Aims of Study
Laparoscopic colposuspension
(LC) remains a controversial technique almost a decade after its development
(1). It is not yet accepted as a first line treatment (2), mainly
due to a lack of objective followup data.
So far, only two randomised controlled series have been published,
both showing LC to be inferior to traditional open colposuspension
(OC), (3,4). For this paper we performed a case control study to compare
the two procedures.
Methods
50 patients who had undergone laparoscopic colposuspension
between 1994 and 1997 were compared to the same number of women seen
previously as part of a longterm followup study of open colposuspension.
The study design included questionnaire, clinical assessment, flowmetry,
pad test and ultrasound imaging for the assessment of bladder neck
position and mobility as well as trigonal deformation. Both procedures
were performed at the same institutions, resulting in similar suture
placement, and all with involvement of the second author (PDW), between 1991 and 1997.
Prior to analysis patients were matched for the five most important
confounding variables, i.e., age at operation, length of followup,
body weight, previous procedures and preop. urodynamic diagnosis (see
table 1). This involved substituting OC patients in pairs until body
weight was well matched without affecting matching for other variables.
All followup assessments were performed by the first author (HPD).
| |
OC |
LC |
p |
| Age at operation |
51.3
(12.2) |
51
(10.4) |
0.699 |
| Length
of followup (yrs) |
3.4
(1.2) |
3.3 (1.2) |
0.466 |
| Body weight (kg) |
73.6 (11.9) |
71.3 (12.4) |
0.565 |
| Prev. inc./prol. procedures |
6/50 |
4/50 |
0.505 |
| Preop. urodynamics |
50 GSI, 1 DI, 1 VD |
50 GSI, 3 DI, 1 VD |
0.400 |
Table 1: Confounding
variables used for matching (n= 50 in both groups) (X2 for qualitative, paired
t-test for quantitative data, standard deviation in parentheses).
Results
Average length of followup was 3.3
years in the laparoscopic and 3.4 years in the open colposuspension
group. Table 2 shows subjective symptoms and the proportion of completely
asymptomatic patients.
| Symptoms
|
OC |
LC |
p
|
| Stress Incontinence |
13 (26%) |
12 (24%) |
n.s. |
| Urge Incontinence |
20
(40%) |
17
(34%) |
n.s. |
| Frequency |
12 (24%) |
4 (8%) |
0.02 |
| Nocturia |
12 (24%) |
4 (8%) |
0.02 |
| Asymptomatic |
15
(30%) |
27 (54%) |
0.03 |
Table 2: Subjective findings
1.5-5.5 years after laparoscopic and open colposusupension (X2
test)
Table 3 demonstrates ultrasound findings.
Laparoscopic colposuspensions showed significantly more bladder
neck descent and less evidence of trigonal distortion.
| US parameters |
OC |
LC |
p |
| Bladder neck position at rest (cm) |
2.74 (.30) |
2.75 (.39) |
n |
| Bladder neck descent on Vals. (cm) |
0.86 (.46) |
1.18 (.64) |
0.005 |
| Urethral rotation on Valsalva (deg) |
18 (11.1) |
22 (13.6) |
n.s. |
| Funnelling (n) |
7 |
11 |
n.s. |
| Colposuspension ridge (n) |
38 |
27 |
0.02 |
| Depth of colposuspension ridge (mm) |
2.1 (1.6) |
2.2 (2.2) |
n.s. |
Table 3: Ultrasound findings
1.5-5.5 years after open and laparoscopic colposuspension
(X2 for qualitative, paired
t-test for quantitative data, standard deviation in parentheses).
Conclusion
This study is limited by the fact
that it is not a randomised controlled trial. However, as is evident
from the presented data, both groups were well matched for the tested
parameters. The results show nonsignificant differences in stress
and urge incontinence 1.5- 5.5 years after open and laparoscopic colposuspension,
with significantly less frequency and nocturia in the laparoscopic
group. Significantly more patients were completely asymptomatic after
LC. On ultrasound imaging OC appeared to more commonly result in permanent
distortion of the trigone (colposuspension ridge), with significantly
less bladder neck descent on Valsalva.
The data presented here is not consistent
with the two published randomised controlled trials (Burton, 1999,
Su, 1997) in that the success rate of our OC patients was relatively
low, resulting in a more balanced comparison with LC. Consequently
it appears from our data that, in the population assessed here, laparoscopic
colposuspension is a valid alternative to the traditional open procedure.
Less obvious elevation and distortion of the trigonal area does not
seem to be associated with faster recurrence of stress incontinence
at a mean followup of 3.3 years.
Literature
1
J.Laparoendosc.Surg. 1(3):169-173,
1991.
2 Incontinence:
First international consultation on Incontinence. Plymouth:Health
Publications Ltd, 1999,p. 637-656.
3
Int.Urogynecol.J 10:S44-S45,
1999. (Abstract)
4 Acta Obstet.Gynecol.Scand. 76(6):576-582, 1997.
