Restoring Genital Hiatus to Normative Values After Apical Suspension Alone Versus With Level 3 Support Procedures

Carter-Brooks, Charelle M.; Lowder, Jerry L.; Du, Angela L.; Lavelle, Erin Seifert; Giugale, Lauren E.; Shepherd, Jonathan

doi:10.1097/spv.0000000000000528

Cited by 23 publications

(18 citation statements)

References 14 publications

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“…We hypothesized that preoperative GH rest would be associated with prolapse recurrence, as GH rest is strongly correlated with GH strain, 10 which has consistently been shown to be associated with prolapse recurrence. 6,8,9,14,15 However, we were unable to show an association between prolapse recurrence and preoperative GH rest or strain. One explanation for this difference may be related to the high colpoperineorrhaphy rate in the current study.…”

Section: Discussioncontrasting

confidence: 60%

“…This study adds new information about the status of the GH by investigating GH rest and its relationship to prolapse recurrence. We hypothesized that preoperative GH rest would be associated with prolapse recurrence, as GH rest is strongly correlated with GH strain, 10 which has consistently been shown to be associated with prolapse recurrence 6,8,9,14,15 . However, we were unable to show an association between prolapse recurrence and preoperative GH rest or strain.…”

Section: Discussionmentioning

confidence: 88%

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Does preoperative resting genital hiatus size predict surgical outcomes?

Schmidt

Cox

DeLancey

et al. 2021

J of Obstet and Gynaecol

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Aim To determine whether preoperative genital hiatus at rest is predictive of medium‐term prolapse recurrence. Methods We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting genital hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ −4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. Results Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting genital hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06–1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000–1.001], p < 0.01) were independently associated with recurrence. Preoperative genital hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). Conclusions Preoperative genital hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short‐term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.

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Section: Discussioncontrasting

confidence: 60%

Section: Discussionmentioning

confidence: 88%

Does preoperative resting genital hiatus size predict surgical outcomes?

Schmidt

Cox

DeLancey

et al. 2021

J of Obstet and Gynaecol

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“…However, our study also demonstrated a reduction in GH when apical POP surgery is performed even without perineorrhaphy. Similarly, Carter-Brooks et al [ 7 ] found that perineorrhaphy may not be necessary for reduction of GH. Interestingly, the postoperative change in GH in the subgroup of patients undergoing sacrocolpopexy was smaller than that seen in those undergoing vaginal native tissue apical suspensions, and the change in GH was not significantly greater in those who had perineorrhaphy vs. no perineorrhaphy.…”

Section: Discussionmentioning

confidence: 99%

“…Although there is evidence indicating a relationship between GH and POP, no such evidence demonstrates that surgical correction of GH is effective in the prevention of POP recurrence. In fact, some recent retrospective evidence suggests that perineorrhaphy may not be necessary [ 7 , 8 ]. Moreover, there is a lack of understanding as to how the GH seen by the surgeon at the end of a POP surgery relates to the GH seen on physical exam at clinical follow up.…”

Section: Introductionmentioning

confidence: 99%

Prospective evaluation of genital hiatus in patients undergoing surgical prolapse repair

