Anterior and Posterior Repair (Colporrhaphy) - MywallpapersMobi

Anterior and Posterior Repair (Colporrhaphy)


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Colporrhaphy (also vaginal wall repair, anterior and/or posterior colporrhaphy, anterior and/or posterior vaginal wall repair, or simply A/P repair or A&P repair) is a surgical procedure in humans that repairs a defect in the wall of the vagina . It is the surgical intervention for both cystocele (protrusion of the urinary bladder into the vagina) and rectocele (protrusion of the rectum into the vagina). [1]

The repair may be to either or both of the anterior (front) or posterior (rear) vaginal walls, thus the origin of some of its alternative names.

References[ edit ]

  1. ^ Encyclopedia of Surgery

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      1. Surgery
      2. Ce-Fi
      3. Colporrhaphy



      Colporrhaphy is the surgical repair of a defect in the vaginal wall,
      including a cystocele (when the bladder protrudes into the vagina) and a
      rectocele (when the rectum protrudes into the vagina).

      In this anterior colporrhaphy, a speculum is used to hold open the vagina, and the cystocele is visualized (A). The wall of the vagina is cut open to reveal an opening in the supporting structures, or fascia (B). The defect is closed (C), and the vaginal skin is repaired (D). (Illustration by GGS Inc.)

      In this anterior colporrhaphy, a speculum is used to hold open the
      vagina, and the cystocele is visualized (A). The wall of the vagina
      is cut open to reveal an opening in the supporting structures, or
      fascia (B). The defect is closed (C), and the vaginal skin is
      repaired (D).


      Illustration by GGS Inc.



      A prolapse occurs when an organ falls or sinks out of its normal
      anatomical place. The pelvic organs normally have tissue (muscle,
      ligaments, etc.) holding them in place. Certain factors, however, may
      cause those tissues to weaken, leading to prolapse of the organs. A
      cystocele is defined as the protrusion or prolapse of the bladder into the
      vagina; a urethrocele is the prolapse of the urethra into the vagina.
      These are caused by a defect in the pubocervical fascia (fibrous tissue
      that separates the bladder and vagina). A rectocele occurs when the rectum
      prolapses into the vagina, caused by a defect in the rectovaginal fascia
      (fibrous tissue that separates the rectum and vagina). When a part of the
      small intestine prolapses into the vagina, it is called an enterocele.
      Uterine prolapse occurs when the uterus protrudes downward into the

      Factors that are linked to pelvic organ prolapse include age, repeated
      childbirth, hormone deficiency, ongoing physical activity, and prior


      . Symptoms of pelvic organ prolapse include stress incontinence
      (inadvertent leakage of urine with physical activity), a vaginal bulge,
      painful sexual intercourse, back pain, and difficult urination or bowel


      Approximately 50% of women report occasional urinary incontinence, with
      10% reporting regular incontinence. This percentage increases with age;
      daily incontinence is experienced by 20% of women over the age of 75.
      According to a recent study, approximately 16% of women ages 45 to 55
      experience mild pelvic organ prolapse, while only 3% experience prolapse
      severe enough to warrant surgical repair.


      Colporrhaphy may be performed on the anterior (front) and/or posterior
      (back) walls of the vagina. An anterior colporrhaphy treats a cystocele or
      urethrocele, while a posterior colporrhaphy treats a rectocele. Surgery is
      generally not performed unless the symptoms of the prolapse have begun to
      interfere with daily life.

      The patient is first given general, regional, or local anesthesia. A
      speculum is inserted into the vagina to hold it open during the procedure.
      An incision is made into the vaginal skin and the defect in the underlying
      fascia is identified. The vaginal skin is separated from the fascia and
      the defect is folded over and sutured (stitched). Any excess vaginal skin
      is removed and the incision is closed with stitches.


      Physical examination

      is most often used to diagnose prolapse of the pelvic organs. A speculum
      is inserted into the vagina, and the patient is asked to strain or sit in
      an upright position. The physician then inspects the anterior, posterior,
      upper (apex), and side (lateral) walls of the vagina for prolapse or
      bulging. In some cases, a physical examination cannot sufficiently
      diagnose pelvic prolapse. For example, cystogram may be used to determine
      the extent of a cystocele; the bladder is filled by urinary catheter with
      contrast medium and then x-rayed.

      The patient will be asked to refrain from eating or drinking after
      midnight on the day of the procedure. The physician may request that an
      enema be administered the night before the procedure if posterior
      colporrhaphy will be performed.


      A Foley catheter may remain for one to two days after surgery. The patient
      will be given a liquid diet until normal bowel function returns. The
      patient will be instructed to avoid activities for several weeks that will
      cause strain on the surgical site, including lifting, coughing, long
      periods of standing, sneezing, straining with bowel movements, and sexual


      Risks of colporrhaphy include potential complications associated with
      anesthesia, infection, bleeding, injury to other pelvic structures,
      dyspareunia (painful intercourse), recurrent prolapse, and failure to
      correct the defect. A fistula is a rare complication of colporrhaphy in
      which an opening develops between the vagina and bladder or the vagina and

      Normal results

      A woman will usually be able to resume normal activities, including sexual
      intercourse, about four weeks after the procedure. After successful
      colporrhaphy, the symptoms associated with cystocele or rectocele will
      recede, although a separate procedure may be needed to treat stress
      incontinence. Anterior colporrhaphy is approximately 66% successful at
      restoring urinary continence.

      Morbidity and mortality rates

      There is approximately a 1% risk of serious complications associated with
      colporrhaphy; the procedure is generally viewed to be safe with a very low
      rate of overall complications.


      Surgery is generally reserved for more severe cases of pelvic organ
      prolapse. Milder cases may be treated by a number of medical
      interventions. The physician may recommend that the patient do Kegel
      exercises, a series of contractions and relaxations of the muscles in the
      perineal area. These exercises are thought to strengthen the pelvic floor
      and may help prevent urinary incontinence. One study showed an decrease of
      62% in the amount of urine leakage among women ages 35 to 75 who performed
      Kegel exercises regularly for 16 weeks.

