AUGS Papers www. AJOG.

org

Quality of life and surgical satisfaction

after vaginal reconstructive vs obliterative surgery
for the treatment of advanced pelvic organ prolapse
Miles Murphy, MD, MSPH; Gina Sternschuss, MD; Robin Haff, RN;
Heather van Raalte, MD; Stephanie Saltz, MD; Vincent Lucente, MD, MBA

OBJECTIVE: We sought to compare quality of life and patient satisfac-
tion after obliterative vs reconstructive surgery.
STUDY DESIGN: A retrospective cohort study of women who met the fol-
lowing inclusion criteria: age 65 years or older, leading edge of prolapse 4
cm or greater beyond the hymen, and vaginal reconstructive or obliterative
surgery. Preoperative responses to the Urogenital Distress Inventory
(UDI-6) and Incontinence Impact Questionnaire (IIQ-7) were collected ret-
rospectively. We then mailed the same questionnaires, and the Surgical
Satisfaction Questionnaire (SSQ-8), to these subjects postoperatively.
RESULTS: Mode of surgery was evenly split (n 45 per group) be-
tween the 90 patients meeting the inclusion criteria. Improvements
from the preoperative to postoperative Incontinence Impact Question-
naire and Urogenital Distress Inventory were comparable as were post-
operative Surgical Satisfaction Questionnaire scores.
CONCLUSION: Improvements in condition-specific quality of life and
postoperative patient satisfaction measures are comparable in women
with prolapse who undergo either reconstructive or obliterative
surgery.
Key words: pelvic organ prolapse, obliterative surgery, vaginal
reconstructive surgery, mesh, quality of life

Cite this article as: Murphy M, Sternschuss G, Haff R, et al. 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;198:573.e1-573.e7.

O ver $1 billion is spent on the surgi-

cal treatment of pelvic organ pro-
lapse each year in the United States, with
rates of complication exceeding 15%.1 A
common procedure performed for el-
derly women with severe prolapse is
obliterative colpocleisis in the form of
the LeFort procedure or total colpec-
tomy. As women age, the risk of morbid-
ity and mortality increase after uro-
gynecologic surgery,2 and although
colpocleisis precludes future coital func-
From the Institute for Female Pelvic
Medicine & Reconstructive Surgery, North
Wales and Allentown, PA (Drs Murphy, van
Raalte, Saltz, and Lucente and Ms Haff);
and the Department of Obstetrics and
Gynecology (Dr Sternschuss), Abington
Memorial Hospital, Abington, PA.
Presented at the 28th Annual Scientific
Meeting of the American Urogynecologic
Society, Hollywood, FL, Sept. 27-29, 2007.
Received Aug. 3, 2007; revised Nov. 17,
2007; accepted Dec. 31, 2007.
Reprints not available from authors.
0002-9378/$34.00
2008 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2007.12.036
tion, it is often used to minimize the risk
of these untoward surgical outcomes
while providing long-term relief of pro-
lapse symptoms. Because the number of
women older than the age of 60 years
seeking care for pelvic floor disorders is
expected to increase by at least 45% over
the next few decades,3 it is imperative
that we understand the risks and benefits
of the various approaches to the surgical
correction of prolapse in our aging
population.
Often, surgical success is measured by
anatomic outcomes, complications, and
recovery time; with less consideration
given to how patients view its effect on
their quality of life and overall satisfac-
tion with the surgery. A recent review of
the literature by Fitzgerald et al4 on oblit-
erative prolapse surgery shows that most
investigations have been limited to case
series assessing traditional measures of
surgical success. However, some re-
search shows that quality of life may be as
important to patients as the status of
their physical condition.5 This has been
reflected in the growing trend toward in-
cluding validated quality-of-life instru-
ment outcomes in surgical research pro-
tocols. To date, we know of 2 published
studies6,7 that use such instruments to
measure outcomes after obliterative sur-
gery, and only one of them compared
these measures with patients undergoing
reconstructive surgery.7
Of specific concern with colpocleisis is
the risk of regret with the loss of coital
function. A number of series have looked
at regret after obliterative surgery.6,8-11
But there are numerous reasons people
may be unsatisfied with the outcome of
their surgery and regret having it per-
formed. No studies have compared sat-
isfaction and regret after obliterative vs
reconstructive surgery. The aim of the
current study was to compare preopera-
tive and postoperative quality-of-life
measures and postoperative surgical sat-
isfaction after obliterative and recon-
structive vaginal surgery in an elderly co-
hort of women with severe pelvic organ
prolapse.
M ATERIALS AND M ETHODS
This retrospective cohort study was ini-
tiated after obtaining Institutional Re-
view Board (IRB) approval. The data-

