Hypothesis / aims of study
Anterior colporrhaphy is the surgery with the highest recurrence rates among traditional pelvic floor reconstructive surgeries, but the specific factors involved in this recurrence are not well established yet. A recent systematic review, including a large number of different pelvic organ prolapse (POP) surgeries affecting one, two or the three compartments, has point out that levator avulsion, prolapse stage, and family history of POP are significant risk factors for prolapse recurrence (1). Nevertheless, studies focused in the prolapse recurrence after anterior vaginal repair are scarce.
The aim of this study was to identify which demographic or clinical factors were associated with prolapse recurrence in the anterior compartment one year after anterior vaginal repair. Our study hypothesis was that mayor defects in the pelvic floor structures could be associated with higher recurrence rates.
Study design, materials and methods
This was a prospective multicentre study including all women with symptomatic anterior compartment prolapse that were scheduled for surgery in the pelvic floor units of two different hospitals between May 2015 and September 2017. Those women who finally did not have surgery were excluded. Other exclusion criteria were prior POP surgery, use of meshes in POP surgery, or patients unable to complete questionnaires.
Pelvic organ prolapse was described according to the Pelvic Organ Prolapse Quantification (POPQ) system. Prolapse symptoms were identified using the specific questions of the validated Spanish version of the Pelvic Floor Distress Inventory short form (PFDI-20). Levator ani avulsion and hiatal area were identified by translabial three-dimensional ultrasonography performed in supine position with an empty bladder. A complete avulsion was diagnosed on tomographic ultrasound imaging if all three central slices showed an abnormal insertion of the puborectalis muscle on the inferior pubic ramus (2). Levator hiatal area during Valsalva was measured at the plane of minimal hiatal dimensions, and categorized with a cut-off point of 25 cm2 (3). All women underwent a traditional anterior colporrhaphy with fascial plication. Anterior anatomical recurrence was defined as a point Ba equal or greater than 0, and symptomatic anterior recurrence was defined as feeling and/or seeing a vaginal bulge in the vaginal area (women that answered “yes” to the question 3 of the PFDI-20) among women who had been identified as having an anterior anatomical recurrence.
The potential associations of clinical and demographic characteristics with recurrent anterior prolapse were explored by comparison of percentages (Chi-square and Fisher’s test). Multiple logistic regression was used to investigate independent associations. Statistical significance was set at p=0.05.
Results
We recruit 455 patients with symptomatic anterior compartment prolapse that underwent primary vaginal surgery during the inclusion period. One year after surgery 442 (97.1%) attended the follow up visit. In three cases ultrasound data were not available, the remaining 439 women formed the study group.
Mean age was 63.0 years (SD:9.7; range:37-86) and mean body mass index (BMI) was 29.7 kg/m2 (SD:5.4; range:16.8-49.5). The surgery was performed only in the anterior compartment in 185 (32,1%) women, in two compartments in 103 (56.3%), and in the three compartments in 51 (11.6%). Vaginal hysterectomy was performed in 216 (49.2%), posterior colporrahpy in 89 (20.3), and urinary incontinence surgery in 75 (17.1%) women. Avulsion was present in 185 (42.1%) women and hiatal area >25 cm2 in 150 (34.2%).
One year after surgery anatomical recurrence was identified in 126 (28.3%) women and symptomatic recurrence in 21 (4.8%). Risk factors in the univariable analysis for anatomical and symptomatic recurrence were POPQ stage >2, levator avulsion and hiatus area >25 cm2. Age>60 was only a risk factor for anatomical recurrence. We did not find any statistical association between anatomical or symptomatic recurrence and BMI, family history of POP, constipation, abdominal hernia or bronchopulmonary diseases. The results of the multivariable model built with the variables that reached statistical significance is shown in table 1. Women with preoperative more advanced prolapse (POPQ>2), levator avulsion and hiatal area >25 cm2, were independently associated with an increased risk of both anatomical and symptomatic recurrence in the anterior compartment one year after native tissue anterior vaginal repair. Age >60 was associated with a greater risk of anatomical recurrence, but not symptomatic.
Interpretation of results
Anatomical recurrence of anterior compartment prolapse after anterior vaginal repair is high, while symptomatic recurrence occurs less frequently. In this study we have identified three independent risk factors for both anatomical and symptomatic anterior prolapse recurrence, reflecting all of them an important pelvic floor damage. Levator avulsion and abnormal distensibility of the levator hiatus area are considered muscular injuries that could favor connective tissue damage. Advanced prolapse also represents significant structural damage of the patient’s pelvic floor. Therefore, recurrence risk after anterior colporrhaphy is mainly determined by the mayor defects of the pelvic floor structures prior to surgery. The preoperative identification of this greater damage could have as a result a mayor probability of recurrence.