      A pessary, a device that is inserted into the vagina to help support the
      pelvic organs, may be recommended. Pessaries come in different shapes and
      sizes and must be fitted to the patient by a physician. Hormone
      replacement therapy may also be prescribed if the woman has gone through
      menopause; hormones may improve the quality of the supporting tissues in
      the pelvis.



      Cespedes, R. Duane, Cindy A. Cross, and Edward J. McGuire. "Pelvic
      Prolapse: Diagnosing and Treating Cystoceles, Rectoceles, and

      Medscape Women's Health eJournal

      3, no. 4 (1998).

      Viera, Anthony, and Margaret Larkins-Pettigrew. "Practice Use of
      the Pessary."

      American Family Physician

      61 (May 1, 2000): 2719–26.


      American Academy of Family Physicians. 8880 Ward Parkway, Kansas City, MO
      64114. (816) 333-9700.


      American Board of Obstetrics and Gynecology. 2915 Vine Street, Dallas, TX
      75204. (214) 871-1619.


      American Urological Association. 1120 North Charles Street, Baltimore, MD
      21201. (410) 727-1100.



      "Cystocele (Fallen Bladder)."

      National Kidney and Urologic

      Diseases Information Clearinghouse,

      March 2002 [cited March 20, 2003].


      Jelovsek, Frederick R. "Cystocoele, Rectocoele, and Pelvic Support

      Society of Gynecologic Surgeons,

      2001 [cited March 20, 2003]. pro002.html


      Miklos, John R., and Robert D. Moore. "Prolapse Treatment."

      Atlanta Center for Laparoscopic Urogynecology,

      2002 [cited March 20, 2003].


      Stendardo, Stef. "Urinary Incontinence: Assessment and Management
      in Family Practice."

      American Academy of Family Physicians,

      2002 [cited March 20, 2003].


      "Surgical Treatment of Genuine Stress Incontinence."


      College of Obstetricians and Gynaecologists,

      2002 [cited March 20, 2003].


      Stephanie Dionne Sherk


      Colporrhaphy is usually performed in a hospital

      operating room

      by a gynecologist or urologist. A gynecologist is a medical doctor who
      specializes in the areas of women's general and reproductive
      health, pregnancy, and labor and childbirth. A urologist is a medical
      doctor who specializes in the diagnosis and treatment of diseases of the
      urinary tract and genital organs.


      • Why is colphorrhaphy recommended in my case?
      • What non-surgical options are available to treat pelvic organ prolapse?
      • How long after surgery may I resume normal activity?

      User Contributions:

