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OBJECTIVE: We sought to compare quality of life and patient satisfac- from the preoperative to postoperative Incontinence Impact Question-
tion after obliterative vs reconstructive surgery. naire and Urogenital Distress Inventory were comparable as were post-
operative Surgical Satisfaction Questionnaire scores.
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 CONCLUSION: Improvements in condition-specific quality of life and
surgery. Preoperative responses to the Urogenital Distress Inventory postoperative patient satisfaction measures are comparable in women
(UDI-6) and Incontinence Impact Questionnaire (IIQ-7) were collected ret- with prolapse who undergo either reconstructive or obliterative
rospectively. We then mailed the same questionnaires, and the Surgical surgery.
Satisfaction Questionnaire (SSQ-8), to these subjects postoperatively.
RESULTS: Mode of surgery was evenly split (n 45 per group) be- Key words: pelvic organ prolapse, obliterative surgery, vaginal
tween the 90 patients meeting the inclusion criteria. Improvements 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.
base of our practices electronic medical sponses to the preoperative short-forms gical groups was conducted by using the
record system was used to identify pa- of the IIQ-7 and UDI-6,14 plus 2 addi- Pearson 2 statistic for categorical data,
tients meeting the following inclusion tional prolapse-specific questions from the independent-samples t test for con-
criteria: leading edge of preoperative the long-form of the UDI15 (How much tinuous data, and the paired samples t
prolapse 4 cm or greater beyond the hy- are you bothered by. . . : 1. a feeling or test for repeated measures. Statistical
men, status postvaginal reconstructive or bulging or protrusion in the vaginal area; analysis was performed by using SPSS
obliterative surgery between October and 2. bulging or protrusion you can see 15.0 for Windows (SPSS Inc, Chi-
2004 and October 2006, and age 65 years in the vaginal area?), demographics, cago, IL).
or older at time of surgery. We chose to medical/social/surgical history, results of We performed a power calculation to
start our 2-year study period in October the preoperative Pelvic Organ Prolapse determine whether we had enough pa-
of 2004, because that is when we began to Quantification (POP-Q)16 examination tients in our cohort to detect a 33.3-point
routinely ask our patients to fill out the and urodynamic testing (if performed), difference (a change from moderate to
Incontinence Impact Questionnaire surgical procedure(s) performed, peri- slight bother) between groups in our
(IIQ-7) and Urogenital Distress Inven- operative outcomes, postoperative ex- primary dependent variable, change in
tory (UDI-6) before their first office visit. amination findings, further surgical in- UDI-Obstructive/Discomfort subscale
Obliterative surgeries included in the terventions, and length of office score. Group sample sizes of 32 in each
analysis included both the Lefort colpo- follow-up. arm were required to achieve an 80%
cleisis and total colpectomy both per- All patients who met the inclusion cri- power to detect this difference between
formed in the standard manner.12 No teria were then mailed a postoperative the obliterative and reconstructive
high perineorrhaphy or levator plication survey that contained a consent form, groups with an of .05 by using a
was performed in either of these proce- the IIQ-7, the extended UDI-6, and the 2-tailed test.
dures. Vaginal reconstructive surgeries Surgical Satisfaction Questionnaire
included any prolapse repair designed to (SSQ) (Appendix 1). Our research nurse
restore support to the vagina and enable attempted to contact by phone any pa- R ESULTS
future coital function performed tients who did not mail back the survey Ninety patients met the inclusion crite-
through a vaginal approach (all laparo- and obtain verbal consent to administer ria. By chance, the 2 surgical groups had
scopic or open abdominal repairs were the questionnaires verbally. These data the same number of patients (n 45).
