Study Subjects
Thirty-five patients underwent gynecological surgery at Peking University Third Hospital between February 2022 and October 2022. All patients provided written informed consent before participating in the study. This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Research Ethics Committee of Peking University Third Hospital (NO: IRB00006761-M2022853).
Inclusion Criteria:
(1) Patients diagnosed with symptomatic stage III-IV (POP-Q staging) anterior vaginal wall prolapse, who have chosen to undergo transvaginal anterior wall repair with autologous fascia lata after reviewing educational materials and engaging in thorough patient-doctor communication.
(2) Concurrent uterine prolapse or posterior vaginal wall prolapse may also be present.
Exclusion Criteria:
(1) History of previous pelvic organ prolapse surgery.
(2) Diagnosis of malignant tumors during or after surgery.
Preoperative Preparation
All patients were evaluated by a urogynecologist, including POP-Q staging and PFDI-20 questionnaire[13]. In addition to routine preoperative examinations, lower limb venous ultrasound was also required. Three days prior to surgery, patients were instructed to take potassium permanganate sitz baths, and their vaginas were irrigated twice daily with 5% chlorhexidine solution two days before surgery.
Surgical Procedure
1. Fascia Lata Harvest
After induction of general anesthesia, the patient is positioned in a supine posture. If there is no history of prior surgery on the right thigh, the right thigh is preferred. After routine disinfection and draping procedures, the area for harvesting fascia lata is delineated (Fig. 1A). The upper boundary is marked along the line connecting the anterior superior iliac spine to the lateral tibial condyle, and the lower boundary along the line connecting the greater trochanter to the lateral tibial condyle. The incision is marked 10cm above the lateral tibial condyle, perpendicular to the longitudinal axis of the thigh, and an skin incision approximately 3cm in length is made (Fig. 1B). A stripper (Fig. 1C) was used to harvest the fascia measuring 12-14cm in length, and 1-1.5cm and 2-2.5cm in width respectively (Fig. 1D). The ends of the first thin fascia strip are sutured with 2 − 0 non-absorbable sutures (Ethibond®, Ethicon, USA) for obturator puncture. The wound is closed routinely, and the harvest site is compressed with an elastic bandage.
2. Fascia Lata Augmentation of the Anterior Vaginal Wall
After performing a vaginal hysterectomy and high sacrospinous ligament suspension, the suspension sutures on both sides of the sacrospinous ligament are preserved. The vesicovaginal space is opened, with dissection extending distally to 3cm below the bladder neck and laterally to the posterior of the pubic rami. A purse-string suture using 2 − 0 absorbable sutures is applied to the fascia overlying the prolapsed bladder. Puncture points are marked at the level of the urethral orifice intersects with the genital fold on both sides. The first thin fascia strip is guided through the obturator puncture tool from outside to inside. The second fascia strip is placed centrally over the first strip, folded in half to form a sheet, and laid over the vesicovaginal space (Fig. 2A-2D). After fixation of the fascia strips, and the proximal end is sutured to the vaginal stump, then suspended together to the high sacrospinous ligament.
Postoperative Management
On the first day after surgery, patients are encouraged to start moving and perform ankle pump exercises. For high-risk patients, heparin is given 24 hours postoperatively to prevent thrombosis. On the second or third day after surgery, the iodine gauze strips in the vagina are removed, the urinary catheter is removed, and the residual urine volume is measured. Routine postoperative care includes the administration of antibiotics to prevent infection and pain management. The elastic bandages on the lower limbs are taken off one week after surgery. Sutures on the vulva and thigh are removed two weeks after surgery.
Statistical Data and Follow-up
1. General Information:
Age, Body Mass Index (BMI), parity, menopausal status, history of hysterectomy, medical comorbidities, proportion of high-risk factors for pelvic organ prolapse (e.g., delivering a large baby, chronic constipation, or coughing, heavy physical labor, more than two deliveries), the duration of prolapse. preoperative POP-Q staging and PFDI-20 questionnaire results.
2. Perioperative Data:
Duration of fascia harvesting surgery and pelvic floor reconstruction surgery, blood loss, blood transfusion, intraoperative complications, 24-hours post-surgery thigh pain, urinary catheter retention days, urinary retention, and postoperative hospital stay.
3. Follow-up:
Outpatient follow-up at 2 months post-surgery, with additional follow-ups at 6 months, 1 year, and annually thereafter via outpatient visits or telephone.
Follow-up Content Includes:
1. Subjective Recurrence Symptoms: Whether the patient experiences a bulge at the vaginal opening.
2.POP-Q Staging for Outpatient Follow-up Patients,objective recurrence: Aa>0 or Ba>0.
3. PFDI-20 Questionnaire.
4. Patient Satisfaction: Very satisfied, Satisfied, Unsure, Dissatisfied, Very dissatisfied.
5. Patient PGI-I Score[12]: ①. very much improved, ②. improved, ③. little improved, ④. no change, ⑤. slightly worse, ⑥. worse, ⑦. very much worse.
6. Whether the Patient Regrets Choosing This Surgery.
7. Willingness to Recommend This Surgery to Others.
8. Postoperative Complications:
The classification of complications involving augmented grafts using the Native Tissue Surgery Complications (CTS) classification, and the Clavien-Dindo classification[14].
9. Harvesting site: Whether it affects appearance, whether it is paresthesia, and whether there is any thigh bulge.
10. Postoperative Sexual Activity:
Whether the patient has engaged in sexual activity postoperatively, and whether there are any difficulties or discomfort during sexual activity.
Statistical Methods
Statistical analysis was performed using SPSS Version 26.0 (IBM, Armonk, NY, USA). Continuous variables were summarized using means and medians. The analysis of continuous variables was conducted using the t-test. Categorical variables were summarized using frequencies and percentages. The analysis of categorical variables was conducted using the chi-square test. A P < 0.05 was considered statistically significant.