This is the first systematic review aiming to investigate the variation in techniques used for sacrohysteropexy using synthetic mesh.   Sacrohysteropexy has gained recognition as an effective treatment for uterine prolapse with overall low complication rates. (1) However, the surgical technique used in sacrohysteropexy lacks standardization. Mesh configuration for sacrohysteropexy has never been studied. We aimed to first describe the various techniques and mesh configuration used for sacrohysteropexy, and then compare outcomes between techniques. We hypothesized that the type of configuration has an impact on objective and subjective pelvic organ prolapse (POP) outcomes.

A systematic search was conducted across major electronic databases (MEDLINE, Embase and CENTRAL) for relevant studies published from 2005-2022 (restriction: English and French). We included randomized controlled trials (RCTs), observational comparative studies and case series with accessible full text, describing population of women with uterine prolapse who underwent sacrohysteropexy in at least one of the arms. Studies were screened for inclusion independently by 2 researchers.    We extracted data on surgical technique, including type of mesh used, surgical route, mesh configuration, extent of dissection, type and number of sutures/tacks, and retroperitonealization. Outcomes of objective and subjective success rates, surgical parameters, and complications were also extracted. Study quality was assessed based on Cochrane Risk of Bias for RCTs, Newcastle-Ottawa Scale for comparative observational studies, and NIH Quality Assessment Tool for case series.  Descriptive statistics are presented as N (%).  Logistic regression was performed to test the association between the type of mesh configuration and each binary outcome. Mesh configuration categories were defined as 1. posterior attachment only, 2. anterior attachment only, or 3. both anterior and posterior attachment; studies including combinations or variable attachments were not included in the technique comparison but were included in overall results. The Generalized Estimating Equation (GEE) approach was used to account for the clustering due to different studies.(2) For each outcome, rates and 95% confidence interval were computed from the estimate of each logit model. For the rare event outcomes (organ injury rates), crude rates and Firth logistic model were used instead.

The search yielded 1985 studies, and an additional 4 studies were found through backwards citation chaining. Fifty-five manuscripts, from 52 distinct studies, with a total of 4,560 cases of sacrohysteropexy met inclusion criteria. We included 5 RCTs, 22 comparative studies, and 25 case series. Evidence was of moderate to low quality overall. Average/median age varied from 30-69 years old between studies (range 19-91). Technique variations are described in Table 1. Exact number or range of sutures used for vaginal mesh attachment was reported in 26 (50%) studies, which varied from 1-14. Twenty studies reported number of sutures or tacks used for sacral mesh attachment, which varied from 1-5. Most (29 studies; 55.8%) used permanent sutures for sacral attachment, 15 (28.8%) used tacks, 6 (11.5%) used either a combination of tacks/sutures, non-specified sutures, or delayed absorbable sutures, and 2 (3.8%) studies did not specify type of sacral attachment. 
Median follow-up was 1.6 years (range 0-10 years). Outcomes overall and by mesh configuration are presented in Table 2.

There were a wide range of technique variations identified in the literature. The heterogeneity in techniques affects interpretation of the literature when trying to compare sacrohysteropexy outcomes with those of other apical POP procedures. Unfortunately, comprehensive description of surgical technique was not present in all studies. Overall, the most commonly reported technique used laparoscopic approach, a polypropylene mesh, mesh attachments to both the anterior and posterior cervix/vagina, and included closure of the peritoneum over the mesh.

Overall objective success rate of the procedure was 72.6%, and 88.2% were subjectively cured at a median of 1 year postoperatively. Five percent of women required a reoperation for POP recurrence at a median of 2 years after the surgery, and 2.1% required a reintervention for mesh exposure within 4 years of surgery. Organ injury rates were very low. We did not identify differences in outcomes based on mesh attachment, except for bladder injury rates which appeared higher in the anterior and posterior attachment group compared to the anterior attachment only group. Further analyses will be required to determine if other factors, such as extent of dissection were associated with this finding.

This was the first systematic review to report on technique variations of sacrohysteropexy and their respective outcomes. Significant technique heterogeneity was found. Futures studies on sacrohysteropexy should aim to accurately and completely describe surgical technique to ensure reproducibility of findings. In addition, trials directly comparing sacrohysteropexy techniques are needed to determine the optimal mesh configuration.

Meriwether KV, Balk EM, Antosh DD, Olivera CK, Kim-Fine S, Murphy M, Grimes CL, Sleemi A, Singh R, Dieter AA, Crisp CC, Rahn DD. Uterine-preserving surgeries for the repair of pelvic organ prolapse: a systematic review with meta-analysis and clinical practice guidelines. Int Urogynecol J. 2019 Apr;30(4):505-522. doi: 10.1007/s00192-019-03876-2. Epub 2019 Feb 11. PMID: 30741318.
Fitzmaurice GM, Laird NM, Ware JH. Applied Longitudinal Analysis, 2nd Edition. 2011. John Wiley & Sons, Hoboken, New Jersey, USA.