Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension A Retrospective Cohort Heather M. Barbier, MD, MPH,* Margo Z. Smith, MD,* Chidimma U. Eto, MD,† Jeffrey A. Welgoss, MD,‡ Walter Von Pechmann, MD,‡ Nicolette Horbach, MD,‡ and Daniel D. Gruber, MS, MD* Objectives: The aim of this study was to evaluate if ureteral compro- mise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS). Methods: This is a retrospective cohort study comparing all women who underwent laparoscopic and vaginal USLSs at 2 institutions (part of a sin- gle training program with procedures performed by 11 fellowship-trained Female Pelvic Medicine and Reconstructive Surgery gynecologic surgeons) between January 2008 and June 2013. Results: A total of 208 patients in the study underwent a USLS, 148 in the laparoscopic group and 60 in the vaginal group. At baseline, there were statistically significant differences between the groups in mean age (50.4 vs 55.3 years, P = 0.008), parity (2.44 vs 2.77, P = 0.040), and prior hysterec- tomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively; P = 0.042). There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.0% vs 10.0%, respectively; P < 0.001). In an analy- sis evaluating only those ureteral compromises requiring stent placement, the higher rate of ureteral compromise in the vaginal group persisted de- spite exclusion of those cases requiring only suture removal and replace- ment (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; P = 0.023). There was a lower median blood loss in the laparoscopic group (137.5 vs 200.0 mL, respectively; P = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; P = 0.025). There were no other significant differences in postoperative complications between the 2 groups. Conclusions: We found a lower rate of ureteral compromise in the lapa- roscopic approach to USLS compared with the traditional vaginal approach. Key Words: uterosacral ligament suspension, ureteral compromise, laparoscopic prolapse repair, vaginal prolapse repair (Female Pelvic Med Reconstr Surg 2015;21: 363–368) P elvic organ prolapse is a common problem encountered in gy- necologic practice with the potential to significantly impact a woman's quality of life. The overall lifetime risk of a woman un- dergoing surgery for pelvic organ prolapse or urinary inconti- nence has been reported to be up to 20%. 1 Uterosacral ligament suspension (USLS), also referred to as high or deep USLS, is performed in several ways. The main objective was to restore level I or apical support. This suspension typically involves plication or shortening of the uterosacral liga- ments at their insertion into the cervix up to the level of the ischial spine and is more than 90% effective in correcting apical pro- lapse. 2 One of the risks of this procedure is the proximity of the ureter to the uterosacral ligament, with a reported ureteral compro- mise rate of up to 11% in vaginal USLS. 3 A recent randomized control trial by the Pelvic Floor Disorders Network comparing vaginal USLS to vaginal sacrospinous ligament fixation found an intraoperative ureteral obstruction rate of 3.2% in the USLS group. In addition, they found 1 injury (0.5%) postoperatively. 4 Although traditionally a vaginal procedure, this procedure is now frequently being performed laparoscopically. In seve- ral studies evaluating laparoscopic USLS, no ureteral compro- mises were identified. These studies were mainly case series, although 1 study was a retrospective cohort but had relatively small numbers, particularly in the laparoscopic group. Larger studies are needed to further address the laparoscopic approach to the procedure. 5–7 The objective of this study was to determine if the rate of ure- teral compromise is different between the laparoscopic and vagi- nal approach to USLS. Our hypothesis is that there is a lower rate of ureteral compromise with the laparoscopic compared with the vaginal approach. MATERIALS AND METHODS This is a retrospective cohort study of all women who underwent a USLS between January 2008 and July 2013 at 2 institutions, Walter Reed National Military Medical Center and Inova Fairfax Hospital. Both institutions are part of a single fellowship training program. This protocol was approved by the institutional review boards at both hospitals (392425-1 at Walter Reed National Military Medical Center and 13–1378 at Inova Fairfax Hospital). Patients were identified using billing records, electronic operative scheduling systems, and trainee case logs. These 3 methods of identifying patients overlapped and were used to avoid missing cases that might not be identified by a single method alone. Once these subjects were identified, operative re- ports were reviewed to ensure that the procedure being studied was in fact performed (Fig. 1). Demographic and follow-up data were collected from out- patient records. Inpatient records were reviewed for operative technique, estimated blood loss, and complications (readmission, reoperation, transfusion, ileus, and urinary tract infection [UTI] within 6 weeks). All surgeries were performed by 1 of 11 fellowship- trained Female Pelvic Medicine and Reconstructive Surgery gyneco- logic surgeons along with trainees, including residents and fellows. All patients had cystoscopy performed intraoperatively to evaluate for ureteral patency. Patients who underwent a vaginal or laparoscopic (including robotic) USLS were included. Patients who had an open abdo- minal approach were excluded as we felt this approach differed from the laparoscopic or vaginal approach, and there were only From the *Division of Urogynecology, Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, Bethesda, MD; †Department of Obstetrics and Gynecology, George Washington University, Washington, DC; and ‡Inova Fairfax Hospital, Annandale, VA. Reprints: Heather M. Barbier, MD, MPH, Department of Obstetrics and Gynecology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bldg 9, 2nd Floor, Bethesda, MD 20889. E-mail: hbarbier@mac.com. The authors have declared they have no conflicts of interest. All authors have no relevant disclosures. The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Air Force, Department of Defense, or the US Government. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/SPV.0000000000000202 ORIGINAL ARTICLE Female Pelvic Medicine & Reconstructive Surgery • Volume 21, Number 6, November/December 2015 www.fpmrs.net 363 Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.