excluded). On the basis of our practice were then added to the study database. Demographics, surgical history, and
patterns, we anticipated that the major- The IIQ-7 and UDI-6 are validated baseline quality-of-life measures were
ity of these repairs would have been per- condition-specific questionnaires that comparable between the 2 surgical arms
formed with the use of anterior and/or have been used extensively in the litera- with the following exceptions: mean age
posterior compartment bodies of ture to compare preoperative and post- (80.0 vs 75.7 years, P .01) and preop-
polypropylene mesh anchored with operative status of women undergoing erative leading edge of prolapse (7.0 vs
straps passed percutaneously through pelvic reconstructive surgery.6,17 The 5.0 cm, P .01) were greater in the
the obturator and/or ischiorectal fossae. SSQ is an 8-item questionnaire, with re- obliterative group (Table 1). The per-
These procedures were performed by us- sponses recorded on a 5-point Likert- centage of group members undergoing
ing the previously described transvaginal type scale with responses from 0 Very concomitant minimally-invasive sling
mesh technique13 that used the Prolift Unsatisfied to 4 Very Satisfied. procedures was comparable (71.1% vs
system (Ethicon Womens Health and Scoring is similar to the IIQ-7 and UDI-6 73.3%, P .34); this and other informa-
Urology, Johnson & Johnson, Somer- with the mean average of the 8 scores be- tion on the procedures performed in
ville, NJ). ing multiplied by 25 (the questionnaire is each group can be found in Table 2. Al-
The decision to proceed with an oblit- considered incomplete if more than 2 though we did not design the study to
erative vs a reconstructive surgery was items are not answered), yielding a po- compare vaginal reconstruction that
made after extensive discussion between tential range of scores from 0 to 100. The used grafts to obliterative surgery, the
the surgeon and patient. The choice was higher the score is, the greater the degree only patients undergoing reconstructive
made after discussing the various pros of surgical satisfaction. Items 1 and 2 are surgery who met the inclusion criteria
and cons of each approach and was in no used to calculate the Pain subscale; items had undergone the Prolift procedure. No
way randomized. All patients who chose 3, 4, and 5 are used for the Return to patients in either group underwent hys-
the obliterative approach were aware baseline subscale: and items 6, 7, and 8 terectomy during their surgery.
that future vaginal intercourse would are used for the Global satisfaction sub- Operative time was shorter in the re-
not be possible. Patients who chose the scale. Each subscale is calculated in the constructive group, but perioperative
reconstructive approach were not neces- same manner as the overall SSQ score. outcomes were otherwise similar be-
sarily sexually active, nor did they all de- The SSQ is not designed to be condition- tween groups (Table 3). Of the oblitera-
sire future sexual function. specific and has not yet been validated. tive surgeries, the colpectomies on aver-
A retrospective chart review was per- Univariate analysis comparing base- age took longer than the LeForts, but this
formed to collect the following data: re- line and outcome data between the 2 sur- difference did not meet statistical signif-
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- All values listed as mean ( SD) or n (%).
Multichannel urodynamic testing performed with prolapse supported.
ences were found, but our sample size Independent samples t test used for continuous data and Pearson 2 for categorical data.
requirements were not met. Analyses of 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
these instruments were only completed cm of water pressure); SD, standard deviation; SUI, stress urinary incontinence, UDI-6, short form of Urogenital Distress
for patients who had fully completed Inventory.
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
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 TABLE 2
also looked at the responses to the 2 ad- Procedures performed in each group
ditional prolapse-specific questions Obliterative (n 45) Reconstructive (n 45)
from the long-form of the UDI included LeFort colpocleisis 28 (62.2%)
..............................................................................................................................................................................................................................................
in our survey. When comparing the de- Total colpectomy 17 (37.8%)
gree of preoperative to postoperative im- ..............................................................................................................................................................................................................................................
