Sacrospinous Ligament Fixation – A Malaysian’s Tertiary Centre Experience

During the study period from January 2008 to December 2012, 177 women had transvaginal sacrospinous ligament fixation (SSF) for vault suspension at General Hospital Kuala Lumpur. Of the 177 women, 133 (75.1%) had severe uterovaginal prolapse while 44 (24.9%) had post-hysterectomy vault prolapse. All patients with severe uterovaginal prolapse and rectocele undergone vaginal hysterectomy and posterior colporrhaphy respectively. A hundred and seventy-four patients (98.3%) had anterior repair whilst 48 (27.1%) received midurethral sling as concomitant procedure to vault suspension (SSF). The mean duration of surgery was 92.1±30.2 minutes and the mean estimated blood loss was 319±199.3mls. There was no surgical mortality. Two patients (1.1%) had rectal injuries. No patient had bladder injury or de novo urinary symptoms. The commonest immediate postoperative complications was fever (98; 55.4%) followed by buttock pain in 18 (10.2%) patients. Both complications were resolved with conservative measures. Seven patients (3.9%) had sutures erosion as late complications. Of the 177 women, 158 (89.3%) and 141 (79.7%) came for the 6 and 12 months follow-up, respectively. The success rate for all three compartments ranged from 92.4% to 98.1% at 6 months and reduced to range from 85.7% to 94.4% at 12 months. The highest success rate was observed in the posterior compartment followed by apical and anterior compartment. Equally, the recurrence rate was lowest in the posterior compartment (1.9%), followed by the central (3.8%) and anterior compartment (7.5%) at 6 months’ review. This increased to 5.7% for rectocele, 7.8% for vault prolapse and 14.2% for cystocele at 12 months’ follow-up. None had repeated surgery for prolapse recurrence during the study period. In conclusion, SSF remains a high priority in our therapeutic regime for the treatment of severe uterovaginal and vault prolapse as it has a reasonably good success rate with lower serious complications in the skillful hands.

The Prevalence and Risk Factors of Occult Stress Urinary Incontinence in Women Undergoing Genitourinary Prolapse Surgery

De novo stress urinary incontinence (SUI) may occur in up to 80% of clinically continent women following genitourinary prolapse surgery. This had resulted in an increase in the rate of concurrent continence surgery during prolapse repair from 38% in 2001 to 47% in 2009 in the United States. To date, there is no local data available to estimate the prevalence of occult SUI (OSUI) among Malaysian women awaiting surgery. Therefore, this study was conducted to elicit the prevalence of occult SUI and its associated risks factors in patients awaiting prolapse surgery. We retrospectively studied the records of 296 consecutive women with significant pelvic organ prolapse awaiting reconstructive repair. All patients attended the Urogynaecology Unit in Hospital Kuala Lumpur Malaysia between October 2007 and September 2011. They had undergone standardized interviews, clinical examinations and urodynamic studies. During the urodynamic testings, all prolapses were reduced using ring pessaries to elicit OSUI. Primary outcome was the prevalence of OSUI with prolapse reduction to predict possibility of developing de novo SUI following prolapse surgery. Secondary outcome was the assessment of potential risk factors for OSUI. Among the 296 women studied, 121 (40.9%) were found to have OSUI. The risk factors associated with OSUI included age, BMI, numbers of SVD, recurrent UTI, reduction of urinary flow symptoms and grade 2 to 4 central compartment prolapses. We concluded that preoperative urodynamic testing with reduction of prolapse is useful to identify women with OSUI. This is important for preoperative counselling as well as planning for one step approach of prophylactic concomitant anti-incontinence procedures during prolapse surgery in order to avoid postoperative de novo SUI.