Abdominal mesh sacrocolpopexy for recurrent triple-compartment pelvic organ prolapse

Authors

  • Jason P. Gilleran,

    1. Department of Urology, The Ohio State University Medical Center, Columbus, OH, and UT South-western Medical Center, Dallas, TX, USA
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  • Philippe Zimmern

    1. Department of Urology, The Ohio State University Medical Center, Columbus, OH, and UT South-western Medical Center, Dallas, TX, USA
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Jason Gilleran, Urology, University of Texas South-western Medical Center, Dallas, 5323 Harry Hines Blvd. ♯J8-122 Dallas, TX 75204, USA.
e-mail: jason.gilleran@osumc.edu

Abstract

OBJECTIVE

To report the short- and intermediate- term outcome of safety and efficacy after abdominal-mesh sacrocolpopexy (MSC) for recurrent anterior, posterior and vault (‘triple-compartment’) pelvic organ prolapse (POP).

PATIENTS AND METHODS

In a database review we identified non-neurogenic women who had MSC for recurrent triple-compartment POP and with a ≥6-month cystographic follow-up. The preoperative evaluation included a history, physical examination, Urogenital Distress Inventory (UDI-6) and visual analogue quality-of-life (QoL) questionnaires, urodynamic studies, and a standing lateral voiding cysto-urethrogram (VCUG) with rest-strain views. All surgery as performed by the same surgeon, using polypropylene (Marlex) mesh. Perioperative data, the VCUG at 6 months, and interval pelvic examinations were recorded.

RESULTS

Between 2000 and 2006, 29 postmenopausal women (Caucasian, mean age 64 years, sd 11) underwent MSC. The mean (sd, range) operative duration was 228 (75, 170–340) min, the estimated blood loss 150 (100) mL and the inpatient stay 3 (1) days. At a mean (sd) follow-up of 23 (16) months, the physical examination showed no evidence of POP of grade ≥2, with mean POP-Quantification scores of −2.8 (0.4), −2.9 (0.4) and −9.3 (0.8) for points Aa, Ap and C, respectively. Two patients (8%) had evidence of grade ≥2 cystocele at the 6-month VCUG. After MSC, four of the six UDI and the QoL scores were significantly lower at the last follow-up than at baseline, with no change in sexual or defecatory function.

CONCLUSIONS

The objective and subjective improvement at the short and intermediate follow-up after MSC suggest that this is a safe and effective treatment for recurrent triple-compartment POP.

Abbreviations
POP(-Q)

pelvic organ prolapse (-Quantification)

MSC

mesh sacrocolpopexy

UDI

Urogenital Distress Inventory

QoL

quality-of-life

BMI

body mass index

UDS

urodynamic studies

VCUG

voiding cysto-urethrogram.

INTRODUCTION

With an ageing population, the incidence of and demand for repair of pelvic organ prolapse (POP) is increasing [1]. The surgical management of POP is challenging and remains debated. Due to various risk factors, POP repair procedures are at risk of failure. In a commonly cited epidemiological study [2], the incidence of repeat surgery for POP was estimated at 29%, with the interval between repairs being less with each successive repair. The abdominal mesh sacrocolpopexy (MSC) technique has been described for vault prolapse alone, but also to repair advanced stages of anterior, vault and posterior prolapse (‘triple-compartment’). However, existing reports have focused on MSC for isolated vault fixation or as a first-line option to address high-grade, multicompartment POP. As most contemporary case series report on patients undergoing both primary and secondary repairs, outcome data specifically for patients with recurrence of POP and undergoing MSC is lacking. Blanchard et al.[3] reported recurrence of any prolapse of grade >2 in 22 of 40 (45%) women undergoing sacrocolpopexy, with 10% requiring a secondary procedure for prolapse. Another short series by Marinkovic et al.[4] reported outcomes on 12 ‘complicated’ patients who had a triple-compartment MSC at a median follow-up of 39 months. In the present study we report on patients who had MSC for recurrent triple-compartment POP to determine if the safety and efficacy of MSC as a secondary repair is consistent with published outcomes for primary repairs.

