Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele

OBJECTIVE: This study compared 3 surgical methods of prophylaxis against en terocele formation employed at the time of vaginal hysterectomy. STUDY DESIGN: One hundred consecutive women undergoing total vaginal hyster ectomy for various reasons were randomly assigned to have 1 of 3 surgical m ethods applied to the posterior superior aspect of the vagina for prophylax is against enterocele formation. The first procedure involved closing the c ul-de-sac and bringing the uterosacral-cardinal complex together in the mid line in a vaginal Moschcowitz-type operation. The second procedure was a Mc Call-type culdeplasty to obliterate the cul-de-sac, plicate the uterosacral -cardinal complex, and elevate any redundant posterior vaginal apex. The th ird technique used only the peritoneum to close the cul-de-sac, allowing pa ssive movement of the uterosacral-cardinal complex to the midline, no oblit eration per se, and no elevation of the posterior vagina. Postoperative fin dings on pelvic examination were evaluated at 6 weeks, 3 months, and 1, 2, and 3 years. Statistical analysis was performed with the chi(2) test of ind ependence. RESULTS: At 6 weeks' follow-up and at 3 months' follow-up there were no pro lapses involving the posterior superior segment of the vagina. At I year of follow-up 11 patients had stage 1 or 2 posterior superior segment prolapse . At 2 years' follow-up this number was 16. At 3 years' follow-up the McCal l-type method was statistically better (chi(2) = 11.27 With 2 degrees of fr eedom, P=.004) than the other 2 in preventing postoperative enterocele (n = 2 of 32 with McCall-type procedure, n = 10 of 33 with vaginal Moschcowitz- type procedure, and n = 13 of 33 with peritoneal closure only). CONCLUSION: When applied at the time of vaginal hysterectomy the McCall-typ e culdeplasty is superior to a vaginal Moschcowitz-type procedure and to si mple peritoneal closure in preventing subsequent enterocele.