Introduction 1 2 3 4 10 11 Materials and methods Patients In the period between December 2001 and April 2005, 72 women underwent a sacrospinous hysteropexy at the University Medical Center Utrecht, The Netherlands. A woman was eligible for participation if she had a symptomatic pelvic organ prolapse and wanted surgical correction with preservation of the uterus. Exclusion criteria were abnormal uterus or ovaries on ultrasound examination, abnormal bleeding pattern and abnormal cervical cytology. All women answered a standardized questionnaire covering urogenital symptoms, defecatory symptoms and quality of life before and after surgery. Urodynamic assessment was performed in all women preoperatively. We did not try to diagnose occult stress incontinence. The study was approved by the local ethics committee. Surgery 12 Measurements 13 14 15 16 4 9 17 15 Effect sizes were measured as a useful way to estimate whether an improvement on a particular domain was considered to have a small, moderate or large clinical relevance. Statistical analysis t α d 18 18 Results 1 Table 1 Patient characteristics Patient characteristics n a 57.2 (11.9) Surgery for prolapse in medical history 3 (4.2) Surgery for urinary incontinence in medical history 4 (5.6) b 40 (55.6)  Urge incontinence 9 (12.5)  Stress incontinence 21 (29.2)  Combination stress and urge incontinence 10 (13.9) Gynecological examination before surgery Descensus uteri stage 2 or more 67 (93.2) Cystoceles stage 2 or more 57 (79.2) Rectoceles stage 2 or more 19 (26.4) Enterocele 1 (1.4) Surgery Sacrospinous hysteropexy 8 (11.1) Sacrospinous hysteropexy + anterior colporrhaphy 54 (75) Sacrospinous hysteropexy + anterior and posterior colporrhaphy 9 (12.5) Sacrospinous hysteropexy + posterior colporrhaphy 1 (1.4) Additional TVT 15 (20.8) c 3.5 (1–8) c 12.7 (3–33) Data are numbers (%) a b c 2 Table 2 Complications related to surgery Patient characteristics n Complications during surgery 0 (0) Complications after surgery 32 (44.4)  Second surgery because of bleeding 1 (1.4)  Buttock pain 13 (18.1)   Buttock pain <2 weeks 8 (11.1)   Buttock pain >2 weeks 5 (6.9)  Vaginal hematoma 2 (2.8)  Urinary tract infection 7 (9.7)  Retention bladder 20 (27.8)   Bladder catheterisation <2 weeks 15 (20.8)   Bladder catheterisation >2 weeks 5 (6.9)  Vaginal adhesion 3 (4.2) Data are numbers (%) During the follow-up period, a total of 16 women (22.2%) had a recurrent prolapse of one of the compartments. Five women (6.9%) had a recurrent prolapse of the uterus (four women stage 2, one woman stage 3). Ten women (13.9%) had a cystocele stage 2 or more (eight women stage 2, two women stage 3) and two women (2.8%) had a prolapse of the posterior compartment stage 2. All the women with a recurrent cystocele had had surgery of the anterior compartment combined with the hysteropexy, so there were no de novo cystoceles. The two women with a recurrent rectocele did not have surgery of the posterior compartment combined with the sacrospinous hysteropexy, so these can be considered as de novo rectoceles. 3 Table 3 Urinary Distress Inventory (UDI), Defecatory Distress Inventory (DDI) and Incontinence Impact Questionnaire (IIQ)   a n a n P Effect size UDI Urinary incontinence 18.5 (24.2) 10.5 (21.0) 0.012 0.35 Overactive bladder 29.5 (26.7) 14.4 (18.6) 0.000 0.66 Pain 30.1 (26.7) 9.5 (16.7) 0.000 0.92 Obstructive micturition 27.0 (28.3) 10.8 (19.7) 0.000 0.66 Genital prolapse 56.6 (32.0) 5.6 (17.4) 0.000 2.0 DDI Constipation 11.9 (18.8) 6.3 (9.8) 0.021 0.37 Obstructive defecation 13.3 (19.7) 8.3 (11.8) 0.016 0.22 Pain 4.5 (16.3) 2.8 (8.3) 0.498 0.13 Fecal incontinence 8.6 (20.7) 8.5 (14.4) 0.955 0.01 IIQ Physical functioning 26.0 (24.4) 9.4 (15.1) 0.000 0.82 Mobility 25.0 (22.8) 12.6 (18.4) 0.000 0.60 Emotional health 23.2 (23.3) 8.0 (14.2) 0.000 0.79 Social functioning 14.8 (19.1) 4.5 (11.8) 0.000 0.65 Embarrassment 11.2 (13.8) 6.7 (11.1) 0.013 0.41 Effect size: 0.2 = small effect, 0.5 = median effect, 0.8 = large effect a p p p p Discussion The objective of this study was to assess quality of life and urogenital and defecatory symptoms before and after sacrospinous hysteropexy. The results show that a sacrospinous hysteropexy significantly reduced all urogenital and several defecatory symptoms and significantly improved quality of life. Effect sizes were large on domain genital prolapse and pain (UDI), and on domain physical functioning and emotional health (IIQ). It also anatomically cured the uterine descent in 93.1% of women. 19 20 21 22 1 4 23 24 25 26 3 6 8 10 27 6 8 27 3 5 9 10 28 2 29 30 11 11 . 9 27 31 32 14 33 34 35 36 37 9 The strength of our study is that we measured urogenital and defecatory symptoms and quality of life in a large group of women who underwent a sacrospinous hysteropexy, with a validated questionnaire before and after surgery. There are some potential drawbacks that need to be discussed. First, there might be an indication bias. In our country, a vaginal hysterectomy is the standard surgical technique for correcting a uterine descent. Therefore, women that came to our hospital may have chosen specifically for this operation. They might have had high expectations of this procedure which could have influenced their outcome with respect to quality of life. Second, in some patients, follow-up time was limited to 3 months. Possibly, some recurrences had not yet developed at that time. Third, the study was performed in a single university hospital. The sacrospinous ligament fixation has become rapidly popular in our center and is performed by two surgeons. They are highly trained in performing the procedure. This might have influenced the outcome. Fourth, we did not compare the sacrospinous hysteropexy with another surgical technique to correct a uterine descent. Therefore, we cannot conclude that the sacrospinous hysteropexy is superior to other procedures. However, it is a safe and effective operation for women who wish to preserve their uterus at time of genital prolapse surgery.