International Urogynecology Journal https://doi.org/10.1007/s00192-018-3559-9
ORIGINAL ARTICLE
Quality of life following vaginal reconstructive versus obliterative surgery for treating advanced pelvic organ prolapse Alin Petcharopas 1 & Supreeya Wongtra-ngan 1 & Orawee Chinthakanan 2 Received: 2 August 2017 / Accepted: 8 January 2018 # The International Urogynecological Association 2018
Abstract Introduction and hypothesis Although colpocleisis is effective in selected women, the low-morbidity obliterative procedure for treating pelvic organ prolapse (POP) and its impact on postoperative quality of life (QOL) have rarely been studied. Our aim was to assess QOL in women after colpocleisis and compare it with that of women after reconstructive vaginal surgery. Methods This retrospective cohort study included women (aged 35–85 years) with POP who underwent obliterative or reconstructive surgical correction during 2009–2015. Patients who met the inclusion criteria underwent telephone interviews that included the validated Prolapse QOL questionnaire (P-QOL Thai). Results Of 295 potential participants, 197 (67%) completed the questionnaire: 93 (47%) with obliterative and 104 (53%) with reconstructive surgery. Most were Thai (95.4%), multiparous (87%), and sexually inactive (76%). Their histories included hysterectomy (12%), incontinence or prolapse surgery (11%), and POP stage 3/4 (77%). Patients undergoing obliterative surgery were significantly older than those undergoing a reconstructive procedure (69 vs 58 years, P < 0.05). The obliterative group had more children, less education, and more advanced POP. There were no significant differences in operative parameters or complications. The obliterative surgery group had a significantly shorter hospital stay: median 2 (range 1–17) days vs 3 (1– 20) days (P = 0.016). P-QOL scale revealed significantly less postoperative impairment in the obliterative surgery group (1.75 vs 5.26, P = 0.023). There were no significant differences in other P-QOL domains. Conclusions Colpocleisis improves condition-specific QOL in selected patients with advanced POP and remains an option for this group. Surgeons should consider counseling elderly women with advanced POP about obliterative vaginal surgery. Keywords Colpocleisis . Elderly . Obliterative vaginal surgery . Pelvic organ prolapse . Quality of life
Introduction Pelvic organ prolapse (POP) is a common condition in elderly women, with an incidence that increases with age [1].
This abstract was a poster presentation at IUGA 2016 in Cape Town, South Africa Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00192-018-3559-9) contains supplementary material, which is available to authorized users * Orawee Chinthakanan
[email protected] 1
Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
2
Department of Obstetrics & Gynecology, Female Pelvic Medicine & Reconstructive Surgery, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
According to the Women’s Health Initiative study of postmenopausal women, the prevalence of POP was 41% in those who had not undergone hysterectomy and 39% in those who had [2]. A Thai study reported a 43.3% prevalence of POP in their menopausal clinic [3]. A variety of procedures can be used for POP management. When selecting the appropriate surgical procedure, however, many factors must be taken into consideration, including the severity of the POP, the patient’s general condition, and the patient’s preference. Obliterative surgery is appropriate in elderly women who have advanced-stage prolapse, cannot tolerate extensive surgery, and no longer desire preservation of coital function. The success of treatment is evaluated by regression of the POP stage, postoperative complications, postoperative hospital stay, quality of life (QOL), and patient satisfaction. The anatomical success of colpocleisis is nearly 100% [4]. There are limited data, however, on short- and
Int Urogynecol J
long-term outcomes, including subjective outcomes and patient satisfaction [5–7]. The primary objective of this study was to determine the QOL of women who underwent POP surgery—either obliterative or reconstructive vaginal surgery. A secondary objective was to compare the operative data, including postoperative complications, intraoperative blood loss, and postoperative hospital stay in women with POP who underwent obliterative versus reconstructive vaginal surgery. We hypothesized that obliterative vaginal surgery for POP improves the QOL more effectively than reconstructive vaginal surgery.
