Surgical Outcomes of a Combined Surgical Approach for Apical Prolapse Repair

A retrospective chart review of all patients (n =135) who underwent apical prolapse repair from February 2009 to December 2012 performed in a collaborative manner by a Minimally Invasive Gynecologic Surgeon and a Urogynecologist. Demographic data (age, body mass index [BMI], race, gravidity, parity) and surgical information (estimated blood loss, operative time, intraoperative complications, readmission and reoperation rates, presence of postoperative infection) were collected.

Results

The majority of patients were postmenopausal (58.91%), multiparous (mean parity =2.49) and overweight (mean BMI =27.71). Nearly 20% had previous prolapse surgery. The most common surgical procedure was laparoscopic supracervical hysterectomy (LSH) with sacrocervicopexy (59.26%), and the most common vaginal repair was of the posterior compartment (78.68%). The median operative time was 149 minutes (82-302), and the estimated blood loss was 100 mL (10-530). Five intraoperative complications, five readmissions and four reoperations were noted. Performance of a concomitant hysterectomy did not affect surgical or anatomical outcomes.

Conclusion

Combination laparoscopic/vaginal prolapse repair by two separate surgeons seems to be an efficient option for operative management.

Keywords:
sacrocolpopexy; operative time; combined surgery; apical prolapse

Variable	Median (range)	N (%)
Age (years)	55 (31–78)
BMI (kg/m²)	26.60 (18.52–51.30)
Gravidity	3 (0–12)
Parity	2 (0–9)
Menopausal status
Premenopause		53 (41.1%)
Postmenopause		76 (58.9%)
Prior prolapse surgery
Yes		22 (16.3%)
No		113 (83.7%)
Type of surgery for apical prolapse^*
LSH + sacrocervicopexy		80 (59.3%)
Sacrocolpopexy		22 (62.9%)
TLH + USLS		11 (8.1%)
Sacrocervicopexy		7 (5.2%)
TLH + sacrocolpopexy		5 (3.7%)
Histeropexy		4 (2.9%)
LSH + USLS		3 (2.2%)
LSC paravaginal repair		2 (1.5%)
USLS		1 (0.7%)
Concomitant type of vaginal repair
Anterior colporrhaphy		98 (72.6%)
Posterior colporrhaphy		107 (79.5%)
Perineorrhaphy		79 (58.5%)
Operative time (minutes)	149 (82–302)
EBL (mL)	100 (10–330)
Length of stay (days)	1 (0–3)
Intraoperative complications		5 (3.7%)

Variable	Prior hysterectomy(n= 36)	Concomitant hysterectomy(n= 99)	p
Age (mean/SD - years)	57.5 ± 7.5	54.8 ± 9	0.18^a
BMI (mean/SD - kg/m²)	26.3 ± 3.9	28.4 ± 6.9	0.36^a
Gravidity (mean/SD)	2.80 ± 1.64	3.35 ± 1.88	0.12^a
Parity (mean/SD)	2.33 ± 1.07	2.54 ± 1.32	0.39^a
Race (n/%)			0.25^b
White	31 (86.1%)	87 (87.9%)
African American	2 (5.6%)	2 (2%)
Hispanic/other	3 (8.3%)	8 (10.1)
Prior prolapse surgery (n/%)	13 (36.1%)	9 (2.8%)	0.01^b
Prolapse subtype (n/%)
Anterior	21 (58.3%)	56 (56.6%)	0.85^b
Posterior	20 (55.5%)	60 (60.6%)	0.60^b
Uterine		98 (98.9%)	0.45^b
Vaginal vault	13 (36.1%)	4 (0.4%)	0.01^b
Concomitant procedures (n/%)
Transobturator sling	8 (22.2%)	17 (17.2%)	0.02^b
Retropubic sling	4 (11.1%)	35 (35.4%)	0.02^b
Cystoscopy	31 (86.1%)	84 (84.8%)	0.85^b
LSC adhesiolysis	17 (47.2%)	16 (16.2%)	0.01^b
Anexectomy	3 (8.3%)	20 (20.2%)	0.10^b
Surgical variables (n/%) EBL (mean/SD - mL)	95.14 ± 88.09	89.85 ± 51.30	0.67^a
Operative time (mean/SD - minutes)	117.67 ± 36.83	132.19 ± 38.47	0.05^a
Readmission	1 (2.8%)	3 (3%)	0.92^b
Reoperation	2 (5.6%)	3 (3%)	0.52^b
Postoperative infection	4 (11.1%)	8 (8%)	0.65^b
Prolapse recurrence (6 months F/U)	4 (11.1%)	3 (3%)	0.09^b
Mesh complications (n/%)			0.09^b
Infection	2 (5.5%)	0
Infection and erosion	0	1 (0.9%)
Other complications	0	3 (3%)
Mean change in POP-Q measurements
Aa	−3.46	−2.96	0.26^a
Ba	−5.29	−3.59	0.69^a
C	−8.68	−6.53	0.38^a
D	−5	−5.04	0.81^a
Ap	−2.11	−1.21	0.09^a
Bp	−2.96	−1.33	0.07^a
Gh	−2.32	−2	0.29^a
Pb	0.14	0.01	0.70^a
TVL	0.18	0.32	0.44^a

