Association between Adjuvant Posterior Repair and Success of Native Tissue Apical Suspension

Abstract Background Posterior repairs and perineorrhaphies are often performed in prolapse surgery to reduce the size of the genital hiatus. The benefit of an adjuvant posterior repair at the time of sacrospinous ligament fixation or uterosacral ligament suspension is unknown. Objective We aimed to determine if an adjuvant posterior repair at transvaginal apical suspension is associated with improved surgical success. Study Design This secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss [OPTIMAL] trial compared 24-month outcomes in 190 participants who had a posterior repair (posterior repair group) and 184 who did not (No posterior repair) at the time of SSLF or USLS. Concomitant posterior repair was performed at surgeon’s discretion. Primary composite outcome of ‘surgical success’ was defined as no prolapse beyond the hymen, point C ≤ -2/3TVL, no bothersome bulge symptoms, and no retreatment at 24 months. The individual components were secondary outcomes. Propensity score methods were employed to build models that balanced posterior repair and No posterior repair groups for ethnographic factors and preoperative Pelvic Organ Prolapse Quantification (POPQ) values. Adjusted ORs were calculated to predict surgical success based on the performance of a posterior repair. Groups were also compared with unadjusted Chi Square analyses. An unadjusted probability curve was created for surgical success as predicted by preoperative genital hiatus (GH). Results Women in the posterior repair group were less likely to be Hispanic or Latino, were more likely to have had a prior hysterectomy and be on estrogen therapy. The groups did not differ with respect to pre-operative POPQ stage; however, subjects in the posterior repair group had significantly greater preoperative posterior wall prolapse. There were no group differences in surgical success using PS methods (66.7% posterior repair vs 62.0% no posterior repair, aOR 1.07 (0.56, 2.07), p: 0.83) or unadjusted test (66.2% posterior repair vs. 61.7% No posterior repair, p: 0.47). Individual outcome measures of prolapse recurrence (bothersome bulge symptoms, prolapse beyond the hymen or retreatment for prolapse) also did not differ by group. Similarly, there were no differences between groups in anatomic outcomes of any individual compartment (anterior, apical, or posterior) at 24 months. There was high variation in performance of posterior repair by surgeon [IQR 15%-79%]. The unadjusted probability of overall success at 24 months, regardless of posterior repair, decreased with increasing GH such that a GH of 4.5 cm was associated with 65.8% success (95% CI: 60.1%, 71.1%). Conclusion Concomitant posterior repair at sacrospinous ligament fixation or uterosacral ligament suspension was not associated with surgical success after adjusting for baseline covariates using propensity scores or unadjusted comparison. Posterior repair may not compensate for the pathophysiology that lead to enlarged pre-operative GH which remains prognostic of prolapse recurrence.