Can levator avulsion be repaired surgically? A prospective surgical pilot study

Introduction and hypothesis: Avulsion of the puborectalis muscle from its bony insertion is common in women presenting with prolapse. We present a simple vaginal technique for levator reconstruction. Methods: This is a prospective surgical pilot study comprising 17 patients enrolled to undergo levator repair in the context of prolapse surgery. This was performed through a lateral colpotomy at the level of the hymen using a mesh patch for reinforcement. Results: We performed 20 levator repairs in 17 women (three bilateral). There were no intraoperative complications. Recovery was unremarkable in all cases. Results are given for a mean follow-up of 1.3 years. Most (13/17, 76 %) women were satisfied with the outcome. Six patients complained of symptoms of recurrent prolapse, three of de novo dyspareunia, and four of pain related to the repair site on palpation. There were two mesh erosions, one of which healed with oestrogen treatment. Prolapse recurrence beyond the hymen was observed in five patients. The mean hiatal area on Valsalva was reduced from 36.84 cm ² to 30.71 cm² (P = 0.001). Conclusions: Direct surgical repair of a levator avulsion is feasible at the time of prolapse surgery. However, its effect on prolapse recurrence and hiatal dimensions is relatively disappointing, suggesting that there often is microscopic trauma and functional muscle impairment in addition to the avulsion.