Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts

Gynecological Surgery, Mar 2013

The surgical treatment of vaginal vault prolapse can either be performed by the vaginal or the abdominal (laparoscopic) route. The objective of this study was to compare the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM) for vaginal vault prolapse. This study compared a prospective cohort of LSC with bone-anchor fixation and mesh limited to the apex to a prospective cohort of TVM as treatment modalities in patients with a symptomatic vaginal vault prolapse (pelvic organ prolapse-quantification (POP-Q) point C ≥ −3). Primary outcome was failure in the apical compartment after 6 month follow-up, defined as POP-Q stage ≥ II with prolapse complaints or re-treatment in apical compartment. Based on an overall failure in all compartments of 23 % in the LSC group and 57 % in the TVM group, 29 patients would be needed in each group with a power of 80 % and alpha 0.05. Ninety-seven women were included, 45 LSC and 52 TVM. The failure rate of symptomatic vault prolapse was 1 (2 %) in each group (p = 0.99). The failure rate (POP stage ≥ II) in any compartment was 23 (51 %) in the LSC group and 11 (21 %) in the TVM group (p = 0.002). Each technique had its own type of complications. Short-term failure rates in the apical compartment after TVM and LSC were similar. In case of anterior or posterior prolapsed, additional mesh insertion or additional vaginal colporrhaphy is indicated in LSC surgery.

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Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts

Gynecol Surg Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts Mariëlla I. J. Withagen 0 1 2 4 Mark E. Vierhout 0 1 2 4 Alfredo L. Milani 0 1 2 4 Guido H. H. Mannaerts 0 1 2 4 Kirsten B. Kluivers 0 1 2 4 Robin M. F. van der Weiden 0 1 2 4 0 G. H. H. Mannaerts Department of Surgery, Sint Franciscus Gasthuis , Rotterdam , The Netherlands 1 A. L. Milani Department of Obstetrics and Gynaecology, Reinier de Graaf Group , Delft , The Netherlands 2 M. I. J. Withagen 3 Department of Obstetrics and Gynaecology, Sint Franciscus Gasthuis , 3045 PM, Rotterdam , The Netherlands 4 R. M. F. van der Weiden ( The surgical treatment of vaginal vault prolapse can either be performed by the vaginal or the abdominal (laparoscopic) route. The objective of this study was to compare the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM) for vaginal vault prolapse. This study compared a prospective cohort of LSC with bone-anchor fixation and mesh limited to the apex to a prospective cohort of TVM as treatment modalities in patients with a symptomatic vaginal vault prolapse (pelvic organ prolapsequantification (POP-Q) point C≥−3). Primary outcome was failure in the apical compartment after 6 month follow-up, defined as POP-Q stage≥II with prolapse complaints or retreatment in apical compartment. Based on an overall failure in all compartments of 23 % in the LSC group and 57 % in the TVM group, 29 patients would be needed in each group with a power of 80 % and alpha 0.05. Ninety-seven women were included, 45 LSC and 52 TVM. The failure rate of symptomatic vault prolapse was 1 (2 %) in each group (p=0.99). The failure rate (POP stage≥II) in any compartment was 23 (51 %) in the LSC group and 11 (21 %) in the TVM group (p=0.002). Each technique had its own type of complications. Short-term failure rates in the apical compartment after TVM and LSC were similar. In case of anterior or posterior prolapsed, additional mesh insertion or additional vaginal colporrhaphy is indicated in LSC surgery. Bone anchor; Laparoscopic sacral colpopexy; Pelvic organ prolapse; Vaginal mesh; Vaginal vault Introduction The incidence of post-hysterectomy vaginal vault prolapse that requires surgery has been estimated at 1.3 per 1,000 women-years [ 1 ]. The risk of pelvic organ prolapse surgery was 4.7 times higher in women whose initial hysterectomy was indicated by prolapsed [ 1 ]. The surgical treatment of vaginal vault prolapse can either be performed by the vaginal (e.g., vaginal sacrospinous colpopexy and total vaginal mesh (TVM), involving mesh placement in the anterior, and apical and posterior compartments) or the abdominal route (e.g., sacral colpopexy). A Cochrane systematic review and meta-analysis on the topic has shown that for the treatment of vaginal vault prolapse the abdominal sacral colpopexy was the superior procedure compared with vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse and less dyspareunia [ 2 ]. Vaginal sacrospinous colpopexy was, however, quicker and cheaper to perform and women returned earlier to activities of daily living. Laparoscopic sacral colpopexy (LSC) provides the potential to combine the success rate of an abdominal approach with the faster recovery associated with a minimally invasive technique. The success rate of LSC has been reported to be 90–100 % for the apical compartment [ 3–8 ]. TVM aims at suspension of the apical compartment by means of a bilateral sacrospinous ligament fixation. The success rate of a TVM has been reported to be 96 to 99 % for the apical compartment and 91 % for all the compartments [ 9, 10 ]. Since the recent publication of the update of the FDA notification on complications of surgical mesh for transvaginal repair of POP, it is even more important to consider which treatment of apical compartment prolapse should be used in the individual patient [ 11 ]. Both abdominal and vaginal techniques treat the apical compartment, but the techniques are very different and not many gynecologists perform both procedures. As a result, only limited data are available that compare these two techniques. In a recent randomized controlled trial, success rate in all vaginal compartments was 77 % for LSC as compared with 43 % in the TVM group [ 12 ]. The aim of this study was to compare LSC and TVM with regard to the management of vaginal vault prolapse in centers with special expertise in either LSC or TVM. Methods This study compared two prospective observational cohorts of consecutive women with symptomatic vault prolapse referred to three centers: Sint Franciscus Gasthuis (SFG), Rotterdam, Radboud University Nijmegen Medical Centre (RUNMC), and Reinier de Graaf Group (RdGG) Delft, the Netherlands. SFG is specialized in LSC with bone-anchor fixation and at the time of the inclusion TVM was not an available therapy in this centre. Both RdGG and RUNMC are specialized in pelvic organ prola (...truncated)


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Mariëlla I. J. Withagen, Mark E. Vierhout, Alfredo L. Milani, Guido H. H. Mannaerts, Kirsten B. Kluivers, Robin M. F. van der Weiden. Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts, Gynecological Surgery, 2013, pp. 143-150, Volume 10, Issue 2, DOI: 10.1007/s10397-013-0786-4