Mid-Term Outcomes of Laparoscopic Versus Vaginal Uterosacral Ligament Suspension for Pelvic Organ Prolapse: A Propensity Score Overlap-Weighted Retrospective Cohort Study

INTRODUCTION AND HYPOTHESIS: Comparative data regarding the optimal surgical route for uterosacral ligament suspension (USLS) remain limited. This study compared mid-term efficacy and safety between laparoscopic (L-USLS) and vaginal (V-USLS) for apical pelvic organ prolapse (POP), utilizing propensity score overlap-weighted (PS-OW) to minimize selection bias. METHODS: This retrospective cohort study included patients with symptomatic stage II or higher POP undergoing concurrent hysterectomy with L-USLS (n = 135) or V-USLS (n = 43). PS-OW balanced baseline characteristics. Primary outcome was composite success. Secondary outcomes included perioperative parameters, anatomic results, patient-reported outcomes, and complications. RESULTS: After PS-OW, all baseline covariates were well balanced. L-USLS demonstrated significantly shorter total operative time. L-USLS also enabled concomitant adnexal surgery in all patients without additional assistance. At a mean follow-up of approximately 3 years, composite success (86.1% vs 85.1%), anatomical success (91.8% vs 94.7%), subjective success (86.2% vs 85.1%), and retreatment (4.1% vs 1.6%) rates were comparable between groups (all P > 0.05). V-USLS required routine intraoperative cystoscopy, and two cases of postoperative ureteral obstruction needing intervention. CONCLUSIONS: L-USLS and V-USLS provide equivalent mid-term outcomes for apical POP. L-USLS presents superior perioperative advantages and greater flexibility for concomitant adnexal surgery. V-USLS avoids a transabdominal approach but requires routine cystoscopy and carries ureteral obstruction risks.