Laparoscopic Sacrocolpopexy Plus Colporrhaphy With a Small Intestine Submucosa Graft Versus Total Pelvic Floor Reconstruction for Advanced Prolapse: A Retrospective Cohort Study

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Int Neurourol J. 2019;23(2):144-150

Publication date (electronic) : 2019 June 30

doi : https://doi.org/10.5213/inj.1938014.007

Junyan Wang^1,2,*, Xiaojuan Wang^1,2,*, Keqin Hua^,1,2, Yisong Chen^,1,2

¹Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China

²Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China

Corresponding author: Yisong Chen http://orcid.org/0000-0002-2639-8753 Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai 200090, China E-mail: cys373900207@qq.com / Tel: +86-13601913713 / Fax: +86-21-63455090

Co-corresponding author: Keqin Hua http://orcid.org/0000-0001-5359-8841 Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai 200090, China E-mail: huakeqinjiaoshou@163.com / Tel: +86-21-33189900 / Fax: +86-21-63455090

*Junyan Wang and Xiaojuan Wang contributed equally to this study as co-first authors.

Received 2019 January 14; Accepted 2019 February 27.

Abstract

INTRODUCTION

Pelvic organ prolapse (POP) is a major healthcare problem for elderly women worldwide and has a serious impact on the quality of life. The prevalence rates of POP varied from 41% to 75% [1-3]. Surgery is the main treatment for advanced POP [4]. Since the introduction of polypropylene mesh for POP in the late 1990s, evidence from randomized trials has shown that transvaginal mesh (TVM) resulted in greater treatment rates than native tissue surgery [5]. Over the years, TVM has ever become a global treatment for POP and has been entered in main surgery in majority pelvic floor surgery centers worldwide [6].

However, the high complications, such as mesh exposure, pelvic pain, and dyspareunia, related to synthetic mesh resulted in warnings from the U.S. Food and Drug Administration in 2008 and 2011 [7]. To decrease mesh-associated complications and improve anatomical outcomes, biological grafts were used as alternatives to synthetic mesh, and grafts derived from cadavers and animal-derived collagen matrices were developed [8]. Culligan et al. [9] compared the surgical outcomes 12 months after laparoscopic sacrocolpopexy (LSC) with porcine dermis and that with polypropylene mesh and found that both had similar outcomes in subjective or objective results. Feldner et al. [8] compared the small intestine submucosa (SIS) graft with traditional colporrhaphy for surgical treatment of anterior vaginal prolapse and found that SIS repair improved point Ba significantly. Liang et al. [10] used complete and nonsplice SIS patches for total pelvic anatomical repair of organ prolapse in 17 patients and found that one patient experienced stage II anterior vaginal wall prolapse after surgery and no organ damage, infection, erosion, or rejection was observed.

Additionally, sacrocolpopexy is the gold standard for the treatment of advanced apical prolapse [11], which is associated with fewer complications. There are few publications about LSC plus colporrhaphy with an SIS graft for advanced POP. Here, we aimed to compare anatomic and functional outcomes after the treatment of advanced POP by LSC plus colporrhaphy with an SIS graft versus TVM.

MATERIALS AND METHODS

This study was approved by the Ethics Committee and the Institutional Review Board of Obstetrics and Gynecology Hospital. For this retrospective study, data were analyzed from patients who underwent LSC plus colporrhaphy with SIS graft (group A) or TVM (group B) at a tertiary university-affiliated hospital between September 1, 2015 and November 30, 2016. All patients who underwent the above surgical procedures were diagnosed with stage III genital prolapse in at least 2 parts according to the Pelvic Organ Prolapse Quantification (POP-Q) system [11]. Patients with incomplete data, mental disorders, or death during follow-ups were excluded. This study has been reported in accordance with the STROCSS (Strengthening the Reporting of Cohort Studies in Surgery) criteria [12].

The demographic information included age, body mass index, parity, degree of prolapse upon examination, history of either prolapse surgery or hysterectomy and were recorded. Anatomical outcomes were based on POP-Q measurements by 2 experienced surgeons. Functional outcomes were assessed preoperatively and postoperatively by the validated Chinese version of the Pelvic Floor Distress Inventory questionnaire (PFDI-20; range 0–80, with higher scores indicating worse function), including the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), the Colorectal-Anal Distress Inventory 8 (CRADI-8), the Urinary Distress Inventory 6 (UDI-6), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12; range 0–80, with higher scores indicating better function) [13,14].

RESULTS

During the study period, 76 patients were enrolled for analysis. In total, 26 patients experienced LSC plus colporrhaphy with the SIS graft, 2 of them were performed concurrent midurethral sling (MUS); 50 patients underwent TVM, 5 of them were given MUS. There were no significant differences in age, body mass index, frequency of stress urinary incontinence, or other characteristics between the 2 groups (Table 1). The estimated blood loss during the operation was similar in both groups. However, the length of operation was significantly longer in LSC plus colporrhaphy with the SIS graft than in TVM (P<0.001). There were no blood transfusions in either group. One patient who underwent TVM experienced bladder injury and was given suturing during the operation and then recovered completely. Nine patients (34.6%) underwent LSC plus colporrhaphy with the SIS graft experienced vaginal infection, which was significantly more than those who underwent TVM (n=7; 14%) (P=0.038). Vaginal infection usually occurred 5 days postoperation and was proven to be infected with Escherichia coli or Enterococcus faecalis by culturing the vaginal discharge. Moreover, the postoperative hospital stay of group A was significantly longer than that of group B (P<0.0001). Mesh exposure occurred in both groups, with 8 patients (30.7%) in group A and 5 patients (10%) in group B, which was significantly different (P=0.027). These patients were successfully given mesh excision in outpatients. Patients with mesh exposure in group A were nearly the same as those with vaginal infection. Four women (15.4%) who underwent LSC plus colporrhaphy with the SIS graft complained of pain in the pelvic area, which was relieved gradually after 3 months. The mentioned above patients with complications often had at least 2 complications. Eleven patients with TVM complained of blunt pelvic pain, which gradually diminished after 4 months. The above results are shown in Table 2.

