Operative Treatment of Genital Prolapse

Pelvic organ prolapse is a major health issue. Eleven per cent of women require surgical treatment for prolapse or urinary incontinence by the age of 80 years. Possible modes of operative treatment include vaginal or abdominal approach. The aim here was to study outcomes of sacrospinous ligament fixation (SSLF) with pelvic floor reconstruction for vaginal vault prolapse and uterine procidentia, its tolerability in elderly women and the effect of concomitant vaginal hysterectomy on operative complications, and to compare outcomes of SSLF to those of abdominal sacral colpopexy (ASC). A further aim was to compare vaginal and transanal techniques for rectocele repair. The study population consisted of 138 women who had undergone SSLF and 26 patients who had undergone ASC in Tampere University Hospital. Eightyeight percent of patients who had undergone SSLF and 77 % of those who had undergone ASC were available for follow-up. At follow-up patients were assessed by interview and clinical examination. A total of 30 patients attended a prospective randomized study comparing the two techniques for rectocele repair. These patients were evaluated by interview, clinical examination, defecography, colon transit study and anorectal manometry. At follow-up, 21 % of patients had suffered recurrence after SSLF, mostly cystocele, but only eight per cent had symptoms and five per cent were reoperated. The most significant factors predisposing to recurrence were postoperative pelvic infection, inexperienced surgeon, patient’s low age and length of follow-up. Lack of intravenous antibiotic prophylaxis was the most significant risk factor for postoperative infection. Patients aged 80 years or more with no medical condition did well after surgery whereas women with a history of vascular disease had more often serious complications, including one death caused by pulmonary embolism. Concomitant vaginal hysterectomy did not affect the complication rate despite longer operative time. Recurrent apical prolapse was noted in three out of 26 patients (12 %) after ASC but in none out of 26 counterpart after SSLF. The overall recurrence rates were 12 vs 3, respectively. Posterior vaginal wall recurrences were noted in one (7 %) patient after vaginal and 10 (67 %) after transanal repair. No differences were noted between the groups in respect of symptom improvement. SSLF with pelvic floor reconstruction is an effective means of treating massive genital prolapse. For good long-term outcomes avoidance of infections is essential. It is also a viable technique for elderly women, but those with vascular disease are at elevated risk of serious complications. If indicated, it can be performed concomitantly with vaginal hysterectomy without extra