Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications.

INTRODUCTION AND HYPOTHESIS: We compared treatment success and adverse events between women undergoing open abdominal sacrocolpopexy (ASC) vs vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. METHODS: Participants underwent apical repair of stage 2-4 prolapse. Vaginal repair included uterosacral, sacrospinous, and iliococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen, and no retreatment up to 24 months. Adverse events were collected at multiple time points. Outcomes were analyzed using longitudinal mixed-effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, body mass index (BMI), initial Pelvic Organ Prolapse Quantification (POP-Q) stage, baseline scores, prior prolapse repair, and concurrent repairs. RESULTS: Of women who met inclusion criteria (1022 of 1159 eligibile), 701 underwent vaginal repair. The ASC group (n = 321) was older, more likely white, had prior prolapse repairs, and stage 4 prolapse (all p < 0.05). While POP-Q measurements and symptoms improved in both groups, treatment success was higher in the ASC group [odds ratio (OR) 6.00, 95% confidence interval (CI) 3.45-10.44). The groups did not differ significantly in most questionnaire responses at 12 months and overall improvement in bowel and bladder function. By 24 months, fewer patients had undergone retreatment (2% ASC vs 5% VAR); serious adverse events did not differ significantly through 6 weeks (13% vs 5%, OR 2.0, 95% CI 0.9-4.7), and 12 months (26% vs 13%, OR 1.6, 95% CI 0.9-2.9), respectively. CONCLUSIONS: Open sacrocolpopexy resulted in more successful prolapse treatment at 2 years.

A randomized trial of urodynamic testing before stress-incontinence surgery.

BACKGROUND: Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes. METHODS: We performed a multicenter, randomized, noninferiority trial involving women with uncomplicated, demonstrable stress urinary incontinence to compare outcomes after preoperative office evaluation and urodynamic tests or evaluation only. The primary outcome was treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of "much better" or "very much better" on the Patient Global Impression of Improvement. The predetermined noninferiority margin was 11 percentage points. RESULTS: A total of 630 women were randomly assigned to undergo office evaluation with urodynamic tests or evaluation only (315 per group); the proportion in whom treatment was successful was 76.9% in the urodynamic-testing group versus 77.2% in the evaluation-only group (difference, -0.3 percentage points; 95% confidence interval, -7.5 to 6.9), which was consistent with noninferiority. There were no significant between-group differences in secondary measures of incontinence severity, quality of life, patient satisfaction, rates of positive provocative stress tests, voiding dysfunction, or adverse events. Women who underwent urodynamic tests were significantly less likely to receive a diagnosis of overactive bladder and more likely to receive a diagnosis of voiding-phase dysfunction, but these changes did not lead to significant between-group differences in treatment selection or outcomes. CONCLUSIONS: For women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00803959.).

Effects of walking speeds and carrying techniques on intra-abdominal pressure in women.

INTRODUCTION AND HYPOTHESIS: Walking speed and carrying technique affect intra-abdominal pressure (IAP) in women. In this study, we tested the feasibility of monitoring IAP outside the laboratory environment and compared IAP while study participants were (1) carrying 13.6 kg (similar to a 3-month old in car seat) in six different ways while walking 100 m; and (2) while walking 400 m at self-selected slow, normal, and fast paces. METHODS: Forty-six healthy women between 19 and 54 years completed the walking and lifting activities; the order for each was randomized. IAP was monitored with an intravaginal pressure transducer that wirelessly transmitted pressure data to a portable base station. We analyzed maximal peak IAP and area under the curve (AUC) IAP. RESULTS: Monitoring IAP outside of the laboratory was feasible. Mean maximal IAP during walking increased as pace increased: 42.5 [standard deviation (SD) 10.2], 50.5 (10.9), and 62.0 (12.1) cmH2O for slow, medium, and fast speeds, respectively: p < 0.0001 by mixed-model analysis of variance (ANOVA). The corresponding AUC of IAP for walking decreased as pace increased. The awkward carry, side carry, and front carry activities each resulted in higher mean maximal IAP [65.8 (10.6), 67.7 (12.8), and 77.3 (13.1) cmH2O, respectively] than the carry-in-backpack activity [55.5 (11.4) cmH2O; p < 0.0001]. CONCLUSION: Subtle variations in walking speed or method of carrying a toddler-size load can produce significant changes in IAP. Whether these changes increase the risk of pelvic floor disorders is not yet clear. However, these data suggest that further inquiry into optimal methods and appliances to assist women in carrying may create a lower IAP profile.

