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Abdominal and Vaginal Colpopexy Comparable for Vault Prolapse
Abstract and Commentary
Synopsis: Both surgical approaches are highly effective in the management of vaginal vault prolapse.
Source: Maher CF, et al. Am J Obstet Gynecol. 2004; 190:20-26.
Ninety-five patients with vaginal vault prolapse were randomly assigned to having either an abdominal sacral colpopexy with Prolene mesh or unilateral sacrospinous colpopexy. All patients in both groups with stress incontinence also had Burch colposuspension. Follow-up for up to 5 years after surgery revealed both subjective success for the abdominal (94%) and vaginal approaches (91%) and objective success (76% and 69% respectively). The abdominal approach was associated with longer operating room time, higher cost, and longer convalescence.
Comment by Frank W. Ling
First, there’s the article itself. This well-designed Australian study addresses an increasingly common condition, post-hysterectomy vault prolapse. With an aging patient population, additional risk factors of years since hysterectomy and hysterectomy for genital prolapse are of even greater import. Extensive baseline data allow for thorough comparison of preoperative and postoperative conditions. A patient who has no prolapse symptoms is considered a "subjective success." Objective "success" is defined as no prolapse beyond the halfway point of the vagina during Valsalva. Trends in the data bring Maher and colleagues to suggest that the abdominal approach may be preferable if the prolapse is predominately anterior while the vaginal surgical approach may be preferred for posterior prolapse. In either approach the procedure is likely to cure any pre-operative urinary voiding dysfunction while having little effect on bowel function.
Second, there’s your practice. You aren’t going to do enough of these cases to do your own randomized study. By the same token, you are likely to already prefer one procedure over the other. The perspective that you should adopt is that of thorough consideration at several critical points:
a. At the
time of any hysterectomy, but particularly when prolapse is present, make sure
that support to the vault is provided when needed;
b. When caring for a patient after hysterectomy, watch for signs and symptoms of prolapse;
c. When vault prolapse is found, pursue non-surgical options such as Kegel exercises and pessary placement initially;
d. As prolapse is being diagnosed and treated, assess urinary function completely;
e. When selecting a surgical approach for prolapse, factor in the findings of this study as well as your own surgical experiences.
Frank W. Ling, MD, UT Medical Group Professor and Chair, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, is aan Associate Editor for OB/GYN Clinical Alert.