Pullout testing for sacrospinous ligament and uterosacral ligament in apical suspension: A cadaveric biomechanical study

OBJECTIVE: This study evaluates the biomechanical strength of the sacrospinous ligament (SSL) and the uterosacral ligament (USL) in managing apical prolapse. METHODS: This study was conducted during a surgical competency cadaveric workshop, focusing on evaluating the biomechanical strength of the SSL and the USL. Eight fresh-frozen cadavers were studied for various procedures for apical suspension. The AnchorSure System (SSLF-t) was used on the right SSL of six cadavers. The Miya hook ligature carrier (SSLF-m) and uterosacral ligament suspension (USLS) were used on the bilateral SSL and USL of the other two cadavers. The maximum load at failure was recorded by measuring the pullout strengths of these ligaments using a Newton meter. RESULTS: For SSLF-t, the highest mean load at failure was 52.5 ± 11.3 N (confidence interval [CI] 17.4-33.2), and the overall mean load at failure was 44.0 ± 15.9 N (CI 38.1-49.6; P < 0.001). For SSLF-m, the highest mean value was 69.7 ± 8.8 N, and the overall mean value was 69.2 ± 5.9 N (CI 59.8-78.2; P = 0.004). For USLS, the highest mean value was 81.9 ± 5.1 N, and the overall mean value was 81.4 ± 5.5 N (CI 72.6-90.1). CONCLUSION: Uterosacral ligament suspension demonstrated the highest biomechanical strength, followed by SSLF-m and SSLF-t, suggesting it might be more effective in managing pelvic organ prolapse. The degree of tissue engagement and mechanism of fixation do affect the overall strength and long-term stability. The choice of suture also contributed to the ultimate repair outcome.