      Report this comment as inappropriate
      Jun 30, 2007 @ 10:10 am
      If a woman is 60 and postmenopausal is better to remove the ovaries during a vaginal hysterctomy?
      Marlene Lambright
      Report this comment as inappropriate
      Aug 6, 2007 @ 1:13 pm
      I underwent my very first colonoscopy on 03/31/2006. During the procedure, I woke out of sedation screaming, and then I was put back down under.The following week, my right leg swelled fist size into a bloodclot. It was too painful to sit without a pillow as well. I had to use a cain for months, and as of today I use a walker. I have been telling doctors that I was fine before the colonoscopy 03/31/06. No one believes me. I went all the way to New Jersey to Dr. Patrick Foye MD. He does not believe me also. I had a rectal EMG and EMG for both lower legs.Results: Irreversible nerve damage in my rectum. I also have been diagnosed with rectocele recently. I have been getting electric shock treatments through the rectum for 3 months. Now I get to have a machine at home to treat myself permanently.Two surgeons told me that these injuries are from chidbirth 26 years ago. Every doctor I spoke with says that colonoscopies do not and hever has been heard of injurying anyone. I am handicapped for life now..My family docotor wants me to see a psychiatrist..I was walking and in good physical shape before 03/31/ you know any other human being that has been injured by a colonoscopy? Thanks, Marlene Lambright 614-624-6022
      Report this comment as inappropriate
      May 9, 2008 @ 10:10 am
      I too, in October of 2007 at age 53, had undergone a routine colonoscopy (my 1st and only) shortly AFTER which, I discovered Rectocele – and it scared the heck out of me. I have been having problems with urination, constipation, and back and leg pain ever since. I believe that during the colonoscopy there was a “surge” of air into the rectum (which was to be bathed with air to facilitate visibility), that caused the stretching and/or weakening which in effect, caused all these problems. These Dr’s will not admit to this procedure causing these problems, but I know this is when all my problems began. I believe that the medical profession has an obligation to convey a warning to women and to list the colonoscopy as a possible cause for pelvic prolapse, and should be held accountable for this negligence when they lie in the name of self-interest- taking a course of action to cover up the truth. Instead they should be telling us that this is what happened during the procedure, and the possibility of pelvic prolapse, and options for treatment. Needless to say, I am very disgusted with the medical profession and their cover-ups.
      Report this comment as inappropriate
      Oct 14, 2008 @ 6:06 am
      I have just had a bladder and anterior repair,I can get no info that tells you exactly what you can and cannot do the phsio in the hospital said you cannot even lift the kettle,the consultant said just no heavy lifting!!I need exact detail!! can u go on car journey’s,how far should you walk and how soon after op?what exactly should you do and not do it is a minefield I do not want to be lazy but I want to be ralistic help!!!!
      Report this comment as inappropriate
      Feb 5, 2009 @ 9:09 am
      i am need information, because very very important or my health in the world
      Report this comment as inappropriate
      Feb 5, 2009 @ 9:09 am
      i am architect, but very needed information about medical clinic for my life
      Report this comment as inappropriate
      Feb 5, 2009 @ 9:09 am
      A gynecologist is a medical doctor who specializes in the areas of women’s general and reproductive health, pregnancy, and labor and childbirth. A urologist is a medical doctor who specializes in the diagnosis and treatment of diseases of the urinary tract and genital organs.
      jo jo
      Report this comment as inappropriate
      Feb 25, 2009 @ 12:12 pm
      Hi had the interior exterior colporrhaphy + tvt and i must say everything is great , would recomend to all.
      rachel gonzalez
      Report this comment as inappropriate
      Jul 10, 2009 @ 3:15 pm
      I recently had surgery for a prolaped hysterectomy and colporrhaphy rectum repair. I was in the best physical condition since high school, I’ll be 50 in 8/10/59. The day after surgery I was in so much pain I wanted to die. Went home after 3 days in hospital & continued to feel worse, long story short-have developed an anal fissure from hell. Went to see my OBGYN after a week and she wouldn’t even touch me instead referred me to an ass specialist. It;s been for weeks since my surgery,I can bearly do chores at home, can’t sit, stand, lye down for to long cause I’m in so much pain, so my questions is "is it possible that my fissure occurred during the surgery?" Any comments, please let me know.
      Report this comment as inappropriate
      Jan 2, 2012 @ 4:16 pm
      I need some help i had a colporraphy done 3 months ago and I’having pain after I empty my blader I feel some presure on my lower abdomen (on my pelvic area).We tried to have sex about 2 weeks ago and we couldnt .Have any want experience some of this problems.I have a dr appt in two days will see what he have to say about my situation.I’m no happy at all I think it was a waste of time (5weeks) out of work plus deductible,out of pocket ciins and copay
      jacquie robinson
      Report this comment as inappropriate
      Jan 8, 2013 @ 5:05 am
      Report this comment as inappropriate
      Sep 22, 2013 @ 8:08 am
      I have been reading about colporraphy because I have rectocele and cystole as well as pundental neuralgia. I see that a few other people had trouble after colonoscopy and wonder if that’s what caused my pundental nerve damage.
      Report this comment as inappropriate
      Mar 8, 2014 @ 11:11 am
      What is treatment of urine retention complication of ant colporrhphy
      Josephine kizidio
      Report this comment as inappropriate
      Apr 23, 2014 @ 1:13 pm
      I had colporrhaphy a year ago. I get lower abdominal pain every month like cramps and sometimes I feel pain when bladder is full. I have checked by several doctors but they tell me I am ok. I have ultrasound to check if there is anything wrong but nothing was found. I have also had my uterus removed. Please advice
      mary w
      Report this comment as inappropriate
      Aug 23, 2014 @ 8:08 am
      I had a colporrhaphy last oct. and over the last 3/4 mos ive had bladder problems, feels like ive got to urinate and when I go I have to press on lower stomach to get me going them sometimes I pee good and have pain and a feeling all inside and some times I still feel like ive got to and cant. Is this normal?? got appointment in sept to see dr. the repair was vaginal amd rectum both> I think heused mess also/ could that be the problem??
      Report this comment as inappropriate
      Sep 27, 2014 @ 2:02 am
      I was having problems urinating and bowel movements, & vaginal prolapse, twenty years before I had a hysterectomy. Test stated I had a tumor and unsure if on bladder or urethra. OB/GYN Dr. did a colporrhaphy and I was in so much pain I was in tears after coming home with a Foley Catheter. Returned to surgeon who told me everything was fine. I spent about another three days hysterically in pain until I ended up in emergency room. Appears the foley catheter was not attached to my leg when they released me and nobody noticed it was literally yanking my inside out. After a month on the catheter went back to surgeon who removed catheter and sent me on my way. I got home unable to urinate. Back to the emergency room and a catheter was put back in until a Urology specialist could see me. NOBODY COULD GET ME IN TO SEE A UROLOGIST. I had a raging infection. My primary tried to get me an appointment and so did the OB/GYN (or so she said) tried for 30 more days I was attached to a catheter. I still have the same problems I had when I started, except more abdominal pain. THE KICKER IS THE PATHOLOGY REPORT STATED THIS SO CALLED TUMOR WAS A UTERINE FIBROID. I DON’T HAVE A UTERUS. I suffered so badly, I never went back to doctor, my urine smells like death but I am so traumatized by my experience I wouldn’t recommend this to anyone.
      Report this comment as inappropriate
      Nov 23, 2014 @ 6:18 pm
