Posterior colporrhaphy: its effects on bowel and sexual function

Objective To determine the anatomical cure rate of posterior colporrhaphy and its effect on bowel and sexual function one to six years later.
Design Retrospective observational study.
Setting Urogynaecology Unit, St George's Hospital, London.
Participants Two hundred and thirty-one women who underwent posterior colporrhaphy.
Main outcome measures Anatomical and symptomatic cure of rectocoele.
Methods The charts of 231 women who underwent 244 posterior colporrhaphies between 1 January 1989 and 4 January 1994 were reviewed. One hundred and seventy one (74%) were interviewed; 140 (61%) were examined. Mean follow up time was 42.5 months (range 11–74).
Results Two hundred and nine women had prior or concurrent vaginal and/or bladder neck surgery including 38 previous posterior colporrhaphies. Postoperatively prolapse symptoms due to rectocoele decreased (64% vs 31%). Constipation (22% vs 33%), incomplete bowel emptying (27% vs 38%), incontinence of faeces (4% vs 11%) and sexual dysfunction (18% vs 27%) increased. Those with incontinence of stool were more likely to have had two or more posterior colporrhaphies. Sixty-two percent felt that they improved over all after surgery. Additional postoperative symptoms included: vaginal and/or perineal splinting (33%), soiling and/or inability to wipe clean (16%), rectal digitation (23%), incontinence of flatus (19%), and rectal and/or vaginal pain (22%). Thirty-three women (24%) had large rectocoeles, seven of whom did not have impaired bowel emptying.
Conclusions Posterior colporrhaphy corrects the vaginal defect in 76% of women. It does not necessarily correct and may contribute to bowel and sexual dysfunction, particularly in those requiring multiple procedures. The presence of the anatomical defect does not imply dysfunction. The prevalence of bowel symptoms suggests the need for close questioning about bowel habits and the selective use of bowel investigations for some women before surgery.     

Planned cesarean hysterectomy: A preferred alternative to separate operations

Objective: The aim of this study was to evaluate our institutional experience with planned cesarean hysterectomy. Study Design: In this retrospective case-control investigation of a 16-year experience, 100 pregnant women who underwent planned cesarean hysterectomy were compared with 37 patients who underwent cesarean delivery followed by a hysterectomy performed within 6 months. Results: Women undergoing planned cesarean hysterectomy did not have any demonstrable increase in intraoperative or postoperative complications when compared with the cesarean delivery plus later hysterectomy group. Primarily as a result of significantly reduced hospital stay and shorter total operative time, there was a significant financial advantage associated with a single planned cesarean hysterectomy with respect to separate operations. Conclusions: A policy to undertake planned cesarean hysterectomy for carefully selected patients appeared to produce advantages without increasing risks for these patients. Secondarily, it provided resident physicians the opportunity to learn the operation with supervision and under controlled circumstances. (Am J Obstet Gynecol 1999;180:1385-93.)     

Vaginal sacrospinous colpopexy and perineorrhaphy for faecal incontinence: preliminary report

Objective: To review our experience with vaginal sacrospinous colpopexy combined with perineorraphy performed for patients with genital prolapse who concomitantly suffered from faecal incontinence (FI). Setting: Gynaecology Department, Benenden Hospital, Benenden, Kent, UK. Subjects and methods: Between January 1997 and December 2001, 16 patients presented with symptoms of genital prolapse and faecal incontinence. Eleven out of the 16 patients (69%) had anorectal physiological tests and endoanal ultrasound performed before surgery. All patients had sacrospinous colpopexy and perineorraphy. Simultaneous vaginal hysterectomy was performed in two patients and anterior colporrhaphy in six patients. Results: The mean age was 60 years and median parity was 2. The mean operative time was 62 min (range 35–100) and the mean blood loss was 60 ml (range 30–160). The mean follow-up period was 37 months (6–65). Thirteen patients (81%) reported no faecal incontinence after surgery, and two patients (12.5%) reported improvement. One patient (6.5%) had no improvement in her symptom of faecal incontinence after surgery. None of the patients had recurrence of genital prolapse during follow up. Conclusion: Sacrospinous colpopexy combined with perineorraphy can help to cure symptoms of faecal incontinence associated with genital prolapse. The possible mechanisms for such a favourable result are discussed.     

