A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments

OBJECTIVE: The objectives of this study were (1) to describe a group of wom en with pelvic organ prolapse associated with apical loss of support throug h grading with the Baden-Walker halfway system before, during, and after th e corrective operation, (2) to describe the operative repair of the support defects, (3) to report the morbidity associated with the operative repair, and (4) to assess the durability of the repair at each site. STUDY DESIGN: Between January 1, 1994, and December 31, 1998, a total of 30 2 consecutive women with apical and associated other support defects were e valuated before, during, and after the corrective operation by the senior a uthor (Bob L. Shull). All patients underwent transvaginal reconstructive su rgery with native tissue. Two hundred eighty-nine patients (96%) returned f or at least one postoperative visit, and they constitute the group used for the follow-up data. Perioperative morbidity was considered to include hemo rrhage necessitating homologous blood transfusion, visceral injury, neurolo gic impairment, or death. Durability was assessed by means of life-table an alysis for each of 5 sites in the vagina. RESULTS: All patients had preoperative or intraoperative evidence of grade 1 or greater apical loss of support of and at least one other site of pelvi c organ prolapse. Two hundred eighty-nine patients (96%) returned for at le ast one postoperative visit. Two hundred fifty-one patients (group 1, 87%) had optimal anatomic outcomes, with no persistent or recurrent support defe cts at any site. Thirty-eight patients (group 2, 13%) had one or more sites with at least grade 1 loss of support during the follow-up interval. Twent y-four of these 38 patients had grade 1 defects that were detectable only o n careful pelvic examination. Fourteen of these patients (5%) had grade 2 o r greater persistent or recurrent support defects. The anterior segment (bl adder) was the site with the most persistent or recurrent support defects, which means that it was the site of the least durable repair. The urethra a nd cuff had the most durable repairs. Morbidity included a 1% transfusion r ate, a 1% ureteral injury or ureteral kinking rate, and a 0.3% postoperativ e death rate. CONCLUSION: Careful preoperative and intraoperative evaluation of pelvic su pport defects and the use of native connective tissue and uterosacral ligam ents are associated with excellent anatomic outcomes. The durability of the surgical correction varies according to the individual site of repair and the duration of postoperative follow-up.