      I had tension free taping interior and colporrhaphy done 4 weeks ago on 10/24/2014 I am still spotting with a bit of cramping is that suppose to be normal, it has been 4 weeks since the procedure. Can anyone please tell me if they have had this done and outcome. Thanks
      Diane Hall
      Report this comment as inappropriate
      Apr 7, 2015 @ 6:18 pm
      Isn’t there any GOOD new out there ? I am scheduled to have a posterior colporrhaphy & midurethal sling done next month, but after reading all of these comments I am a bit concerned. I want to be able to walk and ride my bike without so much discomfort – as it is now, the pressure is so great and my low back starts hurting after just a short while. Here I was HOPING this surgery would help me get more back to normal ? Does anyone have some positive feedback for me ?
      Report this comment as inappropriate
      Jun 2, 2015 @ 1:01 am
      mary I have an appointment next month for sling siruge but any one know about it please help me please
      Report this comment as inappropriate
      Nov 27, 2015 @ 6:06 am
      I had anterior repair surgery 9 days ago for prolapsed bladder. My post op advise was no lifting and a little exercise everyday. I have tried walking, gradually increasing distance, but each time am still experiencing pain-dragging pain at the wound site and lower stomach. I am worried the bladder is still prolapsed!
      Report this comment as inappropriate
      Dec 27, 2015 @ 6:18 pm
      16 years ago I had a hysterectomy w/o removal of ovaries and posterior colporrhaphy. I was very naive and didnt ask many questions. I was 40 years old, I now need another surgery. I have a hard time having a bowel movement and pee leaks out of me all day long especially right after I pee. I have pain in my groin, buttocks, lower back, legs, arms and neck. my hair is falling out and it hurts when I have sex with my husband. I feel worse off than someone in there 80s. I tried to talk to my new doctor about it and he acts like I’m crazy. I know i cant live like this so im going to have to take my health into my own hands. I requested my medical report from my surgery in 2000 its now on micro film in a storage some where.
      Report this comment as inappropriate
      Mar 2, 2016 @ 7:19 pm
      Need a colonoscopy . It’s been 3years. I get cancer polyps . I just had my bladder fall and was told my vigina is colapsing . They want to put a device in me to hold up the vigina and the bladder in place. Can I still do my colonoscopy like this. Worried about the pre-clean out.
      joy mary
      Report this comment as inappropriate
      Apr 13, 2016 @ 8:08 am
      can cystocele occur in women who have undergone hysterectomy?
      Report this comment as inappropriate
      Sep 25, 2016 @ 10:10 am
      I had a posterior colporrhaphy done for rectocele on September 12. I stayed overnight in the hospital. I would caution those whose rectocele is not that big, to perhaps consider using a pessary instead, unless they are at the point like I was, where it was impossible to have anything resembling a "normal" bowel movement. A pessary doesn’t fix anything, but it does keep you from having to ‘splint’ (use fingers or thumb via vagina, to force feces out). The recovery time from rectocele or any other sort of "wet" surgical procedure involving the mucous tissues and skin, is NOT short. I took one week off after surgery, but have still been having issues. First I got a bacterial infection (you’ll know if you get one by the horrible smell and yellow discharge), and to this moment, every time I move my bowels I start bleeding again. The line of stitches begins just above my anus – like an episiotomy – and extends in an unbroken and lumpy line all the way up the interior vaginal wall to about 2 centimeters short of the vaginal cuff (I had a hysterectomy in 2012). These sorts of surgical incisions are not fast-healing. Be sure you are prepared for that; if your job entails lots of standing, squatting and walking, you may wish to consider an alternative like the aforementioned pessary device. Anything that stretches the incision, is going to make it take longer to heal. I’m already to the point where my patience is close to an end with the healing, though I am happy I had it done. I have been able to take near-normal bowel movements. Other things to be aware of: you will get a LOT of post-surgical swelling; both interior and exterior. It will feel like a small football was stuffed in there. The swelling slowly fades. Sitting is very uncomfortable unless you have a donut pillow. Bacterial infections are very common during the first week post-procedure; if it starts to stink horribly, see your gynocologist right away, for a round of Clindamycin. Eat TONS of fiber, and chew flavored fiber tablets 3-4x a day. Trust me, being constipated after surgery is a horror you do not want, plus it can rip open the stitches. I personally prepared by going on a clear liquid diet 3 days prior to surgery, and drastically limiting any solid food after so I would not need to defecate for a while. It helped tremendously. Even with pain killers, I had zero constipation when I finally did have a bowel movement 5 days post-procedure. Good luck, and read as much as you can online about everything so you won’t have any surprises. Yes, even with the complications I’ve had, I would do it again just to be able to have a normal BM.
      Pamela Richison
      Report this comment as inappropriate
      Nov 18, 2016 @ 4:16 pm
      I had a total hesterectomy bladder sling in 2005 and had all of the problems that are listed I finally had surgery on November 15 2016 to correct the repair of anterior /posterior colorophany except that in my medical records for my hesterectomy and bladder sling to correct pop and Sui in association with my hesterectomy has no mention of the urologist surgeon that done the bladder sling and the obgyn surgeon that performed my hesterectomy only mentions removing my uterus and one overy I recently found out that I have no female parts including my cervix and fallopian tubes even at that I’m told that without the bar code of the mesh that was implanted I have no case how is that so to be done so wrong and nobody is the wiser I just want the truth about what and why for my own personal satisfaction it’s not about being compensated it’s about just knowing the truth about why all these years I was lead to believe that I still had my cervix my fallopian tubes my vaginal lymph nodes and one overy I never thought twice about why I was never put on hormone therapy and the bladder sling was the whole reason for my treatment of POP and SUI I mean because other than that I’ve got no history of cervical cancer or uterine cancer makes absolutely no sense to me about why the urologist surgeon is not even mentioned and why the obgyn surgeon lied about removing all of my female parts only for me to find out about it 10 12 years later no wonder why I couldn’t get any help for my medical issues I had an ongoing bacteria infection in my vaginal I couldn’t have sex with my husband because of the pain and every time I’d try and get help whether it be in the er or my doctors office I got told that I had jock itch or that I had candida vaginitis and that my problematic symptoms were not addressed I ended up in a divorce my medical career being put on hold no car unable to work and living with my parents all because my medical history is out of balance. Even so god bless America because I have 2,600 clock classroom hours in learning the anatomy and physiology and medical terminology and pharmacology and in medical coding and billing and being in good standing with my primary physician for 15 years is the only thing that’s gotten me through all of this therefore I truly have been blessed without not one reason for having said so yet should I say yet because everything I’ve gone through was all so unnecessary without a shadow of a dought and I have to believe that this will be made right for me I hope
      Darlene Mabrey
      Report this comment as inappropriate
      Apr 24, 2018 @ 6:06 am
      I just had coporrophy yesterday, I had grade 3 rectocele about size of orange, extended outside vagina. Rectal pain worse symptom, I’m using ice pack to rectum which helps almost as well as pain med. I’m very happy I had it, I had female specialist uro-gynecologist in Greenville NC. He’s great!
      Darlene Mabrey
      Report this comment as inappropriate
      Apr 24, 2018 @ 7:07 am
      As related to above comment, spelled colporrophy, and male doctor whose specialty is iron-gynecologist

