Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele.

OBJECTIVE

This study compared 3 surgical methods of prophylaxis against enterocele formation employed at the time of vaginal hysterectomy.

STUDY DESIGN

One hundred consecutive women undergoing total vaginal hysterectomy for various reasons were randomly assigned to have 1 of 3 surgical methods applied to the posterior superior aspect of the vagina for prophylaxis against enterocele formation. The first procedure involved closing the cul-de-sac and bringing the uterosacral-cardinal complex together in the midline in a vaginal Moschcowitz-type operation. The second procedure was a McCall-type culdeplasty to obliterate the cul-de-sac, plicate the uterosacral-cardinal complex, and elevate any redundant posterior vaginal apex. The third technique used only the peritoneum to close the cul-de-sac, allowing passive movement of the uterosacral-cardinal complex to the midline, no obliteration per se, and no elevation of the posterior vagina. Postoperative findings on pelvic examination were evaluated at 6 weeks, 3 months, and 1, 2, and 3 years. Statistical analysis was performed with the chi2 test of independence.

RESULTS

At 6 weeks' follow-up and at 3 months' follow-up there were no prolapses involving the posterior superior segment of the vagina. At 1 year of follow-up 11 patients had stage 1 or 2 posterior superior segment prolapse. At 2 years' follow-up this number was 16. At 3 years' follow-up the McCall-type method was statistically better (chi2 = 11.27 with 2 degrees of freedom, P =. 004) than the other 2 in preventing postoperative enterocele (n = 2 of 32 with McCall-type procedure, n = 10 of 33 with vaginal Moschcowitz-type procedure, and n = 13 of 33 with peritoneal closure only).

CONCLUSION

When applied at the time of vaginal hysterectomy the McCall-type culdeplasty is superior to a vaginal Moschcowitz-type procedure and to simple peritoneal closure in preventing subsequent enterocele.