الفهرس 
Apical uterine prolapseOnly 14 pages are availabe for public view
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Abstract
Pelvic organ prolapse (POP) is a highly prevalent condition. Many women with prolapse experience symptoms that impact the quality of life, daily activities, sexual function, and exercise. The presence of POP can have a detrimental impact on body image and sexuality (Van IJsselmuiden et al., 2020).
The apical prolapse is probably the most complex form and the corner stone of pelvic organ prolapse (POP). Adequate apical support is essential in the treatment of POP, as it contributes to the support in all vaginal compartments. Anterior and posterior vaginal repairs may be unsuccessful if the apex is not well suspended. The choice of an apical suspension procedure should be individualized to the specific patient because each procedure carries its own risk and benefit and is frequently determined by the surgeon’s training and expertise, but no single procedure fits to all patients. When deciding on the proper surgical procedure to be performed (Barber and Maher, 2013).
In a Cochrane review, abdominal sacral cervicopexy was su¬perior to vaginal sacrospinous fixation, with a decreased rate of recurrent vault prolapse. But, vaginal sacrospinous fixation was rapid to perform and less expensive, with an advantage of early return to daily activities. However, Data regarding subjective cure rate, patient satisfaction, and the impact of surgery on quality of life (QoL) were scant to provide a reliable and robust conclusion (Maher et al., 2016).
The aim of the present study was to compare abdominal sacral hystropexy with vaginal sacrospinous hystropexy in women with apical prolapse in terms of operative time, procedures safety and efficacy and the impact of surgery on quality of life (QoL).
The study was conducted at the Urogynaecology unit, Ain Shams University Maternity Hospital on 72 women with symptomatic apical uterine descent stage II or more according to (POP-Q). Each group initially included 37 patients. Two patients from the SSF group were excluded from the analysis, 1 of them withdrew from the study and the other was lost to follow up. The study protocol was approved by Research Ethics Committee of the council of Obstetrics and Gynecology Department, Ain Shams University. Also Informed written consent after explaining the study purpose and method to the subjects was taken. Eligible Women were randomly allocated into two groups; 37 patients in ASH group included and 35 patients in SSF group that were performed by a senior urogynecologist.
The demographic data between the two groups was similar. There were follow up visits at 3, 6 and 12 months postoperative and after the 1 year follow up, we found that recurrence cases were more common in SFF group than abdominal sacropexy group. The Kaplan–Meier survival Curves displayed that the time to surgical failure (recurrent uterine prolapse) was insignificant in both groups.
The number of patients needed another surgery was statistically insignificant between the two groups till 6 months post operative, but was significant at one year post operative, Kaplan-Meier survival curves displayed that the time to re-operation was significantly shorter in the SSF group. Also according to a multivariate logistic regression analysis for independent predictors for recurrent uterine descent, it was found that patient’s age, presence of multiple risk factors, type of surgery (SSF<ASH), Pre Stage of uterine descent and Menopausal state, had a significant positive correlation with the rate of uterine prolapse recurrence.
The overall risk for denovo cystocele at 1 year was insignificant between the two groups, However, the risk was higher in SSF group. In contrary, the rate of denovo rectocele was higher in ASH group however the risk was insignificant between both groups.Although subjective assessment was not statistically significant till 6 months post operative, there was statistically significant difference according to patients symptoms at 1 year post operative.The higher number of symptomatic patients were in SSF. Kaplan-Meier survival curves displayed that the time to be symptomatic for POP after surgery was significantly shorter in the SSF group. There was no statistically significant difference between both groups as regard presence of urinary incontinence, sexual function and quality of life at 1 year.
The operative time, blood loss and the duration of hospital stay were higher in patients with abdominal sacral hysteropexy. There was no difference between the two groups in terms of the need for blood transfusion, fever, wound infection, visceral injuries and the need for post operative analgesia. The main complication of SSF was buttock pain that occurred in 2%.
One of the major complication that requires reoperation in SCP group is mesh erosion. Concomitant total hysterectomy increases the risk of mesh erosion after SCP up to seven-fold.as reported by Rogers et al. (2018). We didn’t face such complication as we operated on preserved uterus so we had no cases of mesh erosion.
In conclusion, abdominal sacral hystropexy is associated with a higher probability of achieving cure and a lower probability of recurrence, but with significantly greater intraoperative blood loss and operating time, along with significantly more patients with postoperative pyrexia, Hospitalization and slower return to daily activities. The vaginal route may be preferable in women with medical disorders and obesity as it is associated with lower intra and postoperative morbidity with shorter operative time, So when anatomic durability is a priority, ASH is a preferable surgical option and when minimizing adverse events is a priority or medical co-morbidities are present, SSF is a preferable surgical option.
Conclusion
Abdominal sacral hystropexy is associated with a lower risk of recurrence, but with significantly greater intraoperative blood loss and operative time, along with significantly more patients with postoperative pyrexia, Hospital stay and slower return to daily activities. The vaginal route may be preferable in women with medical disorders and obesity as it is associated with lower intra and postoperative morbidity with shorter operative time.
Recommendations
When anatomic durability is a priority, ASH is a preferable surgical option. When minimizing adverse events is a priority or medical co-morbidities are present, SSF is a preferable surgical option.