Materials and methods The Research Administration Section of the Faculty of Medicine, Chaing Mai University approved this retrospective cohort study (OBG-2558-03305). Participants were retrospectively enrolled from among women who had been diagnosed with pelvic organ prolapse and visited the Urogynecology Clinic at Chiang Mai University Hospital between January 2009 and November 2015. We included only women aged 35–90 years who had undergone either obliterative or reconstructive surgical correction of POP and who could complete an extensive questionnaire by telephone. For this study, obliterative vaginal surgery was defined as either total colpocleisis, Le Fort partial colpocleisis, or partial colpocleisis in which the resultant vaginal cuff was closed. Pelvic floor reconstructive vaginal surgery consisted of any transvaginal procedures other than obliterative procedures, including anterior colporrhaphy, posterior colpoperineorrhaphy, McCall culdoplasty, vaginal sling, and transvaginal mesh placement. The exclusion criteria were an inability to complete the questionnaire, unavailability to be contacted by phone, and/or having undergone some other surgical correction technique that did not meet the inclusion criteria. After completing an approved informed consent process, the electronic medical records of participants who met the inclusion criteria were identified and reviewed. The medical records review included baseline characteristics, POP-Q stage, and the operative notes for each participant. The potential participants were then contacted by telephone. The approved phone interview script included questions about demographic data and the validated Thai version of the Prolapse Quality of Life Questionnaire (P-QOL-Thai) for assessing postoperative QOL. The Thai version of the P-QOL has been validated, is reliable, and allows simple assessment of symptom severity and the QOL of Thai-speaking patients with POP [8]. It consisted of 20 questions in nine domains, which, overall, address general health perceptions, prolapse impact, role limitations, physical limitations, social limitations, personal relationships, emotional problems, sleep or energy disturbance, and
symptom severity. Each item carries a total of four points except for the first question on general health, which carries five points. The total score of each domain is then converted on a scale of 0–100. A higher score indicates greater impairment of that domain [8]. Data were analyzed using the Chisquared test and Fisher’s exact test for categorical data. Student’s test and the Mann–Whitney U test were used to analyze continuous data. STATA version 14.2 software (Stata Corp., College Station, TX, USA) was used for the analyses.
Results In total, 295 participants were eligible for this study, 91 of whom could not be contacted by telephone, 6 died, and 1 refused to participate in the study. Hence, 197 (66.8%) women were able to complete the questionnaire by telephone interview and were enrolled in the study: 93 (47.2%) who had undergone obliterative surgery and 104 (52.8%) who had had reconstructive surgery. Table 1 shows baseline demographic characteristics. The mean age was 63.2 ± 10.2 years. Participants in the obliterative surgery group were statistically significantly older than those in the reconstructive group (69.04 ± 8.03 vs 58.06 ± 9.05 years, P < 0.001). Most of the patients were Thai (95.4%), Buddhists (96.5%), married (60.9%), multiparous (87.3%), and sexually inactive (75.6%). None of the patients in the obliterative surgery group were sexually active. Fortyeight participants of the reconstructive group were sexually active before surgery. The reconstructive surgery group were more likely to have had a higher education, to be sexually active, and to be married. In contrast, the obliterative surgery group had higher parity, had undergone more hysterectomies, and more often had advanced-stage POP. In the obliterative surgery group, 88.17% underwent total colpocleisis, 7.53% partial colpocleisis, and 4.30% Le Fort colpocleisis. In addition, they underwent concurrent surgical procedures, including vaginal hysterectomy (55.91%), posterior colporrhaphy (20.43%), vaginal sling (19.35%), and others (9.68%). Vaginal hysterectomy, however, was performed in fewer women in the obliterative surgery group than in the reconstructive surgery group (55.91% vs 77.88%, P = 0.001). Table 2 shows the concurrent surgical procedures. The mean follow-up time of the obliterative and reconstructive groups were 23.87 months and 32.32 months respectively. Operative data and postoperative complications are shown in Table 3. The mean operative time for those who underwent obliterative surgery was shorter than that for those who underwent reconstructive surgery (110.45 vs 117.5 min respectively), but the difference was not statistically significant. There was no difference in blood loss between the two groups. However, there was a significant difference in the length of