Table 1.

Characteristics of the patients enrolled

Table 2.

Perioperative outcomes by surgical groups

Anatomic success (POP stage≤ I) in the LSC plus colporrhaphy with the SIS graft group at 12 months was 92.3% (95% confidence interval [CI], 81.3%) and 96% (95% CI, 90.4%–101.6%) in the TVM group. Anatomic outcomes based on POP-Q scores were greatly improved in both groups (Table 3). The average POP-Q Aa score was shorter in the TVM group than in the LSC plus colporrhaphy with the SIS graft group at the 12-month follow-up (P=0.05). No differences in Ba, Ap, Bp, or C scores were observed in either group at the follow-ups.

Table 3.

Anatomic outcomes measured by POP-Q at 2 timepoints after surgery

PFDI-20 scores were significantly improved 12 months after operation in both groups (P<0.001) (Table 4). Subjective improvement was reported at the 12-month follow-up by 24 of 26 women (92.3%) in the LSC plus colporrhaphy with the SIS graft group and 46 of 50 women (92%) in the TVM group (P=0.667). When inventories were analyzed separately, POPDI-6 scores and UDI-6 scores were significantly improved in both groups at the 12-month follow-up (P≤0.001). Regarding the CRADI-8 scores, colorectal symptoms were also improved in both groups. In terms of sexual function, 65 patients from both groups were sexually active preoperation, and all of them completed a PISQ-12 questionnaire. There was a statistically significant improvement in these patients after surgery, especially those who underwent LSC combined with colporrhaphy with the SIS graft (P<0.001) (Table 4).

Table 4.

Functional outcomes at two timepoints after surgery

DISCUSSION

It is well known that mesh sacrocolpopexy is the preferred surgical option for apical prolapse [17] and is associated with fewer complications. This present study revealed that LSC plus colporrhaphy with the SIS graft had the same outcomes as TVM in improved anatomic and functional outcomes in patients with advanced POP. The objective outcomes were 95% in patients who underwent LSC plus colporrhaphy with absorbable mesh and 92% in patients who underwent TVM, which were similar to previous studies [18]. The subjective outcomes based on validated questionnaires were 92.3% in the LSC plus colporrhaphy with absorbable mesh group and 92% in the TVM group, demonstrating similar improvements in the quality of life reported in previous studies [19,20].

At more than 1-year follow-up in this study, although the overall success rate was similar, the improvement of sexual function in the LSC plus colporrhaphy with an SIS graft group seemed better than that in the TVM group. Due to cultural reasons, many women in China are reluctant to discuss their sexual experience, which is why our PISQ scores were apparently lower before surgery compared to other studies [21]. In addition, women in the LSC plus colporrhaphy with the SIS graft group achieved better sexual function than that in the TVM group, and this result may be due to longer TVL, absorbable grafts, or both.

The laparoscopic approach should facilitate a more precise anatomic repair and faster recovery. However, the incidence of vaginal infection in the LSC plus colporrhaphy with the SIS graft group was significantly higher than that in the TVM group, and hospital stays were also longer. Vaginal infection usually occurred 5-day postoperation and was proven to be caused by E. coli or E. faecalis by culturing the vaginal discharge; vaginal infection may result in vaginal apical mesh exposure later. The reasons for this result might be due to the greater degree of skill, extensive specialized training required, longer operative duration, and graft itself [20]. Due to higher complications, we terminated this LSC plus colporrhaphy with the SIS graft for advanced POP; thus, there were only 26 patients enrolled in our study. However, with good anatomical outcomes and substantial improvement of sexual function, LSC plus colporrhaphy with the SIS graft could be considered as an option for treating advanced POP but with extra precaution against vaginal infection, which may increase mesh exposure [22].

The strength of our study included that validated questionnaires were used to preoperatively and postoperatively evaluate every participant. In addition, every woman in our study had follow-ups for at least 1.5 years after surgery, which was longer than most publications. However, there were several limitations to our study. First, this study has the inherent weakness of being a retrospective study. Second, the sample size could be inadequate to detect small differences in the groups, and the power calculation was suboptimal. Further studies with larger samples and longer follow-ups are required to validate the above outcomes.

In conclusion, both surgeries showed excellent results for anatomical outcomes and quality of life after surgeries. The sexual functional improvement in LSC plus colporrhaphy with the SIS graft group was better than that in TVM group. However, the use of SIS graft might increase the exposure of polypropylene mesh exposure. Therefore, we do not recommend LSC plus colporrhaphy with the SIS graft for advanced multiple-compartments prolapse.

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