MAY 2008 American Journal of Obstetrics & Gynecology 573.e1

AUGS Papers
base of our practices electronic medical
record system was used to identify pa-
tients meeting the following inclusion
criteria: leading edge of preoperative
prolapse 4 cm or greater beyond the hy-
men, status postvaginal reconstructive or
obliterative surgery between October
2004 and October 2006, and age 65 years
or older at time of surgery. We chose to
start our 2-year study period in October
of 2004, because that is when we began to
routinely ask our patients to fill out the
Incontinence Impact Questionnaire
(IIQ-7) and Urogenital Distress Inven-
tory (UDI-6) before their first office visit.
Obliterative surgeries included in the
analysis included both the Lefort colpo-
cleisis and total colpectomy both per-
formed in the standard manner.12 No
high perineorrhaphy or levator plication
was performed in either of these proce-
dures. Vaginal reconstructive surgeries
included any prolapse repair designed to
restore support to the vagina and enable
future coital function performed
through a vaginal approach (all laparo-
scopic or open abdominal repairs were
excluded). On the basis of our practice
patterns, we anticipated that the major-
ity of these repairs would have been per-
formed with the use of anterior and/or
posterior compartment bodies of
polypropylene mesh anchored with
straps passed percutaneously through
the obturator and/or ischiorectal fossae.
These procedures were performed by us-
ing the previously described transvaginal
mesh technique13 that used the Prolift
system (Ethicon Womens Health and
Urology, Johnson & Johnson, Somer-
ville, NJ).
The decision to proceed with an oblit-
erative vs a reconstructive surgery was
made after extensive discussion between
the surgeon and patient. The choice was
made after discussing the various pros
and cons of each approach and was in no
way randomized. All patients who chose
the obliterative approach were aware
that future vaginal intercourse would
not be possible. Patients who chose the
reconstructive approach were not neces-
sarily sexually active, nor did they all de-
sire future sexual function.
A retrospective chart review was per-
formed to collect the following data: re-
573.e2 American Journal of Obstetrics & Gynecology MAY 2008
sponses to the preoperative short-forms
of the IIQ-7 and UDI-6,14 plus 2 addi-
tional prolapse-specific questions from
the long-form of the UDI15 (How much
are you bothered by. . . : 1. a feeling or
bulging or protrusion in the vaginal area;
and 2. bulging or protrusion you can see
in the vaginal area?), demographics,
medical/social/surgical history, results of
the preoperative Pelvic Organ Prolapse
Quantification (POP-Q)16 examination
and urodynamic testing (if performed),
surgical procedure(s) performed, peri-
operative outcomes, postoperative ex-
amination findings, further surgical in-
terventions, and length of office
follow-up.
All patients who met the inclusion cri-
teria were then mailed a postoperative
survey that contained a consent form,
the IIQ-7, the extended UDI-6, and the
Surgical Satisfaction Questionnaire
(SSQ) (Appendix 1). Our research nurse
attempted to contact by phone any pa-
tients who did not mail back the survey
and obtain verbal consent to administer
the questionnaires verbally. These data
were then added to the study database.
The IIQ-7 and UDI-6 are validated
condition-specific questionnaires that
have been used extensively in the litera-
ture to compare preoperative and post-
operative status of women undergoing
pelvic reconstructive surgery.6,17 The
SSQ is an 8-item questionnaire, with re-
sponses recorded on a 5-point Likert-
type scale with responses from 0 Very
Unsatisfied to 4 Very Satisfied. procedures was comparable (71.1% vs
Scoring is similar to the IIQ-7 and UDI-6
with the mean average of the 8 scores be-
ing multiplied by 25 (the questionnaire is
considered incomplete if more than 2
items are not answered), yielding a po-
tential range of scores from 0 to 100. The
higher the score is, the greater the degree
of surgical satisfaction. Items 1 and 2 are
used to calculate the Pain subscale; items
3, 4, and 5 are used for the Return to
baseline subscale: and items 6, 7, and 8
are used for the Global satisfaction sub-
scale. Each subscale is calculated in the
same manner as the overall SSQ score.
The SSQ is not designed to be condition-
specific and has not yet been validated.
Univariate analysis comparing base-
line and outcome data between the 2 sur-
www.AJOG.org
gical groups was conducted by using the
Pearson 2 statistic for categorical data,
the independent-samples t test for con-
tinuous data, and the paired samples t
test for repeated measures. Statistical
analysis was performed by using SPSS
15.0 for Windows (SPSS Inc, Chi-
cago, IL).
We performed a power calculation to
determine whether we had enough pa-
tients in our cohort to detect a 33.3-point
difference (a change from moderate to
slight bother) between groups in our
primary dependent variable, change in
UDI-Obstructive/Discomfort subscale
score. Group sample sizes of 32 in each
arm were required to achieve an 80%
power to detect this difference between
the obliterative and reconstructive
groups with an of .05 by using a
2-tailed test.
R ESULTS
Ninety patients met the inclusion crite-
ria. By chance, the 2 surgical groups had
the same number of patients (n 45).
Demographics, surgical history, and
baseline quality-of-life measures were
comparable between the 2 surgical arms
with the following exceptions: mean age
(80.0 vs 75.7 years, P .01) and preop-
erative leading edge of prolapse (7.0 vs
5.0 cm, P .01) were greater in the
obliterative group (Table 1). The per-
centage of group members undergoing
concomitant minimally-invasive sling
73.3%, P .34); this and other informa-
tion on the procedures performed in
each group can be found in Table 2. Al-
though we did not design the study to
compare vaginal reconstruction that
used grafts to obliterative surgery, the
only patients undergoing reconstructive
surgery who met the inclusion criteria
had undergone the Prolift procedure. No
patients in either group underwent hys-
terectomy during their surgery.
Operative time was shorter in the re-
constructive group, but perioperative
outcomes were otherwise similar be-
tween groups (Table 3). Of the oblitera-
tive surgeries, the colpectomies on aver-
age took longer than the LeForts, but this
difference did not meet statistical signif-
www.AJOG.org AUGS Papers

