Randomization 1: Surgical Approach
Arm A · n = 188
ULS
Bilateral uterosacral ligament suspension (Shull technique)
Arm B · n = 186
SSLF
Unilateral sacrospinous ligament fixation (Michigan 4-wall technique)
Randomization 2: Perioperative BPMT (n=186) vs. usual care (n=188). All patients received concomitant retropubic TVT for SUI. BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years (treatment difference UDI: −6.7 [95% CI −19.7, 6.2]; p=0.31).
Primary Outcome: Surgical Success at 2 Years
59.2%
ULS Success
93 / 157
60.5%
SSLF Success
92 / 152
OR 0.9
95% CI 0.6–1.5
p = 0.75
Key Outcome Components
Bothersome Bulge Symptoms
Differential Complications
Higher with ULS
Ureteral obstruction: 3.2% vs 0%
Granulation tissue: 19.1% vs 14.0% (p=0.18)
Bladder injury: 11.7% vs 9.7% (p=0.60)
Higher with SSLF
Neurologic pain requiring Tx: 12.4% vs 6.9% (p=0.049)
Suture exposure: 17.2% vs 15.4% (p=0.60)
Clinical Bottom Line
ULS and SSLF are equivalent transvaginal apical suspension options at 2 years, with ~60% composite surgical success. Surgeons may choose based on anatomy and expertise. Composite success rates were lower than commonly reported 70–90% due to rigorous blinded assessment. Perioperative BPMT did not improve outcomes.