Our current data, acquired 48 months after surgery, indicate that our modified version of paravaginal repair is a very effective native-tissue operation for the treatment of anterior vaginal prolapse and cystocele. The rate of success was 94.9% when assessed 12 months after surgery, 91.0% when assessed 24 months after surgery, and 76.2% when assessed 48 months after surgery. The cure rate was significantly higher than that achieved with most other types of mesh or non-mesh repair surgery. The success rates for paravaginal defect repair have been reported to range from 60% to 89%[10]. Menefee et al. previously reported that repairs for anterior vaginal wall prolapse with mesh were associated with a significantly lower anatomical failure rate (18%) than repairs for anterior vaginal wall prolapse with colporrhaphy (58%) when assessed 2 years after surgery [12]. In the present study, our anatomical failure rate was 9%; this was lower than that achieved with mesh repair, as reported by Menefee et al. With our new technique, only a limited number of silk sutures remain under the vaginal mucosa; this minimizes the risk of vaginal bleeding, granulation, and suture exposure. All vaginal bleeding beyond one month postoperatively was caused by prolapse of the fallopian tubes and granulation in the vaginal stump. The silk sutures under the vaginal mucosa appeared to be unrelated to vaginal bleeding. In general, modified paravaginal repair is a safe and effective mesh-free procedure for the treatment of anterior vaginal prolapse. However, for patients with apical prolapse, modified paravaginal repair is not an effective treatment. In these cases, middle pelvic cavity repair (sacral ligament suspension/sacrospinous ligament fixation) was always performed simultaneously. This was only a retrospective study without control groups. In order to acquire higher levels of evidence, we need to perform randomized controlled trials. The mean length of postoperative hospital stay was 4.1±1.7 days, which was longer than expected. This was predominantly due to management policies; our department required that patients to be discharged at least 72 hours after surgery. In recent months, we have discharged patients 24 hours after surgery.
Polypropylene mesh is easy to use, does not prolong the time required for surgery, and is associated with a low rate of recurrence[13]. This form of mesh can be used for various pelvic floor repair operations. However, there is an increasing body of publications reporting adverse events that are related to the use of mesh, including the exposure of vaginal mesh, pain, infection, issues related to urination, neuromuscular problems, vaginal scars or contractures, issues related to sensation, and even death[14]. In January 2012, the FDA announced that transvaginal mesh should be considered as a class III medical device and forced manufacturers to conduct post-marketing monitoring research. A subsequent Cochrane review [15] (published in 2016) described the results obtained when repairs were carried out with a synthetic non-absorbable mesh, compared with standard (native tissue) repair. The review included 37 trials involving 4023 women and concluded that repairs with synthetic non-absorbable mesh were associated with fewer prolapse symptoms or measurable prolapse, and less likely to be followed by repeat prolapse surgery. However, insufficient evidence was available to indicate whether women had a better quality of life after repair with a synthetic non-absorbable mesh.
Over recent years, the importance of non-mesh repair surgery has been revisited. The main disadvantage of non-mesh repair surgery is the rate of symptom recurrence [16].According to the traditional view, cystocele is likely to result from overstretching and thinning of the vaginal wall and other structures supporting the bladder. Notably, traditional repair of the anterior vaginal wall required surgeons to suture the urethra and the bladder fascia in order to tighten the pubic cervical fascia. However, the recurrence rate for this technique was as high as 40%, suggesting that our traditional understanding of the pathogenesis of cystocele may be incomplete. As early as the early 20th century, White proposed that tears in the white line, which fixes the pubic cervical fascia onto the lateral pelvic wall, were the main causative factor for cystocele [17]. White also proposed a surgical method with which to correct this injury. However, White’s theory and surgical proposal were not recognized until the 1970s. Raz [18] and Safir [19] subsequently proposed a simplified classification scheme for cystocele (types I, II, and III) in accordance with the anatomical mechanisms associated with severe cystocele. Type I refers to a central defect in the pubic cervical fascia. Type II refers to defects in the attachment of the pubic cervical fascia to the vagina. Type III refers to a defect with characteristics of type I as well as type II defects. These authors believed that patients with severe cystocele often have type III defects. Because most instances of cystocele are caused by paravaginal defects, surgical repair should focus on reconnecting the pubic cervical fascia with the lateral pelvic wall. In another paper, Young et al. described their experience of paravaginal repair and reported a good short-term rate of objective cure[8]. However, subsequent research showed that the long-term objective cure rate for paravaginal repair was inferior to that achieved with mesh [7,11]. To address this problem, we developed a modified technique for paravaginal repair. Our surgical procedure features two modifications to the traditional technique used for paravaginal repair. First, our technique combines paravaginal repair with reverse bridge repair of the anterior wall. Second, our technique involves cross-knotting of the bilateral paravaginal sutures. We also advocate an individualized approach that considers the specifics of a particular case when selecting treatment options. For example, in our case series, we performed middle pelvic cavity repair (sacral ligament suspension/sacrospinous ligament fixation) for patients with apical prolapse. In total, 61 patients (62.2%) received middle pelvic cavity repair (sacral ligament suspension, n=18; sacrospinous ligament fixation, n=43).
