Indian Journal of Obstetrics and Gynecology Research

Print ISSN: 2394-2746

Online ISSN: 2394-2754

CODEN : IJOGCS

Indian Journal of Obstetrics and Gynecology Research (IJOGR) open access, peer-reviewed quarterly journal publishing since 2014 and is published under auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to uplift researchers, scholars, academicians, and professionals in all academic and scientific disciplines. IESRF is dedicated to the transfer of technology and research by publishing scientific journals, research content, providing professional’s membership, more...


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Sawant, Bhalerao, and Bhalerao: Effect of traditional versus site specific anterior repair in reduction of urinary symptoms in women with pelvic organ prolapse


Introduction

Pelvic organ prolapse can be defined as a downward descent of female pelvic organs, including the bladder, uterus, post hysterectomy vaginal cuff and the small or large bowel resulting in protrusion of vaginal walls, uterus or both.1

Pelvic organ prolapse is a poorly understood condition that affects millions of women worldwide.2 It is a disease with low morbidity and it affects primarily quality of life. 1

Poor understanding of symptoms related to pelvic organ prolapse makes it difficult to counsel patients as to which of the symptoms will improve with treatment.2

Women with pelvic organ prolapse may present with a variety of bladder dysfunctions such as increased frequency of micturition, urge incontinence and stress urinary incontinence.2, 3, 4, 5, 6 Most studies evaluating outcomes of pelvic organ prolapse surgery have focused exclusively on anatomical success without considering the most important issue for the patient which is patient relief. 4

Limited studies have been conducted to understand the frequency of symptoms and exact way to lead to the outcome, improvement or relief of symptoms following surgery for pelvic organ prolapse is the important goal of International Community. A careful consideration of various factors as risk factors, symptomatology, specific surgical interventions is necessary for clinicians considering appropriate management.

There is paucity of guidelines for selection of surgery for various symptoms for pelvic organ prolapse so such setting in low research setting will be of great value in synthesising evidence regarding management in women of pelvic organ prolapse. There has been a trend towards repair of site specific defects in the anatomy of pelvic floor for management of pelvic organ prolapse. Till date review of literature reveals very few studies comparing the symptomatic outcome in relation to type of surgery as traditional anterior repair of pelvic organ prolapse versus site specific anterior repair of pelvic organ prolapse. This study therefore is being done to determine the veracity of hypothesis – Site specific anterior repair of pelvic organ prolapse is better than Traditional anterior repair of pelvic organ prolapse.

The objectives of the study are as follows

  1. To evaluate effect of traditional pelvic prolapse surgeries on reduction in urinary symptoms.

  2. To evaluate effect of site specific anterior repair in reduction of urinary symptoms.

  3. To compare traditional versus site specific anterior repair in reduction of urinary symptoms.

Materials and Methods

This hospital based prospective, comparative, experimental, longitudinal, randomized controlled trial of centre to study the Effect of Traditional Versus Site specific anterior repair in reduction of Urinary symptoms in women with pelvic organ prolapse in 140 reproductive, perimenopausal and postmenopausal women admitted to gynecology-ward of a tertiary care hospital was carried out in the Department of Obstetrics and Gynecology over 2 years after proper and adequate authorization from Institutional Ethics Committee.

Women with pelvic organ prolapse with history of urinary symptoms (frequency/urgency/incomplete bladder emptying/urine leakage with coughing)

Method of measurement

By Pelvic Organ Prolapse – Quantification (POP-Q) system

Nine specific measurements in centimeters are recorded as indicated.

Table 1

Data collection tool was a case record form

Anterior wall

Anterior wall

Cervix

Aa

Ba

C

Genital hiatus

perineal body

total vaginal length

gh

pb

tvl

Posterior wall

posterior wall

posterior

Ap

Bp

fornix D

[i] Aa- 3 cm proximal or apical to external urethral meatus on anterior vaginal wall

[ii] Ap-3 cm proximal to the hymen on posterior vaginal wall

[iii] Ba- most distal portion of the remaining anterior vaginal wall

[iv] Bp-most distal portion of the remaining posterior vaginal wall

[v] C-most distal edge of cervix or vaginal cuff

[vi] D-posterior fornix

[vii] gh-measured from middle of external urethral meatus to posterior midline hymen

[viii] Pb-measured from posterior margin of gh to middle of anal opening

[ix] Tvl –depth of vagina when point D or C is reduced to normal position

Type of surgery (vaginal hysterectomy with traditional anterior repair and site specific repair) to be done for women with Pelvic Organ Prolapse was selected by randomisation (Ralloc software). Women with prolapse with urinary symptoms requiring surgery were randomized in 2 groups.

Group A women were subjected to – traditional anterior repair

Group B women were subjected to Site specific anterior repair along with vaginal hysterectomy and posterior repair.