PATIENTS AND METHODS

After obtaining Institutional Review Board approval, in a retrospective database review we identified all women who had abdominal MSC from 2000 to 2006 at one institution. Inclusion criteria were abdominal MSC for combined symptomatic cystocele, rectocele and vault prolapse, a history of at least one failed previous prolapse repair, and a follow-up of ≥6-month by cystography and/or physical examination. All patients had a detailed history taken, a physical examination with grading of POP using the Baden-Walker halfway classification system [5], two questionnaires, i.e. the Urogenital Distress Inventory (UDI-6), and a visual analogue quality-of-life (QoL) score (0–10, where 0 is ‘pleased’ and 10 ‘terrible’) [6] and urodynamic studies (UDS). Standing voiding cysto-urethrograms (VCUG), with lateral rest and strain views, were obtained to document cystocele severity, defined by the lateral height of the cystocele below the lower edge of the symphysis pubis on straining views, scored as no cystocele, grade 1 (0–2 cm), grade 2 (2–5 cm) or grade 3 (>5 cm) [7].

All surgical procedures were performed by the same surgeon using the same technique. After isolating the right ureter, a broad peritoneal flap is raised extending from the promontory to the vaginal apex. After the apex is exposed, the dissection continues posteriorly as far distally as possible, frequently stopping at the distal third of the vagina because of a previous posterior repair. Next, the supratrigonal bladder is dissected off the anterior vaginal wall (Fig. 1a). After administering i.v. indigo carmine, cystoscopy is used to exclude injury. The mesh material, Marlex (Boston Scientific; Natick, MA, USA), is fixed in place posteriorly and at the apex with fine nonabsorbable sutures. A separate piece of mesh is secured similarly to the anterior vaginal wall, then to the posterior mesh in a T-configuration. The vagina is carefully inspected to exclude suture passage through the vaginal wall and, if present, the suture is removed and passed again at a different site. Based on the local vascular arrangement (Fig. 1b), the mesh is anchored either to the sacral promontory at the top of the sacrum or the anterior longitudinal ligament under no tension using one or two nonabsorbable 3–0 polypropylene sutures (Fig. 1c). The mesh is then covered by the peritoneal flap to prevent bowel adhesions (Fig. 1d). Cystoscopy with i.v. indigo carmine is repeated to exclude ureteric obstruction during the peritoneal closure, and a vaginal pack is placed for 24 h to allow the mesh to lie flat along the rectosigmoid groove with no tension.

Figure 1.

Intraoperative images of MSC showing (a) dissection of the supratrigonal bladder off the anterior vaginal wall, complicated by a scar from a previous anterior colporrhaphy; (b) local vascular arrangement at the sacral promontory, with an example of one possible configuration (inset) and suture placement in the anterior vertebral longitudinal ligament; (c) Marlex mesh secured into position with fine nonabsorbable sutures. The mesh is placed with no tension in a prepared groove alongside the rectosigmoid. (d) Image of the closed peritoneal flap, separating the Marlex mesh from peritoneal contents.

The operative duration, estimated blood loss, hospital stay and early voiding trial information were recorded. Patients were followed at 6 weeks, 6 months, 1 year and yearly thereafter, with a pelvic examination, using both the Baden-Walker and POP Quantification (POP-Q) [8] score, and subjective questionnaires at each visit. The UDI-6 and QoL scores were recorded, categorized as early (<12 months) and intermediate (12–24 and ≥24 months) follow-up, and analysed. Scores from the last visit (i.e. the longest follow-up) in each follow-up period (early or intermediate) were included and compared with the mean baseline (preoperative) scores.

A standing lateral VCUG with rest-strain views was obtained at 6 months after MSC to confirm the repair. Information on bowel and sexual function was recorded but questionnaires on these domains had not yet been validated at the start of this study and therefore were not used. Failure was defined as any prolapse of grade ≥2 on physical examination [7], bladder base descent of >2 cm on the standing lateral straining view of the VCUG, or the need for a reoperation.

The means were compared between baseline and follow-up questionnaire scores using Student’s t-test, with P < 0.05 considered to indicate statistically significance, and with 95% CI provided.

RESULTS

Of 47 patients who had MSC between 2000 and 2006, we excluded those who did not have a triple-compartment repair (13), who did not have a ≥6-month follow-up (three), or who had MSC for a primary repair of POP (two), leaving 29 patients for the final analysis. The preoperative patient characteristics and history are summarized in Table 1[9,10]. All patients had undergone hysterectomy and had failed at least one vaginal repair. Presenting symptoms included a vaginal mass, pressure or bulge (25), voiding difficulties (18), dyspareunia (10), urge incontinence (10), chronic constipation (six), and stress incontinence (two). On physical examination, all patients had prolapse in all three compartments, but 15 had anterior prolapse as the predominant component (Baden-Walker grade 3), seven vault, and seven posterior wall. The preoperative standing cystogram showed grade 3 cystocele in six, grade 2 in 10 and grade 1 in six women. No cystocele was identified on VCUG in four women who had predominantly posterior wall and/or vault prolapse that masked the anterior vaginal wall descent.

