Pelvic organ prolapse (POP) is defined as the downward descent of pelvic organs that results in the protrusion of the vagina, uterus, or both from the vaginal introitus [1]. The prevalence of POP has ranged from 3% to 41% in previous studies, because the definition for POP varies from study to study [2-7]. Pelvic organ support deteriorates with age, and hence, a majority of women over 50 years of age experience POP. The prevalence of POP continues to rise owing to an increase in the elderly population [8]. In Korea, the prevalence of POP was much lower than that in previous studies (180 per 100,000 population for women over 50 years), as the definition of POP excluded subjective symptoms and included only POP diagnosed by doctors. In addition, the rate of POP surgery peaked among those aged approximately 70 years [7].

Patients with symptomatic POP who decline or show no improvement with nonsurgical treatment are candidates for surgical treatment. The route of repair (abdominal or vaginal approach) depends on a multitude of patient factors (age, presence of uterus, site of prolapse, comorbidities) and the surgeon’s preference. Previous studies have shown that the vaginal approach has a shorter operation time (OT) and hospital stay, and a lower complication rate than the abdominal approach [9-11]. Therefore, surgery via the vaginal approach may be preferred for elderly or medically compromised patients, as it is associated with low morbidity.

There are various surgical methods for the vaginal approach, including reconstructive procedures, obliterative procedures, and procedures that preserve the uterus with a synthetic mesh [12]. To date, hysterectomy is the recommended procedure for the treatment of POP; however, clinical data on its effectiveness compared to uterine preservation are limited. A recent cohort study of 100,000 women demonstrated that hysterectomy for POP is associated with a decreased risk of POP recurrence at any site: anterior, apical, and posterior [13]. There are limited studies on the efficacy of vaginal hysterectomy combined with anterior and posterior colporrhaphy (VH APR), and only a few studies have compared colporrhaphy with other POP surgical methods. Anterior colporrhaphy has a high surgical success rate of 70-89%, although the results of surgical success in comparison to those with mesh surgery are controversial according to the definition of anatomic success [14-16]. In contrast, posterior colporrhaphy has proven to be effective in correcting the posterior vaginal compartment compared to other surgical methods [16,17]. In addition, one study revealed that VH APR is effective in treating uterine prolapse at stage >2 [18]. However, data on the efficacy of APR are unclear, and further clinical studies must be undertaken.

Limited data are available on VH APR and its outcomes in POP treatment in the Korean population. This study aimed to report the surgical outcomes of VH APR over the past 10 years, evaluate the complications of surgery, and calculate the recurrence rate to identify the safety and efficacy of VH APR.

Our study found that VH APR showed significant improvement in the clinical stage of POP patients, which was well maintained up to 1 year after surgery. In addition, VH APR proved to be a safe surgical procedure for elderly patients because it resulted in less EBL and fewer surgical complications.

With advancements in the field of surgery, many surgical methods have emerged as alternatives to traditional VH for POP patients. Many studies have been conducted on the merits and demerits of uterus preservation surgeries, as well as the efficacy of a mesh in preserving the uterus [17,21,22]. A recent randomized controlled trial (RCT) demonstrated that vaginal repair with a mesh or graft was not superior to native tissue repair in terms of improvement of prolapse symptoms, quality of life, and objective failure within 2 years after surgery [14]. In addition, mesh exposure occurred in 12% of patients. Another RCT comparing vaginal mesh hysteropexy with VH USLS found that there was no difference between the two procedures in terms of re-treatment and recurrence of POP [23]. In addition, VH APR was found to be better than abdominal sacrocolpopexy with preservation of the uterus in terms of maintaining urogenital function and preventing an overactive bladder [18]. In conclusion, a Cochrane review stated that there was insufficient evidence to use a mesh as a first-line treatment in apical or posterior prolapse as well as prolapse in the anterior compartment (the site most affected by POP) [17,21,22]. In this study population, most patients had POP-Q stage 2 or 3 (96.7%), and the anterior compartment was the most affected site (Aa, Ba; median 1 cm); thus, we deemed VH APR without mesh as an appropriate treatment.

We demonstrated that VH APR is a safe operation because it has a short OT, low EBL, and few complications. The OT in our study was the shortest compared to that of previous studies (86.5±20.96 minutes [n=610] vs. 110.7±42.8 [n=81] vs. 156.7±43.9 minutes [n=87]) [15,23]. The blood transfusion rate and the difference in Hb levels in our study were comparable with those in a previous study (transfusion, 0.98% [6/610]; difference in Hb, 1.7±1.0 g/dL vs. transfusion, 1.9% [2/108]; difference in Hb, 2.0 g/dL) [24]. Abdominal hysterectomy has a blood transfusion rate of 2.18% [25,26], while VH has a very low EBL and blood transfusion rate; this demonstrates its safety in the surgical treatment of POP. The intra- and postoperative complications of bladder or ureteral injury were both less than 1%, which is similar to the results of previous studies [13,18]. In addition, infectious complications after VH have been reported to vary from 1% to 13% [13,27], but they were found to be less than 1% in our study. Difficulty in voiding with bladder retention after removal of the urinary catheter was the most common complication (6.4%). A previous study demonstrated that the urinary retention rate was low on postoperative day 2 (12%) compared to that on day 1 (35.2%) or day 3 (21.3%) [28]. The cause of difficulty in voiding after Foley catheter removal has not been fully identified, and there are no guidelines on the timing of Foley catheter removal after VH. In our study, Foley catheter removal on postoperative day 2 was found to be associated with a low incidence of difficulty in voiding, and all patients showed improvement after several days of maintenance on the Foley catheter.