      Comment about this article, ask questions, or add new information about this topic:

      Colporrhaphy forum



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      Am J Obstet Gynecol. Author manuscript; available in PMC 2017 Feb 1.
      Published in final edited form as:
      Am J Obstet Gynecol. 2016 Feb; 214(2): 262.e1–262.e7.

      Published online 2015 Sep 11. doi:  [ 10.1016/j.ajog.2015.08.053 ]

      PMCID: PMC4744488
      NIHMSID: NIHMS722593
      PMID: 26366666

      Rates of Colpopexy and Colporrhaphy at the time of Hysterectomy for Prolapse

      Pamela S Fairchild , MD, Neil S Kamdar , MA, Mitchell B Berger , MD, PhD, and Daniel M Morgan , MD

      Pamela S Fairchild

      University of Michigan Female Pelvic Medicine and Reconstructive Surgery

      Find articles by Pamela S Fairchild

      Neil S Kamdar

      University of Michigan Female Pelvic Medicine and Reconstructive Surgery

      Find articles by Neil S Kamdar

      Mitchell B Berger

      University of Michigan Female Pelvic Medicine and Reconstructive Surgery

      Find articles by Mitchell B Berger

      Daniel M Morgan

      University of Michigan Female Pelvic Medicine and Reconstructive Surgery

      Find articles by Daniel M Morgan
      Author information Copyright and License information Disclaimer
      Pamela S Fairchild, University of Michigan Female Pelvic Medicine and Reconstructive Surgery;
      Contributor Information .
      Correspondence: Pamela S Fairchild, L4000 Women’s Hospital, 1500 E. Medical Center Drive, SPC 5276, Ann Arbor, MI 48109-5276, Phone (734) 763-7513, Fax (734) 615-4270, [email protected]
      Copyright notice
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      See other articles in PMC that cite the published article.

      Associated Data

      Supplementary Materials
      NIHMS722593-supplement-Add1.pdf (1.6M)



      It has been shown that addressing apical support at the time of hysterectomy for POP reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse.


      The objectives of this study were to: 1) determine rates of concomitant procedures for pelvic organ prolapse (POP) in hysterectomies performed with POP as an indication, 2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and 3) identify the influence of surgical complexity on perioperative complication rates.

      Study Design

      This is a retrospective cohort study of hysterectomies performed for POP from January 1, 2013 to May 7, 2014 in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications.


      POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% CI 40.6–45.6) of cases, 32.8% (95% CI 30.4–35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI 22–26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age over 40, POP as the only indication for surgery (OR 1.6, 95% CI 1.185–2.230), laparoscopic surgery (OR 3.2, 95% CI 2.860–5.153), and a surgeon specializing in urogynecology (OR 8.2, 95% CI 5.156–12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR 2.3, 95% CI 1.088–4.686), with the use of a colpopexy procedure (OR 3.1, 95% CI 1.840–5.194), and by a surgeon specializing in urogynecology (OR 2.2, 95% CI 1.144–4.315).


      Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study.

      Keywords: apical suspension, colpopexy, colporrhaphy, pelvic organ prolapse, surgical quality measures


      Hysterectomy is the second most common surgical procedure performed on women in the United States 1 . Pelvic organ prolapse (POP) is the most common indication for hysterectomy in postmenopausal women 2 , and is the indication for 14% of hysterectomies in the United States 3 .

      The role of hysterectomy in the treatment of prolapse is controversial and is an area of active investigation. However, it has been shown that addressing apical support at the time of hysterectomy for POP reduces recurrence and reoperation rates 4 . In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP 5 . Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure 4 , 6 and hysterectomy alone is often utilized for treatment of prolapse 7 .

      Our primary objectives were to describe how often concomitant prolapse procedures are used at the time of hysterectomy for POP, to identify those factors associated with use of colporrhaphy and colpopexy (apical suspension) at the time of hysterectomy for POP, and to identify the influence of surgical complexity on perioperative complication rates.

      Materials and Methods

      This is a retrospective analysis of hysterectomies from the Michigan Surgical Quality Collaborative (MSQC). Funded by the Blue Cross Blue Shield of Michigan/Blue Care Network, MSQC consists of 52 hospitals voluntarily collecting perioperative surgical data on a sample of patients, irrespective of a patient’s insurance, for general surgery, vascular surgery, and hysterectomy cases. This represents 30.2% of hospitals in Michigan. Of these hospitals, 19.2% have ≥500 beds and 53.9% are teaching institutions. Hysterectomy-specific data collection began in January 2013. Data collection occurs on a rotating schedule of different days of the week. The first 25 cases meeting the CPT code inclusion criteria at each participating institution during consecutive 8-day cycles throughout the year are selected. Cases are followed for 30 days postoperatively to capture readmissions and complications. Dedicated registered nurses trained in data abstraction collect data from hospital records. Provider speciality is identified by the nurse abstractor at the hospital where the surgery was performed based on personal knowledge of the physicians’ practice. The data collection is standardized and regularly reviewed through site visits, conference calls, and internal audits.

      We reviewed hysterectomies in the database performed from January 1, 2013 through May 7, 2014. The data presented represent all hysterectomy-specific data available at the time of analysis. Inclusion criteria were age greater than 18 years and a preoperative indication of POP in the operative report. Route of hysterectomy was determined with operative note review. Total and subtotal hysterectomies were grouped together based on surgical approach. Robotic-assisted laparoscopic and laparoscopic hysterectomies were both included as laparoscopic approach. Vaginal and laparoscopic-assisted vaginal hysterectomies were considered vaginal approach. Concomitant procedures were determined with Current Procedural Terminology (CPT) codes. CPT codes indicating use of colporrhaphy were the following: 57240 (anterior), 45560 or 57250 (posterior), and 57260 or 57265 (combined anterior and posterior). CPT codes indicating use of colpopexy or apical suspension were the following: 57425 (laparoscopic), 57280 (abdominal), 57282 (extraperitoneal), and 57425 (intraperitoneal). Subjects were stratified based on surgical intervention into three cohorts. In the first group are “hysterectomy only” cases, in which there were no CPT codes for either colporrhaphy or colpopexy. In the second group are “hysterectomy with colpporrphaphy” cases, in which CPT codes for colporrhaphy are present but CPT codes for colpopexy are not. In the third group are “hysterectomy with colpopexy” cases, in which CPT codes for colpopexy are present and those for colporrhaphy may or may not be present. Perioperative complications were identified by chart review. Data abstracters reviewed the patient chart using predetermined definitions to identify the various complications. For example, urinary tract infection was identified when the patient reported symptoms of urinary tract infection in conjunction with a positive urinalysis and/or urine culture. Complications were then classified as either “major” or “minor.” Major complications included deep incisional surgical site infection (SSI), organ/space SSI, pneumonia, unplanned intubation, pulmonary embolism, acute renal failure/insufficiency, stroke, cardiac arrest, myocardial infarction, cardiac arrhythmia, transfusion, deep vein thrombosis, sepsis, clostridium dificil infection, and central line-associated bloodstream infection. Urinary tract infection (UTI) and superficial SSI were considered minor complications. Conversion from planned surgical route was not considered a complication. The Institutional Review Board (IRB) at the University of Michigan deemed analyses regarding this dataset to be exempt from formal IRB approval (HUM00073978).

