Chapter 4.1 64 treatment.129 After improvement or cure of urge-related symptoms, SUI may become more bothersome. This may explain the substantially higher cure rates for UI after CESA or VASA combined with additional or subsequent TOT. In 206 women with apical prolapse stages 1–4, anatomical success 4 months after surgery was reported in almost all patients. The subjective patient-reported symptoms improved significantly. So, current clinical evidence on the efficacy of CESA and VASA in the short term suggests that this procedure can correct apical prolapse. Overall, recurrent prolapse repair was 4.4%. However, the level of evidence supporting this procedure in the treatment of prolapse is low. The uterosacral ligaments (together with the cardinal ligaments) provide level I support to the apical vagina and uterus.13 The uterosacral ligament Suspension (USLS), the Mc Call culdoplasty, the high USLS and the USL hysteropexy all aim to shorten and/or secure the native uterosacral ligaments. The success rate of these interventions in restoring prolapse was also high (81-98%), however 5.8-9.4% needed additional surgery to treat recurrent prolapse.130 Today, knowledge of the anatomical, microstructural, and mechanical properties of the USL is still ongoing, both in normal and symptomatic patients.125,131,132 Given that structural deficiencies are often present in symptomatic patients, anatomical replacement of the USL seems a logical strategy. Strengths and limitations To our knowledge, this is the first systematic review with a robust methodology, comprehensive literature search, and synthesis and grading of evidence on CESA or VASA. However, our review identified serious potential biases in the current literature. First, most studies were single-arm case series, with allocation at the discretion of the surgeon and including a heterogeneous population. Some studies used an open abdominal approach, whereas others used a laparoscopic approach. The single RCT was of low quality. Second, we suspect duplicated procedures in some of the included case series, which are, however, impossible to detect. Third, there was significant heterogeneity in outcome measurements and there were few patient-reported outcomes. Fourth, follow-up was short (4 months to 2 years), and long-term outcome and safety data were lacking. Fifth, the same mesh was used in all patients, and some studies were financially supported by Textiltechniek GmbH, Aachen, Germany. Financial incentives may have been provided for the authors. Sixth, except for one, all studies were unclear regarding eligibility and inclusion methodology. Seventh, although not detectable, publication bias cannot be excluded. Future directions Besides a physiological base, current synthesis of the evidence on CESA and VASA suggests a beneficial effect in patients with UI and/or genital prolapse. The intervention is already done since many years in multiple centers and is well defined. Our review suggests good safety and beneficial
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