Anterior colporrhaphy: A randomized trial of three surgical techniques

OBJECTIVE: The purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques. STUDY DESIGN: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. We defined "cure" as satisfactory (stage I) or optimal (stage 0) outcome at points Aa and Ba. RESULTS: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (+/- SD) was 64.7 +/- 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) had stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (42%) with standard plus mesh and with 11 of 24 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 +/- 2.7; postoperative score, 1.1 +/- 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation. CONCLUSION: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.     

Vaginal repair with mesh versus colporrhaphy for prolapse: a randomised controlled trial

Objective  To compare vaginal repair augmented by mesh with traditional colporrhaphy for the treatment of pelvic organ prolapse.
Design  Prospective randomised controlled trial.
Setting  Tertiary teaching hospital.
Population  One hundred and thirty-nine women with stage ≥2 prolapse according to the pelvic organ prolapse quantification (POP-Q) system requiring both anterior and posterior compartment repair.
Methods  Subjects were randomised to anterior and posterior vaginal repair with mesh augmentation (mesh group, n  = 69) or traditional anterior and posterior colporrhaphy (no mesh group, n  = 70).
Main outcome measures  The primary outcome was the absence of POP-Q stage ≥2 prolapse at 12 months. Secondary outcomes were symptoms, quality-of-life outcomes and satisfaction with surgery. Complications were also reported.
Results  For subjects attending the 12-month review, success in the mesh group was 81.0% (51 of 63 subjects) compared with 65.6% (40/61) in the no mesh group and was not significantly different ( P -value = 0.07). A high level of satisfaction with surgery and improvements in symptoms and quality-of-life data were observed at 12 months compared to baseline in both groups, but there was no significant difference in these outcomes between the two groups. Vaginal mesh exposure occurred in four women in the mesh group (5.6%). De novo dyspareunia was reported by five of 30 (16.7%) sexually active women in the mesh group and five of 33 (15.2%) in the no mesh group at 12 months.
Conclusion  In this study, vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy 12 months following surgery.     

Posterior intra-vaginal slingplasty for the treatment of vaginal apex prolapse: Medium-term results of 140 operations with a novel procedure

Objectives

Urogynecologists are constantly looking for simple, safe and effective ways to cure vaginal apex prolapse. A novel surgical technique, posterior intra-vaginal slingplasty (PIVS), was reported recently to include both a high therapeutic rate and a low complication rate. The present study was aimed at evaluating the preliminary data of a series of PIVS-treated patients.

Study design

A total of 140 patients with vaginal apex prolapse underwent the PIVS operation in a daycare setting. Pre-operative demographics, operative details and post-operative follow-up data were prospectively collected for all patients.

Results

The PIVS procedure dose requires neither laparotomy nor deep transvaginal dissection as previously required for operative intervention. No intra-operative complications were recorded. The hospitalization period was relatively short. Three patients (2.1%) presented with surgical failure, whereas 137 (97.8%) of the operated patients reported satisfaction with the therapeutic results. One patient had post-operative unilateral gluteal skin infection. She was treated by surgical removal of the infected hemi-tape. Twelve (8.6%) patients had vaginal tape protrusion, of which 11 underwent segmental tape resection at the outpatient clinic. Two patients had spontaneous rejection of the tape while the vaginal apex remained well suspended. One patient suffered from post-operative fever of unknown origin, which was effectively treated with oral antibiotics.

Conclusions

The novel PIVS operation reduces the complication rate and shortens the rehabilitation period previously reported for the types of operation designed in the past to cure vaginal apex prolapse. The current list of results supports the previously reported efficacy, safety and simplicity of this procedure. However, more long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operative technique.     

