A RETROSPECTIVE COMPARISON OF ABDOMINAL VERSUS VAGINAL PARAVAGINAL REPAIR FOR SEVERE CYSTO-URETHROCELE

R.I. Reid

Double Bay, Australia

OBJECTIVE: To compare abdominal (APVR) and vaginal paravaginal repair (VPVR) for severe anterior segment prolapse, and to compare VPVR repair using a “raft graft” of vaginal fibromuscularis, polypropylene mesh or SurgiSIS^® porcine xenograft against “three point” suture re-suspension of the avulsed pubocervical fascia.

MATERIALS AND METHODS: Study design is a retrospective, comparative review of 124 consecutive women having complex pelvic floor repairs, in four Australian hospitals between 1997― 2004. Three records were unlocatable. Of 121 assessable women, 81 had primary and 40 had recurrent prolapse. 55 women also had urinary incontinence. Patients were prospectively evaluated by a symptom severity inventory, a standardized physical examination and urodynamic testing where indicated.  47 women had APVR with Burch colposuspension and 74 had VPVR (+/- low tension suburethral tape). All patients had perineoplasties; 222 additional procedures were done.  Main outcome measures were the recurrence of anterior segment prolapse; the occurrence of urgency, voiding difficulty or dyspareunia; and all significant complications.  Setting α = .05 and β = .80, power calculation required 117 subjects to demonstrate a 15% difference between two effective treatments (outcome being expressed as a categorical variable).  Statistical analyses took two principal forms: short term results (anatomic and functional outcome in the first postoperative year) were submitted to χ² contingency table analysis, and repair durability over the succeeding 6 years was gauged by Kaplan Meier survival analysis.

RESULTS: Transabdominal cystocele repair was more reliable in the short term [45/47 (96%) vs 63/74 (88%); χ² (1) = 4.02, p<.05], and more durable over the long term [cumulative survival on Kaplan Meier analysis = 0.957 vs 0.794 at 60 months]. Functional outcomes were equivalent for both groups, with 39/47 (83%) and 60/74 (81%) being dry without urge, voiding difficulty or dyspareunia. VPVR results displayed substantial heterogeneity. On subgroup analysis, the “raft graft” gave better short term [39/41(95%) vs 22/33 (67%); χ² (1) = 10.22, p=.0014] and long term success [cumulative survival = 0.914 vs 0.418 at 60 months]. Major complications were not statistically different between the abdominal and vaginal groups [8/73 (11%) vs 7/47 (15%); χ² (1) = 0.44, ns].

CONCLUSIONS:  Abdominal paravaginal repair is essentially a gold standard procedure for severe rotatory cysto-urethrocele repair; paradoxically, a mechanically analogous repair done transvaginally had a 17% higher five year failure rate. This differential reflects the fact that “raft graft” VPVR is an easier surgical technique, and that tissue augmentation materials help nullify any decline in tissue quality attributable to transvaginal dissection. A bioabsorbable protein scaffold with tissue engineering properties may represent the best choice for the “raft graft”.

Key Words: Cysto-urethrocele, paravaginal repair, tissue augmentation materials.

Disclosure – Nothing to disclose.