Anterior compartment pelvic organ prolapse surgery (POP) is a challenge due to high reported recurrence rates. Levator ani muscle (LAM) avulsions have been identified as a risk factor for POP recurrence after surgery, and some vaginal surgeons advocate POP repair with tissue reinforcement using transvaginal meshes  in women with avulsions (1) . Recent publications on native tissue repair techniques, such as the Manchester Procedure, have described satisfactory objective and subjective outcomes in cohorts with unknown prevalence of avulsions. Since at least 25 % of women in POP cohorts are likely to have avulsions (2, 3)  we question the concept of poorer surgical outcomes in these women. We therefore aimed at evaluating the impact of LAM avulsions on failure rate, anatomical and patient-reported outcomes one year after surgery for primary anterior compartment pelvic organ prolapse (POP) with the Manchester Procedure.

A prospective cohort study of 189 women undergoing POP surgery with the Manchester Procedure, a uterus-sparing native tissue repair technique including repair of all three compartments, between October 2014 and January 2017.  LAM avulsions were diagnosed prior to surgery by transperineal ultrasound. Intra- and inter-rater reliability between the first author (SO) and an external evaluator (IV) was calculated using Cohen´s Kappa. Women with and without avulsions were compared for one-year postoperative outcomes; failure rate (defined as new POP treatment), POP Quantification (POP-Q) measurements, subjective satisfaction (rated from 1, worsened to 4, cured), postoperative symptom load (Pelvic Floor Distress Inventory Short Form 20 (PFDI-20)), and sexual function (POP/Urinary Incontinence Sexual Questionnaire (PISQ-12)). A composite outcome was the combination of subjective satisfaction with anterior compartment stage 0 – 1. Factors potentially associated with poor postoperative anatomical (anterior compartment stage  2 or above) or symptomatic (PFDI-20 score) outcomes were analyzed using logistic and linear regression analyses.

The prevalence of LAM avulsions was 50.8 %. For the diagnosis of LAM avulsions on transperineal ultrasound, the inter-rater Cohen´s Kappa was 0.82 and the intra-rater Cohen´s Kappa was 0.80, indicating excellent agreement. Failure rate one year after surgery was similar in both groups; 1% (LAM avulsions) vs. 3.2% (intact LAM), p = 0.36.  Less women with LAM avulsions tended to obtain POP-Q stage 0-1 in anterior compartment (46.9% vs. 58.1%; p=0.08) and stage 0 in mid-compartment (77.1% vs. 86.0%; p=0.11) but the between-group differences were not statistically significant. No significant differences between groups were identified for subjective satisfaction nor responses to PFDI-20 or PISQ-12 questionnaires. The composite outcome of subjective satisfaction with anterior compartment stage 0-1 was also similar across groups (36.5% vs 41.9%, p = 0.44). On regression analyses, LAM avulsions were not associated with poor anatomical or symptomatic outcome. Only preoperative anterior compartment stage 3 or above was associated with poor anatomical outcome (p< 0.01, and only preoperative PFDI-20 score with symptomatic outcome (p<0.001).

LAM avulsions did not impact outcomes at one-year follow-up after the Manchester Procedure for primary anterior compartment POP. Several previous studies in which an association between increased POP recurrence risk and LAM avulsions was found, were performed after isolated anterior compartment repairs.  Women with avulsions have larger hiatal areas, a recognised risk factor for POP, and reconstruction of the perineal body as part of the Manchester Procedure will cause a reduction of hiatal dimensions. We therefore believe that the procedure per se explains why outcomes were similar across groups. Our findings imply that women with avulsions may be treated efficiently with native tissue repair techniques as long as thorough repair is performed in all compartments.

Failure rate one year after primary anterior compartment POP surgery with the Manchester Procedure for was low for the whole cohort. LAM avulsions did not impact treatment failures, nor anatomical or symptomatic outcomes. Therefore, indepent of LAM avulsions, the Manchester Procedure is a safe and efficient treatment option for primary anterior compartment prolapse.

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