The incidence of apical uterine descent increases with age. After conservative treatment options have been exhausted, surgical correction with the use of alloplastic material often follows. Laparoscopic cervicosacropexy is often performed, and different materials (staplers vs. sutures) can be used to fix the mesh material to the cervix for apical fixation.
The aim of this in vitro study was to compare the biomechanical properties for fixation of the mesh to the cervix with single button sutures (group 1), non-absorbable staplers (group 2) and absorbable staplers (group 3).

The biomechanical in vitro testing was performed on porcine, non- embalmed, fresh and unfrozen cadaver uteri. In a two-column material testing machine (Instron 5565®) a total of 28 trials were conducted in three groups on uncollected fresh porcine uteri. Each group evaluated the cervical mesh fixation with a different fixation device: Group 1 (n=10) evaluated three interrupted sutures, group 2 (n=10) three titanium tacks (ProTackTM), and group 3 (n=8) three absorbable tacks (AbsorbaTackTM). The mesh used for cervical fixation are composed of nonabsorbable, biostable polyvinylidene fluoride (PVDF) monofilaments.
All trials were conducted until failure of the mesh, tissue or fixation device occurred. Primary endpoints were biomechanical properties maximum load (N), displacement at failure (mm) and stiffness (N/mm). Mode of failure was evaluated as a secondary endpoint.

Significant differences were found between all three groups in terms of maximum load: Group 1 (three single button staples) showed a maximum load of 64 ± 15 N, Group 2 (three titanium staples) 41 ± 10 N and Group 3 (three absorbable staples) reached a maximum load of 15 ± 8 N.
The most common mode of failure for group 1 and 2 was a net tear or rip. In group 3, the limiting factor in all tests was a pull-out of the absorbable tacker.

Fixation of the PVDF tape with three single button sutures is superior to fixation with three titanium staplers as well as absorbable staplers in terms of maximum load. The suture carries 1.5 times the load of titanium staplers and 4.2 times the load of absorbable staplers. All three fixation options can withstand the physiological load of 10 N. Single button sutures are the significantly stronger and less expensive, but could increase surgical time by a factor of 9 compared to staplers. Possible risks of the staplers are not considered in this in vitro analysis.

All three fixation options showed the required strength. Sutures are an inexpensive and stable fixation, but can sometimes lead to increased operating time. In none of the cases did the mesh material show weaknesses.