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Surgical Alteration of Genital Hiatus Size and Anatomic Failure After Vaginal Vault Suspension

Vaughan, Monique, H., MD; Siddiqui, Nazema, Y., MD, MHSc; Newcomb, Laura, K., MD; Weidner, Alison, C., MD; Kawasaki, Amie, MD; Visco, Anthony, G., MD; Bradley, Megan, S., MD

doi: 10.1097/AOG.0000000000002593
Contents: Female Pelvic and Reconstructive Surgery: Original Research

OBJECTIVE: To compare anatomic outcomes after native tissue vaginal vault suspension among women categorized by their preoperative and 6-week postoperative genital hiatus size.

METHODS: We performed a retrospective cohort study in women who underwent native tissue vaginal vault suspension between 2005 and 2015. We defined a wide genital hiatus as 4 cm or greater and a normal genital hiatus as less than 4 cm. We compared three groups: 1) women with a wide genital hiatus preoperatively and 6 weeks postoperatively (persistently wide group), 2) women with a wide genital hiatus preoperatively but normal genital hiatus 6 weeks postoperatively (improved group), and 3) women with a normal genital hiatus preoperatively and 6 weeks postoperatively (stably normal group). Our primary outcome was composite anatomic failure at medium term, defined as either recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or a pessary. Data were analyzed with appropriate bivariate analysis and logistic regression.

RESULTS: Our study population consisted of 260 women, with 39 of 260 (15.0%) in the persistently wide group, 157 of 260 (60.4%) improved, and 64 of 260 (24.6%) stably normal. Composite anatomic failure was significantly more likely in the persistently wide cohort as compared with the other groups (persistently wide 51.3%, improved 16.6%, stably normal 6.3%, overall P<.01, significant for all pairwise comparisons). These results were consistent when examining the anterior, apical, and posterior compartments individually. In a logistic regression analysis, the persistently wide group was associated with a 4.4-fold increased odds of composite failure (adjusted odds ratio [OR] 4.41, 95% CI 1.99–9.76, P<.01) compared with the improved group and a 15.8-fold increased odds compared with the stably normal group (adjusted OR 15.79, 95% CI 4.66–53.57, P<.01).

CONCLUSION: Women with a preoperative genital hiatus 4 cm or greater that is not surgically normalized after native tissue vaginal vault suspension are at significantly increased odds of anatomic failure in all compartments.

In women undergoing native tissue vaginal vault suspension, surgical reduction of a wide genital hiatus is associated with decreased odds of anatomic failure at medium term.

Department of Obstetrics & Gynecology, Division of Urogynecology and Reconstructive Pelvic Surgery, Duke University Medical Center, Durham, North Carolina; and the Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Urogynecology and Reconstructive Pelvic Surgery, Women's Center for Bladder and Pelvic Health, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Corresponding author: Monique H. Vaughan, MD, Duke University Medical Center, DUMC Box 3192, Durham, NC 27710; email: monique.vaughan@duke.edu.

Financial Disclosure Dr. Siddiqui is supported by award number K12-DK100024 from the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Siddiqui has also received grant funding from Medtronic, Inc, although neither of these grant funds were utilized for this study. Dr. Visco discloses stock ownership in NinoMed, LLC. The other authors did not report any potential conflicts of interest.

Presented at the American Urogynecologic Society Meeting, October 2–6, 2017, Providence, Rhode Island.

The authors thank Eric Jelovsek, MD, MMEd, for assistance with confirming our statistical analysis and interpreting the data.

Each author has indicated that he or she has met the journal’s requirements for authorship.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.