      Bivariate analyses were used to compare the three patient groups stratified by surgical procedures and to identify variables for the multivariate analyses. Categorical variables were compared with chi-square statistics and ANOVA with Welch adjustment for normally distributed, continuous variables. Non-normally distributed variables were analyzed with nonparametric Kruskal-Wallis Test. Clinically relevant factors also statistically significant in bivariate analysis (P<0.05) were entered into a stepwise multivariable logistic regression algorithm. The outcome variables of interest were 1) use of colpopexy and 2) any perioperative complication. Variables were evaluated for collinearity through correlation analyses. Final models included only significant variables. Model fit was assessed with Hosmer-Lemeshow chi-square tests and C-statistics (shown at the bottom of tables). Analyses were performed using SPSS Version 21.0 (Armonk, NY: IBM Corp) and SAS Version 9.3 (Cary, NC: SAS Institute).


      Among 9860 hysterectomies in the MSQC, POP was listed as a pre-operative indication for 1557 (15.8%) and as the only indication for 878 (8.9%). The indication for surgery was missing for 49 (0.5%). The mean age of women was 56.7 +/− 12.9 years, the mean body mass index (BMI) was 28.9 +/− 6 kg/m2, and the majority of women were white (1369, 87.9%). Physicians identified as obstetrician-gynecologists performed 90.2% of the hysterectomies for prolapse, urogynecologists performed 7.8%, and the remaining 2% were performed by gynecologic oncologists and/or general surgeons. When prolapse was an indication, the most common route of hysterectomy was vaginal or laparoscopic-assisted vaginal (59.6%). Of the remaining cases, 34.1% were robotic-assisted laparoscopic or laparoscopic, and 6.2% were abdominal.

      Figure 1 displays procedures performed at the time of hysterectomy for POP. In 43.1% (95% CI 40.6–45.6) of cases, POP was treated with hysterectomy alone. Hysterectomy with colporrhaphy but without colpopexy was performed in 32.8% (95% CI 30.4–35.1). There were 376 colpopexies (24.1%, 95% CI 22–26.3) performed. Of these, 79 (21%) were extraperitoneal colpopexies, 136 (36.2%) were intraperitoneal colopoexies, and 161 (42.8) were sacral colpopexies. Generalist obstetrician-gynecologists performed a colpopexy in 289 (25.1%) of their cases with POP. In comparison, urogynecologists performed a colpopexy in 87 (71.9%) of their cases. Patients of urogynecologists were older than those of other providers (60.1 versus 56.4 years, p = 0.03), more likely to have POP as the sole indication for their hysterectomy (68.6% versus 55.4%, p = 0.003), and more likely to have an ASA class 3 or greater (31.4% versus 19.9%, p = 0.003), but were no more likely to have prior pelvic surgery (40.5% versus 46.7%, p = 0.113) or abdominal surgery (34.6% versus 36.8%, p = 0.39).

      An external file that holds a picture, illustration, etc.
Object name is nihms722593f1.jpg

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      Figure 1
      Procedures Performed at the Time of Hysterectomy for POP

      Figure 1 displays the number and percentage of women having additional prolapse-directed procedures at the time of hysterectomy for pelvic organ prolapse. Numbers in colored bars represent n for each group and percentage of all hysterectomies performed for pelvic organ prolapse in the MSQC database.

      POP: pelvic organ prolapse

      Comparisons of demographic and perioperative characteristics associated with the three cohorts are shown in Table 1 . Women having hysterectomy alone were younger, had higher BMI, were more likely to be non-white, had higher prevalence of other indications (in addition to POP) for hysterectomy, had lower prevalence of ASA class 3 or greater, had lower prevalence of medicare insurance, and had higher prevalence of prior pelvic surgery. Of the 878 women who had POP as the sole indication for hysterectomy, 290 (33%) had hysterectomy without concomitant procedures and 246 (28%) had a colpopexy. Women who had colporrhaphy at the time of hysterectomy without colpopexy had higher prevalence of vaginal hysterectomy. Those who had colpopexy performed were more likely to have had their procedure done by a urogynecologist, had higher utilization of laparoscopic approach, and had higher rates of concomitant incontinence sling. Compared to other practitioners, urogynecologists were more likely to perform a concomitant sling (10.6% versus 49.6%, P <.0001) and more likely to perform colpopexy (20.1% versus 71.9%, P<.0001). However, urogynecologists were not more likely to report adhesions adding to operative complexity (3.3% versus 2.5%, P=0.6) or perform concomitant salpingoophorectomy (79.5% versus 80.2%, P=0.9).

      Table 1

      Factors Associated with Surgery Performed for POP

      N = 671
      N = 510
      with Colpopexy
      +/− colporrhaphy
      N = 376
      p value
      or Chi-

      Age (years)53.2 ± 1359.6 ± 12.359 ± 12.2<.0001

      BMI (kg/m2)29.4 ± 6.328.4 ± 5.628.6 ± 12.90.021

      Parity2 [2, 3]2 [2, 3]2 [2, 3]0.67

      Non-white race102 (15.2)50 (9.8)36 (9.6)0.004

      ASA class 3–4122 (18.2)109 (21.4)93 (24.7)0.04

      Medicaid49 (7.3)23 (4.5)8 (2.1)
      Medicare139 (20.7)179 (35.1)111 (29.5)
      Medicaid & Medicare7 (1)10 (2)8 (2.1)
      Private Insurance445 (66.3)284 (55.7)213 (56.6)
      Uninsured11 (1.6)3 (0.6)3 (0.8)
      Other20 (3)11 (2.2)33 (8.8)

