Morphometric analysis of smooth muscle in the anterior vaginal wall of women with pelvic organ prolapse

OBJECTIVE: The purpose of this study was to compare the smooth muscle content of the anterior vaginal wall in normal women and women with pelvic organ prolapse. STUDY DESIGN: Specimens were taken from the apex of the anterior vaginal cuff after abdominal hysterectomy from 28 women with pelvic organ prolapse and 12 control subjects. Smooth muscle cells of the anterior vaginal wall were identified by immunohistochemistry with antibodies to smooth muscle alpha-actin. Morphometric analysis was used to determine the fractional area of nonvascular smooth muscle in the muscularis in histologic cross-sections of the anterior vaginal wall. RESULTS: The fractional area of nonvascular vaginal smooth muscle in the muscularis of women with prolapse was significantly decreased compared with that of control subjects. This decreased fraction of smooth muscle in the anterior vaginal wall was not related to age, race, or stage of prolapse. In women with prolapse, vaginal smooth muscle content was most diminished in specimens from postmenopausal women with no estrogen replacement. The fractional area of muscularis smooth muscle was also decreased significantly in premenopausal women with prolapse. CONCLUSION: The fraction of smooth muscle in the muscularis of the anterior vaginal wall is significantly decreased in women with pelvic organ prolapse compared with normal control subjects.     

Functional and anatomic follow-up of enterocele repairs

OBJECTIVE: To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair. METHODS: Fifty-four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms. RESULTS: Fifty-four women had enterocele repairs as part of their surgery. Mean follow-up time was 16 months (range 6-29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty-three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow-up. CONCLUSION: Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.     

Posterior vaginal wall defects and their relation to measures of pelvic floor neuromuscular function and posterior compartment symptoms

OBJECTIVE: The purpose of this study was to describe the pelvic floor neuromuscular function and posterior compartment symptoms in patients with posterior vaginal wall prolapse. STUDY DESIGN: Two hundred twenty-seven women who were referred to a urogynecology and urology clinic were enrolled prospectively. Each patient completed a health history questionnaire and standardized physical examination that specifically graded uterovaginal prolapse according to the pelvic organ prolapse quantification system. RESULTS: Sixty-nine women had a pelvic organ prolapse quantification system point (most dependent portion of the posterior vaginal wall during straining as measured from the hymeneal ring) of < or =-1. Older age, a history of hysterectomy, a genital hiatus of >3 cm (48% vs 24%; P =.002), and perineal descent of > or =2 cm (14% vs 5%; P =.042) were significantly more common in women with posterior vaginal prolapse. When women with posterior prolapse and symptomatic complaints were compared with asymptomatic women with prolapse, a perineal descent of > or =2 cm (21% vs 0%; P =.004) was significantly more common in the symptomatic group. CONCLUSION: Pelvic floor neuromuscular function should be related to posterior vaginal prolapse and symptoms; however, only perineal descent appears associated strongly with both symptoms and prolapse in this population.     

Biomechanical and biochemical assessments for pelvic organ prolapse

PURPOSE OF REVIEW: It is generally believed that pelvic organ prolapse is multifactorial in etiology. It is still an enigma that some women develop prolapse while others with similar risk factors do not. Assessment of supports of the pelvic organs biomechanically and biochemically may provide the clinician with further insight into the etiology of this complex condition. Furthermore, biomechanical and biochemical studies may prove to be vital in the development of prostheses utilized in the augmentation of surgery for pelvic organ prolapse. RECENT FINDINGS: When compared with clinical studies on pelvic organ prolapse, there is a paucity of recently published literature on biomechanical and biochemical studies of pelvic organ supports. The results on collagen content of vaginal/pelvic tissues in women with prolapse are variable. The amount of smooth muscle in vaginal tissue appears to be lowered in women with prolapse regardless of age compared with controls. Biomechanical analysis of prolapsed tissue in pre and postmenopausal women demonstrates only age-related differences. SUMMARY: Further research is required to ascertain the role of connective tissue components, including smooth muscle, in the support of pelvic organs. Knowledge of biomechanical properties of normal vaginal connective tissue may enhance the development of prostheses designed for use during vaginal prolapse surgery.     

