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234 - THE EFFECT OF A CONCOMITANT PERINEAL BODY REPAIR AT THE TIME OF A POSTERIOR VAGINAL REPAIR: DOES IT PROVIDE A SUPERIOR CLINICAL OUTCOME?

234

THE EFFECT OF A CONCOMITANT PERINEAL BODY REPAIR AT THE TIME OF A POSTERIOR VAGINAL REPAIR: DOES IT PROVIDE A SUPERIOR CLINICAL OUTCOME?

W. HENN;
Dept. Obstetrics & Gynaecology, Bloemfontein, South Africa.

Introduction: The female perineal body is a relatively small, but complex anatomical structure due to the sum of its components. It plays an often underrated role in pelvic floor function. The term perineorrhaphy is used to reflect the surgical repair of this structure. This term does however not define a specific procedure, but is a general description for an assortment of techniques. A perineorrhaphy is often combined with a posterior vaginal repair.
Objective: The aim of this retrospective study was to describe a specific surgical technique for the repair of the perineal body and explore the clinical contribution of this procedure to that of a posterior vaginal repair.
Methods: This is a retrospective case-control study. Records were retrieved for all cases who underwent a perineal body repair in combination with a posterior vaginal repair (PBPR) for the period January 2010 until December 2015 in a referral urogynecology unit. The control group, identified in the same time period, were made up of all women who received only a posterior vaginal repair (PR). Exclusion criteria were patients who underwent associated pelvic floor procedures, those where mesh were used in the posterior compartment and where the follow-up period was less than 12 months. Pre- and post-operative symptoms, clinical findings and quality of life (QOL) metrics were evaluated and reported on. A minimum follow-up period of 12 months was a prerequisite for inclusion. Successful primary surgery was anatomically defined as a posterior compartment pelvic organ prolapse quantification (POP-Q) stage of < 2. Surgical complications were classified by means of the Dindo classification system. Bias was limited by ensuring that the operating surgeon did not perform the post-operative examinations. The qualitative metrics were compared and analyzed with the Chi-square and Fisher’s exact tests and the continuous variables with the student-t test with statistical significance set at a value of p < 0.05. Patients with incomplete data and those lost to follow-up were excluded from the final reporting. The perineal repair technique briefly entails a posterior vaginal incision, development of the rectovaginal space, dissection of the pararectal spaces and lateral mobilization of the external anal sphincter (EAS). Polydiaxonone sutures were used for repair of the EAS, bulbospongiosus and superficial transverse perineal muscles with re-approximation of the hymenal ring.
Results: There were 1349 pelvic floor reconstruction procedures performed during this period. Of these, 849 (59.6%) included a posterior vaginal repair and of these, 139 (10.3%) had only a posterior vaginal repair with/without a perineal body repair. This group could then be separated into 51 PBPR cases and 88 PR controls with complete follow-up data of ≥ 12 months available for 45 (36.6%) cases and 78 (63.45) controls. The group characteristics were similar, except for the women in the PBPR group being younger (Table 1). The respective presenting symptoms were similar for both groups. There was no significant difference in the severity of posterior vaginal prolapse with 47 (92.2%) of the PBPR and 85 (96.6%) of the PR group diagnosed with a POP-Q stage ≥ 2 prolapse. The mean follow-up period was 30 ± 15 months for the cases and 25 ± 15 months for the controls. The post-operative assessment confirmed significant symptomatic improvement in all pelvic floor domains (Table 2). There was however no significant difference in symptomatic improvement between the two groups. An anatomically successful outcome at follow-up was present in 41 (91.1%) of PBPR cases and in 68 (87.2%) of PR cases (p 0.57). The overall peri-operative complication rate was 25.5% vs 12.5% respectively (p 0.06), none of which required additional surgical intervention.
Conclusions: The addition of a perineal body repair at the time of a posterior vaginal repair did not provide any significant benefit in regards to subjective or objective outcome in the medium term and should be considered only on an individual basis. There is a need for further research on this commonly performed procedure.
References:

Table 1: Baseline characteristics of study population

Characteristic

PBPR (N=51)

PR (N=88)

P-value

Age

53.9 ± 13.1

59.2 ± 12.7

0.02*

BMI (kg/m2)

28.4 ± 5

28 ± 4.4

0.62

Parity

3 (0;8)

3 (0;7)

0.83

Menopausal

34 (66.7%)

67 (76.1%)

0.22

HRT

13 (25.5%)

25 (28.4%)

0.70

Previous hysterectomy

24 (47.1%)

33 (37.5%)

0.27

Previous POP surgery

11 (21.6%)

18 (20.4%)

0.87

Previous UI surgery

5 (9.8%)

11 (12.5%)

0.62

 

Table 2: Pre- and post-operative pelvic floor symptoms

 

PBPR (N=51)

  

PR (N=88)

   

Symptom

Pre-op

Post-op

P-value

Pre-op

Post-op

P-value

P-value#

Bulge

24 (47.1)

3 (6.7)

<0.001*

49 (55.7)

7 (8.9)

<0.001*

0.75

OAB

18 (35.3)

6 (13.3)

0.02*

12 (13.6)

7 (8.9)

0.04*

0.45

Recurrent UTI

11 (21.6)

5 (11.1)

0.27

15 (17)

3 (3.9)

0.01*

0.14

Constipation

21 (41.2)

12 (26.7)

0.19

36 (40.9)

23 (29.5)

0.27

0.74

Obstr defecation

15 (29.4)

4 (8.9)

0.02*

34 (38.6)

13 (16.7)

0.002*

0.23

Anal incontinence

11 (21.6)

7 (15.6)

0.60

24 (27.3)

18 (23.1)

0.59

0.32

Dyspareunia

13 (25.5)

8 (17.8)

0.61

12 (13.6)

7 (8.9)

0.22

0.14

Not sex active

10 (19.6)

13 (28.9)

0.34

28 (31.8)

21 (26.9)

0.50

0.84

QOL score

52 ± 17.9

77.4 ± 15

<0.001*

51.4 ± 14.8

72.3 ± 15.2

<0.001*

0.08

# Post-op p-value for PBPR compared to PR