POP is a condition with anatomical symptoms such as palpable swelling, bruising in the genital region, and causing dysfunctions like difficulty in defecation and miction, incontinence and also psychological effects, deteriorating sexual and social life(15). Repairing compartment defects in POP and approaching it to normal anatomy will result in favorable functional and psychological effects.
We used a 5-arm mesh in 37 LLS procedures in stage ≥3 POP patients. Concerning the anatomical outcome, the analysis of the POP-Q stage outcome shows a statistically significant improvement. The best anatomic result was in the apical compartment and the success rate was 95.3%. The success rate was 86.1% in the anterior compartment. All of the patients undergoing surgery had a preoperative posterior compartment defect and desired anatomical improvement was obtained with a rate of 91.9% postoperatively. While postoperative apical and anterior compartment repair outcomes with a 5-arm mesh were similar to LLS and SCP, our posterior vaginal repair outcomes were better than LLS.
LLS procedure is not indicated in the presence of a significant apical/posterior defect (enterocele, high rectocele)(16). When simultaneous anterior and posterior compartment repair was performed in the patients undergoing apical compartment defect repair, the risk of reoperation has reduced(17). Lateral arms performing suspension in cases used a T-shaped synthetic mesh graft in the LLS procedure do not ensure the closure of the pouch of Douglas. This condition may cause the progression of the posterior defect. To repair the apical compartment defect together with the posterior compartment defect or to prevent the occurrence of de novo posterior defect, posterior colporrhaphy performed with the native tissue or an additional posterior compartment repair procedure using a mesh was added to both SCP and LLS surgery. In hysterectomized POP patients undergoing SCP and LLS surgery in whom the mesh placed in the apical compartment was sutured to the deep posterior vaginal wall into the rectovaginal space, an additional posterior repair procedure are not needed any more(18, 19). Dubuisson et al. performed laparoscopic lateral suspension with 2 meshes in size of 14×3 cm placed in the anterior and posterior compartments8. Afterward, while Dubuisson et al. repaired the apical and anterior compartment defects using a T-shaped mesh with the middle part between 5 to 8 cm in length and 4 to 6 cm in width, and arms 3 cm in width, they repaired the posterior compartment defect using a rectangular polyester patch 6 to 8 cm in length and 4 to 6 cm in width fixed on the rectovaginal fascia but not performed suspension9. The risk of mesh-related complications increases with the size of mesh used (20). We repaired the posterior compartment defect by suturing 2 short arms of a 5-arm mesh 6 cm in length and 2 cm in width to the sacrouterine ligament, the posterior wall of the cervix, and the posterior vaginal wall. When we elevated the long arms, a symmetrical suspension occurred also in the posterior compartment as it was in the anterior and apical compartments. The point Bp was in average −4.32 ± 0.83 cm distance during at least postoperative 1-year follow-ups of our patients. Recurrent posterior compartment prolapse occurred in none of our patients.
A meta-analysis of sacrocolpopexy with hysterectomy compared to sacrocolpopexy without hysterectomy was associated with four times higher risk of mesh exposure (21). Similarly, the success rate in POP patients undergoing hysterectomy simultaneously with LLS was less and the recurrence and mesh erosion rates were higher compared to patients not undergoing hysterectomy(22). We performed a hysterectomy with the indication of prolapse in none of our patients. A 5-arm mesh could easily be performed in the LLS procedure without the need for hysterectomy.
Correction of the damaged anatomical structure in POP patients provided also improvement in symptoms. A marked improvement occurred postoperatively in symptoms of the preoperative vaginal bulge, urinary urgency, incomplete voiding, urinary frequency, constipation, and fecal incontinence.
While the rate of de novo constipation was reported to be 1.9-11.4% in patients undergoing abdominal SCP, the rate of constipation after LLS suspension was reported to be 5.5-8.4% (10, 23). Constipation was present in 8.1% of our patients in whom we used a 5-arm mesh. The rate of occult SUI (stress urinary incontinence) was reported to be 20% in patients with a diagnosis of POP, but this rate was higher in advanced stage POP patients (24). Veit-Rubin N et al.(25) determined the rate of SUI as 6.6% after LLS surgery. In our study, we determined de novo SUI in 7 patients (18.9%).
LLS seemed to preserve normal sexual function and women were determined to be sexually more active after surgery compared to earlier. Not performing hysterectomy simultaneously in LLS caused more favorable sexual outcomes (25). In our study, while we did not interpret regarding the quality of sexual function, the number of sexually active patients was increased postoperatively and the rate of dyspareunia was reduced.
The use of mesh in pelvic organ prolapse surgery reduced the recurrence rates of prolapse. It is impossible to neglect the complications such as mesh-related vaginal erosion, granulomas, dyspareunia, vesicovaginal fistulas, and an increase in overactive bladder symptoms. Vaginal erosion is the most common mesh-related complication. As it can be treated with conservative methods, it can also require complex repeated surgical interventions (26). The risk of mesh erosion increases 10-folds in smoking individuals, 5-folds in patients undergoing POP or UI surgery. A specific finding was that the posterior mesh was associated with a higher risk of erosion than the anterior mesh(27). A systematic review that included more than 7000 women found a median mesh erosion rate of 4% during a 2-year follow-up after abdominal POP surgery with a mesh (28). Mesh erosion occurred in the uncomplicated area of the anterior compartment in a size of 1.5 cm in 1 of our patients (2.7%). To reduce the risk of mesh erosion, surgical precautions such as abstaining from aggressive dissection which may deteriorate perfusion, not damaging surrounding organs like the urinary bladder, rectum, and selection of appropriate mesh (macroporous and monofilamentous polypropylene) should be performed (29).
Strenghts and limitations
Limitations of our study are the retrospective design of the study and the inclusion of a relatively small number of patients. The strength of our study is that it reports the results of a method applied for the first time in the literature. Further studies are required to find the optimal surgical method in POP treatment.