the right distal suture. The left ureter was 2.4 (0.6) cm from the left proximal suture and 2.5 (0.6) cm from the left distal suture. The rectal lumen was 2.7 (0.9) cm from the right proximal suture and 2.6 (0.9) cm from the right distal suture. On the left, the rectum was 2.7 (0.8) cm from the proximal suture and 2.7 (0.8) cm from the distal suture. Further analysis revealed the left ureter to be closer to the sutures in patients ≥60 years old compared with those <60 years old (2.0 cm versus 2.7 cm; p = 0.03). There were no other differences in anatomy relative to the sutures based on body mass index or stage of prolapse. Finally, no subjects were found to have neurologic involvement of the sutures based on neurologic questionnaires and physical examination.

      Conclusion

      In a living model, our study confirms the vasculature, ureter, and rectum of the pelvic side wall are in close proximity to suture placement for uterosacral ligament suspension. This information highlights the importance of careful dissection and awareness of anatomic landmarks. Future research that can delineate neurologic pathways specifically would provide needed information regarding this procedure.
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