Sacral colpopexy with concurrent Burch colposuspension in patients with vaginal vault prolapse.

INTRODUCTION: Abdominal sacral colpopexy (SC) is one option in the management of vaginal vault prolapse. In patients who are additionally incontinent an anti-incontinence procedure such as a Burch colposuspension or pubovaginal sling is usually performed at the same time. For those patients undergoing SC who are continent there are no clear guidelines for the use of a 'prophylactic' anti-incontinence procedure. We describe our experience with SC and concurrent Burch colposuspension.

PATIENTS AND METHODS: 47 patients (mean age 65 years) underwent SC and concurrent Burch colposuspension. The preoperative diagnostic check-up included a validated questionnaire, clinical examination, urodynamic tests, ultrasound and colpocystorectography. Patients were also evaluated using Stress, Emptying, Anatomic, Protection and Instability (SEAPI) scores. All patients had a uterine or vaginal vault prolapse in combination with a cystocele, enterocele or rectocele. Thirty-three of 47 (70%) patients were continent and 14 (30%) incontinent. Nineteen (40%) of the 33 'continent' patients were found to have occult incontinence. Clinical examination according to the Halfway system showed 9 of 47 (19%), 21 of 47 (45%) and 17 of 47 (36%) patients with grade 2, 3 and 4 vaginal vault prolapse, respectively. Thirty-five of 47 (74%) patients demonstrated a grade-4 cystocele and 12 of 47 (26%) a grade-3 cystocele. The mean follow-up was 34 months and included a questionnaire (SEAPI), clinical examination and ultrasound.

RESULTS: Postoperative SEAPI scores showed a statistically significant improvement in all SEAPI domains (p < 0.001). Ninety-four percent of the patients were satisfied, continent and would undergo the surgery again. Three patients were incontinent. No continent patient who underwent concurrent Burch colposuspension had obstructive symptoms or residual urine. Five patients (11%) who had dyspareunia preoperatively were free of this symptom postoperatively. Complications were: dilatation of the upper urinary tract in 2 patients (4%) secondary to distal ureteric deviation by suturing the posterior peritoneum. One patient underwent psoas hitch neoureterocystostomy and 1 patient was successfully treated by insertion of a ureteric stent for 6 weeks. One patient (2%) had a mesh infection necessitating removal of the Gore-Tex mesh.

CONCLUSIONS: Sacral colpopexy provides good patient satisfaction, durable pelvic support and restores vaginal function. Due to excellent continence rates concurrent Burch colposuspension should be considered as a joint procedure even in continent patients.