Hypothesis / aims of study
Levator ani muscle (LAM) avulsions are generally accepted as a risk factor for poorer outcomes after native tissue pelvic organ prolapse (POP) repairs. According to our previously published 1-year results from this study of women operated for anterior and/or midcompartment prolapse with the Manchester procedure, preoperatively diagnosed LAM avulsions on 3D/4D ultrasound had no impact on objective nor patient reported outcomes (1).The aim of this study was therefore to investigate any potential long-term differences in outcomes after the Manchester procedure comparing women with and without LAM avulsions.
Study design, materials and methods
Prospective cohort study of 195 women undergoing the Manchester procedure between October 2014 and January 2017, of whom 160 were controlled at 5 years follow-up (flow-chart). Manchester operations include an anterior colporrhaphy with uterosacral/ cardinal ligament suspension and a colpoperineorraphy, posterior colporrhaphies performed on indication only. LAM avulsions (uni-or bilateral) were diagnosed at inclusion by transperineal ultrasound. At 5 years follow-up the primary outcome was group differences in anatomical anterior and mid-compartment prolapse measurements using the Pelvic Organ Prolapse Quantification (POP-Q) scale. Optimal outcome in the anterior compartment was defined as maximum descent (POP-Q point Ba) to 1 cm above the hymen, equivalent to POP-Q stage 0-1. Optimal outcome in the mid-compartment was defined as maximum descent of cervix (POP-Q point C) to 5 cm or more above the hymen. Secondary outcomes were group comparisons of subjective satisfaction (1-worse to 4-cured), PFDI-20 and PISQ-12 symptom scores and failure rates. Failure was defined as new prolapse treatment, either new surgery, referral to pelvic floor muscle training or pessary treatment. SPSS version 28 (IBM Corp., Armonk, NY, USA) was used for the statistical analyses. Categorical outcomes were compared between women with and without LAM avulsion using Pearsons chi square-test and continous, normally distibuted outcomes were analyzed using independent samples t-test. In cases where the assumptions for these tests were not met, Linear-by-linear association and Fisher's exact test were used, respectively.
Results
Median follow-up time from the Manchester operation was 69 months (range 62-92 months). Women with LAM avulsions were younger (58±12.4 vs 63.2±11.1, p<0.01) and had a lower BMI (24.3 ±3.9 vs 25.7±4.1, p<0.01), but there were no statistically signicificant differences between groups in preoperative POP stage or symptoms. Optimal anatomical outcomes in the anterior and mid-compartments were similar for women with and without avulsions (42% vs 55% and 90% vs 97% respectively),Table 1. Subjective cure was reported by 67% of women with avulsions, compared to 76% without avulsions, p=0.24. Other patient-reported outcomes (subjective satisfaction, PFDI-20 and PISQ-12 symptom scores) were equally good after 5 years among women with and without LAM avulsions, Table 1. Women with LAM injuries reported a significantly greater reduction in sexual distress symptoms with a mean reduction of 3.1 in PISQ-12 scores versus an increase of 6.0 in the no avulsion group (p<0.05). The failure rate also tended to be lower in the avulsion group with 8.0 % versus 9.4 % in the non avulsion group, although the difference was not significant (p=0.75).
Interpretation of results
Long-term (5-years) follow-up show that the Manchester procedure offers equal anatomical and patient-reported outcomes for women with and without LAM avulsions. Anatomical result in the mid compartment was particularly favorable. This contrasts previously published studies using different surgical techniques showing inferior results for women with avulsions.