PROTECTIVE EFFECT OF TRANSVAGINAL SLINGS ON RECURRENT ANTERIOR VAGINAL WALL PROLAPSE AFTER PELVIC RECONSTRUCTIVE SURGERY

C. Kwon, MD, R. Goldberg, MD MPH, S. Koduri, MD, S. Gandhi, MD, S. Krotz, MD, and P. Sand, MD

   Objective: To examine the independent effect of a tranvaginal sling procedure in preventing recurrent anterior vaginal wall prolapse following pelvic reconstructive surgery.

   Methods: Women who underwent vaginal reconstructive surgery for significant anterior vaginal wall prolapse (to the hymenal ring or beyond), with or without a concomitant transvaginal sling procedure were examined. The transvaginal sling was placed suburethrally and anchored full length (no suture bridges) to Cooper’s ligament bilaterally. The patient population was taken from an ongoing prospective, randomized, controlled trial evaluating the effects of Tutoplast processed fascia lata to prevent recurrent anterior vaginal wall prolapse. For this preliminary evaluation, the results from subjects enrolled from July 1999 to April 30, 2002 were evaluated. The patients were evaluated by the Pelvic Organ Prolapse Staging System (POP-Q) preoperatively and at 2, 6, 12, and 52 weeks postoperatively. Results from those patients who did and did not receive a transvaginal sling were evaluated using independent t-tests. Multiple logistic regression analysis was used to co! ntrol for potentially confounding variables.

   Results: During the time period studied, 145 women were initially consented for the original study. Three patients were not randomized prior to performing the procedure, one patient was found not to meet the inclusion criteria for study participation, and one patient was lost to follow-up, leaving 140 patients’ results eligible for analysis. 86 women (61.4%) underwent concomitant transvaginal sling for genuine stress incontinence (GSI), 26 women (19.1%) had an alternate procedure for GSI, and 28 women (20.0%) had no concomitant GSI procedure. For the 2-week postoperative visit, 133 patients (95.0%) returned for evaluation. At 6 and 12 weeks, 130 patients (92.9%) returned for evaluation. For those eligible for one-year follow-up, 89 of 109 patients (81.7%) have returned for evaluation. There were no statistical differences between the two groups at enrollment with respect to major baseline variables. A transvaginal sling was found to be highly protective against Stage ! II or greater recurrent anterior vaginal wall prolapse (p<0.001). This effect was seen as early as 6 weeks postoperatively and remained significant through the 1-year follow-up. At 12 weeks, 16/53 (30.2%) patients without a transvaginal sling vs. 3/77 (3.9%) with a transvaginal sling had developed recurrent anterior vaginal wall prolapse of Stage II or greater. At 1-year follow-up, 16/35 (45.7%) patients without a tranvaginal sling vs. 4/54 (7.4%) with a transvaginal sling had Stage II or greater recurrent prolapse. Logistic regression analysis showed no confounding effects of age, previous anti-incontinence surgery, or concomitant procedures.

   Conclusion: Transvaginal sling procedures appear to significantly reduce the risk of recurrent anterior vaginal wall prolapse by greater than 70%. It should be strongly considered as a concomitant procedure during anterior vaginal wall reconstruction, especially when surgical correction for genuine stress incontinence is planned.

   Key Words: prolapse, sling