Impact of Sacrospinous Colpopexy Associated with Anterior Colporrhaphy for the Treatment of Dome Prolapse on all Three Vaginal Compartments

Abstract Objective To evaluate the results of sacrospinous colpopexy surgery associated with anterior colporrhaphy for the treatment of women with post-hysterectomy vaginal vault prolapse. Methods This prospective study included 20 women with vault prolapse, Pelvic Organ Prolapse Quantification System (POP-Q) stage ≥ 2, treated between January 2003 and February 2006, and evaluated in a follow-up review (more than one year later). Genital prolapse was evaluated qualitatively in stages and quantitatively in centimeters. Prolapse stage < 2 was considered to be the cure criterion. Statistical analysis was performed using the Wilcoxon test (paired samples) to compare the points and stages of prolapse before and after surgery. Results Evaluation of the vaginal vault after one year revealed that 95% of subjects were in stage zero and that 5% were in stage 1. For cystocele, 50% were in stage 1, 10% were in stage 0 (cured) and 40% were in stage 2. For rectocele, three women were in stage 1 (15%), one was in stage 2 (5%) and 16 had no further prolapse. The most frequent complication was pain in the right buttock, with remission of symptoms in all three cases three months after surgery. Conclusions In this retrospective study, the surgical correction of vault prolapse using a sacrospinous ligament fixation technique associated with anterior colporrhaphy proved effective in resolving genital prolapse. Despite the low complication rates, there was a high rate of cystocele, which may be caused by posterior vaginal shifting due to either the technique or an overvaluation by the POP-Q system.


Introduction
The pelvic viscera are supported by two main mechanisms: the endo-pelvic fascia and its condensations (the vesicovaginal fascia, the rectovaginal septum, the utero-sacral ligament, and the cardinal ligament) and the pelvic diaphragm (the levator ani muscles and the coccyx).Vaginal vault prolapse is caused by a weakening of the cardinal and uterosacral ligaments. 1,2he incidence of post-hysterectomy vaginal vault prolapse is unknown but has been estimated at 2.0 to 3.6:1000 person-years.When there is some type of associated dystopia, vault prolapse rates are higher, reaching 15:1000 person-years in patients whose hysterectomy indication was uterine prolapse. 3,4In the gynecology and obstetrics department at the Centro de Atenção Integral à Saúde da Mulher (Women's Health Comprehensive Care Center -CAISM), Universidade Estadual de Campinas (Unicamp), the posthysterectomy prolapse rate was $3.4:1000 for hysterectomies performed between January 1986 and May 1991. 5here are three main interrelated objectives in the treatment of vaginal vault and uterine prolapse: correcting the anatomical defect, restoring sexual function, and restoring or maintaining intestinal and urinary functions. 6Other important medical team goals include improving quality of life and preventing recurrence of the prolapse. 2,7here are several surgical techniques available for the treatment of vaginal vault prolapse, including abdominal sacral colpopexy and vaginal sacrospinous fixation.In an article published by the Cochrane Library Incontinence Review Group 8 that included three prospective randomized studies, abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy, with lower recurrence rates of vaginal prolapse and dyspareunia.There was no significant difference in surgical re-intervention rates between these dystopias.However, sacrospinous colpopexy had a lower cost, shorter operative time, and provided a faster return to daily activities. 8here is a wide variation in the published failure rates for sacrospinous ligament colpopexy, which is explained in part by the choice of method for analyzing the anatomical result and by which vaginal compartments are being considered; however, recurrence appears to be more frequent in the anterior vaginal compartment. 2,9,10n a recent systematic review evaluating sacrospinous ligament colpopexy for the treatment of uterine and vaginal vault prolapse, a very high recurrence rate was found for the anterior vaginal wall, reaching 43.8%. 11Concomitant treatment of the anterior wall can be effective in these women.Therefore, the aim of the present study was to determine the genital prolapse rate after sacrospinous colpopexy surgery associated with anterior colporrhaphy in women who had previously undergone hysterectomy.

Methods
This prospective study evaluated 20 women with post-hysterectomy vaginal vault prolapse and undergoing sacrospinous colpopexy surgery associated with anterior colporrhaphy in the Hospital Estadual de Sumaré da