Int Urogynecol J Table 1 Baseline demographic characteristics
Total (n = 197)
Obliterative (n = 93)
Reconstructive (n = 104)
P value
Age*
63.24 (10.17)
69.04 (8.03)
58.06 (9.05)
<0.001
Thai
188 (95.43)
87 (93.55)
101 (97.12)
0.231
Buddhism Education
190 (96.45)
91 (97.85)
99(95.19)
0.315 0.005
Characteristics
Illiterate
21 (10.66)
16 (17.20)
5 (4.81)
Literate
176 (89.34)
77 (82.80)
99 (95.19)
Married Sexually active
120 (60.91) 48 (24.37)
40 (43.01) 0 (0)
80 (76.92) 48 (46.15)
<0.001 N/A
Para* Multiparity (para ≥ 2)
2.94 (1.72) 172 (87.31)
3.56 (2.02) 84 (90.32)
2.38 (1.16) 88 (84.62)
<0.001 0.23
Cardiovascular Respiratory
126 (63.96) 14 (7.11)
56 (60.22) 10 (9.62)
70 (67.31) 4 (3.85)
0.151 0.147
Gastrointestinal Kidney, ureter, and bladder Endocrine
9 (4.57) 4 (2.03)
3 (3.23) 1 (0.96)
6 (5.77) 3 (3.23)
0.393 0.261
46 (23.35)
21 (22.58)
25 (24.04)
0.809
Other
52 (26.40)
29 (31.18)
23 (22.12)
0.149
24 (12.18) 21 (10.66)
16 (17.20) 13 (13.98)
8 (7.69) 8 (7.69)
0.042 0.153
3.04 (0.72) 1 (0.51) 44 (22.34)
3.35 (0.60) 0 (0) 6 (6.45)
2.75 (0.70) 1 (0.96) 38 (36.54)
<0.001 <0.001**
99 (50.25) 53 (26.90)
48 (51.61) 39 (41.94)
51 (49.04) 14 (13.46)
Underlying disease
Previous hysterectomy Previous incontinence or prolapse surgery Prolapse stage* Stage 1 Stage 2 Stage 3 Stage 4
Results are given as the mean (SD) *Student’s t test**Fisher's Exact test
hospital stay after surgery, with the obliterative surgery group having a shorter hospital stay (2 vs 3 days, P = 0.016). Intraoperative complications were infrequent and there was no difference between the two groups. Postoperatively, the most frequent complication was pyrexia, which occurred in 15.05% of women in the obliterative surgery group and 12.50% in the reconstructive surgery group. There were no Table 2
differences in the two groups regarding other postoperative complications. The primary outcomes are shown in Table 4. The lower the P-QOL scores, the better the postoperative QOL. The obliterative and reconstructive vaginal surgery both resulted in a positive impact to all domains of the P-QOL. The obliterative surgery group exhibited significantly less impairment in the P-
Surgical procedures Procedure
Total (n = 197)
Obliterative (n = 93)
Reconstructive (n = 104)
P value
Total colpocleisis Le Fort colpocleisis
82 (41.62) 4 (2.03)
82 (88.17) 4 (4.30)
0 (0) 0 (0)
NA NA
Partial colpocleisis Vaginal hysterectomy Sling Anterior colporrhaphy Posterior colporrhaphy Vaginal vault suspension McCall culdoplasty Others
7 (3.55) 133 (67.51) 29 (14.72) 80 (40.61) 105 (53.30)
7 (7.53) 52 (55.91) 18 (19.35) 0 (0) 19 (20.43)
0 (0) 81 (77.88) 11 (37.93) 80 (76.92) 86 (82.90)
NA 0.001 0.083 NA NA
32 (16.24) 22 (11.17)
2 (2.15) 7 (7.53)
30 (28.85) 15 (68.18)
<0.001 0.125
Int Urogynecol J Table 3 Operative data and perioperative complications
Operative data
Total (n=197)
Obliterative (n =93)
Reconstructive (n =104)
P value
Operative time (min)
114.17 (39.34) 50 (10–600)
110.45 (38.75)
117.5 (39.76)
0.21
50 (10–600)
50 (10–500)
0.166*
2 (1–20)
2 (1–17)
3 (1–20)
0.016*
0 (0)
0 (0)
0 (0)
N/A
2 (1.02)
0 (0)
2 (1.92)
Blood loss (cc) Length of hospital stay (days after surgery)* Intraoperative complications Blood transfusion Bladder injury
0.277** Ureter injury Bowel injury Postoperative complications Return to operating room
0 (0)
0 (0)
0 (0)
N/A
0 (0)
0 (0)
0 (0)
N/A
1 (0.51)
1 (1.08)
0 (0) 0.472**
Cardiac Pulmonary
0 (0) 0 (0)
0 (0) 0 (0)
0 (0) 0 (0)
Pelvic abscess
7 (3.55)
2 (2.15)
5 (4.81)
Pyrexia Urinary tract infection Others
27 (13.71) 17 (8.63) 15 (7.61)
14 (15.05) 7 (7.53) 7 (7.53)
13 (12.50) 10 (9.62) 8 (7.69)
N/A N/A 0.271** 0.603 0.602 0.965
Results are given as the mean (SD) or the number (%) unless otherwise stated *Median (range), Wilcoxon rank sum test **Fisher’s exact test
QOL domain after surgery than the reconstructive surgery group (1.75 vs 5.26 respectively P = 0.023). There were no significant differences in the other P-QOL domains, which are general health perceptions, role limitations, physical and social limitations, personal relationships, emotions, sleep/energy, and severity measurement.
