A randomized controlled trial of permanent vs absorbable suture for uterosacral ligament suspension


Introduction and hypothesis

Uterosacral ligament suspension (USLS) is a common procedure for apical pelvic organ prolapse. The procedure has been described using only permanent suture, only absorbable suture and a combination of permanent and absorbable suture. We hypothesized that the use of absorbable suture is not inferior to the use of permanent suture.


All women undergoing USLS between October 2016 and November 2017 were approached. Subjects were randomized to permanent or absorbable suture. The primary outcome was POP-Q point C 12 months after surgery (non-inferiority limit = 2 cm). A composite outcome of success at 12 months was defined as no apical prolapse ≥ 1/2 TVL, no prolapse beyond the hymen, no prolapse retreatment and no bulge symptoms.


Forty-four subjects with mean (SD) age 62.9 (12.0) years and body mass index 29.1 (5.4) kg/m2 were enrolled and underwent USLS. Fifteen (34.1%) had POP-Q stage II and 29 (65.9%) stage III prolapse. Twenty-two were randomized to permanent and 22 to absorbable suture. Forty (90.9%) completed the 12-month follow-up. Median (IQR) POP-Q point C at 12 months was −7 (−10, -6) for the permanent and − 7 (−9, -5.5) for the absorbable suture groups (p = 0.65, non-inferiority p < 0.0002). Four (20%) in the permanent and one (5%) in the absorbable suture group reported bulge symptoms (p = 0.34). Fifteen (75%) in the permanent and 18 (90%) in the absorbable suture groups met criteria for composite success (p = 0.41). Intervention-related adverse outcomes were uncommon and not different between groups.


Absorbable suture for USLS is not inferior to permanent suture for apical anatomic outcomes.

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  1. 1.

    Wu JM, et al. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123(6):1201–6.

    Article  Google Scholar 

  2. 2.

    Barber MD, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311(10):1023–34.

    CAS  Article  Google Scholar 

  3. 3.

    Shull BL, et al. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 2000;183(6):1365–73. discussion 1373-4.

    CAS  Article  Google Scholar 

  4. 4.

    Kasturi S, et al. High uterosacral ligament vaginal vault suspension: comparison of absorbable vs. permanent suture for apical fixation. Int Urogynecol J. 2012;23(7):941–5.

    Article  Google Scholar 

  5. 5.

    Chung CP, et al. Permanent suture used in uterosacral ligament suspension offers better anatomical support than delayed absorbable suture. Int Urogynecol J. 2012;23(2):223–7.

    Article  Google Scholar 

  6. 6.

    Bump RC, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10–7.

    CAS  Article  Google Scholar 

  7. 7.

    Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005;193(1):103–13.

    CAS  Article  Google Scholar 

  8. 8.

    Srikrishna S, Robinson D, Cardozo L. Validation of the patient global impression of improvement (PGI-I) for urogenital prolapse. Int Urogynecol J. 2010;21(5):523–8.

    Article  Google Scholar 

  9. 9.

    Snapinn SM. Noninferiority trials. Curr Control Trials Cardiovasc Med. 2000;1(1):19–21.

    Article  Google Scholar 

  10. 10.

    Available from: Sealed Envelope Ltd. 2012. Power calculator for continuous outcome non-inferiority trial. [Online] Available from: https://www.sealedenvelope.com/power/continuous-noninferior/ [Accessed May 31 2016].

  11. 11.

    Bradley MS, et al. Vaginal uterosacral ligament suspension: a retrospective cohort of absorbable and permanent suture groups. Female Pelvic Med Reconstr Surg. 2018;24(3):207–12.

    Article  Google Scholar 

  12. 12.

    Nager CW, et al. Effect of vaginal mesh Hysteropexy vs vaginal hysterectomy with uterosacral ligament suspension on treatment failure in women with Uterovaginal prolapse: a randomized clinical trial. JAMA. 2019;322(11):1054–65.

    Article  Google Scholar 

  13. 13.

    Detollenaere RJ, et al. Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial. BMJ. 2015;351:h3717.

    Article  Google Scholar 

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IUGA 2016 Clinical Research Grant.

The University of Iowa Clinical and Translational Science Award-NIH (UL1TR002537).

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Correspondence to Joseph T. Kowalski.

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Kowalski, J.T., Genadry, R., Ten Eyck, P. et al. A randomized controlled trial of permanent vs absorbable suture for uterosacral ligament suspension. Int Urogynecol J 32, 785–790 (2021). https://doi.org/10.1007/s00192-020-04244-1

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  • Prolapse
  • Surgery
  • Trial