Treatment of Vaginal Cuff Prolapses with Posterior Intravaginal Sling and Evaluation of Efficiency with International Consultation on Incontinence Questionnaire—Vaginal Symptoms Method in the Long Term: Preliminary Results
Correspondence: Ahmet Uysal, MD, Department of Obstetrics and Gynecology, Çanakkale 18 Mart University, Çanakkale, Turkey. Tel: +90 0533 263 55 40; Fax: +90 232 743 10 06. Email: email@example.com
Objectives: The aim of this study was to research the efficiency of posterior intravaginal sling (PIVS) procedure in vaginal cuff prolapse, together with possible complications, long-term effects and effects of the method on vaginal and sexual function and quality of life of patients. This retrospective study comprised 21 patients with vaginal cuff prolapse.
Methods: PIVS procedure was performed in 21 patients with vaginal cuff prolapse with quantification stages 2, 3, or 4 of pelvic organ prolapse. Patients were assessed according to the International Consultation on Incontinence Questionnaire—Vaginal Symptoms before and after operation.
Results: The average follow-up period was 24.6 months. The rate of surgical success was 100%, the rate of mesh erosion was 14.2% and the rate of dyspareunia was 33.3%. Vaginal symptom, sexual matter and quality of life scores were statistically significant in the postoperative period compared to the preoperative period (P = 0.001, P = 0.001, P = 0.001, respectively).
Conclusion: PIVS is an effective and reliable method of treating vaginal cuff prolapse. However, its complication profile is not yet at an acceptable level. We believe that the rate of mesh erosion will regress to a more acceptable level with the improvement of mesh technology and postoperative method. The necessary incontinence surgery is easily performed together with PIVS procedure. PIVS restores the vaginal and sexual functions of patients and increases their quality of life significantly.
Vaginal cuff prolapse is generally seen in older women with total or subtotal hysterectomy when the cervix or vagina sags downwards. Vaginal apex support is performed with uterosacral ligament, cardinal ligament, endopelvic fascia and levator ani muscles. Weakness in one or more of these components causes cuff prolapse and is strongly related to high parity and obesity. Women have a 30–40% lifetime risk of pelvic organ prolapse and an 11.1% possibility of undergoing surgery for this reason. The incidence of prolapse requiring surgical correction following hysterectomy is 3.6 per 1000 person-years of risk. The cumulative risk rises from 1% at 3 years after a hysterectomy to 5% at 15 years after hysterectomy. Also, the risk of prolapse following hysterectomy is 5.5 times higher in women with initial hysterectomy for genital prolapse as opposed to other reasons. Some studies have reported an incidence of up to 43%.[1, 2]
Prolapse treatment is generally due to genetic and biological pelvic changes, as well as changes in tissue homeostasis and the effect of topical hormones. The aim of ideal treatment is symptomatic relaxation; protection of urinary, rectal and sexual function; minimal complications; and improvement of quality of life. Surgical management of apical prolapse requires apical suspension procedure. In recent decades, vaginal prolapse has been treated by several different transvaginal or transabdominal procedures, such as sacrospinous colpopexy or abdominal sacral colpopexy. However, the associated high morbidity and recurrence rates have necessitated trials of more effective therapeutic methods and minimally invasive and less morbid surgical techniques.
The posterior intravaginal sling procedure (PIVS) is a minimally invasive surgical technique developed by Petros in 1997 to treat vaginal wall defects. We studied the efficiency of the method in patients who had undergone PIVS, complications during the observation period and changes in vaginal, sexual and life quality in the preoperative and postoperative periods using the International Consultation on Incontinence Questionnaire—Vaginal Symptoms (ICIQ-VS) scale.