Table 1.  The demographics, symptoms and surgical history of the 29 patients; all numerical values are the
DemographicMean (sd, range), n or n (%)
  • *

    Protruding bulge, vaginal pressure, vaginal ulcerations.

  • †Hesitancy, straining, incomplete emptying, and intermittency.

  • ‡Of 14 sexually active before surgery.

  • §

    §Requiring bowel programme.

  • ¶Paravaginal repair (one), goal-post suspension procedure (one).

  • ††

    ††Uterosacral ligament fixation (two), McCall culdoplasty (one), pubococcygeal plication (one), uterine suspension (one).

  • ‡‡

    ‡‡Retropubic urethrolysis (two) excision of previous mesh (one).

Age, years64 (11, 43–80)
Parity 2.9 (1.2, 1–6)
BMI, kg/m226 (3.4, 21–32)
Caucasian29 (100)
Previous hysterectomy29 (100)
HRT (systemic ± local)18 (61)
Preoperative symptoms 
 Local POP symptoms*20
 Voiding symptoms 9
 Urge incontinence 5
 Stress incontinence 1
 Dyspareunia 9
 Chronic constipation§ 4
Number of previous POP repairs 
 One16
 Two10
 > two 3
Type of previous POP repair 
Anterior(30)
 Anterior colporrhaphy21
 Anterior vaginal wall suspension [9] 11
 Other 2
Apical (19) 
 Levator myorrhaphy [10] 11
 MSC 2
 Other†† 5
Posterior (11) 
 Posterior colporrhaphy 11
 Porcine dermis interposition 1
Anti-incontinence surgery (20) 
 Bladder neck suspension18
 Pubovaginal sling 4
Concomitant procedures 
 Enterocele repair (Nichols) 7
 Burch colposuspension 4
 Uni- or bilateral salpingo-oophorectomy 2
 Other‡‡ 3

UDS before MSC were available in 26 women. The filling cystometrogram with no prolapse reduction showed normal filling in 18, detrusor overactivity in four and stress incontinence in four; three women had stress incontinence with gauze-pack reduction. Pressure-flow studies without prolapse reduction were normal in seven women, showed BOO [11] in eight and voiding dysfunction [12] in nine. Concomitant procedures included Nichols enterocele repair [13] in six, salpingo-oophorectomy in two, retropubic urethrolysis in two, and excision of Gore-TexTM from a previous sacrocolpopexy in one. Perineal defects were not repaired because they had been addressed during previous repairs and had not recurred. Previous anti-incontinence surgery had been performed in 22 of 29 women, all of whom were continent before MSC. Of the remaining seven women, three had a concomitant Burch colposuspension, and four had minimal or no stress incontinence and did not undergo prophylactic anti-incontinence surgery.

The mean (sd, range) operative duration was 228 (75, 170–340) min, with a mean estimated blood loss of 150 (100, 50–500) mL and inpatient stay of 3 (1, 2–6) days. All patients were voiding with low postvoid residuals (<100 mL) by bladder ultrasonography at the time of hospital discharge.

The UDI-6 questionnaire data before and after MSC are summarized in Table 2. There was a trend toward lower QoL scores than at baseline soon after MSC and that persisted at >2 years. Compared to a mean (sd) baseline QoL score of 6.5 (3.5), the mean QoL scores were significantly lower at all follow-up visits, with 23 of 29 (79%) women reporting a QoL score of ≤3 at the last visit. Of the six women with QoL scores of >3, four had persistent urgency, frequency and/or urge incontinence (treated with anticholinergic medication), one had urgency and lower abdominal discomfort from a midline bladder hernia, and one complained of discomfort from bone anchors placed during a previous anti-incontinence procedure. All mean UDI scores during the follow-up were lower than at baseline, with the UDI scores for question 1, 5 and 6 significantly lower (P < 0.05) at all follow-up visits (Table 2). There was no self-reported change in sexual function after MSC in 14 patients sexually active before surgery, and no self-reported de novo defecatory dysfunction.