Tissue trauma after vaginal hysterectomy and colporrhaphy versus abdominal hysterectomy: a randomised controlled study

OBJECTIVE: As the magnitude of tissue trauma can be detected by measuring the blood levels of acute phase reactants, we aimed to evaluate tissue trauma markers after abdominal hysterectomy (AH) and vaginal hysterectomy (VH). We hypothesised that VH will be associated with a reduced increase in the level of acute phase reactants than AH. METHODS: Thirty women out of 92 patients scheduled for hysterectomies between June 2002 and June 2003 were randomised into two equal groups (n = 15) of VH and AH. Their levels of C-reactive protein (CRP), alpha1-antitrypsin (alpha1-AT) and myoglobin (M) were analysed preoperatively and on the second, fourth and sixth days. RESULTS: In both methods of hysterectomy, the operating time (85.3 +/- 6.57 min in the VH group vs 69 +/- 7.54 min in the AH group, P < 0.0001), and hospital stay duration (7.2 +/- 2.5 days in the AH group, 3.1 +/- 1.1 days in the VH group, P < 0.0001) were highly significantly different from each other. Demographic parameters and other parameters which may affect tissue trauma markers were not statistically significantly different in each group. Postoperative increases in all markers were markedly high and showed a high statistical difference in both groups (P < 0.05). The postoperative CRP and M values in both groups were significantly higher in the AH group on the second and fourth days and on the sixth day for M only, whereas alpha1-AT levels were only statistically different on the second day. The tissue trauma markers returned to normal levels on the sixth postoperative day for M, although there still was a statistically significant difference, but remained higher than normal for alpha1-AT and CRP. CONCLUSION: Whenever possible, VH should replace AH because this technique leads to a shorter hospital stay and less tissue trauma, enabling patients to return to their normal lives.     

前盆腔网片重建加阴道后壁桥式修补术治疗子宫脱垂的临床效果

目的:探讨聚丙烯网片前盆腔重建加阴道后壁修补术治疗中重度子宫脱垂的临床效果。方法:选取2010年1月至2013年1月在溧阳市人民医院和同济大学附属同济医院妇产科住院手术治疗的子宫脱垂患者共117例,术前POP-Q评分子宫脱垂Ⅲ~Ⅳ度。患者均采用自制聚丙烯网片前盆腔重建加阴道后壁桥式修补术,术后随访10~46个月,观察治疗效果及手术并发症。结果:117例患者的手术时间45~85min,术中出血量80~170ml。无1例膀胱、直肠损伤,1例于术后12个月复发,3例于术后2年后复发,9例(7.7%)患者术后有会阴部异物感和轻度疼痛,1例网片侵蚀。结论:聚丙烯网片前盆底重建加阴道后壁桥式修补术治疗子宫脱垂的效果良好,术后复发率低,手术并发症少。     

Anterior colporrhaphy versus repair with mesh for anterior vaginal wall prolapse: a comparative clinical study

Purpose

To compare the clinical effectiveness of anterior colporrhaphy versus mesh repair as surgical management of anterior vaginal prolapse.

Methods

Of 50 patients with ≥stage II anterior vaginal prolapse on Pelvic Organ Prolapse Quantification (POPQ) system who were initially approached, 44 consented and underwent surgery. They were randomly recruited into two groups. Group I (23 patients) received anterior colporrhaphy, while group II (21 patients) received soft polypropylene mesh (GYNEMESH*PS, Gynecare, Ethicon, France). Clinical assessment took place preoperatively and postoperatively at definite intervals. Functional and anatomical comparisons were based on comparison between preoperative and 24?months postoperative assessments of symptoms and POPQ stages, respectively. Four patients in total did not complete the follow-up assessments and were excluded.

Results

Both groups showed clinical improvement in their symptoms and POPQ staging at the end of the postoperative follow-up period. Improvement, however, was more significant in the repair with mesh group, as patients in this group reported better improvement of their prolapse symptoms, mainly vaginal bulge/pressure sensation (P?P?P?Conclusion Our data shows that repair with mesh is superior to anterior colporrhaphy with more satisfactory outcome to the patients. Due to the small size of our study and uncertainty of the long-term safety and resilience of the mesh, we recommend larger studies to confirm our preliminary results.     

Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence

OBJECTIVE: Our purpose was to compare the efficacy of anterior colporrhaphy and retropubic urethropexy performed for genuine stress urinary incontinence.STUDY DESIGN: A retrospective analysis was performed on women who underwent either anterior colporrhaphy or retropubic urethropexy for genuine stress urinary incontinence. Patients were identified by a computer-assisted search, and these women were contacted by telephone. The interview was used to assess current continence status. Variables reviewed included demographic data, medications, hormonal status, current smoking history, significant medical and surgical history, and time to recurrence of incontinence. Operative procedure, prior or concomitant hysterectomy, history of previous incontinence procedures, concomitant surgery for repair of other pelvic floor defects, experience level of the primary surgeon, and duration of postoperative catheterization were also documented.RESULTS: Seventy-six women who had undergone surgery for genuine stress incontinence during a 4-year period were identified and evaluated by telephone interview. Fifty-six had undergone anterior colporrhaphy and 20 retropubic urethropexy. Both groups of patients were comparable in age, social status, race, parity, and weight. The duration of follow-up (mean ± SD) was 66.6 ± 14.2 months (range 48 to 96 months). Concurrent surgery to repair other pelvic floor defects was more common in patients undergoing anterior colporrhaphy than in patients undergoing retropubic urethropexy (p < 0.05). Of the 56 patients treated with anterior colporrhaphy, 26 (46%) were continent at the time of interview versus 15 of 20 (75%) treated with retropubic urethropexy (p < 0.05). Times to recurrence for anterior colporrhaphy and retropubic urethropexy were not significantly different. History of previous incontinence procedures, concomitant hysterectomy, previous hysterectomy, duration of postoperative catheterization, obesity, chronic lung disease, and smoking were not correlated with success for either procedure. Experience of the primary surgeon did have a significant effect on success, with attending staff having a better cure rate than resident surgeons (p < 0.05).CONCLUSION: Retropubic urethropexy was significantly more effective than anterior colporrhaphy for long-term cure of genuine stress urinary incontinence. We believe these conclusions should be tempered because of the complex nature of genuine stress incontinence. Patients having anterior colporrhaphy may represent a high-risk group because nearly all of them had associated pelvic floor defects. Experience of the surgeon seems to enhance the liklihood of success and may reflect subtle modifications of technique.     

Incidence of recurrent cystocele after anterior colporrhaphy with and without concomitant transvaginal needle suspension

OBJECTIVE: Our purpose was to compare the recurrent cystocele rate after anterior colporrhaphy versus anterior colporrhaphy performed in conjunction with transvaginal needle bladder neck suspension. STUDY DESIGN: A retrospective chart review of all patients undergoing anterior colporrhaphy with and without needle bladder neck suspension over a 3-year period was conducted. Preoperatively all patients had symptomatic anterior vaginal wall relaxation. Patients undergoing concomitant needle suspension procedures had genuine stress incontinence. Twenty-seven patients underwent anterior colporrhaphy alone, and 40 patients underwent anterior colporrhaphy with needle suspension. Demographic data including age, parity, menopausal status, and use of estrogen replacement was collected for each group. The recurrence rate of anterior vaginal wall relaxation was determined for each group by reviewing standardized postoperative office notes. RESULTS: There was no significant difference in the duration of follow-up between the two groups (13.2 months in the anterior repair group vs 13 months in the anterior repair-needle suspension group). However, a significant difference in recurrent cystocele rates was found between the two groups (7% [2/27] in the anterior repair group compared with 33%[13/40] in the anterior repair-needle suspension group, p < 0.01). CONCLUSION: The incidence of recurrent cystocele is significantly higher after anterior colporrhaphy with concomitant needle bladder neck suspension compared with anterior colporrhaphy alone. This difference may be related to the vaginal retropubic dissection at the time of transvaginal needle bladder neck suspension resulting in an iatrogenic paravaginal defect or denervation of the anterior vaginal wall. (Am J Obstet Gynecol 1996;175:1476-82.)     