2.1. Materials and method
Data was retrospectively collected from 19 patients from Diyarbakır Gynaecology and Children Hospital and two patients from Seferihisar NH State Hospital who had undergone PIVS operation due to vaginal cuff prolapse between 2008 and 2011. Physical examination was performed in all patients before the operation, including detailed history and vaginal smear. Urodynamic test was performed in patients with a complaint of incontinence. Preoperative descensus degrees of patients were assessed using the International Continence Society Pelvic Organ Prolapse Quantification (POPQ) system. Characteristics information was collected for each patient, including age, parity, body mass index, period since the first operation (months), period of complaints (months), operation time (min), period of stay at hospital (h) and use of pessary. Complications in the postoperative period were recorded individually.
2.2. Surgical method
Patients were placed in the dorsal lithotomy position under spinal anesthesia and sterile conditions. The vaginal apex was opened up to the perineum opening. The side-walls of the vagina were opened by hand and the bilateral sacrospinous ligament was reached. A monofilament polypropylene (HEINE Medizin 30 × 30) mesh cut in a T form before the operation was inserted 3-cm lateral and 3-cm inferior to the patient's anus with the aid of j shaped hooks, then moved through the medial of sacrospinous ligament and removed from the vaginal side wall. The T-shaped mesh arms were withdrawn through the same way. The medial proximal section of the T-shaped mesh was fixed to the apex of the vagina and the distal section was fixed to the perineum opening with 2.0 prolene suture. Transobturator tape (TOT) procedure was used for three patients with incontinence symptoms and anterior colporrhaphy (CA) was used for 15 patients with cystocele. Vaginal estrogen treatment was administered for 2 months after the operation.
ICIQ-VS prolapse survey was performed in the preoperative period and 2 years after operation. SPSS version 13.0 (SPSS, Chicago, IL, USA) was used for all statistical analyses. Preoperative and postoperative symptom scores were analyzed using paired t-test.
Average age, parity and body mass index were 61.0 ± 9.2, 8.0 ± 3.5, 29.0 ± 4.7, respectively. On average, patients had undergone previous operation nearly 8 years prior and had complaint of cuff prolapse for approximately 1.5 years. Average operation time was 54 ± 10.46 min and duration of hospital stay was 46 ± 11.49 h. The majority of patients (18/21) had not previously used a pessary for symptoms. PIVS procedure was applied on patients nearly 24.6 months previously (Table 1). One patient had undergone abdominal hysterectomy (TAH), 13 had total abdominal hysterectomy and bilateral salpingo-oopherectomy (TAH + BSO), and seven had vaginal hysterectomy, anterior and posterior colporrhaphy (VAH + CAP) operation before prolapse surgery. According to POP-Q classification, five patients had stage 2, eight had stage 3 and eight had stage 4 descensus (Table 2). Transobturator tape (TOT) was included simultaneously in the treatment of two patients who had stress incontinence in urodynamic tests and incontinence complaint, and colporrhaphy anterior (CA) was included in the treatment of 15 patients who had cystocele symptoms.
Table 1. Patient characteristics
|Age||61.04 ± 9.20||30–70|
|Parity||8.3 ± 3.5||0–16|
|Body mass index||29.76 ± 4.70||22–37|
|Time elapsed since operation (months)||96.95 ± 67.30||8–240|
|Period of complaints (months)||19.80 ± 19.20||2–72|
|Operation time (min)||54.38 ± 10.46||40–72|
|Duration of hospital stay (h)||46.23 ± 11.49||24–70|
|Use of pessary||Yes (3)||No (18)|
|Time since previous PIVS (months)||24.6||18–31|
Table 2. Surgical characteristics of patients
|TAH (1)||Sagging (8)||Stage 2 (5)||PIVS (4)|
|TAH + BSO (13)||Sagging + irritation (7)||Stage 3 (8)||PIVS + CA (14)|
|VAH + CAP (7)||Sagging + chronic pelvic pain + sexual dysfunction + irritation (6)||Stage 4 (8)||PIVS + TOT (2)|
| || || ||PIVS + TOT + CA (1)|
Twenty-four hours postoperatively, urinary infection developed in two patients, temporary urinary retention in one, mesh erosion in three, dyspareunia in seven, and meningitis associated with spinal anesthesia complication in one. The patient with meningitis was treates successfully after 1 week of antibiotic therapy. All mesh erosions developed between the first 2 and 6 months postoperatively. Mesh erosion was less than 2 cm in two patients and healed with local estrogen treatment. One patient had an erosion of 3 cm; partial resection of the erosion was performed, the area was primarily sutured and local estrogen treatment was administered. There were no erosion symptoms in any of the patients at the end of 2 years (Table 3).