Discussion Obliterative vaginal surgery is an option for treating patients with advanced POP who are elderly, not sexually active, and are medical compromised. There are numerous case series [9–11] that have supported the use of colpocleisis to treat POP after determining that it was successful in nearly 100% of cases. A prospective study also showed that colpocleisis improved body image and alleviated pelvic floor symptoms. Definitive treatment options resulted in high patient satisfaction and little patient regret [5]. The contemporary literature, however, provides little information about the patient’s QOL after colpocleisis [5]. The retrospective cohort study reported herein determined that obliterative vaginal surgery provided an improved QOL
for patients with POP and compared this change with that provided by reconstructive vaginal surgery. The results show that both operations provided improved QOL. The obliterative vaginal surgery group, however, reported significantly more improvement on the P-QOL scale postoperatively than those who underwent reconstructive vaginal surgery. There were no significant differences, however, in general health perceptions, role limitations, physical limitations, social limitations, personal relationships, emotional problems, sleep or energy disturbance, or symptom severity between the two groups. A pilot study on QOL using the P-QOL questionnaire in women undergoing colpocleisis found that colpocleisis significantly improved their QOL [12]. A retrospective study revealed improved postoperative QOL and patient satisfaction in women with prolapse who underwent obliterative or reconstructive surgery. The study showed that QOL and satisfaction, measured by other means (Urogenital Distress Inventory 6, Incontinence Impact Questionnaire 7, Surgical Satisfaction Questionnaire 8), were comparable in women who underwent colpocleisis versus reconstructive surgery [13]. A prospective cohort study showed significant improvements in the POP in addition to alleviation of urinary and colorectal problems at 6 and 12 months after surgery, with no differences between the
Int Urogynecol J Table 4 Prolapse Quality of Life Questionnaire (P-QOL) scores after surgery, median (range)
P- QOL domain
Total (n = 197)
Obliterative (n = 93)
Reconstructive (n = 104)
P value*
General health perceptions Prolapse impact
25 (0–75) 3.51 (1.75–36.84) 0 (0–66.67) 0 (0–83.33)
25 (0–50) 1.75 (1.75–36.84)
25 (0–75) 5.26 (1.75–36.84)
0.744 0.023
0 (0–33.33) 0 (0–33.33)
0 (0–66.67) 0 (0–83.33)
0.561 0.405
0 (0–77.78)
0 (0–0)
0 (0–77.78)
0.001
Emotions Sleep/energy
0 (0–55.56) 0 (0–66.67)
0 (0–33.33) 0 (0–33.33)
0 (0–55.56) 0 (0–66.67)
0.354 0.771
Severity measures
0 (0–16.67)
0 (0–16.67)
0 (0–16.67)
0.393
Role limitations Physical and social limitations Personal relationships
Results are given as the median (range) P-QOL prolapse quality of life *Mann–Whitney U test
two treatment groups. Also, both the obliterative and reconstructive surgery groups showed a significant and clinically important reduction of pain, with increased vitality, social functioning, and mental health, and fewer emotional problems, with no significant difference between the groups [14]. Our study results are consistent with those of previous studies. Both obliterative and reconstructive vaginal surgery improved QOL in all domains. In addition, our study demonstrated that colpocleisis provided better improvement in the prolapse domain than reconstructive surgery. It is possible that patients in our cohort were evaluated for QOL over a longer period of time than in other studies, and the reconstructive vaginal surgery shows greater impairment with the prolapse issue. Another study found that colpocleisis brings about improved QOL and goal attainment, with only 5% of patients expressing regret postoperatively [15]. None of our study patients regretted the surgery. We suggest that all women who undergo vaginal surgery for POP might be satisfied with the treatment when their health problems associated with the prolapse and their bowel and bladder issues have been resolved, regardless of whether they are treated by an obliterative or a reconstructive technique. Our study has almost the same results as others, but the alleviation of problems associated with the prolapse in our study shows a significant difference in improvement between the two treatment groups. The advantages of our study are that it had a concurrent control group (those who underwent reconstructive vaginal surgery). It also used a validated Thai-language questionnaire suitable for a Thai population. Also, the questionnaire is simple and can evaluate the patient in several domains. Although the study was retrospective, the study period covers approximately 5 years, thereby reflecting a long-term effect of the vaginal surgery on QOL. Additionally, we accumulated a large sample so that we could detect clinically significant differences between the two treatment groups. Nonetheless, our study does have several limitations. First, several concurrent procedures were performed in
the obliterative surgery group, which could affect the surgical outcomes. Second, the study was retrospective. We could not determine the preoperative QOL using the same questionnaire to compare with postoperative QOL; therefore, changes in QOL after surgery were difficult to estimate. In addition, there were possible confounding factors (e.g., age, procedures, etc.) that required further prospective or randomized controlled studies to evaluate the promising outcomes. Last, our study was conducted via the telephone, therefore potentially affecting responses and causing response bias. In conclusion, POP is an important condition, especially in elderly women; therefore, the treatment options and decisionmaking for treatment must be carefully conceived. Both obliterative surgery and reconstructive surgery provide good QOL postoperatively. Based on our study results, obliterative vaginal surgery has a more positive impact on the prolapse scales than reconstructive vaginal surgery. In addition, obliterative surgery is associated with a shorter hospital stay than that following reconstructive surgery. Thus, surgeons should consider counseling elderly women with advanced POP and those who are not sexually active about the option of obliterative vaginal surgery. Acknowledgements We thank Nancy Schatken, BS, MT(ASCP), from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.