Effectiveness of blinding: sham suprapubic incisions in a randomized trial of retropubic midurethral sling in women undergoing vaginal prolapse surgery.

OBJECTIVE: This planned secondary analysis of the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial assessed whether treatment knowledge differed between randomized groups at 12 months and whether treatment success was affected by treatment perception. STUDY DESIGN: Sham suprapubic tension-free vaginal tape (TVT) incisions were made in the Outcomes Following Vaginal Prolapse Repairs and Midurethral Sling trial participants randomized to no-TVT. Primary surgical outcomes and maintenance of blinding was assessed at 12 months. Knowledge of treatment assignment was compared between groups, and the relationship with treatment success rates was assessed. RESULTS: Prior to the 12 month postoperative visit, only 4% of treated participants (13 of 336) formally reported unmasking. At 12 months, 94% of the randomized participants (315 of 336) provided treatment knowledge data. Sixteen TVT participants (10%) reported treatment knowledge; most (n = 15, 94%) were correct; 17 of the sham participants (11%) reported treatment knowledge; half (n = 8, 47%) were correct. Similar proportions of unmasked participants who reported no treatment knowledge correctly guessed/perceived treatment assignment (sham, 46 [33%] vs TVT, 44 [33%]). We did not detect significant differences in treatment success rates based on perception within and across received treatment groups (perceived sham vs TVT overall [P = .76]). Of those receiving TVT, more participants perceiving TVT had treatment success compared with those who perceived sham (84% vs 74%; P = .29). Among sham participants, more participants perceiving sham had success compared with those who perceived receiving TVT (65% vs 56%; P = .42). CONCLUSION: Sham surgical incisions effectively mask TVT randomization. These findings may help to inform future surgical trial designs.

Intra-abdominal pressures during activity in women using an intra-vaginal pressure transducer.

Strenuous physical activity has been linked to pelvic floor disorders in women. Using a novel wireless intra-vaginal pressure transducer, intra-abdominal pressure was measured during diverse activities in a laboratory. Fifty-seven women performed a prescribed protocol using the intra-vaginal pressure transducer. We calculated maximal, area under the curve and first moment of the area intra-abdominal pressure for each activity. Planned comparisons of pressure were made between levels of walking and cycling and between activities with reported high pressure in the literature. Findings indicate variability in intra-abdominal pressure amongst individuals doing the same activity, especially in activities that required regulation of effort. There were statistically significant differences in maximal pressure between levels of walking, cycling and high pressure activities. Results for area under the curve and first moment of the area were not always consistent with maximal pressure. Coughing had the highest maximal pressure, but had lower area under the curve and first moment of the area compared to most activities. Our data reflect novel findings of maximal, area under the curve and first moment of the area measures of intra-abdominal pressure, which may have clinical relevance for how physical activity relates to pelvic floor dysfunction.

A novel technique to measure in vivo uterine suspensory ligament stiffness.

OBJECTIVE: The purpose of this study was to describe a new computer-controlled research apparatus for measuring in vivo uterine ligament force-displacement behavior and stiffness and to present pilot data for women with and without prolapse. STUDY DESIGN: Seventeen women with varying uterine support underwent testing in the operating room (OR) after anesthetic induction. A tripod-mounted computer-controlled linear servoactuator was used to quantify force-displacement behavior of the cervix and supporting ligaments. The servoactuator applied a caudally directed force to a tenaculum at 4 mm/sec velocity until the traction force reached 17.8 N (4 lbs). Cervix location on Pelvic Organ Prolapse Quantification system (POP-Q) in the clinic, in the OR, at rest, and with minimal force (<1.1 N); maximum force (17.8 N) was recorded. Ligament "stiffness" between minimum and maximum force was calculated. RESULTS: The mean ± SD subject age was 54.5 ± 12.7 years; parity was 2.9 ± 1.1; body mass index was 29.0 ± 4.3 kg/m(2), and POP-Q point C was -3.1 ± 3.9 cm. POP-Q point C was correlated most strongly with cervix location at maximum force (r = +0.68; P = .003) and at rest (r = +0.62; P = .009). Associations between cervix location at minimum force (r = +0.46; P = .059) and ligament stiffness (r = -0.44; P = .079) were not statistically significant. Cervix location in the OR with minimal traction lay below the lowest point found on POP-Q for 13 women. CONCLUSION: POP-Q point C was correlated strongly with cervix location at rest and at maximum traction force; however, only 19% of the variation in POP-Q point C location was explained by ligament stiffness. The cervix location in the OR at minimal traction lay below POP-Q point C value in three-fourths of the women.