盆腔器官脱垂患者外周血和盆底组织中mtDNA和mtDNA~(4977)的含量及意义

目的:探讨盆腔器官脱垂(POP)患者外周血和盆底不同组织中线粒体DNA(mtDNA)及mtDNA 4977bp缺失(mtDNA4977)的含量变化与POP发生发展之间的关系。方法:采用实时定量PCR法分别检测26例POP患者和21例非POP患者外周血、骶韧带、阴道前后壁组织中mtDNA和mtDNA4977的相对含量。结果:(1)mtDNA在骶韧带中的含量,POP组明显低于非POP组,差异有统计学意义(P<0.05);而mtDNA在POP患者的外周血、阴道前壁和后壁中的含量,与非POP组比较,差异均无统计学意义(P>0.05)。mtDNA4977在POP患者的外周血、骶韧带、阴道前壁和后壁中的含量均显著高于非POP患者,差异有统计学意义(P<0.05)。无论mtDNA还是mtDNA4977,其含量在阴道前壁和后壁之间均无显著差异(P>0.05)。(2)随着POP程度不断加重(分析0到Ⅲ期POP),发现骶韧带中mtDNA含量呈下降趋势,而外周血、阴道前壁和后壁中此趋势不明显;在外周血、骶韧带、阴道前壁和后壁中mtDNA4977的比例却显著增加(P<0.05)。(3)POP患者外周血、骶韧带及阴道壁中mtDNA与mtDNA4977含量均无明显相关性(P>0.05)。mtDNA在POP患者外周血和骶韧带之间呈正相关(P<0.05),而mtDNA4977在POP患者外周血和骶韧带之间无显著相关性(P>0.05)。结论:mtDNA的消耗和mtDNA4977比例增加可能在POP分子水平的发病机制中起重要作用。     

Contractile response of human anterior vaginal muscularis in women with and without pelvic organ prolapse

The aim of this study was to compare the contractility of the anterior vaginal muscularis (AVM) from women with and without pelvic organ prolapse (POP). In vitro experiments were performed to measure the peak force generated in response to potassium chloride (KCl; 125 mmol/L) and phenylephrine by AVM tissue from women with and without POP. Cross-sectional areas and co-localization of α(1A) adrenergic receptor protein with smooth muscle α-actin in AVM strips were determined by histology and immunofluorescence, respectively. There were no differences in the mean amplitude of force generated in response to KCl normalized to either wet weight or muscle cross-sectional area (mN/mm(2)) between women with and without POP (P > .30). However, AVM from women with prolapse produced a significantly higher mean force to KCl normalized to total cross-sectional area compared to controls (P = .007). While the control samples demonstrated a consistent response to phenylephrine, there was no response to this stimulant generated by AVM tissue from women with POP. The proportion of co-localized α(1A) adrenergic receptors with smooth muscle α actin in AVM tissue was significantly less in women with POP compared to normal controls (P < .0001). Although there was significantly greater tissue stress generated by AVM from women with prolapse compared to controls, there were no differences in muscle stress. Absent response to phenylephrine by AVM from women with prolapse may be related to a lower expression of α(1A) adrenergic receptors in vaginal smooth muscle.     

Enterocele: is there a histologic defect?

OBJECTIVE: To examine the histology of the vaginal wall in women with an enterocele confirmed by physical examination, cystoproctography, and intraoperative exploration. METHODS: Thirteen women with posthysterectomy apical and posterior wall prolapse were evaluated with a detailed physical examination, cystoproctography, and intraoperative exploration. All women had enterocele repair. A specimen of full thickness vaginal wall from the leading edge of the enterocele was excised and examined histologically. The histology of these patients was compared with the histology of two comparison groups, five women undergoing hysterectomy without prolapse and 13 women undergoing radical hysterectomy. RESULTS: One woman with an enterocele repaired intraoperatively did not have an enterocele by cystoproctography. One woman with an enterocele repaired intraoperatively did not have an enterocele detected by physical examination. All women with an enterocele repaired had an intact vaginal wall muscularis. No woman had vaginal wall epithelium in direct contact with the peritoneum. The average vaginal wall muscularis thickness in women with enteroceles was 3.5 +/- 1.4 mm, in women with no prolapse 3.2 +/- 0.8 mm, and in women undergoing radical hysterectomy 2.8 +/- 0.9 mm. CONCLUSION: Women with enteroceles have a well-defined vaginal muscularis between the peritoneum and vaginal epithelium.     

Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse

Objective

To determine whether the presence of obstructive defecatory symptoms is associated with the site and severity of pelvic organ prolapse. Methods: A cross-sectional study was performed of women with pelvic organ prolapse of grade 2 or greater who had completed a validated questionnaire that surveyed pelvic floor symptoms. Associations between patient characteristics, site and severity of prolapse, and obstructive bowel symptoms were investigated.

Results

Among 260 women with pelvic organ prolapse, women with posterior vaginal wall prolapse were more likely to report obstructive symptoms, such as incomplete emptying (41% vs 21%, P = 0.003), straining at defecation (39% vs 19%, P = 0.002), and splinting with defecation (36% vs 14%, P < 0.001) compared with women without posterior vaginal wall prolapse. There was no significant association between any bowel symptom and increasing severity of prolapse.

Conclusions

Obstructive bowel symptoms are significantly associated with the presence of posterior vaginal wall prolapse, but not with the severity of prolapse.     

Which women are most affected by delivery-related changes in pelvic organ mobility?

OBJECTIVE: Vaginal childbirth is a risk factor for female pelvic organ prolapse and stress incontinence. Imaging studies have suggested that vaginal delivery leads to increased anterior vaginal wall mobility. The authors intended to define the relationship between antepartum pelvic organ mobility and delivery-related changes in these parameters. STUDY DESIGN: Prospective observational clinical study conducted on 200 nulliparous women recruited from antenatal clinic. Patients were assessed by translabial ultrasound in late pregnancy and 2-5 months postpartum. RESULTS: Vaginal childbirth resulted in highly significant changes to all parameters used to describe pelvic organ mobility. These alterations were more marked in those women with limited pelvic organ mobility prior to childbirth, and these negative correlations were highly significant (anterior compartment r=-0.519, P<0.0001, central compartment r=-0.539, P<0.0001, posterior compartment r=-0.604, P<0.0001). CONCLUSIONS: Women with little pelvic organ mobility before childbirth appear to be those that show most marked delivery-related changes.     

Patient characteristics that are associated with continued pessary use versus surgery after 1 year

OBJECTIVE: The purpose of this study was to identify patient characteristics in women with symptomatic pelvic organ prolapse that is associated with continued pessary use versus surgery after 1 year. STUDY DESIGN: Fifty-nine women with symptomatic pelvic organ prolapse who were satisfied with their pessary at 2 months were evaluated prospectively at 1 year. Characteristics of women who continued to use a pessary were compared with women who underwent pelvic reconstructive surgery to identify predictors for continued pessary use versus surgery. RESULTS: Forty-three women (73%) continued pessary use, and 16 women (27%) underwent surgery. Characteristics that were associated with continued pessary use were older age (76 vs 61 years; p <.001) and poor surgical risk (26% vs 0%; P =.03). Characteristics that were associated with surgery were sexual activity (81% vs 26%; P <.001), stress incontinence (44% vs 16%; P =.03), stage III-IV posterior vaginal wall prolapse (44% vs 16%; P =.03), and desire for surgery at the first visit (63% vs 12%; P <.001). Age >or=65 years was the best cut-off value for continued pessary use, with sensitivity of 95% (95% CI, 84%, 99%) and a positive predictive value of 87% (95% CI, 74%, 94%). Logistic regression demonstrated that age >or=65 years ( P <.001), stage III-IV posterior vaginal wall prolapse ( P =.007), and desire for surgery ( P =.04) were independent predictors. CONCLUSION: Age >or=65 years was associated highly with continued pessary use. Desire for surgery and stage III-IV posterior vaginal wall prolapse were associated with discontinued pessary use and pelvic reconstructive surgery.     

