Posterior Repair May Improve Outcomes with Sacrocolpopexy

Women with vaginal prolapse often also have rectoceles because of defects in their posterior vaginal wall. Even if the rectoceles are asymptomatic, repairing them at the time of sacrocolpopexy may reduce the odds of prolapse recurrence, a new study finds. The study will be presented at the American Urogynecologic Society/International Urogynecological Association’s Joint Scientific Meeting, 2019.

“What drove this research is that currently, there is no standard regarding whether a posterior repair or any Level III pelvic organ prolapse support procedures are needed at time of sacrocolpopexy,” says Olivia Chang, MD, MPH, a fellow in the Cleveland Clinic Center for Urogynecology & Pelvic Reconstructive Surgery and first author on the study.

“There are two trains of thought,” Dr. Chang continues. “Some people think that repair is needed to provide Level III pelvic organ support. Others believe repair may actually cause more harm by leading to dyspareunia and defecatory dysfunction. We wanted to see if posterior repair actually reduces prolapse recurrence.”

The study included a retrospective chart review and prospective follow-up survey of 709 patients who undergone laparoscopic, robotic or abdominal sacrocolpopexy at a tertiary care center from 2004 to 2014. The study included patients with asymptomatic rectoceles.

Asymptomatic rectoceles

“We focused on patients who have rectocele but no constipation, dyschezia, excessive straining or splinting because some physicians may do posterior repair for those symptoms,” says Dr. Chang.

In patients with asymptomatic rectoceles, 185 (54%) had sacrocolpopexy-only and 159 (46.2%) had sacrocolpopexy plus a concurrent posterior repair. The women who had sacrocolpopexy-only were older (60.6 vs 56.9 years, P < 0.001) and more likely to have had a prior relapse repair (46.0% vs 20.3%, P < 0.001).

The majority of patients in both groups had a Bp of -1 or more on the Pelvic Organ Prolapse Quantification system (POP-Q) and a stage III prolapse in the leading compartment. POP-Q is an objective, site-specific system approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons to describe female pelvic organ prolapse. With POP-Q, six anatomic points — three anterior (Aa, Ba, and C) and three posterior (Ap, Bp, and D) — are used as reference for measurements.

For the retrospective part of the study, the authors collected demographic and perioperative data from the patients’ medical records. For the prospective portion of the study, patients were surveyed by telephone about their symptoms, retreatment or complications after surgery. For both groups, median anatomic follow-up time was 169 days and mean survey follow-up time was 6 years and 11 months.

“We used a composite patient-centered outcome as our primary outcome. We included subjective bulge symptoms and retreatment. We found a higher rate of composite failure in patients who had a sacrocolpopexy-only. On regression analysis, the odds of having a failure were 2.79 times higher in patients who had sacrocolpopexy alone compared to those who had sacrocolpopexy combined with a posterior repair,” says Dr. Chang.

Composite failure lower in sacrocolpopexy with concurrent posterior repair

In both groups, the composite failure rate was 10.2% (95% CI 7.4-13.8%). A significantly higher percentage of patients in the group that had sacrocolpopexy alone had composite failure (13.5%) than in the group that had sacrocolpopexy plus a concurrent posterior repair (6.3%; P < 0.001). In both groups, incidence of new defecatory dysfunction following surgery was low (5.6% for sacrocolpopexy alone vs 7.5% for sacrocolpopexy plus concurrent posterior repair).

“A lot of literature suggests that a posterior repair may cause sexual dysfunction or defecatory dysfunction. We were surprised that we did not find that in our population,” says Cecile Ferrando, MD, MPH, Associate Program Director of Cleveland Clinic’s Female Pelvic Medicine & Reconstructive Surgery Fellowship program and Director of Cleveland Clinic’s Transgender Surgery & Medicine program. “Based on our results, this suggests that a posterior repair at the time of sacrocolpopexy can reduce patient-centered prolapse recurrence in women who are asymptomatic. However, patients and surgeons must make a joint decision in weighing the risks of prolapse recurrence with the development of possible dyspareunia and defecatory dysfunction. A very interesting new direction for research in this area would be a prospective, randomized controlled trial comparing posterior repair with no posterior repair at the time of sacrocolpopexy in asymptomatic patients.”