Table 3. Postoperative complications
| Urinary infection||2||9.5|
| Short-term urinary retention||1||4.8|
| Meningitis associated with anesthesia||1||4.8|
| Mesh erosion||3||14.2|
Gynecologic controls of patients were made at 2 and 6 months, and at 1 and 2 years, postoperatively. ICIQ-VS scale applied in the preoperative period, and at the follow-up visits in the second year (Table 4). Vaginal symptom, sexual matter and quality of life scores in the preoperative and postoperative periods were P = 0.001, P = 0.001 and P = 0.001, respectively. Postoperative scores were statistically significant individually according to the preoperative period after paired t-test (P = 0.001, P = 0.001, P = 0.001, respectively).
Table 4. International Consultation on Incontinence Questionnaire—Vaginal Symptoms (ICIQ-VS) score
|Vaginal symptom score (ICQVCS)||86.09 ± 11.90||26.19 ± 6.80||0.000|
|Sexual matter score (ICQSMS)||78.90 ± 48.00||46.19 ± 37.60||0.000|
|Quality of life score (ICQQLS)||6.85 ± 1.70||3.14 ± 1.70||0.000|
Using the ICIQ-VS we retrospectively analyzed the efficiency of PIVS procedure, postoperative complication rates and changes in symptoms and life quality of patients. The rate of surgical success was 100% and the rate of postoperative complications associated with the method in the early period was 14.3%. The success of the method in improving the vaginal and sexual symptoms, and quality of life of the patients in comparison to the preoperative period was statistically significant (P = 0.001, P = 0.001, P = 0.001, respectively).
PIVS is effective in patients with vaginal cuff prolapse, it increases their quality of life significantly and has been reported as safe at middle and long follow-up periods
The rate of mesh erosion, which is one of the most important complications of the method, is not clear as no large series have been conducted. This rate, which was reported as about 10%, increased up to 40% in different series. The average rate of mesh erosion was recently reported to be 12%.[10-13] In our series, after 2 years of follow-up, the rate of mesh erosion was 14.2% (3/21), which is in compliance with the average rate reported in the literature. Three mesh erosions occurred in the first 6 months. Two of the patients with mesh erosion (less than 2 cm erosion) were healed using local estrogen and the other patient (3 cm erosion) was healed with partial resection and estrogen treatment. There were no symptoms of erosion in any of the patients at the end of 2 years.
The worldwide rate of mesh erosion is still not within acceptable limits. This problem can be solved by improvement of mesh technology and a more effective postoperative method. The range of complications associated with the method is wide, except the mesh erosion, which varies due to the old age of the patient group and decrease of blood build-up caused by the lack of estrogen effect in the operation area over a long period. Cases of cystitis, fever, vaginal wall hematoma, gluteal vaginal fistula, bladder problems, and rectovaginal fistula have been reported.[10-12] The rates of cystitis and short-term urinary retention (9.5% and 4.8%, respectively) in our series that could be considered as early stage complications were in compliance with the literature. Another important complication associated with surgery is dyspareunia. The rate of dyspareunia secondary to operation varies between 0 and 21%. The rate of dyspareunia was higher (33.3%) in our series in comparison to that in the literature. As all of our patients were sexually active, and partial surgical dilatation was performed with local anesthesia accompanied with estrogen treatment in patients who developed dyspareunia. The patients considered partial dyspareunia as they regained sexual function as a result of prolapse treatment.