北京郊区女性尿失禁及盆腔脏器脱垂发病情况及其对生活质量影响的抽样调查

目的 调查北京郊区女性尿失禁及盆腔器官脱垂发病情况及其对生活质量的影响。方法 按照整群抽样的方法，选取生活在北京市房山区某自然村18岁以上的常住已婚女性，进行问卷调查，并行妇科检查和B超检查。结果 全村符合调查的女性202人，回收问卷190份，应答率94．1％。调查结果显示，尿失禁的患病率为67例（35．3％）。子宫脱垂49例（25．8％），阴道前壁膨出79例（41．6％），阴道后壁膨出61例（32．1％）。尿失禁对女性日常生活、情绪和性生活的影响率分别为29．9％、23．9％、29．9％，尿失禁以轻度尿失禁为主（占82．1％），尿失禁合并子宫脱垂占31．3％，合并阴道前壁膨出59．7％，合并阴道后壁膨出44．8％。结论 整群抽样调查显示，北京郊区女性尿失禁及盆腔脏器脱垂均较常见，尿失禁患者多合并盆腔脏器脱垂，尤其是阴道前壁膨出，并对生活质量有较大影响。     

The relationship of vaginal prolapse severity to symptoms and quality of life

OBJECTIVE: To assess the relationship and location of vaginal prolapse severity to symptoms and quality of life. DESIGN: A prospective observational study. SETTING: Urogynaecology Unit, Imperial College, St Mary's Hospital, London. POPULATION: Women with and without symptoms of vaginal prolapse. METHODS: All women completed a validated Prolapse Quality of Life (P-QOL) questionnaire. This included a urinary, bowel and sexual symptom questionnaire. All women were examined using the Pelvic Organ Prolapse Quantification system (POP-Q). POP-Q scores in those with and without prolapse symptoms were compared. Urinary and bowel symptoms and sexual function were compared and related to prolapse severity and location. MAIN OUTCOME MEASURES: POP-Q scores, P-QOL scores, urinary and bowel symptoms and sexual function. RESULTS: Three hundred and fifty-five women were recruited-233 symptomatic and 122 asymptomatic of prolapse. The median P-QOL domain scores ranged between 42-100 in symptomatic women and 0-25 in those who were asymptomatic. The stage of prolapse was significantly higher in those symptomatic of prolapse (P < 0.001) except for perineal body (PB) measurement. Urinary symptoms were not correlated with uterovaginal prolapse severity whereas bowel symptoms were strongly associated with posterior vaginal wall prolapse. Cervical descent was found to have a relationship with sexual dysfunction symptoms. CONCLUSIONS: Women who present with symptoms specific to pelvic organ prolapse demonstrate greater degrees of pelvic relaxation than women who present without symptoms. Prolapse severity and quality of life scores are significantly different in those women symptomatic of prolapse. There was a stronger relationship between posterior prolapse and bowel symptoms than anterior prolapse and urinary symptoms. Sexual dysfunction was related to cervical descent.     

Vaginal wall descensus and pelvic floor symptoms in older women

OBJECTIVE: To understand the clinical significance of early pelvic organ prolapse in older women, we studied associations between vaginal descensus and pelvic floor symptoms. METHODS: In this cross-sectional study, 270 women enrolled at one site of the Women's Health Initiative clinical trial completed a questionnaire modified from the Pelvic Floor Distress Inventory on pelvic floor symptoms and underwent a Pelvic Organ Prolapse Quantification (POP-Q) examination. We tested associations between symptoms (individual and grouped) with anterior, posterior, uterine, and maximum vaginal descensus. RESULTS: Mean age was 68 years. Ninety-six percent had POP-Q stages I or II. Only obstructive urinary symptoms and feeling a bulge were associated with vaginal descensus. Obstructive urinary symptom scores increased as anterior (P = .04), posterior (P < .01), and maximal (P = .01) vaginal descensus increased. Urinary incontinence or bowel symptoms were not associated with descensus of any vaginal compartment. 'See or feel a bulge,' reported by 11 women (4%), was associated with descensus in all compartments (P < or = .04 for all) and with prolapse at or beyond the hymen (P < .001). This symptom was specific (100%), but not sensitive (16%) for prolapse, defined as descensus at or beyond the hymen. CONCLUSION: Vaginal support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge. However, symptoms are not useful in discriminating between women with and without milder vaginal wall descensus. Based on these results, we suggest that other etiologies for bothersome bladder or bowel complaints be considered before performing surgery for early pelvic organ prolapse.     