icance (147.6 vs 169.1 minutes, P .18).

More than 85% of the surgeries were TABLE 1
performed under regional anesthesia. Baseline characteristics of the 2 surgical groups
Both groups had an average of at least 6 Characteristic Obliterative Reconstructive P
months of office follow-up. There were Age 80.0 (6.2) 75.7 (5.2) .001
..............................................................................................................................................................................................................................................
no differences in the number of prolapse BMI 28.8 (5.5) 27.4 (4.3) .19
recurrences beyond the hymen or num- ..............................................................................................................................................................................................................................................
Parity 3.4 (2.7) 3.2 (1.7) .70
ber of reoperations in the obliterative vs ..............................................................................................................................................................................................................................................

the reconstructive group. The mean Race

.....................................................................................................................................................................................................................................
length of survey follow-up and the per- White 43 (95.6) 45 (100) .36
.....................................................................................................................................................................................................................................
centage of patients lost to follow-up were Other 2 (4.4) 0 (0)
comparable between groups. ..............................................................................................................................................................................................................................................
Marital status
A flow chart detailing patient partici- .....................................................................................................................................................................................................................................

pation is found in the Figure. Of the 90 Single 1 (2.2) 2 (4.4) .04

.....................................................................................................................................................................................................................................
patients meeting the inclusion criteria, Married 13 (28.9) 23 (51.1)
.....................................................................................................................................................................................................................................
72 (80%) completed the postoperative Widowed 31 (68.9) 18 (40)
IIQ-7 and UDI-6 with a median fol- .....................................................................................................................................................................................................................................
Divorced 0 (0) 2 (4.4)
low-up time of 17.5 (range, 3-28) ..............................................................................................................................................................................................................................................

