17: Impact of genital hiatus size on anatomic outcomes after mesh-augmented sacrospinous ligament fixation

Abstract

To compare anatomic outcomes after Uphold™ mesh-augmented sacrospinous ligament fixation (SSLF) among women categorized by their pre- and post-operative genital hiatus (GH) size. We performed a multi-center retrospective cohort study in women undergoing Uphold™ mesh-augmented SSLF between 2010 and 2017. We compared three groups: 1) women with a wide GH pre-operatively and 6 weeks post-operatively (“Persistently Wide” [PW] cohort); 2) women with a wide GH pre-operatively and normal GH 6 weeks post-operatively (“Improved” cohort); and 3) women with a normal GH pre-operatively and 6 weeks post-operatively (“Stably Normal” [SN] cohort). We defined a wide GH as ≥ 4 cm and a normal GH as < 4cm. Women were included if they had POP-Q exams from a pre-operatively and 6-week post-operative visit, and if the primary outcome could be assessed from a visit between 3 months and 2 years after surgery. The primary outcome was anatomic failure, defined as recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or pessary. We performed a secondary analysis in which we compared the mean decrease in GH size from baseline to 6-weeks postoperatively between patients who received a posterior colporrhaphy/perineorrhaphy (“posterior repair”) vs those that did not. We analyzed our data with one-way ANOVA, chi-square, Kruskal-Wallis, and t-test, as appropriate. We performed logistic regression to evaluate for independent risk factors for anatomic failure. Within the study timeframe, 191 patients underwent an UpholdTM procedure, but only 97 women met inclusion criteria, which required a medium-term follow up visit for outcome assessment. In terms of GH group distribution, 13 (13%) were PW, 54 (56%) were Improved, and 30 (31%) were SN. Overall, mean age was 68 years (±7.15), mean BMI was 28.36 kg/m2 (±5.34) and mean follow up time was 400±216 days. There were no differences among groups in terms of comorbidities such as diabetes (p=0.14) or concomitant procedures like posterior repair (p=0.58). Composite anatomic failure did not differ between groups (PW 15.4%, Improved 11.1%, SN 10.0%, p=0.88). These results were consistent when examining each vaginal compartment individually and when considering reoperation. On logistic regression controlling for baseline GH size and concomitant posterior repair, the odds of anatomic failure remained similar among all GH groups (p=0.93).There was no difference in the mean reduction in GH between patients who received a posterior repair and those who did not (-1.48 cm vs -1.37 cm, respectively, p=0.60). Though previous studies suggest that women with a persistently wide GH after native tissue vaginal vault suspension or robotic sacrocolpopexy are at increased odds of anatomic failure, a persistently wide GH did not appear to predispose patients to anatomic failure after Uphold™ mesh-augmented SSLF. These results may be limited by a small sample size.