Table 2.  The mean (sd) UDI-6 and QoL questionnaire scores at baseline and at intervals after MSC (early, <12 months; short-term, 12–24 months; and intermediate, >24 months)
VariableBaseline<1212–24>24
  • *

    statistically significant (P < 0.05) by Student’s t-test, vs baseline score.

  • ‘Do you experience, and if so, how much are you bothered by . . .’ 1: ‘frequent urination?’, 2: ‘urine leakage related to the feeling of urgency (sudden desire to urinate)?’, 3: ‘urine leakage related to physical activity, coughing, or sneezing?’, 4: ‘small amounts of urine leakage?’ 5: ‘difficulty emptying your bladder?’ 6: ‘pain or discomfort in the lower abdominal or genital area?(0 = never, 1 = slightly, 2 = moderately, 3 = greatly). QoL: ‘If you had to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?’ (0 = pleased, 10 = terrible).

N patients29252012
Mean (sd) follow-up, months
 NA 6 (4)14 (2)34 (14)
UDI question    
 1 1.7 (1.1) 1.0 (0.9)* 1.0 (0.9)* 0.7 (0.6)*
 2 1.3 (1.2) 1.0 (1.0) 0.8 (0.8) 0.7 (0.6)*
 3 1.2 (1.1) 1.0 (1.0) 0.9 (0.9) 0.8 (0.8)
 4 1.2 (1.1) 0.8 (0.7) 1.0 (0.7) 0.9 (1.1)
 5 1.4 (1.2) 0.4 (0.9)* 0.3 (0.6)* 0.7 (0.9)*
 6 1.6 (1.2) 0.5 (0.8)* 0.7 (1.0)* 0.5 (1.0)*
QoL 6.5 (3.5) 2.2 (2.8)* 1.3 (1.9)* 1.7 (2.7)*

At a mean (sd, range) follow-up of 23 (16, 6–76) months, with 22, 15 and four women with >1, 2 and 3 years of follow-up, respectively, the physical examination showed an asymptomatic grade 1 cystocele in five and a grade 1 rectocele in one. No patient had recurrent enterocele, vault prolapse or required complete removal of the mesh. No woman had significant (grade ≥2) prolapse on follow-up examination, or required a reoperation for recurrent POP. The POP-Q scores at last follow-up showed mean (sd) Aa point of −2.8 (0.4), an Ap point of −2.9 (0.4) and a C point of −9.3 (0.8). No preoperative POP-Q scores were available as we had not yet adopted this system at the inception of the study.

The VCUG at 6 months after MSC was completed in 26 of the 29 women, showing 14 with no evidence of cystocele and 10 with a grade 1 cystocele. Two women (8%) had evidence of a grade 2 cystocele recurrence by VCUG criteria [7]. Physical examination in these two patients showed a grade 1 cystocele in one and no cystocele in the other. Of the three with no VCUG, one was lost to follow-up after 8 months but was doing well at the time with a grade 1 cystocele, while the other two had no recurrent prolapse on physical examination. No patient with grade 1 cystocele was symptomatic and required further surgery. For stress incontinence, 28 of 29 remained dry. One patient, who had undergone a sling procedure, had recurrent stress incontinence 1 year after MSC and proceeded to repeat sling surgery with autologous fascia.

Complications included small bowel obstruction requiring re-exploration and adhesiolysis, and readmission for colitis at 30 and 14 days after MSC, respectively, occurring in one patient each. Vaginal erosion occurred in two patients who presented with vaginal discharge and mild dyspareunia, and required limited mesh excision through a transvaginal repair.

DISCUSSION

This study addresses the use of the current ‘gold standard’ for apical prolapse repair as a secondary procedure for patients in whom previous reconstruction has failed and who present with symptomatic ‘triple-compartment’ POP. The outcomes were comparable with those in previous reports on MSC that have either focused on women undergoing primary repair for POP or have failed to make a distinction between patients with primary or recurrent prolapse [12]. The recently completed CARE trial [14] reported that ≈ 40% of the patients had undergone previous prolapse repair, but made no distinction on outcome after recurrence, as this was not the study’s primary endpoint.