Cardinal and deep uterosacral ligament lines of action: MRI based 3D technique development and preliminary findings in normal women.

INTRODUCTION AND HYPOTHESIS: The cardinal ligament (CL) and deep uterosacral ligament (US) play a critical role in utero-vaginal support. This study aims to quantify their geometrical relationships in living women using a MRI-based 3D technique. METHODS: The angles between ligaments, the ligaments length and curvature were assessed on 3D models constructed from twenty MRIs of volunteers with normal support. How angle variation theoretically affects ligament tension was investigated using a simplified biomechanical model. RESULTS: The CLs are 18.1 ° ± 6.8 °(SD) from the cephalic-caudal body axis , and the USs are dorsally directed and 92.5 ° ± 13.5 from the body axis. The CLs are longer and more curved than US. The theoretical calculated tension on CL is 52 % larger than that on US. CONCLUSIONS: The CL is relatively parallel to the body axis while the US is dorsally directed. The tensions on these ligaments are affected by their orientations.

Pelvic floor disorders clinical trials: participant recruitment and retention.

INTRODUCTION AND HYPOTHESIS: We used a focus-group methodology to gather information about women's knowledge and attitudes regarding research participation. METHODS: Two in-person focus groups at seven clinical sites were conducted in women with pelvic floor disorder (PFD): one of women with clinical trial study experience and the other without such experience. One Web-based focus group combining both groups was also conducted. RESULTS: One hundred and five women (average age 58.6 years) participated. Participants in both groups believed that their physicians were the best source of information about clinical trials yet felt that other sources of trial information were important. Financial compensation was not a primary motivating factor for PFD trial enrollment but was, however, cited as an important consideration. Internet collection of data was feasible and provided information comparable with in-person focus groups. CONCLUSIONS: This study identified central themes guiding successful recruitment to and retention in PFD-related trials and provided insight regarding strategies that may guide future trials.

More complicated than it looks: the vagaries of calculating intra-abdominal pressure.

Activities thought to induce high intra-abdominal pressure (IAP), such as lifting weights, are restricted in women with pelvic floor disorders. Standardized procedures to assess IAP during activity are lacking and typically only focus on maximal IAP variably defined. Our intent in this methods article is to establish the best strategies for calculating maximal IAP and to add area under the curve and first moment of the area as potentially useful measures in understanding biologic effects of IAP. Thirteen women completed a range of activities while wearing an intravaginal pressure transducer. We first analyzed various strategies heuristically using data from 3 women. The measure that seemed to best represent maximal IAP was an average of the 3, 5, or 10 highest values, depending on activity, determined using a top-down approach, with peaks at least 1 second apart using algorithms written for Matlab computer software, we then compared this strategy with others commonly reported in the literature quantitatively using data from 10 additional volunteers. Maximal IAP calculated using the top-down approach differed for some, but not all, activities compared with the single highest peak or to averaging all peaks. We also calculated area under the curve, which allows for a time component, and first moment of the area, which maintains the time component while weighing pressure amplitude. We validated methods of assessing IAP using computer-generated sine waves. We offer standardized methods for assessing maximal area under the curve and first moment of the area for IAP to improve future reporting and application of this clinically relevant measure in exercise science.

Development of a wireless intra-vaginal transducer for monitoring intra-abdominal pressure in women.

Pelvic floor disorders (PFD) affect one of every four women in the United States. Elevated intra-abdominal pressure (IAP) during daily activity or strenuous physical activity has been identified as a risk factor in the prevalence of PFD. However, the relationship between IAP and physical activity is poorly understood and oftentimes activity restrictions are prescribed by physicians without clinical evidence linking various activities to elevated IAP. There are currently no pressure transducers capable of monitoring IAP non-invasively out of a clinical environment. To overcome this shortcoming, a novel intra-vaginal pressure transducer (IVT) was developed to continuously monitor IAP. Improvements were made to the first generation IVT by incorporating wireless capability to enhance the device's mobility while creating a more robust IAP monitoring system. To ensure the changes maintained the functionality of the original device design, comparison testing with standard clinical pressure transducers in both bench top and clinical settings was conducted. The wireless device was found to have high linearity, robust signal transmission, and dynamic response that outperforms the clinical standard rectal transducer and is similar to the original first generation non-wireless design. The wireless IVT presented here is a mobile wireless device capable of measuring, storing and transmitting IAP data during various physical activities.