There were two cases of severe postoperative complications, one with left ureteral obstruction and the other with VVF. One patient was diagnosed with left ureteral obstruction at 7 days post-surgery, and she also showed decreased renal function and left hydronephrosis. Left percutaneous nephrostomy (PCN) was performed, and a double J (DJ) stent was inserted into the ureter. After 8 months of maintenance of the PCN and DJ stents, the patient’s kidney function normalized. Another patient underwent bladder repair for bladder injury during surgery, after which a Foley catheter was placed; after 2 weeks, cystoscopy and CT were performed for symptoms of persistent leakage of urine despite maintaining a Foley catheter, and a fistula between the vagina and the bladder, a VVF, was diagnosed. After 3 months of maintenance on the Foley catheter, there was no leakage on cystoscopy, and the Foley catheter was removed. No abnormal findings were found during outpatient observation for the following 3 years. Bladder injury, which is more frequent than ureteral injury, occurs when the prevesical space is dissected. An analysis of 3,076 patients who underwent VH showed one ureteral injury and four VVFs [29]. All VVFs occurred because of bladder laceration during the procedure, with an incidence of 0.13% in the overall population. Thus, it should be noted that subsequent VVFs can occur if bladder injury occurs during surgery.

Our study found that VH APR showed a significant reduction in POP and a low recurrence rate. However, only 68% of patients returned at the 1-year follow-up; this may have caused an overestimation of the recurrence rate (9.6%). If all patients who did not visit the hospital 1 year after the surgery were assumed to have had no symptoms of recurrence, the recurrence rate would have been 6.6% to 9.6%. The recurrence rate in this study was much lower than that reported in previous studies [14,15,23]. Nager et al. [23] evaluated the outcomes of VH with USLS for 3 years, and the cumulative recurrence rates gradually increased from 25% (1 year, n=21) to 41% (3 years, n=28). However, among the cases of recurrence, there was only one case wherein re-treatment was required. Similarly, another study showed that the anterior compartment (Ba ≤0) was the most common site for recurrence, with a recurrence rate of 29.6% (n=24), and three patients underwent reoperation within 1 year [15]. Our study also found that the anterior compartment was the most common site of recurrence. Glazener et al. [14] conducted a study on VH APR with native tissue repair versus mesh or graft repair. The study showed that the native repair group showed recurrence of stage 2 (45%), followed by stage 1 (32%) POP at 1 year after surgery, and 6% of the patients underwent reoperation within 2 years. Three patients required re-treatment for POP recurrence in our study; most of the remaining patients did not require further treatment for prolapse because the symptoms were not severe. Two patients underwent colpocleisis with posterior colporrhaphy (at 18 months) and APR (at 6 years), both with an initial POP stage of 3. In the other patient, a pessary was used for 7 years after surgery, as her initial POP stage was 2. The reason for the low recurrence rate in our study compared to that in previous studies may be attributed to the fact that less than half of the patients (38.7%) in our study had preoperative advanced POP (stages 3 and 4). However, the comparison with our study is limited because each study had different descriptions of preoperative POP stages and patient characteristics.

Possible reasons for recurrent POP are patient factors, such as age, BMI, and underlying diseases or procedural factors [20]. A systematic review by Vergeldt et al. evaluated 30 risk factors for recurrent POP after native tissue repair and concluded that advanced preoperative stage was the only risk factor (stage 3 or 4 vs. stage 1 or 2, OR, 2.0-3.9, 95% CI, 1.0-13.0, P<0.05) for recurrence, and other factors (parity, vaginal delivery, age, and BMI) were associated with primary POP [30]. Our study corroborates these findings. In conclusion, the anterior compartment was the most common recurrence site, and the risk factor for recurrence was an advanced stage of POP at the initial presentation. Additional evidence is required to improve preventive strategies and to determine effective surgical or conservative management options.

The strength of this study is that it was a relatively largescale study, as we analyzed 610 patients. Moreover, we excluded surgeries performed by surgeons with less experience in performing VH. Consequently, we analyzed only the results of surgeries performed by a single surgeon. Since one surgeon performed all the operations of VH APR with USLS and POP-Q tests, inter-surgeon bias was eliminated. However, since this was a retrospective study, there may have been selection bias because not all patients visited the outpatient clinic for a year. Further studies are necessary to confirm the long-term outcomes of VH APR.

In conclusion, VH APR demonstrated good surgical outcomes in POP patients, as it was associated with low morbidity and a low recurrence rate. In addition, advanced preoperative stage was the only risk factor for recurrent POP. Many surgeons still prefer VH in POP patients; however, in recent years, there has been an increase in the number of specialized surgeries being performed, such as hysteropexy and sacrocolpopexy. The number of patients with POP is increasing, and various surgical methods are being developed. An appropriate surgical method should be chosen for POP patients after considering patient factors and the operating surgeon’s experience and preference.