Pilot study of novel technique for POP repair

August 26, 2020

A new technique for repair of pelvic organ prolapse (POP) appears to be associated with good short-term outcomes, based on results of a new pilot study.

The novel procedure involves creating a temporary latticework to provide support during healing, by intertwining sutures from a midline anterior colporrhaphy with the obturator sutures.

A description of the surgery and experience with it in a pilot study of 109 patients were published in Urology.1 All of the women had Stage 2 or greater anterior compartment prolapse, based on examination with Valsalva in the dorsal lithotomy position. Their average age was 62 and average body mass index was 28.1

Of the women, 34% had a bothersome recurrence after a previous anterior repair. All of them completed the three questionnaires in the Pelvic Floors Disorders Inventory-2 (PDFI2.0) in anticipation of a primary outcome of recurrence of anterior prolapse.

Secondary outcomes consisted of time to anterior recurrence; recurrence of any compartment; recurrence of bothersome bulge symptoms; incidence of intraoperative, perioperative, and postoperative complications; and patient characteristics associated with recurrence.

The key steps in creation of the latticework, as depicted in the report, are (1) dissection of the vaginal epithelium off the perivesical fascia laterally to the obturator fascia; (2) placement of 2.0 PDS sutures distally and proximally on each side at the level of the obturator fascia/arcus tendinous followed by midline anterior colporrhaphy with four 2.0 PDS sutures; and (3) intertwining of the four lateral and four midline sutures, which are then tied together.

The mean surgical time was 132 minutes, and 60 minutes for patients who only had an anterior repair. No intraoperative complications were reported. At 30 days post-surgery, six patients (5.5%) had new-onset stress urinary incontinence (SUI).

Seventeen patients (15.3%) had urinary tract infection (>20,000 bacterial colonies with irritative voiding symptoms). Forty-eight patients (43.9%) had new-onset overactive bladder, 11 of whom required medical treatment. Thirty-seven patients (34%) required catheterization for transient urinary retention, all of whom eventually voided to completion.

Mean follow-up in the study was 12 months, during which 12 patients (11%) had anatomic recurrence of POP. Mean time to recurrence was 13.9 months. There was a 31% improvement in PDF12.0 (P = .02), mostly associated with a 55% improvement in patient responses to the Pelvic Organ Prolapse Distress Inventory.

The authors said their technique of interlocking central defect sutures unilaterally to the arcus tendinous fascial pelvis, “encourages scarring throughout the defect, maintaining the repair after the sutures dissolve.

This results in a reduction of the midline defect with a concomitant elevation of the whole bladder laterally in the paravaginal space.” While acknowledging the increased risk of retention associated with the procedure, the authors characterized it as “self-limiting” and said it “may decrease the likelihood of developing SUI.”

They also noted that “longer follow up is needed in order to evaluate the durability of these initial encouraging results.”

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Reference

  1. Rude T, Sanford M, Cai J, Sevilla C, Ginsberg D, Rodriguez LV. Transvaginal paravaginal native tissue anterior repair technique: initial outcomes. Urology. https://doi.org/10.1016/j.urology.2020.06.070