The surgery was done by two surgeons of the same experience and skill. Women were assessed post-operatively on day 7 for functional outcome of surgery depending upon the individual history (pre-operative and post-operative) in the form of complete/incomplete/no relief of symptoms and for anatomical outcome depending upon the pre-operative and post-operative POP-Q assessment.

Results

The present study was undertaken to study the Effect of Traditional  anterior repair  Versus Site specific anterior repair in reduction of Urinary  symptoms in women with pelvic organ prolapse. The anatomical and functional improvement with traditional anterior repair  and site specific anterior repair was assessed.

Age‌ ‌distribution

Table 3 showing distribution of women according to age in traditional anterior repair and site specific anterior repair group

Table 2

Showing distribution of women according to age in traditional anterior repair and site specific anterior repair group

Traditional anterior repair

Site specific anterior repair

Age in years

Number of women

Percentage

Number of women

Percentage

P-Value

40-45

2

2.9%

3

4.3%

0.0

46-50

22

31.4%

19

27.1%

51-55

2

2.9%

2

2.9%

56-60

13

18.6%

21

30.0%

61-65

23

32.9%

22

31.4%

66-70

8

11.4%

3

4.3%

Table 3

Showing distribution of women according to urinary symptoms done in traditional anterior repair  & site specific anterior repair group

Traditional anterior repair

Site specific anterior repair

Number of women

Percentage

Number of women

Percentage

P Value

Urinary Complaints

Bulge in vagina

31

44.3%

17

24.3%

0.02

Sense of urgency/ frequency of urination

61

87.1%

67

95.7%

Incomplete bladder evacuation

60

85.7%

65

92.9%

Has to push bulge inside for complete urination

15

21.4%

27

38.6%

Urine leakage with coughing

14

20.0%

14

20.0%

[i] *multiple responses allowed

Table 4

Showing distribution of women according to level of prolapse in traditional anterior repair & site specific anterior repair group

Traditional method

Site specific method

Number of women

Percentage

Number of women

Percentage

P Value

Level of prolapse

Level 1

21

30%

15

21.42%

0.0

Level 1,2

34

48.57%

23

32.85%

Level 1,2,3

28

40%

32

45.71%

[i] *multiple reponses allowed

Table 5

Showing distribution of women according to surgery done

Surgery

Frequency

Percentage

Vaginal hysterectomy with traditional anterior repair

70

50%

Vaginal hysterectomy with site specific anterior repair

70

50%

Total

140

100%

Table 6

Showing comparison of means of preoperative and postoperative pop-q in traditional anterior repair and site specific anterior repair group

POPQ classification

Type of repair

Pre-operative

Post-operative

Standard deviation

P values

Aa

T

0.40

-2.49

16.0

0.02

S

0.52

-2.47

20.1

Ba

T

0.76

-1.55

13.6

0.05

S

1.51

-1.58

19.6

Ap

T

1.46

-1.62

2.0

0.04

S

1.4

-1.7

9.8

Bp

T

0.97

-1.43

13.0

0.06

S

0.01

-1.54

18.2

C

T

3.18

-2.85

8.3

0.05

S

2.65

-2.94

16.3

D

T

3.48

-7.68

20.0

0.03

S

4.24

-7.71

23.5

Total vaginal length

T

7.71

8.39

25.1

0.05

S

7.87

8.41

11.0

Genital hiatus

T

4.42

4.54

10.2

0.007

S

4.51

4.84

13.6

Perineal body

T

3.40

3.42

23.1

0.0009

S

3.52

3.81

23.4

Table 7

Showing post operative anatomical improvement of anterior vaginal wall prolapse

Traditional Anterior Repair

Site Specific Anterior Repair

Anatomical improvement of anterior vaginal wall prolapse

Number of women

Percentage

Number of women

Percentage

P value

Complete improvement

12

17.1

48

68.6

0.0

Partial improvement

44

62.9

22

31.4

No improvement

14

20.0

0

0.0

Table 8 depicts 60 women (42.85%) with complete anatomical improvement post-operatively; of which 12 women (17.1%) were assessed and evaluated according to POP-Q  and subjected to traditional anterior repair and remaining 48 women  (68.6%) were evaluated by POP –Q and subjected to site specific anterior  repair. 66 women (48.9%) showed incomplete improvement and remaining 14 women (4.62%) showed no improvement. All 14 women of no improvement belonged to traditional anterior repair group A. None were without improvement in site specific repair group B. 