Anterior Prolift 19 (42.2%)
provement in these questions between ..............................................................................................................................................................................................................................................
dure is to minimize the risk of medical Irritative symptoms 14.8 (33.4) 24.0 (33.0) .32
.....................................................................................................................................................................................................................................
and surgical complications in sexually Obstructive/discomfort 29.0 (29.5) 34.7 (32.2) .51
.....................................................................................................................................................................................................................................
inactive, elderly, and often medically Stress symptoms 14.3 (38.7) 19.3 (29.9) .60
..............................................................................................................................................................................................................................................
compromised women that they would Data presented as mean ( SD), and calculated with the independent samples t test.
otherwise be exposed to with reconstruc- IIQ-7, short form of Incontinence Impact Questionnaire; SD, standard deviation; UDI-6, short form of Urogenital Distress
Inventory.
tive surgery. It is therefore noteworthy
Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
that we failed to find a greater risk of
complications or blood loss in our re-
constructive group (although given the tive time and blood loss when concomi- vorable results in respect to the Stress
relatively small sample size it would be tant hysterectomy is performed).10,19 and Irritative symptoms subscales of the
unlikely to find a significant difference in The decision to perform a concomi- UDI-6 support these findings, because
rare complications). The vast majority of tant antiincontinence procedure at the 71% of patients in the obliterative group
patients in both groups had their surgery time of colpocleisis for either clinical, had a concomitant midurethral sling
under regional anesthesia, and the oper- urodynamic, or potential/occult stress placed. Although the improvements in
ative time was actually shorter in the re- urinary incontinence has also been a per- irritative symptoms may be related to re-
constructive group. The operative times plexing issue. One study showed a 27% duction of prolapse as suggested by Fos-
for our obliterative cases may seem incidence of de novo incontinence after ter et al,7 the use of a midurethral sling in
longer than many people associate with colpocleisis.20 However, the risk of de the majority of our population certainly
these types of procedures. It is important novo stress incontinence has to be bal- did not result in a significant amount of
to point out that this time includes place- anced with the risk of iatrogenic voiding
voiding dysfunction in either the recon-
ment of a midurethral sling and cystos- dysfunction after concomitant prophy-
structive or obliterative groups.
copy in more than 70% of these cases. lactic antiincontinence procedures.
The type of prolapse repair per-
The primary operator for most of the Most series of colpocleisis have used sub-
formed in the reconstructive group
obliterative surgeries was a resident, as urethral plication as their primary anti-
incontinence procedure with varied re- also separates this investigation from
opposed to the reconstructive cases. Be-
cause of the deep dissection and blind sults.6,9,10,18 More recently, though, 1 other comparative studies and may
trocar placement associated with the series looking at the use of minimally in- limit the external validity of our find-
type of reconstruction used in this inves- vasive midurethral synthetic slings at the ings. The senior authors performed
tigation, the primary operator in most of time of obliterative surgery showed many reconstructive surgeries without
the reconstructive surgeries was more promising long-term results.21 Our fa- grafts. However, in this cohort all of
likely to be either the attending or a fel-
low as opposed to a resident, thus this TABLE 5
bias may contribute to the difference in Comparison of Surgical Satisfaction Questionnaire
operative time we found. responses between groups
Our standardized surgical satisfaction
Obliterative Reconstructive
questionnaire failed to show a difference Instrument (n 38) (n 35) P
in the 2 groups in regard to the amount
SSQ total score 89.6 (12.7) 86.4 (16.0) .33
of pain they experienced and how ..............................................................................................................................................................................................................................................
the common denominator responsible Data presented as mean ( SD), and calculated with the independent samples t test.
SD, standard deviation; SSQ, Surgical Satisfaction Questionnaire.
for these similarities (other case series of Murphy. Satisfaction after vaginal reconstructive vs obliterative surgery. Am J Obstet Gynecol 2008.
colpocleisis have shown greater opera-
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ACKNOWLEDGMENTS
organ prolapse. J Reprod Med 2003;48:703-6. and vaginal prolapse and stress urinary incon-
We thank Jerry Cohen for his assistance in con- 12. Karram MM, Sze EH, Walters MD. Surgical tinence under local anesthesia. J Am Assoc Gy-
ducting this research. treatment of vaginal vault prolapse. In: Walters necol Laprosc 2003;10(2):276-80.
A PPENDIX 1
Date: _____/______/_______
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