Sexual activity and function in women more than 2 years after midurethral sling placement.

OBJECTIVE: The purpose of this study was to assess prospectively the effects of midurethral sling surgery on sexual function and activity. STUDY DESIGN: Sexual activity and function was assessed in 597 women with stress urinary incontinence who were enrolled in a randomized equivalence trial of retropubic compared with transobturator midurethral slings. Repeated measures analysis of variance was used to assess changes in Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores over a 2-year period. RESULTS: Significant, similar improvements in sexual function were seen in both midurethral sling groups. Mean Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire scores increased from 32.8 at baseline to 37.6 at 6 months and 37.3 at 24 months (P < .0001). Dyspareunia, incontinence during sex, and fear of incontinence during sex each significantly improved after surgery. Preoperative urge incontinence was associated with abstinence after surgery (P = .02); postoperative urge incontinence negatively impacted sexual function (P = .047). CONCLUSION: Midurethral sling surgery for stress urinary incontinence significantly improves sexual function, although coexistent urge incontinence has a negative impact.

Clinical evaluation of a wireless intra-vaginal pressure transducer.

OBJECTIVE: To describe the development, feasibility and validity of a wireless intra-vaginal pressure transducer (IVT) which can be used to measure intra-abdominal pressure in real-world settings. STUDY DESIGN: A feasibility study was conducted in sixteen physically active women to determine retention and comfort of various IVT prototype designs during activity. A criterion validity study was conducted among women undergoing urodynamic testing to determine the accuracy of the IVT prototypes when compared to accepted clinical standards. RESULTS: A final prototype wireless IVT was developed after four design revisions of the second generation model. The feasibility study found that women reported the final prototype comfortable to wear and easily retained during physical activity. Intra-abdominal pressure measurements from the final prototype IVT compared favorably to standard urodynamic transducers, thus confirming evidence of its utility. CONCLUSION: We have successfully advanced the design of a wireless, intra-vaginal pressure transducer which provides accurate measures of intra-abdominal pressure. The final wireless IVT is better tolerated by patients and overcomes limitations of traditional urodynamic testing while laying the foundations for intra-abdominal pressure monitoring outside of the clinic environment.

Nonmyeloablative allogeneic stem cell transplantation in relapsed/refractory chronic lymphocytic leukemia: long-term follow-up, prognostic factors, and effect of human leukocyte histocompatibility antigen subtype on outcome.

BACKGROUND: The role of nonmyeloablative allogeneic stem cell transplantation (NST) in the treatment of chronic lymphocytic leukemia (CLL) is not well established. The authors report on long-term experience with NST in relapsed/refractory CLL and define prognostic factors associated with outcome. METHODS: The authors reviewed the outcome of 86 patients with relapsed/relapsed CLL enrolled in sequential NST protocols. RESULTS: The median patient age was 58 years. Patients were heavily pretreated before transplantation, and 43 required immunomanipulation after NST for persistent or recurrent disease. Immunomanipulation included withdrawal of immunosuppression, rituximab, and step-wise donor lymphocyte infusions. Of 43 patients receiving immunomanipulation, 20 (47%) experienced a complete remission. Patients with human leukocyte antigen (HLA) genotype A1(+) /A2(-) /B44(-) were more likely to experience a complete remission (P = .0009), with rates of 9%, 36%, 50%, and 91%, respectively, for 0, 1, 2, and 3 of these HLA factors. This resulted in significant improvement in progression-free-survival rates of 68.2% at 5 years for patients with all 3 HLA factors. Overall, the estimated 5-year survival rate was 51%. In a multivariate model, a CD4 count of <100/mm(3) and a below normal serum immunoglobulin G level at study entry were associated with a short survival duration (P < .0001). CONCLUSIONS: These results confirm the potential cure of relapsed/refractory CLL with NST and provide the first evidence that immunoglobulin G and CD4 levels are predictive of overall survival after NST in CLL and that human leukocyte antigen alleles predict response to immunomanipulation.

Do repetitive Valsalva maneuvers change maximum prolapse on dynamic MRI?