Table 8

Showing functional and anatomical outcome after traditional  anterior and site specific anterior repair in women with pelvic organ prolapse

Outcome measure

Traditional anterior repair

Site specific anterior repair

Functional outcome

48(68.2%)

52(73.4%)

Anatomical outcome

58(83.2%)

67(95.3%)

Table 9

Comparison with other studies

Studies

Weber et al (2001)

Rodriguez et al (2005)

Maher et al (2008)

Raizada Nivedita et al (2010)

Thakare Yuvraj et al (2014)

Vandana Dhama et al (2015)

Bhalerao et al (2015)

Our study

Sample Size

114

98

30

100

50

100

95

140

Mean Age (Years)

64.7 +/-11.1 Years

65+/- 15 years

-

60+/-10years

51-70 years

48+/- 12 years

49+/- 12 years

56.76+/- 7.28years

Presenting Symptoms

Mass coming out per vaginum- 100%

Mass coming out per vaginum-100% Urinary symptoms

Mass coming out per vaginum-100% Urinary symptoms-74% Bowel symptoms-34%

Mass coming out per vaginum-84%

-

-

Mass coming out per vaginum-100% Urinary symptoms

Mass coming out per vaginum-100% Urinary symptoms-100% Bowel symptoms-30%

Intervention Used

30%-standard anterior colporrhaphy 42% standard push mesh 46% ultralateral anterior colporrhaphy

26%-vaginal hysterectomy 45%-enterocele repair 94%-rectocele repair

-

Hysterectomy-88% Uterine conservation with repair-12%

Elective vaginal hysterectomy-100%

Vaginal hysterectomy with Traditional repair-47% Vaginal hysterectomy with Site specific repair-53%

Vaginal hysterectomy with Traditional anterior repair-50% Vaginal hysterectomy with Site specific anterior repair-50%

POP Q findings

Preoperative score- Aa 6.9 +/- 2.7; postoperative score, Aa 1.1 +/- 0.8)

Pre-operative: Post-operative :

Pre-op Aa : 0.52 Post-op Aa : -2.47

Pre-op Ap : 1.4 Post-op Ap : -1.7

Pre-op Ba : 1.51 Post-op Ba : -1.55

Pre-op Bp : -0.1 Post-op Bp : -1.54

Pre-op C : 2.65 Post-op C : -2.94

Pre-op D : -4.24 Post-op D : -7.71

Pre-op gh : 4.51 Post-op gh : 4.84

Pre-op pb : 3.52 Post-op pb : 3.81

Pre-op tvl : 7.87 Post-op tvl : 8.41

Fs success rate

Site specific -86.37 Traditional – 82.28%

Site specific anterior repair-95.3% Traditional anterior repair-83.2%

Table 9 shows functional and anatomical outcomes of traditional anterior repair and site specific anterior repair. 48 of 70 women (68.2%) who were subjected to traditional anterior repair and 52 of 70 women (73.4%) who were subjected to site specific anterior repair had marked functional improvement after surgery. 58 of 70 women (83.2%) belonging to traditional anterior repair group and 67 of 70women (95.3%) belonging to Site specific anterior repair group had considerable anatomical improvement post-operatively. This impresses the role of site specific anterior repair in women with pelvic organ prolapse for attaining better functional and anatomical outcome.

Discussion

Meta-analytical research today shows POP-Q is being used by only 3% investigators. There is paucity of guidelines and studies for use of a particular classification in deciding the type of surgery for pelvic organ prolapse.

Our study was undertaken to find a better surgery for relief of symptoms postoperatively.

The above study concludes that site specific repair for anterior vaginal wall prolapse with urinary symptoms was more effective than traditional anterior colporraphy.

There was significant improvement anatomically and functionally in women with pelvic organ prolapse with urinary symptoms who where treated with site specific repair compared to traditional repair.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgement

I would like to thank unit incharges, all teachers and collegues of LMH.

References

1 

FI Torre F Pucciani G Dodi G Gluliani A Frasson D Coletta Pelvic Organ Prolapse Working Group (SICCR):Doubts and Evidence for a Practical GuideJ Inflam Bowel Dis Disor201721710

2 

A Miedel G Tegerstedt B Mörlin M Hammarström A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapseInt Urogynecol J200819121593601

3 

M Pakbaz Vaginal prolapse–clinical outcomes and patients’ perspectives: a study using quantitative and qualitative methods http://www.diva-portal.org/smash/record.jsf?pid=diva2%3A401371&dswid=-37

4 

LJ Burrows LA Meyn MD Walters AM Weber Pelvic symptoms in women with pelvic organ prolapseObstet Gynecol200410459828

5 

IG Kusuma IG Putra IW Megadhana IN Sanjaya IF Manuaba Characteristic of patients with pelvic organ prolapse in obstetric and gynecologic outpatient clinic in Sanglah HospitalBALI Med J2014617681

6 

N Joseph C Krishnan BA Reddy NA Adnan LM Han YJ Min Clinical profile of uterine prolapse cases in South IndiaJ Obstet Gynecol India20166642834



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Article type

Original Article


Article page

507-512


Authors Details

Aditi Sawant*, Anuja Bhalerao, Kritika Bhalerao


Article History

Received : 19-06-2021

Accepted : 05-08-2021

Available online : 26-11-2021


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