Evaluation of suture material used in anterior colporrhaphy and the risk of recurrence.

Valtersson E1, Husby K1, Elmelund M1, Klarskov N1

Research Type

Clinical

Abstract Category

Pelvic Organ Prolapse

Abstract 462
Urogynaecology 4 - Pelvic Organ Prolapse
Scientific Podium Short Oral Session 22
Thursday 5th September 2019
17:15 - 17:22
Hall H2
Pelvic Organ Prolapse Prolapse Symptoms Surgery
1.Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital
Presenter
E

Emelie Valtersson

Links

Abstract

Hypothesis / aims of study
The wide variety of suture material used in colporrhaphy shows a lack of consensus on the optimal choice. The evidence guiding the choice of suture material is scant. 
In the field of abdominal surgery, the importance of suture material and technique has been thoroughly studied. In the European Hernia Society guidelines on the closure of abdominal wall incision it is recommended to use continuous suture with slowly absorbable material for midline closure of fascia (1). An evidence-based guideline on suture choice in anterior colporrhaphy is far from existing.
Our hypothesis was that the use of rapid absorbable multifilament suture is associated with a higher risk of recurrence in native tissue anterior colporrhaphy than the use of slowly absorbable monofilament suture.
The aim of this study was to investigate the effects of rapid versus slowly absorbable suture on risk of recurrence after native tissue anterior colporrhaphy.
Study design, materials and methods
This longitudinal cohort study was performed secondary to a previously published study on pelvic organ prolapse recurrence after Manchester-Fothergill procedure versus vaginal hysterectomy. Data were collected from four Danish databases and corresponding electronic medical records. The cohort from the primary study included 590 women operated between 2010 to 2014 (2). 
In this study, women were included if they had an anterior colporrhaphy performed in addition to the VH/MP-operation and if information on suture material used during surgery was available. The description of surgical procedures from electronic medical records was read through again by one single author, and data on suture material and suture technique were collected. 
Suture material was divided in three groups based on the length of the strength of the suture. Sutures where the strength was half of the initial strength at 3 weeks or less were categorized as rapid absorbable and sutures where the strength was more than half of the initial strength at 3 weeks were categorized as slowly absorbable sutures. The sutures were also divided into groups based on if they were multifilament or monofilament. There were no slowly absorbable multifilament sutures, thus three groups were made: Rapid absorbable multifilament sutures  (RAMuS), rapid absorbable monofilament sutures (RAMoS), and slowly absorbable monofilament sutures (SAMoS). 
The main outcome was recurrence of POP in the anterior compartment. Recurrence was defined as one or more of the following: POP treated with pessary or surgery, POP-Q stage 2 with POP symptoms, or POP-Q stage > 3 independent of POP symptoms.
Data were analyzed with Cox proportional hazard ratio using univariate and multivariate analyses. Variables with p <0.1 in the univariate analyses were included in the multivariate analysis. 
A p-value of <0.05 was considered statistically significant for all comparisons.
Results
A total of 462 women were included in this study. The groups were comparable on several baseline characteristics, including parity, caesarean section, age, menopausal status and body mass index. However, they differed on some of the parameters, e.g. primary operation, former anterior colporrhaphy, smoking status, stage of anterior and apical prolapse. 
No significant difference in recurrence was found between the three suture-groups. However, a non-significant tendency towards a higher risk of recurrence in the RAMoS group (HR 2.14 (0.75-6.10) p=0.16; Table 2) when compared to the RAMuS group was observed in the cox proportional hazard analysis and in the Kaplan Meier plot (Fig.1).
Interpretation of results
No significant difference in recurrence was found between the three suture-groups, however, when compared to the RAMuS, a non-significant tendency towards a higher risk of recurrence in the group of RAMoS was observed. 
Since this is a secondary study, no power calculation was made, thus, the study might be underpowered to find a difference between the suture material. However, as the RAMuS had the lowest observed recurrence rate in this study, we do not find evidence to support our hypothesis that the use of RAMuS should dispose for recurrence.
Concluding message
In this study, the use of rapid absorbable multifilament suture compared to slowly absorbable monofilament suture does not seem to dispose for a higher risk of recurrence after anterior colporrhaphy. Furthermore, the combination of rapid loss of tensile strength and monofilament structure in suture material might be associated with an elevated risk of recurrence in native tissue anterior colporrhaphy.
Figure 1 Figure 1. Kaplan-Meier curve showing cumulative incidence of recurrence in the anterior compartment as a function of time from having had an anterior colporrhaphy.
Figure 2 Table 2. Univariate and multivariate analyses of recurrence in the anterior compartment using cox proportional hazards ratio (n=462)
References
  1. Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze J, Cuccurullo D, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19(1):1-24.
  2. Tolstrup CK, Husby KR, Lose G, Kopp TI, Viborg PH, Kesmodel US, et al. The Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: a matched historical cohort study. Int Urogynecol J. 2018;29(3):431-40.
Disclosures
Funding NONE Clinical Trial No Subjects Human Ethics not Req'd According to Danish law, ethical approval is not required for non-intervention registry-based studies. Helsinki not Req'd Since the study was a non-intervention registry based study. Informed Consent No