INTRODUCTION AND HYPOTHESIS: This study seeks to quantify differences in anterior vaginal wall prolapse during sequential Valsalva attempts on dynamic magnetic resonance imaging (MRI). METHODS: Subjects were taken from an on-going case-control study evaluating anterior vaginal wall prolapse. Women with a prolapse whose leading edge extended >or=1 cm beyond the hymenal ring were included (n = 40). All subjects performed three maximal Valsalva efforts while mid-sagittal dynamic MRI scans were obtained. Bladder descent between the first, second, and third maximal Valsalva efforts were compared. RESULTS: Forty percent of women had a greater than 2-cm increase in prolapse size from their first to third Valsalva attempt. Ninety-five percent of women extended their prolapse further with a third Valsalva. CONCLUSIONS: As is true during clinical examination, several attempts may be required to have maximal anterior compartment prolapse present during dynamic MRI of the pelvic floor.

In vivo assessment of anterior compartment compliance and its relation to prolapse.

INTRODUCTION AND HYPOTHESIS: The objective of the study was to compare anterior compartment compliance between women with and without pelvic organ prolapse and to explore factors determining the extent of anterior compartment prolapse. METHODS: Ten women with normal pelvic support and nine with anterior compartment prolapse were analyzed. Abdominal pressure was measured during Valsalva and simultaneous midsagittal dynamic MR imaging. The distance between the most dependent anterior vaginal wall point and a previously determined average nulliparous anterior vaginal wall point was measured. A best-fit line was determined when anterior vaginal wall displacement was plotted relative to abdominal pressure. The slope of this line is a measure of anterior compartment compliance. Multivariate analyses and t tests were performed. RESULTS: Mean compliance (centimeters per centimeter of water) was higher for cases [0.05 +/- 0.006 standard error of the mean (SEM)] than controls (0.03 +/- .007, p = 0.039). Degree of anterior compartment prolapse correlated best with compliance (R (2) = 0.75, p < 0.01) and also with resting anterior vaginal wall point (R (2) = 0.55, p < 0.01). CONCLUSIONS: Women with anterior compartment prolapse have a 67% more compliant support system compared with those with normal support. Both compliance and resting anterior vaginal wall location are predictors of the degree of anterior compartment prolapse.

Magnetic resonance imaging-based three-dimensional model of anterior vaginal wall position at rest and maximal strain in women with and without prolapse.

INTRODUCTION AND HYPOTHESIS: Two-dimensional magnetic resonance imaging (MRI) demonstrates apical support and vaginal length contribute to anterior wall prolapse (AWP). This paper describes a novel three-dimensional technique to examine the vagina and its relationship to pelvic sidewalls at rest and Valsalva. METHODS: Twenty women (10 with AWP and 10 with normal support) underwent pelvic magnetic resonance imaging at rest and Valsalva. Three-dimensional reconstructions of the pelvic bones and anterior vaginal wall were created to assess morphologic changes occurring in prolapse. RESULTS: In women with AWP, Valsalva caused downward translation of the vagina along its length. A transition point separated a proximal region supported by levator muscles and a distal, unsupported region no longer in contact with the perineal body. In this latter region, sagittal and frontal plane "cupping" occurs. The distal vagina rotated inferiorly along an arc centered on the inferior pubis. CONCLUSION: Downward translation, cupping, and distal rotation are three novel characteristics of AWP demonstrated by this three-dimensional technique.

The relationship between superior attachment points for anterior wall mesh operations and the upper vagina using a 3-dimensional magnetic resonance model in women with normal support.

OBJECTIVE: We examined structural relationships between anterior mesh kit suspension points and the upper vagina in women with normal support. STUDY DESIGN: Eleven women with normal support underwent supine, multiplanar magnetic resonance pelvic imaging at rest and maximal Valsalva. Using 3-dimensional models generated from these images, anterior wall mesh kit anchoring points were identified along the arcus tendineus fascia pelvis. We then measured the percentage of anterior vagina above and posterior to superior suspension points. RESULTS: The anterior vagina extended above superior attachment points in 100% of women at rest and in 73% during Valsalva. It extended posterior to them in 82% and 100% (rest and Valsalva, respectively). The mean percentage of anterior vaginal length above superior anchoring sites was 40 +/- 14% at rest and 29 +/- 12% during Valsalva. CONCLUSION: The upper vagina lies above and posterior to superior suspension points in the majority of women with normal support.

Posterior compartment anatomy as seen in magnetic resonance imaging and 3-dimensional reconstruction from asymptomatic nulliparas.