months. Preoperative to postoperative Tobacco use 1 (2.2) 0 (0) .32

..............................................................................................................................................................................................................................................
change in IIQ-7 and UDI-6 was com- Leading edge of prolapse 7.0 (2.5) 5.0 (0.9) .001
..............................................................................................................................................................................................................................................
pared within each operative group by us- Prior surgery for:
ing the paired samples t test. Significant .....................................................................................................................................................................................................................................
Prolapse 7 (15.6) 5 (11.1) .54
improvements were found in both the .....................................................................................................................................................................................................................................

obliterative and reconstructive group for Incontinence 3 (6.7) 3 (6.7) 1.0

.....................................................................................................................................................................................................................................
both instruments (P .02). Significant Hysterectomy 22 (48.9) 18 (40.0) .40
..............................................................................................................................................................................................................................................
improvements were also seen in all 3 Preoperative urodynamics: 43 (95.6) 39 (86.7) .14
subscales of the UDI-6 with the excep- .....................................................................................................................................................................................................................................
SUI 38 (84.4) 27 (60.0) .051
tion of the UDI-6 subscale in the obliter- .....................................................................................................................................................................................................................................

ative group, which only trended toward ISD 20 (44.4) 11 (24.4) .11
.....................................................................................................................................................................................................................................
significance (P .06). DO 7 (15.6) 1 (2.2) .04
..............................................................................................................................................................................................................................................
When the changes in the IIQ-7, the Preoperative IIQ-7 40.5 (33.3) 31.7 (31.3) .30
UDI-6, and the subscales of the UDI-6 ..............................................................................................................................................................................................................................................
Preoperative UDI-6 43.3 (28.0) 44.4 (26.8) .87
were compared between the 2 operative ..............................................................................................................................................................................................................................................

groups (Table 4), no significant differ-
ences were found, but our sample size
requirements were not met. Analyses of
these instruments were only completed
for patients who had fully completed
both the preoperative and postoperative
forms. The baseline characteristics of
these subjects were comparable with
those who did not complete both sets of
forms. Of note, the greatest improve-
ments were found in the Obstructive/
discomfort subscale of the UDI-6. We
also looked at the responses to the 2 ad-
ditional prolapse-specific questions
from the long-form of the UDI included
in our survey. When comparing the de-
gree of preoperative to postoperative im-
provement in these questions between
All values listed as mean ( SD) or n (%).
Multichannel urodynamic testing performed with prolapse supported.
Independent samples t test used for continuous data and Pearson 2 for categorical data.
BMI, body mass index; DO, detrusor overactivity; IIQ-7, short form of Incontinence Impact Questionnaire; ISD, intrinsic
sphincter deficiency (defined as maximum urethral closure pressure less than 20 and/or leak point pressure greater than 60
cm of water pressure); SD, standard deviation; SUI, stress urinary incontinence, UDI-6, short form of Urogenital Distress
Inventory.
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
TABLE 2
Procedures performed in each group
Obliterative (n 45) Reconstructive (n 45)
LeFort colpocleisis 28 (62.2%)
..............................................................................................................................................................................................................................................
Total colpectomy 17 (37.8%)
..............................................................................................................................................................................................................................................
Anterior Prolift 19 (42.2%)
..............................................................................................................................................................................................................................................

the obliterative and reconstructive Posterior Prolift 10 (22.2%)

..............................................................................................................................................................................................................................................
groups, no significant differences were Total Prolift 16 (35.6%)
..............................................................................................................................................................................................................................................
found (P .25). Minimally invasive sling 32 (71.1%) 33 (73.3%)
The overall scores for the Surgical Sat- Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
isfaction Questionnaire (SSQ) and its

