Hypothesis / aims of study
Permanent suture has been widely used for attaching mesh to the vagina in the operation, which is to confirm the mesh securely to providing stable repair with a as much as possible lower failure rate. However, in a published study(1) of sacrospinous ligament suspensions, they used permanent suture and obtained an incredible suture-related complications including suture erosion, persistent vaginal bleeding and granulation tissue generation. In this situation, they had to remove the suture. More horrible thing is that the permanent suture exist a long time, and one of the included study above observed 2 permanent suture erosion into the bladder occurring more than 30 weeks after surgery(2). The choice of suture materials become a question and in recent years, absorbable suture have started to be used in sacrocolpopexy. Thus, we performed the first meta-analysis to investigate the priority of absorbable sutures and permanent sutures. The aims of this study were to compare surgical results and suture-related complications after sacrocopolpexy (SCP) with absorbable suture (AS) vs permanent suture (PS).
Study design, materials and methods
We systematically searched PubMed, Embase, clinicalTrial.gov, and Cochrane Library Central Register of Controlled Trials for articles that compared AS with PS for SCP. The primary outcomes were surgical success rate and suture related complications (suture exposure/erosion, mesh erosion and suture removal). Review Manager 5.3 (Cochrane Collaboration, Oxford, UK) was applied to conduct all analyses.
Results
Four articles involving 689 patients were eventually included. The total success rates of the two group were 96.6% and 93.9%.Our findings demonstrated that AS had similar surgical success rates in comparison with PS (RR=1.03; 95% CI, 0.97-1.09) and no significant differences in failure rates were noted between two groups (RR=0.53; 95% CI, 0.22-1.26）. Subgroup analyses in patients with anatomic failure revealed no statistical differences in recurrent posterior prolapse（RR=0.33; 95% CI, 0.06-2.02）, as well as in recurrent apical or anterior prolapse (P=0.78, P=0.68, respectively). However, Our finding demonstrated that AS indicated a lower risk in suture exposure/erosion（RR=0.20; 95% CI, 0.06-0.61）, suture removal（RR=0.19; 95% CI, 0.04-0.84）and retreatment（RR=0.44; 95% CI, 0.14-1.35）. These results confirmed our hypothesis that AS is as effective as PS with a better security. Interestingly, the mesh erosion in the two had no statistical differences（RR=1.00; 95% CI, 0.51-1.94）.
Interpretation of results
Our finding observed that the success rate is similar between the two materials (RR=1.03; 95% CI, 0.97-1.09) and there was also no differences in failure rate（RR=0.53; 95% CI, 0.22-1.26）. Subgroup analyses demonstrated no statistical differences in recurrent apical prolapse, anterior prolapse or posterior prolapse（P=0.78, P=0.68, P=0.23）. The total success rates of the two group were 96.6% and 93.9% and that were consistent with published studies.
The function of the suture is to attach the mesh from the vagina to the anterior longitudinal ligament covering the sacral promontory. Thus, the corrections of looking for the exact anatomical site is necessary. In the abstract, in case of a stable scar is formatted with sufficient time provide by suture materials and then we could obtain solid apical support. The apical support is the most likely to be derived from scarring of the vaginal apex to the anterior longitudinal ligament rather than depending on suture longevity. Absorbable materials such as polydioxanone dissolves at an average of 3 months and is completely dissolved at 6 months. After the suture completely dissolved, the apical support will still in the place with a newly established anatomical structure. Under this situation, after 6 months, it is unlikely that PS has any benefit over the scarring that remains in place. The average duration of studies included was 6 months. Our finding demonstrated that AS indicated a lower risk in suture exposure/erosion（RR=0.20; 95% CI, 0.06-0.61）, suture removal（RR=0.19; 95% CI, 0.04-0.84）and retreatment（RR=0.44; 95% CI, 0.14-1.35）. These results confirmed our hypothesis that AS is as effective as PS with a better security. Interestingly, the mesh erosion in the two had no statistical differences（RR=1.00; 95% CI, 0.51-1.94）. For the mesh materials, it needs more technical support to improve affinity.