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)