MAY 2008 American Journal of Obstetrics & Gynecology 573.e3

AUGS Papers www.AJOG.org

Unsatisfied. Question 7 asks, Looking

TABLE 3 back, if you had to do it all over again
Perioperative, office, and survey follow-up would you have the surgery again?
Outcome Obliterative Reconstructive P When defining regret as answering
Operative time (min) 156.1 (50.8) 105.3 (29.2) .001 No, 0 members (0%) of the oblitera-
..............................................................................................................................................................................................................................................
EBL (mL) 113.3 (119.5) 83.4 (63.3) .15 tive group and 2 (5.7%) of the recon-
..............................................................................................................................................................................................................................................
structive group responders regretted
Complications 1 (2.2%) 1 (2.2%) .99
.............................................................................................................................................................................................................................................. having the surgery (P .14) (other
Recurrent prolapse beyond hymen 3 (6.7%) 1 (2.2%) .30 possible answers were Do not think
..............................................................................................................................................................................................................................................
Erosion of mesh 0 (0%) so, Unsure, Maybe, and Yes).
..............................................................................................................................................................................................................................................
Takedown of sling 0 (0%) 1 (2.2%) .32 When defining regret as failing to answer
..............................................................................................................................................................................................................................................
Yes, 4 of the obliterative (10.5%) and 4
Reoperation for incontinence 0 (0%) 1 (2.2%) .32
.............................................................................................................................................................................................................................................. of the reconstructive (11.4%) group re-
Reoperation for prolapse 3 (6.7%) 0 (0%) .08 sponders regretted having the surgery
..............................................................................................................................................................................................................................................
Length of office follow-up (mo) 6.0 (5.3) 10.4 (6.8) .001 (P .90).
..............................................................................................................................................................................................................................................
Responded to postoperative survey* 35 (77.7%) 37 (82.2%) .60
..............................................................................................................................................................................................................................................
Length of survey follow-up (mo) 16.6 (7.6) 17.6 (4.1) .46
.............................................................................................................................................................................................................................................. C OMMENT
Data presented as mean ( SD) for continuous data or number (%) for categorical data. Independent samples t test used Improvements in urogenital-related
for continuous data and Pearson 2 for categorical data.
EBL, estimated blood loss; IIQ-7, short form of Incontinence Impact Questionnaire; SD, standard deviation; UDI-6, short form quality of life instruments and responses
of Urogenital Distress Inventory. to postoperative surgical satisfaction
* Completed postoperative IIQ-7 and UDI-6.
questionnaires appear to be comparable
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
in this cohort of patients who underwent
obliterative or reconstructive surgery.
subscales were comparable between sponse of either Very Satisfied or Sat- The few other comparative studies of
groups (Table 5). A dichotomous suba- isfied, 35 of 38 responders (92.1%) in colpocleisis in the literature have like-
nalysis of 2 questionnaire items was per- the obliterative and 30 of the 35 (85.7%) wise demonstrated minimal difference
formed to answer 2 basic questions. in the reconstructive group were satis- in outcomes between surgical groups.7,18
Question 6 asks, How satisfied are you fied with their surgery (P .38). Only 1 The current investigation benefits
with the results of your surgery? When subject in each group (2.6% and 2.9%, from relatively long-term follow-up (av-
defining satisfaction as a patient re- respectively) responded that they were eraging approximately 1.5 years in each
group) and the use of validated condi-
tion-specific quality-of-life instruments.
FIGURE We also had a good survey response rate
Meeting inclusion criteria of 80% in this elderly population that is
notoriously difficult to follow-up.
90 patients
met inclusion
Group selection was not randomized,
criteria but the specific inclusion criteria we used
resulted in only a few differences in
group characteristics thus minimizing
45 had 45 had selection bias and the risk of
obliterative reconstructive confounding.
surgery surgery
Despite the good postoperative survey
return rate, not all of the patients had
10 did not complete 35 completed 37 completed 8 did not complete completed the preoperative IIQ-7 and
post-op IIQ-7 & UDI-6 post-operative post-operative post-op IIQ-7 & UDI-6 UDI-6 resulting in a failure to meet our
(4 with dementia, IIQ-7 & UDI-6 IIQ-7 & UDI-6 (3 deceased,5 lost to
3 lost to follow-up, follow-up) and power requirement for our primary out-
3 completed only 2 completed IIQ/UDI come variable, the UDI Obstructive/dis-
the SSQ) but not the SSQ comfort subscale. This limits our ability
to draw definitive conclusions from our
38 completed 27 with pre- & 25 with pre- & 35 completed
results. We did reach the sample size
post-operative post-operative post-operative post-operative from the power calculation in those who
SSQ IIQ-7 & UDI-6 IIQ-7 & UDI-6 SSQ responded to the postoperative surgical
Study flow of patients meeting inclusion criteria. satisfaction questionnaire, but this in-
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008. strument has not yet been fully validated
and the study was not powered for this

