One traditional teaching in pelvic organ prolapse repair requires concomitant anterior and posterior compartment repair in the setting of isolated compartment prolapse (DeLancey level 2) due to the presumption that fixing one compartment in isolation could lead to development of prolapse in the opposite compartment.  Literature supporting this practice is sparse.  Some have noted that over-correction, and not simply repair, can lead to posterior compartment prolapse.  This suggests certain repairs may be less prone to cause posterior compartment prolapse.  We sought to test this traditional teaching and determine the rate of de-novo posterior compartment prolapse following a native tissue repair known as anterior vaginal wall suspension (AVWS) to repair the anterior compartment without over-correction.  Native tissue repairs have been noted to have more anterior compartment recurrences than repairs employing polypropylene mesh overlay techniques (RR 3.0, or estimated 32-45% failure rate for native tissue based on meta analysis of 16 RCTs) but the price of this improved anatomic result comes with more morbidity, with native tissue repairs having a LOWER re-operation rate for incontinence, pain, and mesh exposure (RR 0.59, based on meta analysis of 12 RCTs by Maher, Feiner et al. 2016).  This has caused a renewed enthusiasm for native tissue repairs for the woman suffering from isolated anterior compartment prolapse.  Isolated anterior repair for Delancey level 2 prolapse is the gold standard, classically plicating tissue for a central defect, or utilizing Arcus Tendineous Fascia Pelvis laterally as an anchor for lateral defect.  The AVWS technique utilizes a retropubic suspension to enlist further support from the rectus abdominus fascia, similar to McGuire’s Pubovaginal sling or Raz 4-corner suspension (Raz, Klutke et al. 1989).   Unlike these well known procedures, however, the AVWS takes 4 “corner” bites of the entire anterior vaginal wall, with sutures overlapping in the midline, so that the entire anterior vaginal wall becomes the support structure, not just the bladder neck or mid-urethra(Coskun, Lavelle et al. 2014).   The hypothesis is that following an isolated anterior compartment repair the posterior compartment should NOT demonstrate any change in Bp, the distal-most extent of the posterior compartment using the Pelvic Organ Prolapse Quantification (POP-Q) system. Moreover, validated metrics for patient reported outcomes including incontinence, prolapse, and quality of life should improve following isolated anterior compartment repair.

After approval by the Institutional Review Board for protection of Human Subjects, a prospectively collected registry was examined to obtain a cohort of patients who presented with anterior compartment prolapse (POP-Q stage 2 or 3, Delancey level 2) without apical compartment prolapse (Delancey 1).  The study qualified for Waiver of informed consent.  These patients underwent AVWS with or without concurrent urethral sling.  The technique has been described previously (Coskun, Lavelle et al. 2014).  Patients were excluded who underwent concomitant posterior compartment repair or apical compartment repair. Paired t-test was employed to match a particular patient’s preoperative status with the post-operative status assessed during follow up. The primary outcomes were mean change in Bp and development of posterior prolapse as defined by a Bp≥0.   All repairs were native tissue repairs without mesh.  Outcomes included POP-Q score by physical exam, Urogenital Distress Inventory -6 (UDI-6), Likert Quality-of-Life scale, and Incontinence Impact Questionnaire-7 (IIQ-7) (Harvey, Kristjansson et al. 2001).

Eighty-four patients were enrolled in a prospectively collected database, each of whom underwent AVWS.  Preoperative characteristics are shown in Table 1.  Fifty-six patients were identified for inclusion meeting the criteria described in the Methods section,  with mean(SD) age 57.6(13.5) and BMI 28.9(5.3).  Thirty (53.6%) had a history of prior hysterectomy.  Eighteen (32.1%) underwent concomitant sling.  Mean(SD) pre-operative Bp was -1.6 (0.95) and Ap was -2.1(0.59).   Mean(SD) post-operative Bp was -1.7(1.1) and Ap was -2.1(1.0).  Mean(SD) change in Bp was -0.13 (1.1)(p>0.05).  Three (5.4%) patients developed Bp≥0 whose pre-operative Bp was<0.  Only one patient desired intervention for the new posterior prolapse (1.8%).  Three patients began with Bp 0 that chose not to undergo posterior repair at the time of AVWS, and were noted to have Bp 0 after surgery but remained asymptomatic. These patients had requested no posterior repair be undertaken when deciding to undergo anterior repair.   Mean(SD) follow-up was 9.4(3.7-16.9) months.
With respect to anterior compartment prolapse, 7/84 (8%) patients developed recurrence anteriorly, while 2/84 (2.4%) failed at the apex. 
Complications included one abscess along the suture tract requiring incision and drainage (Clavien 3), one suture perforation of the bladder requiring cystoscopic removal (Clavien 3), one suture erosion through the anterior vaginal wall managed with in-office excision.

Paired results did not demonstrate a change in the posterior compartment following isolated anterior compartment repair on a per-patient analysis.  It was expected that if isolated anterior compartment repair altered the vaginal axis in such a way to cause posterior compartment prolapse this would be seen early in follow up, when analyzed on a patient-by-patient basis (Paired t-test). It is still possible over-correction using the same technique might predispose to posterior compartment prolapse, but when performed as described by Coskun et. al. it it does not appear to. The follow up period is short, but outcomes in this prospective registry will be followed for five years to determine if this could occur in a delayed fashion.

Isolated anterior compartment repair does not appear to promote posterior compartment prolapse.  It is important to note that these are short term results.  The majority of patients with isolated anterior prolapse can be managed with selective correction of only the anterior compartment without risk to the posterior compartment.  Patients can be counseled of a 5% risk of posterior compartment prolapse when AVWS is performed as the anterior repair.

Coskun, B., R. S. Lavelle, F. Alhalabi, A. L. Christie and P. E. Zimmern (2014). "Anterior vaginal wall suspension procedure for moderate bladder and uterine prolapse as a method of uterine preservation." J Urol 192(5): 1461-1467.
Harvey, M. A., B. Kristjansson, D. Griffith and E. Versi (2001). "The Incontinence Impact Questionnaire and the Urogenital Distress Inventory: a revisit of their validity in women without a urodynamic diagnosis." Am J Obstet Gynecol 185(1): 25-31.
Raz, S., C. G. Klutke and J. Golomb (1989). "Four-corner bladder and urethral suspension for moderate cystocele." J Urol 142(3): 712-715.