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Site-specific repair of posterior vaginal wall prolapse: Long term efficacy
IUGA Academy. Schachar J. Jun 30, 2018; 212851
Topic: Pelvic Organ Prolapse
Jeffrey Schachar
Jeffrey Schachar

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337

Site-specific repair of posterior vaginal wall prolapse: Long term efficacy

Schachar, J1; Martin, L1; Ossin, D1; Hurtado, E1; Davila, GW1

1: Cleveland Clinic Florida

Introduction: The cause of posterior vaginal wall defects has been theorized as due to discrete tears in the rectovaginal fibromuscular layer. It has been shown that most defects occur apically. Both traditional posterior colporrhaphy and site-specific repairs have high cure rates. A large retrospective study concluded that traditional colporrhaphy had fewer recurrences than site-specific repair (4% vs 11%), whereas a prospective study noted similar success rates (86% and 78% respectively) [1–3] .

Objective: The objective of this study was to demonstrate the efficacy of combined apical site-specific repair and perineoplasty for posterior vaginal wall prolapse.

Methods: This is a retrospective review of patients who underwent reconstructive surgery for posterior compartment vaginal prolapse, who had adequate apical support upon follow-up. Site-specific apical transverse fibromuscular (fascia) tears were identified intra-op and repaired. Once the posterior compartment was dissected and the tear identified, three interrupted permanent sutures were placed in the posterior aspect of the vaginal apex/cervix and attached to the superior edge of the torn rectovaginal fibromuscular layer and tied to connect the defect. The repair was completed with a midline plication perineoplasty below the levator plate. Failure rates were determined by a combination of subjective (5-point global impression scale) and objective (POP-Q Bp >-1) outcomes. A p-value of less than 0.05 was considered statistically significant.

Results: In our comprehensive, prospectively maintained, database, 190 (73.6%) patients that underwent reconstructive surgery for posterior compartment prolapse had apical transverse defects and underwent the site-specific technique. Average follow up was 2.6 years (range 40-717 weeks). Average age was 58.4 (range 30-82). 6.3% had a prior posterior repair. Pre-op POP-Q stages were mostly stage 2 and 3 (65.7% and 29.8%, respectively). 11.6% underwent a concurrent hysterectomy, 19.0% underwent a concurrent apical suspension. There were only 2 intra-operative complications, neither related to the posterior repair (cystotomy and retropubic hematoma). Eight patients returned to the OR, only 1 of which was for a posterior repair and was considered a failure. Subjectively there was a 9.47% failure rate, however only 3.2% complained of prolapse. Objectively there was a 2.6% failure rate. The primary outcome composite failure rate was 0.53%.

Conclusions: Repair of an apical transverse rectovaginal fibromuscular defect and perineoplasty is a very effective treatment for posterior vaginal wall prolapse.

References

  1. Obstet Gynecol 105:314–318.
  2. Int Urogynecol J 27:735–739.
  3. Am J Obstet Gynecol 195:1762–1771.

Table 1

Surgical Failures of

Site Specific Posterior Repair

N

%

Subjective Only

18

9.47

Objective Only

5

2.63

Composite Score

1

0.53

Disclosure:

Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Acell, Alma Laser, Coloplast, Cook, Pfizer).

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