Randomized study on surgical treatment for vaginal prolapse

Abstract

To the Editors: In their randomized study on surgical treatment for vaginal prolapse, Maher et al1Maher C.F. Qatawneh A.M. Dyer P.L. Carey N.P. Cornish A. Schluter P.J. Abdominal sacrocolpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study.Am J Obstet Gynecol. 2004; 190: 20-26Abstract Full Text Full Text PDF PubMed Scopus (420) Google Scholar make the point that there was a significant increase risk of anterior wall and vault prolapse after sacrospinous colpopexy. They then state that there was a nonsignificant increase tendency of posterior wall prolapse after the sacrocolpopexy, which nullified the difference.On close inspection of Table II, there were rectoceles present preoperatively in 35 of 47 women in the abdominal group, but only 11 of the rectoceles were repaired. In the vaginal group, there were 30 rectoceles present preoperatively, yet there were 44 posterior colporrhaphies performed. It appears an excess number of posterior colporrhaphies were performed in the vaginal group, whereas only one third of the recognized rectoceles were corrected in the abdominal group. This alone would explain why there were more rectoceles present postoperatively in the abdominal group. Had the rectoceles been appropriately corrected at the time of the sacrocolpopexy, it is unlikely that they could conclude that “the abdominal approach may be preferable in women with predominately anterior and vault prolapse, and the vaginal approach may be preferable in those women with predominantly posterior and vault prolapse.” Rather, I suspect they might conclude that (1) recurrent cystoceles and vault prolapse alone continue to be the main drawbacks of the vaginal approach, and (2) if rectoceles are corrected, the abdominal sacral colpopexy yields overall better lasting support. To the Editors: In their randomized study on surgical treatment for vaginal prolapse, Maher et al1Maher C.F. Qatawneh A.M. Dyer P.L. Carey N.P. Cornish A. Schluter P.J. Abdominal sacrocolpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study.Am J Obstet Gynecol. 2004; 190: 20-26Abstract Full Text Full Text PDF PubMed Scopus (420) Google Scholar make the point that there was a significant increase risk of anterior wall and vault prolapse after sacrospinous colpopexy. They then state that there was a nonsignificant increase tendency of posterior wall prolapse after the sacrocolpopexy, which nullified the difference. On close inspection of Table II, there were rectoceles present preoperatively in 35 of 47 women in the abdominal group, but only 11 of the rectoceles were repaired. In the vaginal group, there were 30 rectoceles present preoperatively, yet there were 44 posterior colporrhaphies performed. It appears an excess number of posterior colporrhaphies were performed in the vaginal group, whereas only one third of the recognized rectoceles were corrected in the abdominal group. This alone would explain why there were more rectoceles present postoperatively in the abdominal group. Had the rectoceles been appropriately corrected at the time of the sacrocolpopexy, it is unlikely that they could conclude that “the abdominal approach may be preferable in women with predominately anterior and vault prolapse, and the vaginal approach may be preferable in those women with predominantly posterior and vault prolapse.” Rather, I suspect they might conclude that (1) recurrent cystoceles and vault prolapse alone continue to be the main drawbacks of the vaginal approach, and (2) if rectoceles are corrected, the abdominal sacral colpopexy yields overall better lasting support. ReplyAmerican Journal of Obstetrics & GynecologyVol. 192Issue 2PreviewTo the Editors: Thank you for the opportunity of responding to Dr Thompson's letter. He suggests that if more patients underwent a posterior colporrhaphy (PC) at the time of sacral colpopexy (SC), the success rate of the sacral colpopexy would have been significantly greater resulting in different study conclusions. This statement is based on a presumption that the SC is ineffective in the surgical management of rectocele. This is incorrect for the following reasons. First, the surgical technique of the SC as reported in the methodology describes placing the posterior arm of the mesh 8 cm along the posterior vaginal wall that would correct all but the lowest of rectoceles. Full-Text PDF