COMPARISON OF OUTCOMES: MIDLINE ANTERIOR REPAIR ALONE VERSUS ANTERIOR REPAIR PLUS VAGINAL PARAVAGINAL DEFECT REPAIR.

A.N. Morse, S.B. Young, K.O’Dell, A.E.Howard, S.Baker, MP Aronson. University of Massachusetts Medical School

   Objective: To investigate whether the addition of vaginal paravaginal repair(VPVR) to standard midline anterior colporrhaphy(AC) improved outcomes in the repair of anterior wall prolapse.
   Methods: A “natural experiment” occurred at our institution when a single surgeon began adding VPVR’s to AC’s in 1995. Charts from 148 patients who underwent pelvic prolapse repair including AC(group “AC”) between 1991 and 1995 and 88 patients who underwent pelvic prolapse repair between 1995 and 2001 including AC and VPVR (group “+VPVR”) were reviewed. Phone interviews (70 AC , 60 +VPVR) were conducted in 2002. Recurrence was defined as grade 2(Baden-Walker) or greater anterior wall prolapse. For the interviews, significant symptoms were defined as a rating of >/=2 (0-3 scale) on any question from short forms of the UDI and IIQ. The length of follow-up was markedly different for the two cohorts (last pelvic exam mean 32 months after surgery in the AC group vs. 17 months for the +VPVR group). The mean time from surgery to phone interview was 98 months (AC) vs. 46 months (+VPVR). Therefore, Kaplan-Meyer survival analysis was used to model the rates of prolapse rec! urrence and symptom development post-operatively.
   Results: Significantly more patients in the +VPVR group had had prior pelvic surgery (53/87 vs. 56/142, Fisher’s, p=.0018) The EBL was larger in the +VPVR group (387+/-28 vs. 305+/-15, t(212)=2.87, p=0.0045). The predicted median time to prolapse recurrence (i.e. time at which 50% of patients would be expected to have recurred) was 60 months in the +VPVR group and 75 months in the AC group (tarone-ware(1)=.2, p=0.65). Prior pelvic surgery did appear to be a significant confounder in the risk of recurrence. Analysis of the phone interview results demonstrated a significant difference in the mean time to development urinary or bulge symptoms (118 months AC vs. 61 months +VPVR, tarone-ware(1)=.78, p=0.003).
   Conclusions: There was no indication that the addition of the VPVR improved anatomic outcomes or reduced the occurence of postoperative urinary or prolapse symptoms; however power was low and the recurrence rates were confounded by the higher rate of previous pelvic surgery in the +VPVR group.

   Key words: vaginal paravaginal repair, pelvic organ prolapse, anterior colporrhaphy