573.e4 American Journal of Obstetrics & Gynecology MAY 2008

www.AJOG.org
outcome measure. Despite these limita-
tions, a number of interesting insights
can be drawn and new questions raised
from this investigation.
Unlike most investigations of obliter-
ative surgery for prolapse, this study
compared the outcomes of colpocleisis
with reconstructive surgery. The pri-
mary reason that most surgeons decide
to offer patients an obliterative proce-
dure is to minimize the risk of medical
and surgical complications in sexually
inactive, elderly, and often medically
compromised women that they would
otherwise be exposed to with reconstruc-
tive surgery. It is therefore noteworthy
that we failed to find a greater risk of
complications or blood loss in our re-
constructive group (although given the
relatively small sample size it would be
unlikely to find a significant difference in
rare complications). The vast majority of
patients in both groups had their surgery
under regional anesthesia, and the oper-
ative time was actually shorter in the re-
constructive group. The operative times
for our obliterative cases may seem
longer than many people associate with
these types of procedures. It is important
to point out that this time includes place-
ment of a midurethral sling and cystos-
copy in more than 70% of these cases.
The primary operator for most of the
obliterative surgeries was a resident, as
opposed to the reconstructive cases. Be-
cause of the deep dissection and blind
trocar placement associated with the
type of reconstruction used in this inves-
tigation, the primary operator in most of
the reconstructive surgeries was more
likely to be either the attending or a fel-
low as opposed to a resident, thus this
bias may contribute to the difference in
operative time we found.
Our standardized surgical satisfaction
questionnaire failed to show a difference
in the 2 groups in regard to the amount
of pain they experienced and how
quickly they returned to their normal ac-
tivities after surgery. The vaginal ap-
proach to prolapse repair, frequent use
of regional anesthesia, and lack of any
hysterectomies in both groups may be
the common denominator responsible
for these similarities (other case series of
colpocleisis have shown greater opera-
AUGS Papers
TABLE 4
Comparison of improvement in preoperative to postoperative
condition-specific quality of life measures between groups
Obliterative Reconstructive
Instrument (n 27) (n 25) P
IIQ-7 16.2 (33.1) 18.1 (30.9) .84
..............................................................................................................................................................................................................................................
UDI-6 total 19.3 (28.1) 26.0 (25.5) .38
..............................................................................................................................................................................................................................................
UDI subscales
.....................................................................................................................................................................................................................................
Irritative symptoms 14.8 (33.4) 24.0 (33.0) .32
.....................................................................................................................................................................................................................................
Obstructive/discomfort 29.0 (29.5) 34.7 (32.2) .51
.....................................................................................................................................................................................................................................
Stress symptoms 14.3 (38.7) 19.3 (29.9) .60
..............................................................................................................................................................................................................................................
Data presented as mean ( SD), and calculated with the independent samples t test.
IIQ-7, short form of Incontinence Impact Questionnaire; SD, standard deviation; UDI-6, short form of Urogenital Distress
Inventory.
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
tive time and blood loss when concomi- vorable results in respect to the Stress
tant hysterectomy is performed).10,19 and Irritative symptoms subscales of the
The decision to perform a concomi- UDI-6 support these findings, because
tant antiincontinence procedure at the 71% of patients in the obliterative group
time of colpocleisis for either clinical, had a concomitant midurethral sling
urodynamic, or potential/occult stress placed. Although the improvements in
urinary incontinence has also been a per- irritative symptoms may be related to re-
plexing issue. One study showed a 27% duction of prolapse as suggested by Fos-
incidence of de novo incontinence after ter et al,7 the use of a midurethral sling in
colpocleisis.20 However, the risk of de the majority of our population certainly
novo stress incontinence has to be bal- did not result in a significant amount of
anced with the risk of iatrogenic voiding
voiding dysfunction in either the recon-
dysfunction after concomitant prophy-
structive or obliterative groups.
lactic antiincontinence procedures.
