Aims of study

Sacrocolpopexy is an established operation for vaginal vault prolapse. De novo stress incontinence after sacrocolpopexy (1) and increased posterior vaginal wall prolapse after Burch colposuspension (2) are well known sequelae. This study compares the effect of sacrocolpopexy and posterior mesh interposition (SCPMI) with and without colposuspension on subsequent stress incontinence, vault and posterior vaginal wall prolapse.

Methods
Forty-three consecutive women who underwent sacrocolpopexy for vaginal vault or uterine prolapse > stage 2 (ICS) and posterior mesh (Teflon) interposition to the perineal body to correct a rectocele with a minimum follow up of 12 months and complete preoperative investigations (standardised questionnaire, ICS prolapse staging, CMG) were included. Burch colposuspension for genuine stress incontinence with or without reduction of the prolapse was performed in 21 women (group 1). All 22 women who did not undergo colposuspension (group 2) had had previous bladder neck surgery. This is an ongoing study. To detect a difference of 18% of new stress incontinence with a power of 80% the sample size should be 38 in each group, for a 30% difference of posterior vaginal wall prolapse it should be 19 in each group.

Results
Forty women were interviewed and examined, 19 in group 1and 20 in group 2. Four women could not be traced. The mean follow up was 22 months (range 12-40 months). Age, parity, HRT, BMI, preoperative ICS prolapse measurements-Ap, Bp, C, D, preoperative incomplete bowel emptying and digitation to support defaecation did not differ between groups (t-test, chi-square and Mann-Whitney U test). Women in group 1 had a better supported anterior vaginal wall preoperatively (p<.001, Mann-Whitney U test).

 Postoperatively, there were no differences between groups regarding anatomy (ICS-prolapse stages) and function (bladder, bowel and sexual function; Table 1). The mesh became detached from the perineal body in 11 (28%) women and was felt between 3-5 cm above the hymen. The more the mesh had come off the perineal body the higher the stage of posterior vaginal wall prolapse (Ap, Bp; .72, p<.001). There were no enteroceles found behind the mesh.

 

 Table 1: ICS prolapse staging and symptoms.

		With colposuspension n=19	Without colposuspension n=20
Vault - C	Stage 0 Stage 1	15 (79%) 4 (21%)	20 (100%) 0
Rectocele – Ap, Bp	Stage 0 Stage 1 Stage 2 Worsened	10 (53%) 3 (16%) 6 (32%) 2	14 (70%) 2 (10%) 4 (20%) 0
Incomplete bowel emptying	De novo Worsened	7 (37%) 3/7 3/7	6 (30%) 1/6 1/6
Digitation	De novo	4 (21%) 2/4	5 (25%) 2/5
Stress incontinence	De novo	6 (32%) 0/6	6 (30%) 2/6
Urge incontinence	De novo	13 (68%) 4/13	14 (70%) 1/14
Dyspareunia	De novo	4/13 0	6/12 0

Conclusions
SCPMI was effective for vaginal vault prolapse. If the mesh does not become detached from the perineal body SCPMI will correct rectoceles. If stress incontinence cannot be demonstrated preoperatively, a concomitant Burch colposuspension does not seem to be necessary to prevent postoperative stress incontinence. A concomitant Burch colposuspension does not adversely affect anatomy and function of the posterior compartment.

 References
1.      Outcome of thirty patients who underwent repair of posthysterectomy prolapse of the vaginal vault with abdominal sacral colpopexy. J Am Coll Surg 1994; 178: 283-287.

 The incidence of genital prolapse after the Burch colposuspension. Am J Obstet Gynecol 1992; 167: 3998-405.