VAGINECTOMY WITH CONCOMITANT VAGINALHYSTERECTOMY: A PREFERABLE RECONSTRUCTIVE PROCEDURE FOR ADVANCEDSTAGE PELVIC ORGAN PROLAPSE
P. HENGRASMEE1, P.WACHASIDDHISILPA 2, P. LEERASIRI 2;
1Obstetrics and Gynaecology, Faculty of Med., SirirajHosp., Bangkok, Thailand, 2Siriraj Hosp., Mahidol Univ.,Bangkok, Thailand.
Introduction: Pelvic organprolapse (POP) is one of the major health problems affecting almosthalf of women over 50 years of age. A lifetime risk of POP surgery isestimated to be 12.6% by the age of 80. Although conservativemanagement is effective for treating prolapse, most patients are moreinclined toward permanent solution. Current surgical approaches forPOP repair include abdominal, vaginal, laparoscopic, or combinedtechnique. To select the most appropriate strategy, one should takeinto consideration the sites and severity of POP, concurrent pelvicpathology, patient’s preference, sexual activity, overall healthstatus, and expected outcomes. In healthy elderly patients withsevere prolapse who are no longer sexually active, vaginectomy andconcomitant vaginal hysterectomy may be considered. Though vaginalhysterectomy may increase intraoperative blood loss and prolongoperative time, it is still a preferable procedure among patients andmany gynecologists. The reasons for this include (1) optimal exposureto cul de sac closure and cysto-rectocele repair, (2) removal ofpotential danger of a difficult-to-access uterus, and (3) patient’spreference of the most definitive method.
Objective: Toevaluate clinical outcomes of vaginectomy with or without concomitantvaginal hysterectomy in the treatment of advanced stage POP in termsof success rate, recurrence rate, functional outcomes, and peri- andpost-operative morbidity.
Methods: With ethical approvalfrom our Institutional Review Board, we performed a retrospectivestudy of non-sexually active patients undergoing vaginectomyprocedure for stage 3-4 POP between July 2010 and June 2014.Following clinical symptom assessment, the stage and location ofprolapse were identified according to Pelvic Organ ProlapseQuantification (POP-Q) system. Preoperative urodynamic study wasperformed when indicated. Traditional vaginal hysterectomy wascarried out in all patients with uterovaginal prolapse. Vaginectomywas performed by making a landmark circumferential incision on thevagina approximately 2 cm above hymen, followed by midline incisionon both anterior and posterior vaginal wall. With sharp lateraldissection, vaginal mucosa was separated from pubocervical andrectovaginal fascia. Excess vaginal mucosa was excised. Closure ofperitoneum was performed, followed by plication of perivesical,apical, and perirectal fascia with 2-3 consecutive purse-stringsutures. AP repair, with or without perineorrhaphy, were also carriedout when indicated. Demographic data, operative time, blood loss,peri- and post-operative adverse events were recorded. Postoperativefollow-up was scheduled at 1 month, 3 months, 6 month, 1 year, andannually thereafter. At each follow-up visit, reassessment of symptomand POP-Q measurements was performed. All statistical data wereanalyzed using the SPSS version 18 for Windows. Differences in POP-Qmeasurements were demonstrated using paired Student’s t test. TheP-value of less than 0.05 indicated statistical significance. Theobjective cure was defined according to the NICHD Pelvic FloorDisorders Network recommendations as points Aa, Ap, Ba, Bp and C lessthan or equal to 0 cm. Treatment success was defined as: (1) the mostdescending point at or above hymenal level (2) absence of bulgesymptoms and (3) absence of re-treatment.
Results: Of 53postmenopausal women undergoing vaginal obliteration, one-fourth waspost-hysterectomy patients. Mean age was 69.8 ± 7.2 years and meanBMI was 24.7 ± 3.4 kg/m2. Clinical presentations werecategorized as prolapse, urinary and defecatory symptoms. Meanoperative time for all carried out procedures was 64 ± 24 minutesand mean blood loss was 124 ± 120 ml. Posterior repair, with orwithout perineorrhaphy, was performed in only 7 patients whereasmidurethral sling was required in 30%. Bleeding complication occurredin only 2 patients. De novo stress incontinence was the most commonpostoperative adverse event. Among patients undergoing hysterectomy,the most common uterine pathology included leiomyoma, adenomyosis,and cervicitis. All women returned for one-month postoperative visit;however, 3 were lost to follow-up thereafter. Mean follow-up time was29 months. Significant improvement in clinical symptoms and POP-Qmeasurements was demonstrated from early postoperative period up to 5years. At 3-year follow-up, 8 women were found to have stage 2-3recurrent prolapse without bothersome symptoms. This reflected anobjective cure rate of 85%.
Conclusions: Vaginectomy withconcomitant vaginal hysterectomy is an economical and practicalprocedure with low rate morbidity. With favorable surgical outcomes,it should be considered as one of the treatment options fornon-sexually active women with advanced stage prolapse.
References:1. Colpocleisis for advanced pelvic organ prolapse