Compliance with ethical standards Conflicts of interest None.
References 1.
Subak LL, Waetjen LE, van den Eeden S, Thom DH, Vittinghoff E, Brown JS. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol. 2001;98(4):646–51.
Int Urogynecol J 2.
Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186(6):1160–6. 3. Chuenchompoonut V, Bunyavejchevin S, Wisawasukmongchol W, Taechakraichana N. Prevalence of genital prolapse in Thai menopausal women (using new standardization classification). J Med Assoc Thail. 2005;88(1):1–4. 4. Deffieux X, Thubert T, Donon L, Hermieu JF, Le Normand L, Trichot C. Colpocleisis: guidelines for clinical practice. Prog Urol. 2016;26(Suppl 1):S61–72. https://doi.org/10.1016/s11667087(16)30429-8. 5. Crisp CC, Book NM, Smith AL, Cunkelman JA, Mishan V, Treszezamsky AD, et al. Body image, regret, and satisfaction following colpocleisis. Am J Obstet Gynecol. 2013;209(5):473.e471– 7. https://doi.org/10.1016/j.ajog.2013.05.019. 6. FitzGerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H, Ann Weber for the Pelvic Floor Disorders Network. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(3):261– 71. https://doi.org/10.1007/s00192-005-1339-9. 7. Crisp CC, Book NM, Cunkelman JA, Tieu AL, Pauls RN, Network Society of Gynecologic Surgeons Fellows Pelvic Research Network. Body image, regret, and satisfaction 24 weeks after colpocleisis: a multicenter study. Female Pelvic Med Reconstr Surg. 2016;22(3):132–5. https://doi.org/10.1097/spv. 0000000000000232. 8. Manchana T, Bunyavejchevin S. Validation of the prolapse quality of life (P-QOL) questionnaire in Thai version. Int Urogynecol J. 2010;21(8):985–93. https://doi.org/10.1007/s00192-010-1107-3.
9. 10.
11.
12.
13.
14.
15.
FitzGerald MP, Brubaker L. Colpocleisis and urinary incontinence. Am J Obstet Gynecol. 2003;189(5):1241–4. Zebede S, Smith AL, Plowright LN, Hegde A, Aguilar VC, Davila GW. Obliterative LeFort colpocleisis in a large group of elderly women. Obstet Gynecol. 2013;121(2 Pt 1):279–84. https://doi. org/10.1097/AOG.0b013e31827d8fdb. Thubert T, Dache A, Leguilchet T, Benchikh A, Ravery V, Hermieu JF. Obliterative vaginal surgery for genital prolapse: a retrospective cases series. Prog Urol. 2012;22(17):1071–6. https://doi.org/10. 1016/j.purol.2012.09.021. Yeniel AO, Ergenoglu AM, Askar N, Itil IM, Meseri R. Quality of life scores improve in women undergoing colpocleisis: a pilot study. Eur J Obstet Gynecol Reprod Biol. 2012;163(2):230–3. https://doi. org/10.1016/j.ejogrb.2012.04.016. Murphy M, Sternschuss G, Haff R, van Raalte H, Saltz S, Lucente V. Quality of life and surgical satisfaction after vaginal reconstructive vs obliterative surgery for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol. 2008;198(5):573 e571–7. https://doi.org/10.1016/j.ajog.2007.12.036. Barber MD, Amundsen CL, Paraiso MF, Weidner AC, Romero A, Walters MD. Quality of life after surgery for genital prolapse in elderly women: obliterative and reconstructive surgery. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(7):799–806. https:// doi.org/10.1007/s00192-006-0240-5. Hullfish KL, Bovbjerg VE, Steers WD. Colpocleisis for pelvic organ prolapse: patient goals, quality of life, and satisfaction. Obstet Gynecol. 2007;110(2 Pt 1):341–5. https://doi.org/10.1097/01. AOG.0000270156.71320.de.