Anatomical and functional assessment of anterior colporrhaphy versus polypropylene mesh surgery in cystocele treatment

Objective

To compare the anatomical and functional results of traditional anterior colporrhaphy and polypropylene mesh surgery in cystocele treatment.Study design: Prospective study conducted in the Urogynecology Clinic of Etlik Zubeyde Hanim Maternity and Women's Health Teaching and Research Hospital between June 2006 and February 2007. Forty patients with stage II and III cystocele according to the Pelvic Organ Prolapse Quantification system were allocated by a computer programme to conventional or mesh surgery. Twenty patients each underwent anterior colporrhaphy (group I) or polypropylene mesh (Sofradim^®, Parieten) surgery (group II). Both groups were followed for 12 months.

Results

At the end of the 12th month, anatomical cure rates were 15/20 (75%) and 19/20 (95%) in groups I and II, respectively, and the difference between the two groups was statistically significant (p < 0.05). De novo stress urinary incontinence developed in one patient in group I. Mesh erosion developed postoperatively in three cases (15%).

Conclusion

In terms of anatomical cure rates, polypropylene mesh surgery was the more successful treatment option when compared with anterior colporrhaphy at the end of 1 year follow-up.     

A randomized trial of burch retropubic urethropexy and anterior colporrhaphy for stress urinary incontinence

Objective: In a randomized trial, we compared the success of Burch retropubic urethropexy to the modified anterior colporrhaphy for the treatment of genuine stress urinary incontinence.Methods: Thirty-five patients with stress incontinence were randomly assigned to undergo Burch retropubic urethropexy or modified anterior colporrhaphy. Subjects had preoperative and 1-year postoperative physical examinations, multichannel urodynamic testing, 20-minute pad test, and subjective grading of incontinence severity with questionnaires. Data were evaluated using Fisher exact test, Wilcoxon two-sample test, logistic regression analysis, and analysis of variance.Results: Objective cure 1 year postoperatively was significantly greater for the women treated by Burch retropubic urethropexy than by modified anterior colporrhaphy (16 of 18 [89%] versus five of 16 [31%], relative risk .15, 95% confidence interval .04, .59). Patients’ subjective ratings of incontinence severity 1 year after surgical treatment were significantly lower in women who had Burch retropubic urethropexy.Conclusion: Burch retropubic urethropexy yields a significantly superior objective cure for genuine stress urinary incontinence than the modified anterior colporrhaphy in a randomized trial.     

Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele

STUDY OBJECTIVE: To reveal the efficacy and feasibility of concomitant anterior colporrhaphy and tension-free vaginal tape-obturator to treat stress urinary incontinence (SUI) and concomitant cystocele. DESIGN: Controlled trial without randomization (Canadian Task Force classification II-1). SETTING: University hospitals in Rome, Italy. PATIENTS: Fifty consecutive patients with SUI associated with symptomatic cystocele were enrolled into the study. Exclusion criteria were: uterine prolapse greater than or equal to 1, rectocele greater than or equal to 1, overactive bladder, overactive bladder symptoms, intrinsic urethral sphincter deficiency, urinary retention, previous anti-incontinence and/or prolapse surgery, neurologic bladder, psychiatric disease, body mass index greater than 30, and elevated intraabdominal pressure. The preoperative evaluation consisted of: complete history, physical examination, 3-day voiding diary, and urodynamic testing. The International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) was used to subjectively quantify the patient perception of SUI symptom severity. INTERVENTIONS: All patients underwent an ultralateral anterior colporrhaphy plus tension-free vaginal tape-obturator. MEASUREMENTS AND MAIN RESULTS: In all, 43 (91%) and 46 (92%) patients were objectively cured for cystocele and SUI, respectively. The median operating time, blood loss, and hospitalization were 43 minutes (range 35-56), 64 mL (range 40-148), and 1 day (range 1-2), respectively. Overall early postoperative complication rate was 16%, although all were minor. Only 1 patient, at 12-month follow-up, developed tape erosion that required surgical removal. The ICIQ-UI SF questionnaire scores were 13.4 +/- 6.8 and 3.5 +/- 3.2 (p <.01) between preoperative and 12-month follow-up, respectively. CONCLUSION: Concomitant tension-free vaginal tape-obturator plus ultralateral anterior colporrhaphy are feasible and safe procedures for the treatment of SUI and with associated cystocele with a high success rate and low intraoperative and postoperative complications rate.