OBJECTIVE: The objective of the study was to identify characteristic anatomical features of the posterior compartment using magnetic resonance (MR) cross-sectional anatomy and 3-dimensional (3-D) modeling. STUDY DESIGN: Supine, static proton-density MR images of 20 nulliparas were analyzed. MR images were used to create models in a selected exemplar. RESULTS: The compartment's upper, mid, and lower segments are best seen in the axial plane. It is bounded inferiorly by the perineal body, ventrally by the posterior vaginal wall, and dorsally by the levator ani muscles and coccyx. In the upper portion, the compartment is bordered laterally by the uterosacral ligaments, whereas in the middle portion, there is more direct contact with the lateral levator ani muscles. In the lower portion, the contact becomes obliterated because the vagina and levator ani muscles become fused to each another and to the perineal body. CONCLUSION: The posterior compartment has characteristic anatomic features in MR cross-sectional anatomy that can be further elucidated and integrated with 3-D anatomy.

Variables Affecting Intra-abdominal Pressure During Lifting in the Early Postpartum Period.

OBJECTIVES: Intra-abdominal pressure (IAP) may contribute to pelvic floor health, although the direction and magnitude of such an effect, if any, are not yet known. Identifying individual characteristics, and in particular modifiable factors, associated with higher IAP during recovery from vaginal childbirth might serve to mitigate early pelvic floor dysfunction. The aim of this study was to identify characteristics associated with maximal IAP during lifting in postpartum primiparous women who delivered vaginally. METHODS: At 6 to 10 weeks postpartum, we measured maximal IAP, assessed via an upper vaginal sensor, as participants (enrolled in an ongoing cohort study) lifted a weighted car seat (12.5 kg). We evaluated whether the following independent variables were associated with maximal IAP: age, ethnicity, body mass index, height, abdominal circumference, weight gain during pregnancy, lifting time, breath holding during lifting, lifting technique, measures of muscular fitness, and days since delivery. RESULTS: In the 206 participants, weight, waist circumference, body mass index, and days since delivery were positively associated with mean maximal IAP during lifting, whereas IAP decreased as height increased. As the duration of the lifting task increased, mean maximal IAP during lifting also increased, but there were no associations between lifting technique or breath holding during lifting and IAP. Neither pelvic floor muscle strength nor abdominal muscle endurance was associated with IAP during lifting. CONCLUSIONS: Other than measures of body habitus and lifting duration, we did not identify modifiable factors that could mitigate maximal pressures experienced by the pelvic floor during the early postpartum period.

Surgical Outcomes After Apical Repair for Vault Compared With Uterovaginal Prolapse.

OBJECTIVE: To retrospectively compare surgical success and complications between vaginal vault prolapse compared with uterovaginal prolapse in women who underwent apical prolapse repair for stage II-IV prolapse. METHODS: Women in one of three Pelvic Floor Disorders Network prolapse surgical trials were included. Absence of bothersome bulge symptoms, no prolapse beyond the hymen, and no subsequent prolapse treatment defined success and was our primary outcome. Secondary outcomes included comparison of quality-of-life measures, anatomic changes, and adverse events. Pelvic organ prolapse quantification (POP-Q) and quality-of-life measures were administered at baseline and 1-2 years postoperatively. Comparisons were controlled for study site, age, body mass index, baseline POP-Q, apical and anterior or posterior repair performed, and prior prolapse repair. Outcomes measured at multiple time points were analyzed using longitudinal models to assess whether differences existed across study follow-up. RESULTS: Four hundred twenty-one women underwent vault prolapse, and 601 underwent uterovaginal prolapse apical repair. The vault prolapse group was older, more likely to be white, and to have prior urinary incontinence or prolapse repair, stage IV prolapse, and more prolapse bother on a validated scale (all P≤.034). The vault prolapse group was more likely to undergo sacrocolpopexy (228/421 [54%] vs 93/601 [15%]); the uterovaginal prolapse group was more likely to undergo vaginal repair (508/601 [85%] vs 193/421 [46%] P<.001). There were no differences in success (odds ratio [OR] 0.76 for vault prolapse vs uterovaginal prolapse, 95% CI 0.51-1.15, P=.20), changes in Pelvic Organ Prolapse Distress Inventory scores (-79.4 vs -79.8, P=.89), postoperative POP-Q point C measurements (-7.0 vs -7.1 cm, P=.41), or serious adverse events (86/421 [20%] vs 90/601 [15%], P=.86) between groups. Among women who underwent a vaginal approach for repair of vault prolapse (n=193) or uterovaginal prolapse (n=508), there were no differences in success rates (OR 0.67, 95% CI 0.43-1.04, P=.09) at 1-2 years postoperatively. CONCLUSION: Surgical success of stage II-IV vault prolapse and uterovaginal prolapse apical repair was similar whether performed vaginally or abdominally at 1-2 years postoperatively.