Bilateral uterosacral ligament vaginal vault suspension with site-specific endopelvic fascia defect repair for treatment of pelvic organ prolapse

OBJECTIVE: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. STUDY DESIGN: Forty-six women underwent vaginal site-specific repair of endopelvic fascia defects with suspension of the vaginal cuff to the proximal uterosacral ligaments for pelvic organ prolapse. Outcome measures included operative complications, pelvic organ prolapse quantitation, and assessment of pelvic floor symptoms. RESULTS: After a median follow-up of 15.5 months (range, 3.5 months-3.4 years), 90% of patients had both resolution of vaginal bulging or prolapse symptoms and improvement of the stage of prolapse. There were improvements in all pelvic organ prolapse quantitation measurements except for total vaginal length, for which the median decrease was 0.75 cm. Intraoperatively, ureteral occlusion was noted in 11% (5/46) of patients with universal cystoscopy. In 3 patients the uterosacral suspension sutures were removed and replaced with resolution of the occlusion and in 2 patients ureteral reimplantation was required. Symptomatic prolapse (2 apical segment, 1 anterior, and 1 posterior) developed in 4 patients (10%), and 3 of them underwent reoperation. There were significant improvements in symptoms of bulging and pressure, voiding dysfunction, and vaginal and perineal splinting. CONCLUSION: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.     

脱细胞生物组织补片在盆底重建手术中的应用

目的初步探讨脱细胞生物组织补片在盆腔器官膨出患者盆底重建手术中的应用情况。方法选择北京大学人民医院妇科2006年5月至12月期间接受盆底修补和重建手术并应用脱细胞生物补片的盆腔器官膨出患者20例,其中子宫脱垂19例,子宫切除术后阴道穹隆脱垂Ⅱ度1例;合并存在膀胱膨出20例、直肠膨出17例。20例患者中17例同时行阴道前后壁修补术,3例行阴道前壁修补术;阴道前壁置入补片15例,阴道后壁置入补片2例,阴道前壁和后壁同时置入补片3例。结果20例患者总手术时间平均为113．1min（70～180min）,其中放置补片的时间平均为10min。术中出血平均为175ml（50～300ml）。术后恢复良好,平均随访9．3个月（6～12个月）,未发现补片侵蚀阴道黏膜情况,无感染发生。随访期间4例（20％）患者出现盆腔器官膨出复发,3例为膀胱膨出Ⅰ度,复发时间均为6个月复查时,其中2例随访12个月时仍为膀胱膨出Ⅰ度,另1例随访8个月时也为膀胱膨出Ⅰ度,未见加重;1例为膀胱膨出Ⅱ度,复发时间为6个月复查时;所有复发患者均无临床症状。结论脱细胞生物组织补片用于盆底重建手术,方法简单,操作容易,未见补片侵蚀发生,其长期效果有待进一步观察。     

The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care

OBJECTIVE: This study was undertaken to describe the distribution of pelvic organ support stages in a population of women seen at outpatient gynecology clinics for routine gynecologic health care. STUDY DESIGN: This was an observational study. Women seen for routine gynecologic health care at four outpatient gynecology clinics were recruited to participate. After informed consent was obtained general biographic data were collected regarding obstetric history, medical history, and surgical history. Women then underwent a pelvic examination. Pelvic organ support was measured and described according to the pelvic organ prolapse quantification system. Stages of support were evaluated by variable for trends with Pearson chi(2) statistics. RESULTS: A total of 497 women were examined. The average age was 44 years, with a range of 18 to 82 years. The overall distribution of pelvic organ prolapse quantification system stages was as follows: stage 0, 6.4%; stage 1, 43.3%; stage 2, 47.7%; and stage 3, 2.6%. No subjects examined had pelvic organ prolapse quantification system stage 4 prolapse. Variables with a statistically significant trend toward increased pelvic organ prolapse quantification system stage were advancing age, increasing gravidity and parity, increasing number of vaginal births, delivery of a macrosomic infant, history of hysterectomy or pelvic organ prolapse operations, postmenopausal status, and hypertension. CONCLUSION: The distribution of the pelvic organ prolapse quantification system stages in the population revealed a bell-shaped curve, with most subjects having stage 1 or 2 support. Few subjects had either stage 0 (excellent support) or stage 3 (moderate to severe pelvic support defects) results. There was a statistically significant trend toward increased pelvic organ prolapse quantification system stage of support among women with many of the historically quoted etiologic factors for the development of pelvic organ prolapse.     