et al. 2022

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Introduction and hypothesis Enlarged genital hiatus (GH) is associated with prolapse recurrence following prolapse repair. Perineorrhaphy is often performed to reduce GH. However, changes in GH between the time of surgery and follow up are poorly understood. Our primary aim was to compare the intra-operative resting GH at the conclusion of surgery with the resting GH 3 months post-operatively in patients who undergo perineorrhaphy. We hypothesized that the intra-operative resting GH would be sustained. Methods Patients planning apical prolapse surgery were prospectively enrolled. Perineorrhaphy was performed at the surgeon’s discretion. GH was measured pre-operatively in clinic, intra-operatively before and after surgery (resting), and 3 months post-operatively (resting and Valsalva). Results Twenty-nine perineorrhaphy and 27 no perineorrhaphy patients completed 3-month follow-up. Groups were similar in age (63.9 y, SD 10.4), body mass index (28.3 kg/m 2 , SD 5.2) and prior prolapse surgery (19.6%). Median (interquartile range) baseline Valsalva GH was larger in the perineorrhaphy group (4.5 (4 – 5.5) vs 3.5 (3 – 4) cm, p < 0.01). Median resting GH at 3 months was 0.5 cm less than end of surgery in the perineorrhaphy group ( p < 0.01). The median change in GH between baseline and 3-month follow up was greater with perineorrhaphy (-1.5 vs -0.5 cm, p < 0.01). This difference was not seen in the sacrocolpopexy subgroup (-1.75 vs -1.5, p = 0.14; n = 24). Conclusions Surgeons can be reassured that the intra-operative change in GH resulting from perineorrhaphy is sustained 3 months after surgery and similar to the more commonly measured preoperative to postoperative change in Valsalva GH.

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“…Based on prior literature, the normative value of the genital hiatus (Gh) is approximately 3.4 cm, and postoperative Gh after posterior colporrhaphy and/or perineorrhaphy is approximately 2.8 cm, with standard deviation of approximately 1 cm [ 11 ]. A sample size of 24 would afford 80% power to detect a mean of paired differences of 0.6, with an estimated standard deviation of differences of 1.0, using an alpha level of 0.05 with a paired t -test.…”

Section: Methodsmentioning

confidence: 99%

How does office assessment of prolapse compare to what is seen in the operating room?

Wang

Tunitsky-Bitton

2022

Int Urogynecol J

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Introduction and hypothesis It is not known whether the measurements of pelvic organ assessment under anesthesia accurately estimate prolapse severity. We compared Pelvic Organ Prolapse Quantification (POP-Q) measurements in the office to exams under anesthesia. Methods We prospectively enrolled patients undergoing prolapse surgery between February 2020 and July 2020. POP-Qs at rest and with Valsalva were performed at pre- and postoperative visits. POP-Q under anesthesia was performed, without traction, at the start of case (pre-surgical), following apical suspension, and at the end of case (post-surgical). Primary outcome was change in POP-Q between the office and operating room. Due to the COVID-19 pandemic, additional patients were recruited to maintain the follow-up time frame. Results Out of 66 patients, 63 underwent surgery and 33 had postoperative exams within 6 weeks. Mean age was 61.3 ± 11.9 years, and mean BMI was 28.4 ± 6.5 kg/m 2 . Preoperative Aa, Ba, C, Ap, Bp, and D with Valsalva had greater descent than pre-surgical measurements. However, preoperative Gh with Valsalva (4.1 ± 1.3 cm) was not different from pre-surgical Gh (4.0 ± 1.0 cm) ( P = 0.60). Postoperative Aa, Ba, Ap, Bp, and D were not different from post-surgical measurements. In contrast, postoperative Gh at rest (2.3 ± 0.7 cm) and with Valsalva (2.4 ± 0.8 cm) were both narrower than post-surgical Gh (2.8 ± 0.6 cm) ( P < 0.05). Gh was also narrowed after apical suspension (3.6 ± 1.0 cm, P = 0.005) prior to posterior repair. Conclusions Surgeons should rely on preoperative POP-Q for surgical decisions. Gh should be reassessed after apical suspension, and further correction should consider that Gh may be exaggerated compared to the measurement postoperatively when the patient is awake.

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Restoring Genital Hiatus to Normative Values After Apical Suspension Alone Versus With Level 3 Support Procedures

Abstract: Level 3 support procedures may be unnecessary to restore genital hiatus to normal at time of apical suspension procedures and should be reserved for select patients.

Cited by 23 publications

References 14 publications

Does preoperative resting genital hiatus size predict surgical outcomes?

Does preoperative resting genital hiatus size predict surgical outcomes?

Prospective evaluation of genital hiatus in patients undergoing surgical prolapse repair

How does office assessment of prolapse compare to what is seen in the operating room?

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