The type of prolapse repair per-
Most series of colpocleisis have used sub-
formed in the reconstructive group
urethral plication as their primary anti-
incontinence procedure with varied re- also separates this investigation from
sults.6,9,10,18 More recently, though, 1 other comparative studies and may
series looking at the use of minimally in- limit the external validity of our find-
vasive midurethral synthetic slings at the ings. The senior authors performed
time of obliterative surgery showed many reconstructive surgeries without
promising long-term results.21 Our fa- grafts. However, in this cohort all of
TABLE 5
Comparison of Surgical Satisfaction Questionnaire
responses between groups
Obliterative Reconstructive
Instrument (n 38) (n 35) P
SSQ total score 89.6 (12.7) 86.4 (16.0) .33
..............................................................................................................................................................................................................................................
SSQ subscales
.....................................................................................................................................................................................................................................
Pain 88.1 (17.9) 85.0 (17.6) .45
.....................................................................................................................................................................................................................................
Return to baseline 86.4 (14.7) 82.1 (22.1) .33
.....................................................................................................................................................................................................................................
Global satisfaction 93.9 (15.1) 91.4 (19.9) .56
..............................................................................................................................................................................................................................................
Data presented as mean ( SD), and calculated with the independent samples t test.
SD, standard deviation; SSQ, Surgical Satisfaction Questionnaire.
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
MAY 2008 American Journal of Obstetrics & Gynecology 573.e5
AUGS Papers
the reconstructive repairs happened to
include the use of synthetic, polypro-
pylene mesh.
This is most likely a result of our study
designs inclusion criteria that produced
a study population that was older and
had more severe prolapse than the ma-
jority of our patients.
It is beyond the scope or intention of
this study to address the risks and/or
benefits that may be associated with graft
use in pelvic reconstruction. However,
one could postulate that the low rate of
recurrence seen in this cohort might, at
least in part, be attributed to the rein-
forcement of this permanent material.
One could also postulate that the high
degree of patient satisfaction found in
this group might be lower in a younger,
more sexually active population as a re-
sult of potential dyspareunia from this
permanent material. These uncertainties
highlight the need for further compara-
tive studies of vaginal prolapse repair
with and without grafts. Certainly, the
cost of grafts compared with that of su-
ture alone in obliterative surgery sug-
gests that a cost-benefit analysis would
be an appropriate subject for further in-
vestigation as well. Finally, given the
continually expanding life expectancy of
women and the paucity of catastrophic
complications with vaginal surgery,
longer-term follow-up of larger num-
bers of patients are needed. f
ACKNOWLEDGMENTS
We thank Jerry Cohen for his assistance in con-
ducting this research.
573.e6 American Journal of Obstetrics & Gynecology MAY 2008
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www.AJOG.org AUGS Papers

A PPENDIX 1

Date: _____/______/_______

Surgical Satisfaction Questionnaire

Instructions: Following are a list of questions about your satisfaction with your surgery. All
information is strictly confidential. Please check the box that best answers the question for you.

1. How satisfied are you with how your pain was controlled in the hospital after surgery?
Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied

2. How satisfied are you with how your pain was controlled when you returned home after surgery?
Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied

3. How satisfied are you with the amount of time it took for you to return to your daily activities, for
example housework or social activities outside the home?
Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied

4. How satisfied are you with the amount of time it took for you to return to work?
Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied

5. How satisfied are you with the amount of time it took for you to return to your normal exercise
routine?
Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied

6. How satisfied are you with the results for your surgery?
Very Satisfied Satisfied Neutral Unsatisfied Very unsatisfied

7. Looking back, if you had to do it all over again would you have the surgery again?
Yes Maybe Unsure Do not think so No

8. Would you recommend this surgery to someone else?

Yes Maybe Unsure Do not think so No

MAY 2008 American Journal of Obstetrics & Gynecology 573.e7