      Prior pelvic surgery334 (49.8)218 (42.7)167 (44.4)0.04

      Sole indication POP290 (43.2)342 (67.1)246 (65.4)<.0001

      Other indications

      AUB/Leiomyomas274 (40.8)106 (20.8)74 (19.7)<.0001
      Chronic188 (28)74 (14.5)66 (17.6)<.0001

      Other84 (12.5)37 (7.3)30 (8)0.004

      Surgical approach<.0001
        Laparoscopic239 (35.6)94 (18.4)198 (52.7)
        Abdominal74 (11)9 (1.8)14 (3.7)
        Vaginal358 (53.2)406 (79.6)164 (43.6)

      Concomitant sling41 (6.1)56 (11)115 (30.6)<.0001

      Oophorectomy523 (77.9)406 (79.6)310 (82.4)0.2

      Specimen Weight87 [54, 128.5]64.5 [44, 97]67 [45.4, 108]<.00011

      Severe Adhesions25 (3.7)11 (2.2)14 (3.7)0.3

      Surgical Time (hrs)2.1 ± 1.22.1 ± 0.92.7 ± 1.2<.00011

      Urogynecologist25 (3.7)9 (1.8)87 (23.1)<.0001
      Open in a separate window

      Data presented as Mean ± Standard Deviation, n (%) or median [interquartile range]

      1Welch adjustment for non-normal distribution

      BMI: body mass index; POP: pelvic organ prolapse; AUB: abnormal uterine bleeding

      The multivariable regression model with colpopexy as the outcome of interest is presented in Table 2 . Candidate factors entered were age by decile, BMI, non-white race, prior pelvic surgery, urogynecology subspecialist, insurance status, surgical indication, and surgical approach. The model was also controlled for hospital bed size. After these factors were controlled for, age older than 49 years, POP being the sole indication for surgery, use of laparoscopy versus vaginal approach, and a surgeon specializing in urogynecology were independently associated with colpopexy.

      Table 2

      Multivariable Model of Factors Associated with Performance of a Colpopexy at Time of Hysterectomy1,2

      p value


      Hospital Size ≥500 beds Ref: <500 beds1.81121.8541.291–2.6610.61720.18440.0008

      Sole indication POP Ref: multiple indications including POP1.64381.6091.172–2.2100.47590.1619<.0001

      Surgical Approach
      Ref: Vaginal

      Ref: Age <40

      Urogynecologist Ref: all other surgeons10.1568.0165.057–12.7062.08140.2350<.0001
      Open in a separate window

      Variables Entered: Age in Deciles, BMI, Non-white race, Prior Pelvic Surgery, Urogynecology Specialist, Hospital Size, Teaching Status of Institutation, Insurance Status, Indication for Surgery, Surgical Approach

      1Hosmer-Lemeshow Goodness of Fit Test = 0.8257, 9 groups
      2C–Statistic = 0.752;

      The overall complication rate was 6.6%. The rates of major and minor complications were 1.9% and 4.9%, respectively. Postoperative urinary tract infection was the most common complication, affecting 2.8% (n = 43). Postoperative blood transfusions were reported in 1% (n = 17). Complications occurring in less than 1% of cases included superficial surgical site infection (n = 6), organ or space infection (n = 6), pulmonary embolism (n=3), unplanned intubation (n=3), acute renal insufficiency (n=2), myocardial infarction (n=1), cardiac arrhythmia (n=2), deep vein thrombosis (n=2), and sepsis (n=5). Within the 30-day post operative period, there were 48 (3.1%) readmissions, 49 (3.1%) reoperations, and 117 (7.5%) emergency department evaluations.

      Comparisons of complication rates between groups stratified by surgical procedures are presented in Table 3 . We created a multivariable model to predict any perioperative complication (intraoperative and postopereative adverse events, as well as 30-day readmission or reoperation). In the model, performance of colpopexy, urogynecology subspecialist provider, and abdominal surgical approach were associated with increased odds of complication (Table 4). Laparoscopic approach was associated with an increased complication rate when compared to the vaginal approach. Given the unexpected findings that vaginal approach and surgery performed by urogynecologist being associated with an increased complication rate we created a second model looking at any complication other than UTI. Once UTI is excluded, the complication rate of urogynecologists compared to other providers is no longer significant (OR 0.915, 95% CI 0.257–3.263). In addition, laparoscopic approach compared to vaginal approach no longer had a protective effect (OR 1.119, 95% CI 0.5–2.509). Hosmer and Lemeshow test with 7 groups was 0.633 and C statistic was 0.633. Due to the rarity of major perioperative complications, it was not feasible to create a model looking at these more serious adverse events.

      Table 3

      Multivariable Model of Factors Associated with Any Perioperative Complication at Time of Hysterectomy for POP1,2

      95% C.I.Regression
      p value


      Surgical Approach
      Ref: Vaginal
      Laparoscopic0.580.3690.202 –0.674−0.99620.30690.001

      Colpopexy Ref: No Colpopexy2.9442.9091.720–4.9221.06790.2683<.0001

      Urogynecologist Ref: All Other surgeons3.1362.0881.071–4.0730.73640.34090.03
      Open in a separate window

      Variables Entered: Age, Charlson Comorbidity Index, BMI, Concommitant Oophorectomy, Specimen Weight, Severe Adhesions, Surgical Time, Urogynecology Specialist, Surgical Approach, Performance of Apical Suspension

      1Hosmer-Lemeshow Goodness of Fit Test = 0.695; 10 groups
      2C-Statistic = 0.701


      In this study, we found evidence that prolapse procedures at the time of hysterectomy for pelvic organ prolapse were underutilized. One third of cases in which prolapse was the sole indication for surgery had no concomitant prolapse procedures performed. This number increased to 43% when prolapse was one of several indications for surgery. While hysterectomy alone may be appropriate treatment for a small group of women, it is highly unlikely to be sufficient for a group this large. This cohort’s long-term outcome is unknown, but with reported symptomatic recurrent prolapse rates of 20–25% 8 , 9 and reoperation rates as high as 29% 10 , 11 , it is important to evaluate what is happening in clinical practice.

