Long-Term Outcomes After Vaginal, Open or Robotic Surgery for Vault Prolapse.

IMPORTANCE: Long-term comparative evidence guiding the optimal route and technique for repair of posthysterectomy vaginal vault prolapse is limited. OBJECTIVE: The objective of this study was to compare symptom relief and prolapse retreatment rates after modified McCall culdoplasty (MMC) with uterosacral ligament suspension, abdominal sacrocolpopexy (ASC), and robotic sacrocolpopexy (RSC) for posthysterectomy apical prolapse. STUDY DESIGN: We performed a retrospective cohort study of women treated surgically for posthysterectomy apical prolapse between 2000 and 2018. Baseline characteristics and retreatment events were abstracted from the electronic health record. Pelvic floor symptoms and retreatment outcomes were evaluated through survey-based follow-up including validated questionnaires. Retreatment-free survival was estimated using Cox proportional hazards models with inverse probability weighting (IPW) to adjust for baseline differences. RESULTS: Among 865 patients, 564 (65.2%) responded to follow-up surveys. Median follow-up was 3.4 years (IQR: 0.48, 6.1) for MMC, 4.6 years (IQR: 0.89, 9.9) for ASC, and 3.6 years (IQR: 0.57, 7.1) for RSC. Forty-eight retreatments occurred (5.5%; 28 surgical, 20 pessary). Ten-year retreatment-free survival was higher after ASC compared with MMC (93% vs 87%; P=0.045), although it did not differ between RSC and ASC (P=0.051) or RSC and MMC (P=0.94). In IPW-adjusted analyses, ASC was associated with a lower 10-year retreatment risk compared with MMC (HR, 0.30; 95% CI, 0.10-0.91; P=0.033). Postoperative symptom and sexual function scores were similar across procedures. CONCLUSIONS: All 3 approaches provide high retreatment-free survival with similar symptom relief. Open and robotic sacrocolpopexy demonstrated similar retreatment-free survival. Compared with MMC, ASC was associated with a lower retreatment rate with similar patient-reported outcomes. Shared decision making is important given differences in retreatment and morbidity.