Abstract
Aim: was to improve unsatisfactory results of primary surgery for middle pelvic compartment prolapse with its gradual development in the total pelvic organ prolapse.

Material of study: Study group consisted of 17 patients who underwent various corrective operations using their own tissues from the vaginal access for pelvic prolapse in the area of the middle segment of the pelvis: uterine prolapse or vaginal prolapse after hysterectomy. Of these, the previous hysterectomy for uterine prolapse was performed in 7 patients. In terms of 6.5±0.8 years after the primary surgical treatment, they had a repeated combined pelvic prolapse, including prolapse of the uterus or vaginal apex after hysterectomy, i.e. a relapse of the "middle prolapse", as well as a newly developed pelvic prolapse in the area of the posterior segment of the pelvis: rectal prolapse, rectocele of the III degree, perineum descenfence and prolapse in the anterior segment of the pelvis: urethro-vesical segment or bladder. Re-surgery consisted of combined anterior and posterior abdominal sacrocolporectopexy using synthetic grafts and was combined with the Burch urethral suspension technique for the prevention and correction of stress urinary incontinence.

Results: 12 months after the operation, a clinical study, ultrasound and MRI showed correction of anterior and middle prolapse, while no patients reported stress urinary incontinence. The position of the leading points of the prolapse in the POP-Q system showed that all patients achieved its 0-I degree. Data on the posterior pelvic compartment were confirmed by a digital examination of the rectum, which did not reveal a rectocele of more than I degree in any patient. According to MRI data, there was a correction of the position of the uterus and the vaginal apex in patients with previous hysterectomy, and their displacement during straining did not exceed 1 cm. All patients noted a decrease in the severity of obstructive defecation. According to defecography the level of the perineal position rose from -6.2±0.4 cm to -2.6±0.3 cm (P=0.000) at rest and from -8.9±0.6 cm to -5.7±0.5 cm (P=0.000) when straining. The values of the posterior anorectal angle decreased from 136.7 ° ±5.4 ° to 105.2 ° ±3.5 ° (P=0.000) at rest and from 171.1 ° ±5.3 ° to 142.7 ° ±4.8 ° (P=0.000) when straining. The barium evacuation rate increased from 2.9±0.4 g / sec to 5.1±0.5 g / sec (P=0.001). The percentage of barium suspension remaining after evacuation decreased from 40.3±5.7% to 19.9±3.8% (P=0.005). According to anorectal manometry there was a decrease in the sensitivity threshold from 32.9±1.7 ml to 26.2±1.3 ml (P=0.004); a decrease in the threshold of maximum tolerable distention from 85.3±2.2 ml to 76.2±1.8 ml (P=0.003); a decrease in the amplitude of the recto-anal inhibitory reflex from 49.6±5.8 mm Hg. up to 35.2±4.9 mmHg (P=0.067) and its duration from 29.9±6.1 seconds to 16.8±2.7 seconds (P=0.055). There was also an improvement in the function of fecal continence. The resting pressure in the area of the internal anal sphincter increased from 42.5±4.5 mm Hg up to 57.3±5.1 mm Hg (P=0.092); in the area of the external anal sphincter from 34.6±4.1 mm Hg up to 46.4±4.2 mmHg (P=0.053).

Conclusions: Satisfactory anatomical and functional results were achieved in patients with repeated total pelvic prolapse by performing combined abdominal sacrocolporectopexy using synthetic grafts.

Key words: Repeated pelvic prolapse, re-surgery, sacrocolporectopexy, MRI, defecography, anorectal manometry