Variable	Cervix absent(n= 89)	Cervix present(n= 46)	p
Age (mean/SD - years)	54.94 ± 9.81	54.28 ± 10.18	0.71^a
BMI (mean/SD - kg/m²)	26.9 ± 3.7	28.1 ± 6.9	0.95^a
Gravidity (mean/SD)	3.29 ± 1.74	3.02 ± 1.98	0.41^a
Parity (mean/SD)	2.48 ± 1.13	2.47 ± 1.47	0.96^a
Race (n/%)			0.55^b
White	77 (86.5%)	41 (89.1%)
African American	2 (2.2%)	2 (4.3%)
Hispanic/other	7 (7.9%)	1 (2.2%)
Prior prolapse surgery (n/%)	7 (7.9%)	15 (32.6%)	0.00^b
Prolapse subtype (n/%)
Anterior	51(57.3%)	26 (56.5%)	0.93^b
Posterior	55 (61.8%)	25 (54.3%)	0.40^b
Uterine		44 (95.6%)	0.05^b
Vaginal vault	89 (100%)	13 (28.3%)	0.00^b
Concomitant procedures (n/%)
Transobturator sling	15 (16.9%)	10 (17.9%)	0.23^b
Retropubic sling	30 (30.3%)	9 (19.6%)	0.23^b
Cystoscopy	74 (83.2%)	41 (89.1%)	0.35^b
LSC adhesiolysis	15 (16.9%)	18 (39.1%)	0.00^b
Anexectomy	15 (16.9%)	8 (17.4%)	0.94^b
Surgical variables (n/%)
EBL (mean/SD - mL) Operative time (mean/SD −minutes)	95 ± 49.93131.87 ± 39.13	84.02 ± 82.61121.46 ± 36.53	0.33^a0.13^a
Readmission	3 (3.3%)	1 (2.2%)	0.64^b
Reoperation	3 (3.3%)	2 (4.3%)	0.77^b
Postoperative infection	8 (8.9%)	4 (8.7%)	0.97^b
Prolapse recurrence (6 months F/U)	5 (5.6%)	2 (4.3%)	0.74^b
Mesh complications (n/%)			0.09^b
Infection	2 (2.2%)	0
Infection and erosion	0	1 (2.2%)
Other complications	0	3 (6.5%)
Mean change in POP-Q measurements
Aa	−3.88	−2.83	0.03^a
Ba	−5.81	−3.46	0.01^a
C	−10.31	−6.04	0.01^a
D	−12.00	−4.46	0.02^a
Ap	−1.96	−1.29	0.51^a
Bp	−3.31	−1.26	0.12^a
Gh	−2.54	−1.94	0.06^a
Pb	0.04	0.05	0.88^a
TVL	0.27	0.28	0.75^a

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[1] Address for correspondence Jon Ivar Einarsson, MD, MPH, PhD, Brigham and Women's Hospital, Minimally Invasive Gynecological Surgery Division, 75 Francis Street, ASB 1-3 - Boston, MA 02115, United States (e-mail: jeinarsson@partners.org).