IS PRE-OPERATIVE PELVIC FLOOR MUSCLEWEAKNESS A PREDICTOR OF SURGICAL FAILURE OF ANTERIOR VAGINAL PROLAPSEREPAIRS?
J. S. SCHACHAR, H. DEVAKUMAR, L.MARTIN, N. CHANDRASEKARAN, E. A. HURTADO, G. DAVILA;
ClevelandClinic Florida, Weston, FL.
Introduction: Pelvic floormuscle (PFM) strength has been associated with improvement of vaginalprolapse symptoms and objective Pelvic Organ Prolapse Quantification(POP-Q) stage. Decreased PFM strength has been associated with anincreased risk of pelvic organ prolapse (POP) recurrence and need forre-operation in the short-term. The OPTIMAL Trial assessed PFMtherapy as an adjunct to POP surgery and concluded thatperi-operative PFM therapy did not improve prolapseoutcomes.
Objective: The objective of this study was todetermine whether pre-operative pelvic floor muscle (PFM) weakness isa predictor of failure in subjects who underwent reconstructivesurgery for anterior vaginal prolapse in the long-term.
Methods:This is a retrospective review of all patients who underwentreconstructive surgery for primarily anterior compartment vaginalprolapse at a single institution between 2001 and 2015 with follow upat least 40 weeks post-operatively. Patients were divided into groupsof “weaker” and “stronger” pre-operative PFM strength basedon pre-operative pelvic exams using a modified Oxford scale. Patientswith scores of 0-2 were placed in the “weaker” PFM group (wPFM)and patients with scores of 3-5 were placed in the “stronger” PFMgroup (sPFM). Failure rates were determined by a composite ofsubjective and objective outcomes. Objective failure was defined as agreater than grade 2 cystocele using the Baden-Walker Halfway systemor a point “Ba” of zero or greater using the POP-Q system.Subjective failures were defined as anyone who reported “worsened”or “not improved” on a validated patient improvement satisfactionscale of “worsened”, “not improved”, “somewhat improved”,“greatly improved” and “cured”. Subjects that had anyadditional surgery or procedures due to prolapse of the anteriorcompartment were considered as failures. A p-value of less than 0.05was considered statistically significant.
Results: Threehundred and fourteen patients met inclusion criteria and wereincluded in the final analysis. Overall, the wPFM (n=159) and thesPFM (n=155) had similar descriptive statistics, except subjects inthe wPFM were significantly older (67.42±9.83 vs 63.86±9.27,p=0.0011). Subjects in both groups underwent similar reconstructivesurgeries: with similar rates of hysterectomies, apical suspensions,anterior repairs, posterior repairs, and anti-incontinenceprocedures. Average length of follow-up was similar between the twogroups (p=0.2240), with an average of 142.04 weeks post-operativefollow-up [41 to 717 weeks]. For the primary outcome of compositesubjective and objective failures the wPFM and sPFM had similar ratesof failures, 5.66% and 3.87%, respectively (p=0.4573). A sub-analysiswas performed comparing subjects who had absent PFM strength (aPFM),defined as an Oxford score of 0 (n=36), and those with good PFMstrength (gPFM), defined as an Oxford score of 4 or 5 (n=142). Thesegroups had similar descriptive statistics (except subjects in theaPFM were significantly older p=0.0094), underwent similarreconstructive surgeries, and had similar average length of follow-up(p=0.3566). For the primary outcome of composite subjective andobjective failures the aPFM group had significantly more failuresthan the gPFM group, 13.89% vs 3.52% (p=0.0158).
Conclusions:Patients with weaker pelvic floor muscles on pre-operative assessmentdid not have higher surgical failure rates than those with strongerpelvic floor muscles. However, those with absent pelvic floor musclestrength pre-operatively did have significantly higher surgicalfailure rates in the long-term.
References: (1) Li C, GongY, Wang B. The efficacy of pelvic floor muscle training for pelvicorgan prolapse: a systematic review and meta-analysis. Int UrogynecolJ 2016 Jul;27(7):981-992. (2) Vakili B, Zheng YT, Loesch H, EcholsKT, Franco N, Chesson RR. Levator contraction strength and genitalhiatus as risk factors for recurrent pelvic organ prolapse. Am JObstet Gynecol 2005 May;192(5):1592-1598. (3) Barber MD, Brubaker L,Burgio KL, Richter HE, Nygaard I, Weidner AC, et al. Comparison of 2transvaginal surgical approaches and perioperative behavioral therapyfor apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014Mar 12;311(10):1023-1034.
SurgicalFailure Rates by PFM Strength