Concomitant anterior repair, preoperative prolapse severity, and anatomic prolapse outcomes after vaginal apical procedures
Nager, C. W., Grimes, C. L., Nolen, T. L., Wai, C. Y., Brubaker, L., Jeppson, P. C., Wilson, T. S., Visco, A. G., Barber, M. D., Sutkin, G., Norton, P., Rardin, C. R., Arya, L., Wallace, D., Meikle, S. F., & Pelvic Floor Disorders Network (2017). Concomitant anterior repair, preoperative prolapse severity, and anatomic prolapse outcomes after vaginal apical procedures. Female Pelvic Medicine & Reconstructive Surgery. Advance online publication. https://doi.org/10.1097/SPV.0000000000000526
OBJECTIVE: The aim of the study was to compare anterior and overall prolapse prevalence at 1 year in surgical participants with or without concomitant anterior repair (AR) at the time of sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (ULS).
METHODS: This is a secondary analysis of two surgical trials; concomitant AR was performed at surgeon's discretion. Anterior anatomic success was defined as pelvic organ prolapse quantification of prolapse point Ba ≤0 and overall success was defined as pelvic organ prolapse quantification points Ba, Bp, and C ≤0 at 12 months.
RESULTS: Sixty-three percent (441/701) of the participants underwent concomitant AR and were older, more often postmenopausal, had previous hysterectomy, and had higher-stage anterior, but not apical prolapse. Anterior anatomic success was marginally but statistically better in the combined group (SSLF and ULS) with concomitant AR (82% vs 80%, P = 0.03). In subanalyses, the improvement in anatomic support with AR was observed only in the SSLF subgroup (81% vs 73%, P = 0.02) and mostly in the SSLF subgroup with higher preoperative stage (74% vs 57%, P = 0.02). Anterior repair did not improve success rates in participants with lower-stage prolapse or undergoing ULS. Overall success rates were similar to anterior anatomic success rates. Participants with higher-stage preoperative anterior prolapse had significantly lower success rates.
CONCLUSIONS: In the absence of clinical trial data, this analysis suggests an AR should be considered for women with higher-stage prolapse undergoing an SSLF. Preoperative prolapse severity is a strong predictor of poor anatomic outcomes with native tissue vaginal apical surgeries.