Abdominal Vault Procedures - A retrospective cohort study looking at short, medium and long-term outcome over 16 years

Saidan D1

Research Type

Clinical

Abstract Category

Pelvic Organ Prolapse

Abstract 804
Non Discussion Abstract
Scientific Non Discussion Abstract Session 37
Pelvic Organ Prolapse Prolapse Symptoms Surgery Female Retrospective Study
1.Queen Elizabeth University Hospital, Glasgow
Links

Abstract

Hypothesis / aims of study
Introduction

This is a large  retrospective cohort study analysing open and laparoscopic sacrocolpoxies and hysteropexies (OSCP and LSCP), with follow-up data of 16years. 

Campbell et al’s systematic review (1) identified one RCT(2) comparing both procedures, with follow-up data of 1year, and 6 smaller cohort studies, concluding that surgical outcomes were comparative. 

Aims of study:

To evaluate the success, complications and need for repeat prolapse surgery after abdominal vault procedures (sacrocolpopexy (SCP) and sacrohysteropexy (SHP)with mesh), and compare outcomes based on route of abdominal surgery – LSCP and OSCP.
Study design, materials and methods
Retrospective cohort study. Patients who had abdominal vault procedures from 2002–2018 were identified from hospital audit databases and surgeons’ theatre logs; electronic notes were reviewed. 

 
Success was assessed routinely at 3-6 month follow up, where patients fill out a departmental questionnaire, and are examined. This questionnaire asks patients whether they feel their symptoms are cured, improved, no change or worse, based on BSUG database. We defined success as patients who stated that the prolapse symptoms were improved/cured. 

Medium and long-term data was obtained from patients who re-presented to the urogynaecology service; we have had to assume that patients who did not re-present to our service, who have not moved out the area and not presented to another unit, remain satisfied.
Results
251 patients were identified. 

There were 7 LSCP cases between 2002-2006, 7 in 2007-2011,  37 in 2012-2016, and 53 cases in 2017-2018. 

Patient Demographics. 

The majority of patients 160 (64%) were post-menopausal. 

In OSCP, the age range was 27-77years, with a mean age of 56 years. The Body Mass Index (BMI) in this group ranged 23-38 (mean=28). 

In LSCP, the age range was 24- 88 years, with a mean age of 50years. The BMI range in this group was 22-40 (mean=25). 


112 patients (45%) had pelvic surgery for prolapse previously, including 47 patients (42%) who had surgery for vault prolapse. These included 2patients (4%) who had a previous laparoscopic sacrohysteropexy and 3patients (6%) who had previous open sacrocolpopexy. The remainder of patients had sacrospinous fixation (SSF)19 (40%), and 23 patients who had vaginal hysterectomy without SSF(53%). 
Twenty-six patients (10%) had a total hysterectomy previously. 

204(81%) had SCP for primary vault prolapse and 47 (19%) had surgery for recurrent vault prolapse (table1).

Table 1. OSCP vs LSCP assessing nature of prolapse, surgery and complications  

Multi-compartment Prolapse (Table1): Overall 43(24%) had rectocele and vault, 70(39%) cystocele and vault, and 69(38%) cystocele, rectocele and vault. 

Although 73% had multi-compartment prolapse, only a third of patients in both groups required concomitant pelvic floor repair at the time of vault surgery. In the majority of patients, a Y-mesh implant was used to address multi-compartment prolapse with less patients requiring concomitant PFR.

112 (45%) has concomitant sub-total hysterectomy to aid mesh placement.

Complications 


Intra-operative complications 

Visceral injury: In LSCP group, 3(3%) patients had bladder injury and 1patient (1%) had bowel injury which were managed intra-operatively. There were no visceral injuries in OSCP group.

Return to theatre: In LSCP, 2(2%) patients had port site small bowel herniation in immediate post-operative period and returned to theatre to repair the defect. One patient (0.7%) in OSCP returned to theatre, due to bleeding from the vaginal vault.  

Wound Infection: In LSCP 5 (5%) had wound infection and 11 (7%) in OSCP developed wound infection.

Medium/Long term complications

Mesh related complications: 
•	Vaginal exposure: 1patient in LSCP and 3 in OSCP group. All had trimming of the exposed mesh. The patient in the LSCP group had a vaginal assisted laparoscopic SCP. 
•	Mesh Perforation into bladder. 1(1%) patient in the LSCP group, which was treated with cystoscopic laser mesh excision.

Pain

25 patients (10%) complained of pain (7 backache, 4 abdominal, 6 bladder, 6 vaginal; 2 patients complained of generalised pain that they attributed to the mesh). The pain rate comparable in both groups.  Patients with backache were investigated with MRI scan, with no positive findings related to mesh, and were managed conservatively.

Table 2. Outcomes (Short, medium and long-term) of OSCP and LSCP

Success

Overall 209 (95%) reported success at short term with 100% OSCP and 94% in LSCP. At medium-term (94 patients), overall success was 87%, with 85% OSCP and 90% in LSCP.  14 patients with long-term follow up had 87% success overall with 85% OSCP and 90% LSCP. 

Failed Surgery

Overall, 9(6%) patients in OSCP and 6 (6%) in LSCP had recurrent vault prolapse. 9 opted for further vault surgery, including 6 open SCP, 1 redo SHP and 2 SSF. 

There were 10(5%) recurrences of non-vault POP in OSCP and 6(3%) in LSCP. Five of these opted for further surgery and had vaginal repair of POP. 

There were 2cases in OSCP and 5 in LSCP, of new non-vault POP, 3 of whom opted for vaginal POP repair. 

The maximum failure rates for vault prolapse were identified at medium-term. Similarly, failed non-vault prolapse and new onset non-vault were identified mainly at medium-term.
Interpretation of results
Over the last 16years, our laparoscopic service has developed, with our unit now offering LSCP routinely as surgical management of vault prolapse. 

We found high success rates with SCP, in patients with both primary and recurrent vault prolapse, with comparable results with LSCP and OSCP. 

There were low intraoperative and postoperative complications

The low mesh exposure rate in our cohort is likely due to STH performed with SCP rather than total hysterectomy. Vaginal mesh exposure in OSCP were seen in patient with previous hysterectomy and in LSCP with women having vaginally assisted LSCP, which both are known to have higher mesh exposure rates(1). There was no case of mesh exposure in SHP group.

In our cohort of patients there is no overall difference in outcome based on route of surgery.
Concluding message
Our results confirm previous findings that SCP is a safe and efficacious surgical treatment for apical vaginal prolapse and provides good support. The success rate at short term was maintained at medium term and was high. Though numbers in long-term follow-up group is small, the results are encouraging, with very few patients returning to our service with recurrence. 

LSCP offers comparable outcome with OSCP.
Figure 1
Figure 2
References
  1. P.Campbell,Louise Cloney, Swati Jha. Abdominal Versus Laparoscopic Sacrocolpopexy: A Systematic Review and Meta-analysis.Obstet Gynecol Surv. 2016 Aug;71(7):435-42.
  2. R. M. Freeman , K. Pantazis ,A. Thomson ,J. Frappell , L. Bombieri , P. Moran ,M. Slack ,P. Scott ,M. Waterfield.A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Int Urogynecol J (2013) 24:377–384
Disclosures
Funding None Clinical Trial No Subjects None