In a recent large comprehensive review of 65 series with ≈ 2200 cases treated with MSC (a mean of 33 patients per series), success rates were reported as 78–100% (when defined as lack of apical prolapse on examination) and 58–100% (when defined as no prolapse on examination) [15]. None of these series specifically reported the outcomes of patients with recurrent prolapse after one or more previous repairs, which was the primary focus of the present series. The mean follow-up was 0.5–3 years, similar to that in the present series. Reoperation rates for POP and secondary stress incontinence were 4.4 (0–18.2)% and 4.9 (1.2–30.9)%. Common complications included vaginal erosion (3.4%), bowel obstruction (1.1%) and colitis (1.6%) [15]. In addition to perioperative and postoperative data being comparable to studies involving primary vault prolapse, the present incidence of complications also did not differ significantly from other larger series, suggesting that MSC is equally safe and effective for more complex patients with recurrent triple-compartment POP. Although any wide- pore polypropylene mesh would have been effective in this repair, we chose to use Marlex mesh, based on its established safety and low-cost.

UDS after MSC were considered invasive and thus omitted, choosing rather to use questionnaire scores as surrogate markers for lower urinary tract function. The change in mean UDI-6 scores at the short and intermediate follow-up showed an improvement in responses to all questions, although the most consistently and significantly improved scores were in the voiding domain (question 5). Previous studies reported a similar improvement in voiding dysfunction after prolapse repair [16]. The reduction in mean scores for frequency and urgency (questions 1 and 2) and QoL suggests that prolapse repair can positively affect bladder function. All of these improvements are reflected in the overall improvement in QoL scores.

To correct a cystocele we relied on radiographic outcome criteria at 6 months to document anatomical repair, in addition to physical examination findings. The VCUG is inexpensive, readily available and helpful in documenting the degree of cystocele recurrence [7], because it is done in a standing patient with a full bladder. Because the anterior vaginal wall dissection during an MSC stopped above the trigone, and most women had a previously well-supported bladder neck and urethra from either previous surgery or concomitant colposuspension (24/29), grade 1 cystoceles were detected on VCUG but tended to remain stable over time on physical examination. Indeed, anterior wall prolapse was also the most common site of recurrence on physical examination, suggesting that the MSC might be limited in its ability to completely address anterior wall prolapse. Radiographic documentation of apical and posterior prolapse often requires MRI with or without dynamic defecography, which we felt was much less cost-effective than the VCUG.

Risk factors that predispose to POP and subsequent recurrence include obesity and/or chronic straining due to constipation or respiratory conditions [17]. In our series, 15 women were aged >65 years at the time of repair, and the mean body mass index (BMI) was 26.1 kg/m2, with 15 categorized as overweight (BMI ≥25) and five as obese (BMI ≥30). A history of constipation, pulmonary disease and family history of prolapse repair in a first-degree relative was identified in four women each. We attempted to intervene in these risk factors by optimizing the management of pulmonary disease, strongly advising against any strenuous activity in the first 3 months after surgery, and starting a bowel programme (dietary modifications, stool softeners) to minimize straining with defecation. Whether or not these preventive actions contributed to the same satisfactory outcome data in this series as in existing data for primary POP repair with MSC is speculative.

No validated questionnaires for sexual and bowel function were available for use at the onset of this series. Since then, the Prolapse/Urinary Incontinence Sexual Questionnaire [18] and Fecal Incontinence Severity Index [19] have been validated. MSC preserves vaginal length and calibre better than many common vaginal repair techniques, and these are favourable factors to preserve or improve sexual function [20]. After surgery, no sexually active woman complained of worsening sexual function, and de novo dyspareunia occurred in two patients late in the follow-up. A prospective study examining changes in questionnaire scores between baseline and on resuming sexual activity after surgery would better address the outcome of MSC on sexual and bowel function.

The retrospective study design and lack of long-term follow-up (>5 years) are recognized limitations of the present study. However, Culligan et al.[21] proposed that a 1-year follow-up might be sufficient for prospective trials on MSC, given that 81% of the failures occur in the first year, and 95% in the first 2 years. Although our results were stable beyond 2 years, a longer follow-up will provide much needed information on the durability of this repair in this high-risk group.

In conclusion, an abdominal MSC appears to be a safe and effective procedure for this selected group of patients with recurrent triple-compartment POP. Women with recurrent POP should be considered for this procedure, for which subjective and objective improvements can be documented at an intermediate follow-up.

CONFLICT OF INTEREST

None declared.

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