Association between adjuvant posterior repair and success of native tissue apical suspension

Sutkin G, Zyczynski HM, Sridhar A, Jelovsek JE, Rardin CR, Mazloomdoost D, Rahn DD, Nguyen JN, Andy UU, Meyer I, Gantz MG; NICHD Pelvic Floor Disorders Network.
Am J Obstet Gynecol. 2020 Feb;222(2):161.e1-161.e8
By Dr Tal Fligelman and Dr Anna Padoa

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Women with pelvic organ prolapse (POP) usually have multiple vaginal compartments involved and it’s now understood that adequate apical support is key to achieving successful repair outcomes. In addition, data suggests that enlarged genital hiatus is a poor prognostic factor for prolapse recurrence. Therefore, concomitant posterior repair and perineorrhaphy are typically performed to restore the vaginal axis and more importantly to reduce potential stress on the apical suspension, which is believed to lead to prolapse recurrence. However, the benefit of adjuvant posterior repair after adequate transvaginal native tissue apical support remains unknown.
This was a secondary analysis of The Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial. The authors compared 190 participants who had a posterior repair (posterior repair group – PR group) to 184 who did not (no posterior repair group – no PR group) at the time of native tissue vaginal apical suspension. The primary aim was to determine whether adjuvant posterior repair at the time of sacrospinous ligament fixation (SSF) or uterosacral ligament suspension (USL) was associated with “surgical success”. The authors used the composite outcome of the OPTIMAL Trial to define “surgical success”: no prolapse beyond the hymen, point C ≤ –2/3 total vaginal length, no bothersome bulge symptoms, and no retreatment at 24 months. The individual components were secondary outcomes. Propensity score methods were used to build models that balanced posterior repair group and the no posterior repair group for ethnographic factors and preoperative Pelvic Organ Prolapse Quantification values. An unadjusted probability curve was also created to evaluate for surgical success as predicted by preoperative genital hiatus.
The authors observed no group differences in surgical success, using propensity score methods (66.7% PR vs 62.0% no PR; p=0.83) or unadjusted analyses (66.2% PR vs 61.7% no PR; p=0.47). Individual outcome measures of prolapse recurrence (bothersome bulge symptoms, prolapse beyond the hymen, or retreatment for prolapse) and an anatomic outcome of any individual compartment (anterior, apical, or posterior) also did not differ between groups at 24 months. However, the unadjusted probability of composite success decreased with increasing baseline GH; a baseline GH of 4.5 cm was associated with a predicted 65.8% composite success rate at 24 months.
Based on the study’s findings it’s reasonable to conclude that adjuvant posterior repair at the time of vaginal apical native tissue surgery was not associated with surgical success. However, there are several important limitations that must be noted. Namely, posterior repair was not the primary intervention examined, there was no standardization how adjuvant PR was to be performed, there was wide variation in performance of PR by surgeon (15-79% of surgeries), and there was no subgroup analysis between those who received SSF or USL to see whether they benefited from a PR. Lastly, propensity score method only controls for observed variables and there are hidden variables that as a result can’t be accounted. Therefore, there is still a need for a well-designed, prospective, randomized trial to provide quality evidence for adjuvant PR at the time of native tissue apical suspensions.