Surgical outcomes after apical repair for vault compared with uterovaginal prolapse

The incidence of posthysterectomy prolapse ranges from 6% to 8%. Many surgeons treat posthysterectomy or vault prolapse differently than uterovaginal prolapse in women planning to undergo surgery for apical pelvic organ prolapse (POP), because they believe that a previous hysterectomy increases both risk of prolapse recurrence and adverse events. Despite this, no direct comparisons of prolapse repair in women with vault and uterovaginal prolapse have been made and only limited data are available to help clinicians make evidence-based decisions regarding surgical approach in these women. The aims of this retrospective study were to compare outcomes (surgical success and complications) between women with stage II to IV prolapse undergoing surgical repair of uterovaginal prolapse and those undergoing posthysterectomy vault prolapse. Data obtained from 3 large surgical trials performed in the Pelvic Floor DisordersNetwork were used to compare outcomes in the 2 cohorts. All surgical corrections were performed by experienced pelvic surgeons at 17 study sites in the United States. Success, the primary outcome, was defined as absence of all of the following: (1) bothersome bulge symptoms, (2) no prolapse beyond the hymen on pelvic organ prolapse quantification (POP-Q) examination, and (3) no subsequent retreatment for prolapse. Quality-of life measures, anatomic changes, and adverse events were secondary outcomes. At baseline and 1 to 2 years postoperatively, POP-Q and quality-of-life measures were administered. Comparisons between groups were controlled for study site, age, body mass index, baseline POP-Q, apical repair procedure performed, and prior prolapse repair. To assess whether differences existed across study follow-up, outcomes measured at multiple time points were analyzed using longitudinal models. Of the 1022 women meeting met criteria for inclusion, 421 underwent vault prolapse repair and 601 uterovaginal prolapse repair. The vault prolapse cohort was older, more likely to be white, and to have prior urinary incontinence or prolapse repair, more advanced prolapse (stage IV), and more bother from prolapse on a validated scale (all comparisons, P . 0.034).Women in the vault prolapse group were more likely to undergo sacrocolpopexy (54% vs 15%), whereas those in the uterovaginal prolapse group were more likely to undergo vaginal repair (85% vs 46%, P < 0.001). No differences between groups were found for success (adjusted odds ratio, 0.76 for vault prolapse vs uterovaginal prolapse; 95% confidence interval, 0.51.1.15; P = 0.20), changes in POP distress inventory scores (.79.4 vs .79.8, P = 0.89), or postoperative POP-Q point C measurements (.7.0 vs .7.1 cm, P = 0.41). There were also no differences in serious adverse events (20% vs 15%, P = 0.86). In a subanalysis of women who underwent a vaginal approach for apical repair of vault prolapse (n = 193) or uterovaginal prolapse (n = 508), no differences were found in success rates at 1 to 2 years postoperatively; the adjusted odds ratio was 0.67, with a 95% confidence interval of 0.43 to 1.04, P = 0.09. These findings show that surgical success of stage II to IVvault prolapse and uterovaginal prolapse apical repair was similar at 1 to 2 years postoperatively whether performed vaginally or abdominally.Moreover, there were no differences in quality of life, symptom scales, or adverse events.