The vaginal apex plays a crucial role in maintaining the integrity of the pelvic floor. Vaginal apical suspension may therefore be the most important step in preventing and treating vaginal vault prolapse and for preventing recurrent POP [20]. For patients with apical prolapse, sacral ligament suspension, sacrospinous ligament fixation, and sacrocolpopexy (SCP) are the first-line choices. SCP has long been regarded as the gold standard for the treatment of POP[21]. SCP is also an effective option for primary anterior compartment prolapse repair[22]. However, in their meta-analysis, Coolen et al. [23] reported that a standard treatment could not be used for vaginal vault prolapse. In our study, four patients required a second round of surgery; vaginal apical suspension was not performed during the first operation in any of these cases. Three cases were treated with sacrocolpopexy, and 1 of these cases was treated with sacrospinous ligament fixation during repeat surgery. No recurrences occurred in any of these four patients after the second round of surgery. SCP can be performed to repair defects in the middle and anterior pelvis. However, SCP is a mesh-based form of repair for POP. Sacral ligament suspension and sacrospinous ligament fixation are native-tissue repair operations for vaginal apical POP. However, they are not effective for primary anterior compartment prolapse repair. Vitale et al.[24] studied the efficacy of transvaginal bilateral sacrospinous fixation (TBSF) and its impact on quality of life (QoL) and sexual function in women with second recurrences of vaginal vault prolapse (VVP). In the study reported by Vitale et al., women with low anterior compartment prolapse underwent concomitant paravaginal repair. Our modified paravaginal repair was safe and effective for the treatment of anterior vaginal prolapse and cystocele. Thus, the combination of middle pelvic cavity repair (sacral ligament suspension/sacrospinous ligament fixation) and modified paravaginal repair may represent a good choice for non-mesh repair.
Pelvic organ prolapse is a very complex condition because it includes both physical and functional aspects. Numerous instruments can be used to assess a patient’s quality of life before and after surgery, including the Short Form-36 (SF-36), the Female Sexual Function Index (FSFI), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the IUGA-Revised Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-IR), the Pelvic Floor Distress Inventory questionnaire (PFDI-20), the Prolapse Quality of Life Questionnaire (P-QOL), and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) [25~27]. Only recorded data were included in this retrospective study. If a prospective research study is carried out, these instruments should be chosen carefully.
In our study, the rate of fallopian tube prolapse was 3.1% (3/98); this seems rather high. Prolapse of the fallopian tube into the vaginal vault is a rarely reported complication that may occur after hysterectomy. Prolapse of the fallopian tubes is often neglected and misdiagnosed [28]. According to our clinical experience, the rate of fallopian tube prolapse is higher than reported in the literature. This may also be due to the way we sew up the vaginal stump: we suture the fallopian tube stump to the vaginal stump. Additional research is now needed to investigate the efficacy of this particular part of the procedure.
The effect of pelvic organ prolapse on the quality of a patient’s sexual life includes both physical and psychological aspects. Surgery can improve the quality of a patient’s sexual life by reducing prolapse [29]. In this study, the PISQ -12 score was significantly improved after surgery. Since the surgery was performed without mesh, there were no negative effects relating to the use of mesh.