In the current study, half of the patients recruited underwent abdominal sacrohysteropexy. However, we performed fixation of the uterus at the level of the uterosacral ligament to the anterior longitudinal ligament without using a mesh; and the rest of the patients were managed by vaginal sacrospinous fixation.
The patients recruited in the present study had some of the risk factors of pelvic organ prolapse, such as high parity (3.650±1.531 and 3.100±1.682, respectively) and high BMI (32.5±4.9 and 30.9±4.5 kg/m2, respectively). About 25% of these patients were postmenopausal (six in the vaginal surgery group and four in the abdominal sacropexy group). None of the patients could recall the weights of their babies at birth. Two patients in the vaginal surgery group had undergone instrumental delivery. Less than half of the patients had been treated previously for repairs of pelvic organ prolapse and stress urinary incontinence in the form of classical repairs.
Most of the patients in this study were in grade III according to the POP-Q system for the evaluation of prolapse. Almost all the patients had similar complaints, among which mass protrusion, pelvic discomfort, and pelvic and back pain were the most distressing and were the main symptoms for which they sought medical attention and intervention; among sexually active women, most of them had sexual complaints.
In our study, it was found that abdominal sacropexy was a safe operation, with no reported cases of rectal injury or massive bleeding, and a shorter operative time (26.750±10.915) in relation to vaginal surgery (48.750±15.379) as the technique of fixation is easy and rapid, involving only one tight suture that fixed the uterus to the sacrum.
There are three major controversies associated with a uterus-sparing surgery for POP. First, many surgeons believe that hysterectomy prevents prolapse recurrence, because the presence of the uterus might subject pelvic reconstruction to undue stress. However, hysterectomy-associated pelvic floor dissection might increase the risk of pelvic neuropathy and disrupt natural support structures, such as the uterosacral cardinal ligament complex 5. Second, uterus preservation may expose the patient to potential pathologies (such as cancer) in what might be considered an almost useless organ. However, after subtotal abdominal hysterectomy, the risk of cervical cancer is less than 0.1%, whereas the incidence of endometrial cancer is 0.2% 6. The third point is related to the complications that are associated with hysterectomy. Some studies have reported that abdominal or vaginal hysterectomy may be associated with de novo or worsening symptoms of urinary incontinence 7.
In the present study, in terms of concomitant posterior repair, about 25% of the patients did it with no difference in outcome between who did or not. Our study showed that apical support was adequate to support the posterior compartment; hence, there was no need for concomitant posterior repair with abdominal sacropexy. However, 65% of patients had undergone posterior repair in the vaginal operation group as a complementary technique in the operation.
In our study of 20 patients, 90% of them were group I after the 6-month follow-up and 10% of them were group II prolapse, and this case of recurrence was because of an intraoperative technical fault, and the remaining 90% showed marked improvement in prolapse symptoms and quality of, also, sexual complaints markedly improved after the operation because of maintenance of vaginal length, in comparison with a 70% success rate in the vaginal surgery group, which record 20% group I and 10% group II in the form of vault prolapse and recurrent anterior wall prolapse. Patients who had undergone abdominal sacropexy had shorter hospital stay (46.200±10.501 h) in comparison with the vaginal group (62.400±12.063 h).
Most postoperative complications could be avoided by administration of prophylactic antibiotics, early ambulation, and careful postoperative observation. Two patients developed postoperative fever that was mild and did not exceed 38°C, and improved with antipyretics. Also, three patients complained of backache that was present more than 1 month after the operation, and in one patient, it was present after the 6-month follow-up. The condition was managed by an analgesic and an injection of vitamin B complex, and it was mostly because of a preoperative problem as some patients with backache showed marked improvement after the operation. One patient experienced delayed intestinal movement for 3 days, and investigations showed no evidence of intestinal obstruction, and she already had a history of constipation.
Complications associated with abdominal sacral hysteropexy seem to be comparable with those associated with sacral colpopexy. Other investigators have obtained a 7% rate for intraoperative complications and a 13% rate for minor postoperative complications. In this study, only one patient developed mesh erosion that was observed 2 years after surgery, and another patient developed a bowel obstruction secondary to occlusion by the mesh 4 years after surgery. In addition, postoperative pregnancy was reported in one study that indicated that six patients wished to conceive after surgery, with only three documented pregnancies occurring 3–6 years after the procedure 7.
Another question that requires answering is as follows: what are the definitions of success and cure in pelvic organ prolapse surgeries? The definition of surgical success after prolapse repair is not standardized. Subjective definitions of cure include patient satisfaction and symptomatic improvement, whereas objective definitions include functional and anatomic outcomes. Traditionally, outcomes have been reported in terms of anatomic results, that is reduction in the degree of prolapse. Unfortunately, because of multiple prolapse grading systems and varying definitions of recurrence used throughout the literature, there is no consensus on any one measurement outcome. Further, most studies have reported that perfect anatomy after repair is not a necessity for good outcomes. Clearly, the evaluation and determination of outcomes as well as the significance of those outcomes after prolapse repair are ill defined, leading to considerable difficulty in the comparison of studies and their results 8. In a recent study carried out by Barber et al. 9, 18 different definitions of surgical success were evaluated in participants who underwent abdominal sacrocolpopexy within the Colpopexy and Urinary Reduction Efforts trial. Treatment success varied widely (19.2–97.2%) depending on which definition was used. The absence of vaginal bulge symptoms postoperatively has a significant relationship with a patient’s assessment of overall improvement, whereas anatomic success alone does not. This leads to the following question: ‘Are we curing anatomy or curing symptoms?’ In the current study, it was difficult to define cure or success anatomically, functionally, or subjectively because of the lack of long-term follow-up data of these patients.
In conclusion, the use of our technique in sacrohysteropexy in the treatment of apical prolapse is safe, easy, low cost, and effective, with the benefits of uterine preservation. In comparison with a vaginal operation, almost the same anatomical results are obtained, with less operative hospital stay, fewer complications, and greater patient satisfaction because of preservation of the uterus and improvement in prolapse-induced urinary symptoms and sexual dysfunction. There is a need for large randomized-controlled trials evaluating the efficacy of this different technique, its applicability using laparoscopy, and the use of different types of suture materials.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2012 Lippincott Williams & Wilkins, Inc.
follow-up; prolapse; sacrohysteropexy; sacrospinal fixation