      The relationship between surgeon speciality and the likelihood of undergoing an colpopexy is worthy of comment. Colpopexy was utilized in 24% of cases and urogynecologists were vastly more likely to perform a colpopexy, consistent with prior work by Yurteri-Kaplan, et al 12 . This is a finding that may reflect the training and experience of subspecialists. There is a learning curve in performing the dissections necessary for these procedures and in managing the risk of complications. The risks of ureteral and bladder injury with intraperitoneal colpopexy range from 1 to 5% 13 , while hemorrhage with extraperitoneal colpopexy or sacral colpopexy can be massive and life-threatening. These types of major injuries were extremely rare in our cohort, likely related to the concentration of these procedures in subspecialists’ practices. Our data revealed that the increase in all complications for urogynecologists was related tourinary tract infections—an expected finding given the potential for voiding dysfunction when undertaking additional procedures for prolapse and urinary incontinence. Another unexpected finding was the increased complication rate for vaginal compared to laparoscopic procedures, but again, once UTI was excluded complicaitons were similar between groups. The increased rate of UTI in the vaginal group could be related to increased tissue manipulation around the urethra. Major complications were similar among the groups. Like our study population, Katartzis, et al. noted a statistically-significant higher rate of complications for procedures including colpopexy 14 .

      The rate of colpopexy at the time of hysterectomy we found is consistent with previous reports in the literature. Eilber, et al. reported that 21–26% of hysterectomies for prolapse among Medicare beneficiaries included a colpopexy 4 . In contrast, Alas, et al. 15 and Kantarzis, et al. 14 both reviewed their experiences at a single center and reported that 48% and 55% hysterectomies for POP had concomitant apical procedures. These studies reflect the fact that rates of colpopexy will vary remarkably among hospitals and that subspecialty training is associated with higher rates of utilization.

      Another independent predictor of colpopexy was increasing age. This finding is in agreement with the Kantartzis study, which found that women older than 75 were more likely to have a colpopexy 14 . In our population, older women were also more likely to have surgery with a urogynecology subspecialist. The higher rates of colpopexy among women treated by subspecialists in urogynecology could reflect referral bias, either for more advanced POP or perhaps for increased medical complexity as indicated by the higher proportion of women having ASA class 3 or greater. This finding is particularly interesting given the general concern that younger women are likely at increased risk for symptomatic recurrence and may be the group which would benefit most from appropriate colporrhaphy and colpopexy.

      There are several considerations when assessing this study’s findings. A major strength is the large size of the dataset with dedicated chart abstraction and a formal auditing process to ensure data accuracy. These findings reflect a variety of practices in community and academic centers, making the data more generalizable even though the data is from only one state. It should be noted that the current MSQC sampling methodology is un-weighted and does not directly support estimation of of hysterectomy rates of the target population or total case volume for the target populationat a hospital. With these limitations in mind, hospital bed size was included in the multivariable analysis to account for this potential site variation, we included hospital bed size in the multivariable analysis. The lack of data on severity of POP is also a limitation. For instance, we do not know if urogynecologists were referred more severe cases of prolapse, leading to a higher rate of colpopexy, or whether they were more likely to perform a procedure due to their subspecialty training. Furthermore, though it is widely accepted that hysterectomy alone is not adequate treatement for prolapse, we do not have long-term outcome data for this cohort and cannot determine if women who had hysterectomy alone truly had higher failure rates. Another limitation is the identification of provider specialty, which is based on the provider’s proclaimed specialty status and not board certification status. It is possible that some providers are misclassified; however, their classification reflects their reputation within the community since the nurse abstractors are employed by the hospital and familiar with local practice patterns. A further limitation is the potential for missing data in our complication analsysis. It is possible that some patients sought care for perioperative complications outside of hospitals in the MSQC system. These complications were not captured by the data abstractors and complication rates may be higher than reported.

      This study provides information about current practice patterns in prolapse care in a diverse patient/physician population. While the American Congress of Obstetricians and Gynecologists (ACOG) expressly states that hysterectomy alone is not acceptable treatment for prolapse, 43.1% did not have either colporrhaphy or colpopexy to address pelvic floor laxity. While there are no outcome data for this cohort, these women could be at increased risk for surgical failure and repeat surgery. It is also important to note that while additional surgery may be indicated for many women with POP, it may come at the cost of increased minor perioperative complications. In this analysis, we did not find any significant increase in major complications. Ultimately, the relative risks and benefits of additional surgery and recurrent prolapse should be considered carefully based on particular patient characterics—most importantly, patient goals and specifics of their disease state. In order to best determine how to treat and counsel women with prolapse, data on recurrence with and without colporrhaphy and with and without colpopexy are needed.

      An external file that holds a picture, illustration, etc.
Object name is nihms722593f2.jpg

      Open in a separate window
      Figure 2
      Perioperative Complications Associated with Procedures Performed at the Time of Hysterectomy for Prolapse

      Figure 2 displays percentage of women having perioperative complications at the time of their hysterectomy for prolapse based on types of procedures performed.

      ** P = 0.003, *** P = <.0001, all other P >0.05

      Supplementary Material


      Click here to view. (1.6M, pdf)



      Source of Funding:

      Dr. Berger received funding from BIRCWH grant number: K12 HD001438

      Michigan Surgical Quality Collaborative (MSQC) is supported by funding from Blue Cross/Blue Shield of Michigan


      Publisher’s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

      Conflicts of Interest:

      The authors report no conflict of interest.

      Contributor Information

      Pamela S Fairchild, University of Michigan Female Pelvic Medicine and Reconstructive Surgery.

      Neil S Kamdar, University of Michigan Female Pelvic Medicine and Reconstructive Surgery.

      Mitchell B Berger, University of Michigan Female Pelvic Medicine and Reconstructive Surgery.

      Daniel M Morgan, University of Michigan Female Pelvic Medicine and Reconstructive Surgery.


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