Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study

Abstract

AbstractObjectiveTo identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery.DesignSecondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross‐sectional study.SettingEight clinical sites in the US Pelvic Floor Disorders Network.Population or SampleWomen who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015.MethodsThe MRI (rest, strain) obtained 30–42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI‐based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three‐dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position.Main outcome measuresVaginal angulation (upper, lower and upper–lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid‐vagina) at rest.ResultsOf the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid‐vagina (p = 0.01) at rest than women with successful surgery.ConclusionsVaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.