A prospective randomized trial using solvent dehydrated fascia lata for the prevention of recurrent anterior vaginal wall prolapse

OBJECTIVE: This study was undertaken to compare outcomes after anterior colporrhaphy with and without a solvent dehydrated cadaveric fascia lata graft. STUDY DESIGN: A total of 162 women were enrolled in a prospective, randomized trial that evaluated the impact of a solvent dehydrated cadaveric fascia lata patch on recurrent anterior vaginal prolapse. Subjects were randomly assigned to standard colporrhaphy with or without a patch. Before and after surgery, subjects were evaluated by both the Baden-Walker and pelvic organ prolapse quantification systems. "Failure" was defined as stage II anterior wall prolapse or worse. RESULTS: Of 154 women randomly assigned (76 patch: 78 no patch), all underwent surgery and 153 (99%) returned for follow-up. Sixteen women (21%) in the patch group and 23 (29%) in the control group experienced recurrent anterior vaginal wall prolapse (P = .229). Only 26% of all recurrences were symptomatic. Concomitant transvaginal Cooper's ligament sling procedures were associated with a dramatic decrease in recurrent prolapse (odds ratio [OR] 0.105 , P < .0001). CONCLUSION: Solvent dehydrated fascia lata as a barrier does not decrease recurrent prolapse after anterior colporrhaphy. Transvaginal bladder neck slings were associated with a significant reduction in the risk of recurrent anterior wall prolapse.     

产后盆底肌肉训练对改善盆底功能的作用分析

目的评价产后盆底肌肉训练对盆底肌肉张力的影响及对盆底功能的作用。方法选择中山大学附属第二医院2007年1~3月收治的165例住院分娩产后6周的产妇进入研究,随机分成两组。锻炼组81例于产后6周进行1疗程盆底肌肉训练(包括生物反馈及电刺激)。对照组84例进行一般的产后健康教育。两组均于产后3个月进行一般情况问卷及国际尿失禁咨询委员会尿失禁问卷表简表(ICIQ-SF)调查,并进行盆底肌肉张力测定。产后12个月进行问卷调查及盆底肌肉张力测定和POP-Q分度,评价盆底肌肉训练的效果。结果锻炼组产后3个月、产后12个月盆底肌肉张力高于对照组。锻炼组及对照组产后3个月压力性尿失禁发生率分别为2.5%(2/81)和11.9%(10/81),两组比较P<0.05;锻炼组及对照组产后12个月压力性尿失禁发生率分别为3.7%(3/81)和11.9%(10/81),两组比较P<0.05。锻炼组及对照组产后12个月POP-QⅠ度脱垂发生率分别为33.3%(27/81)和48.8%(41/84),两组比较P<0.05。结论产后盆底肌肉训练能提高盆底肌肉张力,降低尿失禁发生率,改善阴道前壁脱垂。     

Abdominal sacral colpoperineopexy: A new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse

OBJECTIVE: Our purpose was to assess a modification of abdominal sacral colpopexy in 19 patients. STUDY DESIGN: The rectovaginal space was dissected to the superior aspect of the posterior vaginal fascia still contiguous with the perineal body. Mersilene (Ethicon, Somerville, N.J.) mesh was sutured to this fascia and along the entire posterior vaginal wall. Patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles are reported. Outcome measures included bowel symptoms and pelvic organ prolapse staging. Defecography was performed in three patients. Wilcoxon signed rank analysis was used for comparison of prolapse measures. RESULTS: Mean follow-up was 11 weeks. Bowel symptoms improved in 8 of 11 women. No subjects had greater than stage II prolapse postoperatively and median improvement in stage was 3 (range 2 to 4). The mean decrease in the genital hiatus measurement was 3.13 ± 1.25 (range 2 to 6) cm. Postoperative defecography documented correction of rectoceles and enteroceles and improvement in perineal descent with straining. CONCLUSIONS: Abdominal sacral colpoperineopexy is effective surgery for vaginal vault prolapse associated with perineal descent and posterior vaginal defects.(Am J Obstet Gynecol 1997;177:55)