Hypothesis/aims of study: To compare anatomical and functional results of two different surgical strategies in the combined treatment of anterior vaginal wall and vault prolapse: a transobturator (TO) mesh (UgytexA (R) Sofradim-Covidien) associated with a posterior sacrospinous ligament suspension (pSLS) compared with an arcus- anchored (AA) mesh (PolyformA (R) or PinnacleA (R), Boston Scientific) associated with a bilateral anterior sacrospinous ligament suspension (aSLS) using the CapioA (R) needle driver. Our hypothesis was that the second strategy (AA mesh + aSLS) could be more efficient for anterior wall reconstruction, restoring a more physiological vaginal axis than the posterior approach. Study design, materials and methods: Eighty-five women operated for a complex POP were included between March 2005 and March 2009 in a monocentric retrospective and comparative study (group TO/pSLS N = 41; group AA/aSLS N = 44). All patients had at least a POP-Q stage 2 anterior vaginal wall prolapse with Ba point a parts per thousand yen +1 and a stage 2 vault prolapse with C point a parts per thousand yen -1. Associated procedures were: site- specific rectocele repair (18 [40%] in the AA/aSLS group vs 32 [78%] in the TO/pSLS group (P = 0.005)). In the post- operative period, anatomical and functional results were evaluated and compared between groups. Post- operative anatomical success was defined by a stage 0 or 1 cystocele for the anterior compartment and by a post- operative vault prolapse stage inferior to the preoperative one for the medium compartment. Results: The baseline patient characteristics were similar in both groups, except for the history of prolapse surgery (17 patients [38%] in the AA/aSLS group vs four patients [10%] in the TO/pSLS group (P = 0.002)). The average follow- up was 11.5 +/- 8.1 months in the AA/aSLS group and 22.7 +/- 16.1 months in the TO/pSLS group (P = 0.011). Anatomical success rate on the anterior compartment was 40/44 (90.1%) in the AA/aSLS group vs 32/41 (78%) in the TO/pSLS group (P = 0.1). Anatomical success rate on the vaginal vault was 43/44 (98%) in the AA/aSLS group vs 37/41 (90%) in the TO/pSLS group (P = 0.19). Total anatomical success on either anterior compartment and vaginal vault was 39/44 (88.6%) in the AA/aSLS group vs 29/41 (70%) in the TO/pSLS group (P = 0.033). De novo prolapse rate on the untreated posterior compartment was 7/26 (27%) in the AA/aSLS group vs 1/9 (11%) in the TO/pSLS group (P = 0.65). Operative complications are represented by: haematomas (2 [4.6%] vs 1 [2.4%]); vaginal erosions (3 [7%] vs 1 [2.4%]); ureteral kinking (4 [9%] vs 0); severe mesh infection with vesico- vaginal fistula (1 [2.3%] vs 0). De novo dyspareunia rate is similar in both groups (2/10 [20%] vs 2/7 [28%]). In total, 8 patients (18.2%) were reoperated in the AA/aSLS group vs 3 (7.3%) in the TO/pSLS group. Concluding In this comparative series, both techniques have a high rate of complications and reoperations, although they were performed by trained operators in vaginal prosthetic surgery. The bilateral anterior sacrospinous ligament fixation shows promising results, but needs reevaluation because of the high rate of complications.
