Hypothesis / aims of study
Primary prolapse surgery for uterine prolapse is known to have recurrence around 30-50%. Review of surgical outcome of 240 women receiving vaginal hysterectomy and colporrhaphy for stage II or more uterine prolapse found symptomatic recurrence in 31% and anatomical recurrence in 49% over 3.9 years in the same study center. Advanced stage of prolapse, i.e. stage III or above was shown to be a significant risk factor associated with recurrence. In view of high recurrence rate from primary prolapse surgery on advanced stage of uterine prolapse, concomitant laparoscopic sacrocolpopexy could be a possible option to reduce risks of recurrence. Previous study has been limited by a short-term outcome and small sample size. This study aimed to investigate the intermediate term of surgical outcome after combined vaginal hysterectomy and concomitant laparoscopic sacrocolpopexy for advanced stage of uterine prolapse.
Study design, materials and methods
This is a prospective cohort study performed in an urogynecology tertiary center of a university hospital. Women having stage III or IV uterine prolapse by the definition of pelvic organ prolapse quantification system, who underwent vaginal hysterectomy and concomitant laparoscopic sacrocolpopexy were recruited. Data on pre-operative demographics, intra-operative, immediate, short term and intermediate term of post-operative surgical outcome upon follow-up were collected. Patients were asked to rate their subjective surgical outcome as “same, better, or worse” during every post-operative follow-up. The definition of recurrence was adopted by using the opinion from International Urogynaecology Association Research and Development Committe and duration of follow-up was regarded as intermediate term when more than 2 years.  Validated Quality of life questionnaires (Pelvic Floor Distress Inventory questionnaire, PFDI and Pelvic Floor Impact Questionnaire, PFIQ) were administered pre- and post-operatively.
Total 75 patients were recruited and 72 (96%) of them had complete data of surgical outcome for analysis with a mean follow-up duration of 28 ± 6 months. Details of patients' demographics and operation details were presented in table 1. Mean operative time was 248 minutes ± 50 minutes (range 165-450 minutes). The mean estimated blood loss was 200 ml ± 125 ml (range 50-850 ml). No patient needed blood transfusion intra-operatively or post-operatively. There was neither bladder, bowel injury nor need of conversion to laparotomy. The median post-operative length of stay was 1 day (1,2). Regarding the immediate post-operative complication, there was 1 patient with urinary tract infection (1.4%), while 6 others had febrile episodes (5.6%), all resolved with antibiotics alone in 1 to 2 days. All otherwise had uncomplicated post-operative recovery. There was no recurrence of apical vault prolapse. One (1.4%) direct objective recurrence (stage 2b) was noted in anterior compartment. Another one (1.4%) direct subjective recurrence (stage 2b) was found around 2 years after primary surgery, subsequently undergoing anterior vaginal mesh repair and sacrospinous ligament fixation for repair of stage III cystocele 6 years afterwards. Vaginal mesh exposure with a mean size 0.8 cm was found in 4 patients (5.6 %), all with satisfactory treatment outcome without significant symptoms. Two patients (2.8%) with mesh exposure to vagina underwent repair vaginally and recovered well without recurrence. There were 10 patients (13.9%) complaining of stress urinary incontinence after operation and only 5 (6.9%) of them being de novo in nature after operation. Urge urinary incontinence was found in 4 patients (5.6%) but all were not significantly affecting their quality of life and did not need further investigations or medical treatment. All participants were satisfied with their surgical outcome. There was significant improvement in their quality of life after the operation as shown in both the PFDI and PFIQ questionnaires with p-value <.05 listed in table 2. There was no complaint of pelvic, vaginal pain or dyspareunia upon follow-up.
Interpretation of results
The recurrence rate of pelvic organ prolapse after this combination of operations was lower than vaginal hysterectomy with colporrhaphy done for the similar stage of pelvic organ prolapse in the same urogynaecological center with encouraging results in improvement of patients’ quality of life. Rate of mesh complication was similar to studies on sacrocolpopexy performed as secondary procedure for post-hysterectomy vaginal vault prolapse.