Since Petros developed PIVS, it has been discussed whether that method or abdominal sacrocolpopexy should be performed in vaginal cuff prolapse. In a metaanalysis of 321 cases comparing these two methods, the rate of relapse at 2-year follow-up was higher in cases of fixing to the sacrospinous fascia (CI 0.07–0.77). Incisional problems, need for blood transfusion, ileus, and thromboembolism have been seen at rates of 4.6%, 4.4%, 3.6% and 3.35%, respectively, in abdominal sacrocolpopexy operation. Presacral bleeding is a serious problem in abdominal sacrocolpopexy operation. Mesh erosion varies according to mesh type. Some authors have reported that mesh erosion occurs more in sacrocolpopexy performed during hysterectomy. Use of mesh in apex surgery through the vagina is reliable and has a high efficiency. The complication rate requiring reoperation without anesthesia was 0.4–2.3% and the rate of patients requiring reoperation with anesthesia was 1.5–6.0% in follow-up performed between 26 and 78 weeks. The rate of mesh erosion after follow-up at 26–78 weeks was between 4.6% and 10.7%. Although the rate of mesh erosion seems similar in both methods, dyspareunia and bladder problems in vaginal slingoplasties and more systemic and life-threatening complications in abdominal sacrocolpopexy have been encountered. The tolerance rate of the patient for anesthesia, age of patient, experience of the surgeon and cost-effective analyses to be made in further studies will determine which method should be applied.
Some researchers have suggested the need for research into the results of PIVS procedure and its effects on life quality variables in women.[10, 13, 15] There is limited published data on postoperative compared with preoperative life quality. Oliver et al., using the General Health Questionnaire (GHQ-30), stated that PIVS method is a minimally invasive approach in anatomic reshaping of vaginal cuff prolapse. According to their results, it is very successful in correcting vaginal, urinary, intestinal, sexual and psychological symptoms of patients. The scope of the GHQ-30 test includes anxiety, depression, social dysfunction, feelings of incompetence and difficulty in coping. The ICIQ-VS self-completion questionnaire meets the need for a robust instrument to assess a range of vaginal and sexual symptoms, in particular those of pelvic organ prolapse. It can be of use in both routine clinical practice and epidemiological research, particularly when there is a need to assess the severity of these symptoms or the efficacy of treatment.[9, 15] In our study, we have included an assessment of the efficiency of PIVS by explaining in detail the ICIQ-VS scale, which is more specific to our 21 patients during the preoperative and postoperative periods. We believe this is an initiative in the published literature.
Hefni and El-Toukhy evaluated sexual function in 117 patients who underwent sacrospinous colpopexy and determined that 43% had improvement by 2 years. However, those patients were a heterogeneous group of which only 43% had vault prolapse. One study showed that of 75 patients with uterine prolapse, 28% had improvement in sexual function after vaginal hysterectomy and sacrospinous colpopexy. Maher et al. compared abdominal sacral colpopexy and vaginal sacrospinous colpopexy for vaginal vault prolapse. They found no statistically significant difference between the two procedures before and after the operation on sexual function. Cunjian et al. demonstrated the beneficial effects of modified abdominal high uterosacral colpopexy on sexual function of uterine prolapse patients. Pilsgaard and Mouritsen operated on 35 patients with vaginal vault prolapse; after the operation, seven had sexual activity after the operation and two had dyspareunia during follow up.
To our knowledge this is the first study to discuss sexual function after PIVS. We demonstrated that there was statistically significant improvement of sexual function in patients operated with PIVS for vaginal vault prolapse. This result significantly indicates functional relaxation and change in quality of life ensured by the PIVS procedure in the postoperative period in comparison to the preoperative period.
Two years of follow up have shown us that PIVS is an effective and reliable method in the surgical treatment of vaginal cuff prolapse. Its complication profile is not in at acceptable level yet, but we believe mesh erosion will regress to a more acceptable rate with improvements in mesh technology and postoperative methods. The necessary incontinence surgery is easily performed together with PIVS procedure. PIVS recovers vaginal and sexual functions of patients and increases their quality of life significantly.
The authors declare no conflicts of interest.