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Universidade Estadual de Campinas between 2003 and 2006.Inclusion criteria were vaginal vault prolapse after hysterectomy stage ! 2 and vaginal length greater than 8 cm.Exclusion criteria were history of gynecological cancer, rectosigmoid surgery, previous vaginal vault prolapse repair surgery, and vaginal stenosis.The women had their prolapses evaluated before surgery and every six months after surgery, with a mean follow-up of 30 months (14.4 to 48 months) by means of the genital prolapse quantification system (POP-Q). 12he surgical technique employed was vaginal vault fixation onto the right sacrospinous ligament using blunt digital dissection of the ipsilateral ischiorectal fossa with an approach via the posterior vaginal compartment.Two polygalactin-0 sutures were placed on the right sacrospinous ligament by means of direct visualization, and the vaginal vault was repaired, followed by anterior wall colporrhaphy with polygalactin-0 sutures.Women who had posterior genital prolapse underwent site-specific correction during surgery.
We performed statistical analysis using SAS Version 8.2 for Windows, SAS Institute Inc., Cary, North Carolina, and used the Wilcoxon test to compare the points and stages of genital prolapse before and after surgery.Intra-and postoperative complications are described using simple frequencies.All patients signed terms of free and informed consent.The study was approved by the Ethics Committee of the Faculty of Medical Sciences, Unicamp.
Table 2 Stage, according to POP-Q 12   There were no vascular, intestinal, or urinary tract lesions in this group.None of the women who underwent surgery presented infections at the surgical site.The most frequent complication was pain in the right buttock, with remission of symptoms in all three cases three months after surgery.

Discussion
In the present study, surgical repair of vaginal prolapse using the sacrospinous ligament fixation technique associated with anterior colporrhaphy proved to be effective in curing vaginal vault prolapse, with a low rate of complications but with a high rate of cystocele (prolapsed anterior wall), with stage 1 or 0 as the criterion for vaginal prolapse cure.The choice for this cure criterion was based on the fact that symptoms are rare in women with early prolapse, who are most often symptomatic from the hymen (stage 2).
The high apical prolapse cure rates obtained in the present study are consistent with the literature. 13Colpopromontofixation has been accepted as the gold standard for apical prolapse treatment.In a systematic review, the objective success rate of colpopromontofixation with stage < 2 prolapse in POP-Q was superior to the rate for sacrospinous ligament fixation. 14However, this same study showed a similar rate of objective cure between the two techniques, enabling us to infer that the two surgeries are effective forms of apical prolapse treatment.This inference is in agreement with the findings of the present study.
][17] The present study showed an anterior wall failure rate (cystocele) of 55.5%, which is consistent with the findings of a randomized controlled prospective study that evaluated the results of anterior colporrhaphy versus the use of a synthetic fabric after two years of follow-up. 18The study showed cystocele failure rates of 58% in the colporrhaphy group and 18% when synthetic fabric was used. 18he anatomical superiority of the use of synthetic fabric is well described in the literature.Recently, however, the U.S. Food and Drug Administration (FDA) published warnings related to risks associated with the use of synthetic vaginal fabrics. 21The most frequently reported adverse event is mesh extrusion, which may may present severe disorders if any adjacent organ is involved.Because of this possibility, fixation to the sacrospinous ligament, which is a standard procedure, again became interesting because it does not require fabric attachment.In this sense, anterior colporrhaphy to avoid increasing the anterior prolapse would also be interesting.
A previous study suggests that when vaginal length is maintained and site-specific correction of the cystocele is performed, the recurrence of anterior vaginal wall prolapse would be reduced. 22However, we did not observe this effect in our study.Our findings allow us to state that cystocele is common in women undergoing correction with sacrospinous fixation and that colporrhaphy is not effective in preventing this complication.
Colpopexy onto the sacrospinous ligament for the treatment of vault prolapse is commonly used in vaginal surgery and became popular in Europe and the United States in the 1970s. 2,23This procedure results in low morbidity and reports of vascular lesions and hemorrhages are rare. 24The findings of the present study corroborate the literature findings, with no serious adverse events observed in the study's case series.
The present study is limited by the small number of patients and the short follow-up of two years.Studies with a larger sample size and a longer follow-up of 5 years are needed, which should not only include objective evaluation performed by the surgeon via POP-Q, but also subjective evaluations via quality of life questionnaires.Some studies have questioned the use of the POP-Q classification.Lack of success tends to be related to the absence of symptoms rather than to anatomical cure shown by POP-Q. 25evertheless, the strength of the present study is that the population was homogeneous, as we included only women with vaginal vault prolapse.

Conclusion
We conclude that surgical repair of vaginal prolapse via the sacrospinous ligament fixation technique is effective for the treatment of apical vault prolapse but with high rates of cystocele, which are not prevented by performing colporrhaphy concomitant to surgical treatment.

Table 1
Sample description: demographic characteristics of the sample and prior surgeries RBGO Gynecology and Obstetrics Vol.38 No. 2/2016 Sacrospinous Colpopexy with Anterior Colporrhaphy in Treatment of Dome Prolapse Castro et al. 79

Table 3
Comparison between pre-and post-operative anatomical points according to POP-Q 12 classifications POP-Q points Pre-operative Post-operative Abbreviations: Aa, point A of anterior wall; Ap, point A of posterior wall; Ba, point B of anterior wall; Bp, point B of posterior wall; C, cervical point; GH, genital hiatus (in cm); PB, perineal body (in cm); POP-Q, Genital Prolapse Quantification System; TVL, total vaginal length (in cm).Points according to POP-Q classifications.Sacrospinous Colpopexy with Anterior Colporrhaphy in Treatment of Dome Prolapse Castro et al.