Focused Training in Pelvic Floor Surgery: A CUSUM Analysis of the Learning Curve in Uterosacral Ligament Suspension

Introduction: Pelvic organ prolapse (POP) involves the descent of pelvic organs into the vaginal cavity due to weakened pelvic support structures, particularly ligamentous and connective tissue laxity or defects. Surgical interventions are common, with approximately 200,000 procedures annually in the US. Surgical approaches prioritize apical support preservation, often using native tissue for reinforcement. The uterosacral ligament suspension (USLS) via vaginal approach offers advantages in cost and time. Presently, there is a resurgence of interest in transvaginal native-tissue procedures for pelvic floor reconstructive surgery, driven by factors such as cost-effectiveness and the desire to avoid complications associated with mesh. However, the declining use of this approach may result in insufficient exposure for residents and gynecologists to acquire vaginal surgical skills. Our study aims to comprehensively assess the learning curve associated with vaginal hysterectomy, considering the impact of experience on operative outcomes, complications, and patient results. Methods: This retrospective single-center study analyzes consecutive patients who underwent vaginal hysterectomy followed by high uterosacral ligament suspension for pelvic organ prolapse (POP) performed by one pelvic floor surgeon in training at Fondazione IRCCS San Gerardo dei Tintori Hospital in Monza, Italy, between November 2021 and February 2023. Patients underwent transvaginal hysterectomy and salpingectomy, with additional procedures as necessary, followed by high uterosacral ligament suspension. Follow-up assessments were performed periodically to evaluate symptoms and determine objective recurrence. Comparative analyses were conducted on preoperative POP-Q stages, demographic attributes, perioperative outcomes, and recurrence rates. Additionally, we utilized cumulative summation (CUSUM) analysis to examine the learning curve associated with vaginal hysterectomy accompanied by high uterosacral ligament suspension, focusing on surgical failure and operation duration. Results: A total of 43 patients were included in the study. The population had a median age of 62 years and a mean menopausal onset age of 49.7 years. Symptoms included bulging (100%), with 70% reporting bladder emptying difficulties. All patients exhibited stage II or higher anterior compartment prolapse, and the majority had stage II or higher central prolapse. Vaginal hysterectomy and uterosacral ligament suspension were performed on all patients, with additional repairs as needed. The median operative time was 119.45 ± 20.4 min, with a mean blood loss of 303.3 ± 107.9 mL. Postoperative assessment utilizing the POP-Q system revealed significant improvements in the anterior (p < 0.001 for Aa and Ba), central (p < 0.001 for C), and posterior (p < 0.001 for Ap and Bp) compartments compared to preoperative measures. Additionally, a decrease in the genital hiatus and an increase in the perineal body were noted (p < 0.001 for gh and pb). Functional outcomes demonstrated a substantial improvement in micturition symptoms and vaginal bulging compared to baseline (p < 0.001), although not all parameters reached statistical significance. Recurrence rates were 9.3% for the anterior compartment and 2.3% for the central compartment. The CUSUM analysis indicated proficiency in operation time after the 30th procedure, while surgical proficiency, defined by surgical success, entails no recurrence within 12 months postoperatively, was stabilized after 22 cases. Conclusions: Vaginal uterine ligament suspension not only stands as is a safe and effective procedure for pelvic organ prolapse but also boasts a brief learning curve, facilitating rapid enhancement in surgical proficiency within a condensed time frame, particularly in terms of blood loss, anatomical recurrence, and subsequent reintervention.