Study design, materials and methods
We reviewed a prospectively maintained, institutional review board approved database of non-neurogenic women with symptomatic stage 2 or greater anterior prolapse. We included women who underwent prior anterior colporrhaphy with subsequent failure, defined as symptomatic stage 2 anterior compartment prolapse, and were treated by vaginal repair with anterior vaginal wall suspension. The anterior vaginal wall suspension technique is depicted in Figure 1 and Figure 2 below; it restores vaginal support by stabilizing the vaginal plate underneath the urethra and bladder base3. Minimum follow up was one year. Failure following AVWS was defined as stage 2 prolapse or greater, prolapse recurrence on examination, or reoperation for symptomatic anterior pelvic organ prolapse. We collected demographic information, occurrence and location of recurrent prolapse requiring secondary surgical repair, type of secondary surgical repair and perioperative complications. Failure following AVWS was defined as ≥ stage 2 prolapse recurrence on examination or reoperation for symptomatic anterior compartment pelvic organ prolapse. Follow up was evaluated during office visits or, if no recent office visit, then by phone interview with standardized questionnaires for women not seen in past 2 years (n=4). Outcomes measured at the last visit included physical exam and need for further surgery for anterior compartment prolapse.
Between 1996 and 2017, 58 of 587 women met study criteria with mean age 67 years and mean follow-up of 5.5 ± 4.3 years. Intraoperative complication rate was 5% (2 bladder needle passage injuries and 1 patient with blood loss that did not require blood transfusion), and 30-day complication rate was 9% (urinary tract infection, blood loss not requiring transfusion, prolonged catheterization and 3 wound infection). All complications were Clavien I. The median recurrence-free survival was 6.8 years. Prolapse recurrence rate in the anterior compartment was 22%, with a re-operation rate for anterior pelvic organ prolapse recurrence at 14%. These patients requiring reoperation were treated with mesh sacrocolpopexy (n=7) and redo-AC (n=1). Rates of secondary compartment prolapse were 16% apical and 12% posterior.
Interpretation of results
In women with a recurrent cystocele after a traditional anterior colporrhaphy repair, AVWS offers an alternative native tissue repair in the management of recurrent anterior compartment prolapse, especially in women not willing to consider a mesh replacement. AVWS, a modification of the original Raz four-corner suspension, is a vaginal technique with minimal morbidity. Complication rates were low and minor. While the anterior prolapse recurrence rate was 22%, the rate of women requiring re-operation for symptomatic recurrence was only 14%. This vaginal repair technique offers a native tissue repair solution instead of considering a mesh repair placed vaginally or open/robotically. The procedure addresses the residual lateral defect after prior correction of the central defect. Given the delayed timing, long–term follow-up is necessary to detect secondary compartment prolapses.