Hypothesis / aims of study
Pelvic organ prolapse (POP) affects 6-8% of women. Hysterectomy with anterior colporrhaphy has been the standard of treatment for anterior and apical prolapse in women.
Novel approaches like uterine-sparing proceedings are being used to treat apical POP currently (1).
The aim of this study is to evaluate outcomes and quality of life, using a novel uterine sparing transvaginal mesh for treatment of anterior and apical POP and to evaluate efficacy and safety as well.
Study design, materials and methods
Retrospective, nonrandomized and multicentre study.
From July 2015 to February 2018, thirty two patients underwent apical POP correction with this technique. Polypropylene mesh with U-form was implanted, anchored anteriorly to cervix and posteriorly to both sacrospinous ligaments, that functions as new uterosacral ligaments (BSC mesh®, AMI GmbH, Austria). For anterior POP repair, we used anterior colporrhaphy. When necessary, we repaired pubocervical fascia laterally.
Data collection of clinical chart, clinical interview and exploration of patients were performed. Preoperative evaluation was performed by cough stress test with physical exploration and urodynamics (flowmetry or complete study). When necessary, dynamic MRI was performed. During follow-up, outcomes, complications and evolution were registered at 1, 6, 12 and 24 months. Visual analogical scale about satisfaction with surgery was administered during follow-up. Statistical analysis was done through Stata 2.0.
Results
Twenty-seven patients with a follow up of more than 3 months were included. Median age was 58.7 years and median follow-up was 20.8 months. 37% of patients had pelvic surgery previously and 15% had received hysterectomy. Median BMI was 28.1.
In physical examination, all the patients had anterior POP (stage III or IV), 81.5% apical POP (stage II or more) and 22% posterior POP (stage II or less). Three patients had an important lateral defect of pubocervical fascia which was repaired at the same time (11%).
BSC Mesh was placed in anterior surface of the cervix in 14 patients (51.9%) and in posterior surface in 13 patients (48.1%). One Douglascele was repaired during prolapse correction.
Overall success rate was 92.6%. Objective cure at overall compartments was 74.1%, and subjective cure was 92.6%.
Seven patients presented anatomical POP recurrence (25.9%) and 2 patients presented clinical POP recurrence, referred as bulking symptoms (7.4%).
Low rate of complications was observed: one hematoma in colporrhaphy managed conservatively, one transient voiding dysfunction that was corrected with one month of intermittent catheterization and one vaginal granuloma that was removed. No major or mesh complications have been detected and no reoperations for POP have been performed.
Continence was assessed preoperative and postoperative. Ten patients (37%) had stress urinary incontinence (SUI) and 12 patients (44%) had urgency-urge incontinence (UUI) preoperative.
Of 10 patients with SUI, five patients who received a mild urethral sling were dry. Four patients were cured with colporrhaphy and one patient is still with SUI. Three patients developed SUI (11%) postoperative.
Of 12 patients with UUI, five patients were cured after surgery (42%). No patients developed UUI de novo postoperatively.
Eleven patients had recurrent UTI preoperatively (40.7%). Five patients had no more UTI (45%) after surgery.
Patient satisfaction was assessed with visual analogical scale and mean punctuation was 7.6.
Interpretation of results
High-grade uterine prolapse often requires surgical treatment. Usually, hysterectomy has been performed in these prolapses but this surgery has some important complications, such as blood loss.
Other authors have shown that uterine-sparing surgery is safe and effective in high-grade prolapses (1, 2) and our outcomes demonstrate we can solve prolapse and their symptoms, diminishing complications and blood loss.
Simultaneous stress urinary incontinence treatment remains uncertain. 40% of patients with preoperative SUI were cured only with colporrhaphy. Different guidelines recommend simultaneous treatment when SUI is demonstrated preoperative, but our results show another way. Counseling patient in delaying SUI treatment helps avoid a high number of SUI surgeries. Large series and longer follow-up are needed to confirm these results.