Operations and Pelvic Muscle Training in the Management of Apical Support Loss: The OPTIMAL Trial

Status:	Completed
Conditions:	Women's Studies
Therapuetic Areas:	Reproductive
Healthy:	No
Age Range:	18 - Any
Updated:	5/4/2018
Start Date:	February 2008
End Date:	July 2013

Operations and Pelvic Muscle Training in the Management of Apical Support Loss: The OPTIMAL Trial: A Randomized Trial of Sacrospinous Ligament Fixation (SSLF) Versus Uterosacral Ligament Suspension (ULS) With and Without Perioperative Behavioral Therapy/Pelvic Muscle Training

Pelvic organ prolapse is common among women with a prevalence that has been estimated to be
as high as 30%. Pelvic organ prolapse often involves a combination of support defects
involving the anterior, posterior and/or apical vaginal segments. While the anterior vaginal
wall is the segment most likely to demonstrate recurrent prolapse after reconstructive
surgery, reoperations are highest among those who require apical suspension procedures with
or without repair of other vaginal segments (12%-33%). Despite the substantial health impact,
there is a paucity of high quality evidence to support different practices in the management
of prolapse, particularly surgery. Thus, the objectives of the Operations and Pelvic Muscle
Training in the Management of Apical Support Loss (OPTIMAL) Trial are:

1. to compare sacrospinous ligament fixation (SSLF) to uterosacral vaginal vault ligament
suspension (ULS); and

2. to assess the role of perioperative behavioral therapy/pelvic muscle training (PMT) in
women undergoing vaginal surgery for apical or uterine prolapse and stress urinary
incontinence.

Inclusion Criteria:

- Stage 2 to 4 prolapse

- Prolapse of the vaginal apex or cervix to at least half way into the vaginal canal
(POPQ Point C > -TVL/2)

- Vaginal bulge symptoms as indicated by an affirmative response to either questions on
the PFDI

- Vaginal surgery for prolapse is planned, including a vaginal apical suspension
procedure.

- Stress incontinence symptoms as indicated by an affirmative response to the PFDI
Stress incontinence subscale

- Documentation of transurethral stress leakage on an office stress test or urodynamics
with or without prolapse reduction within the previous 12 months

- A TVT is planned to treat stress urinary incontinence.

- A PMT visit can be performed at least 2 weeks and not more than 4 weeks before
surgery.

- Available for 24-months of follow-up.

- Able to complete study assessments, per clinician judgment

- Able and willing to provide written informed consent

Exclusion Criteria:

- Contraindication to SSLF, ULS, or TVT in the opinion of the treating surgeon.

- History of previous surgery that included a SSLF or ULS. (Previous vaginal vault
suspensions using other techniques or in which the previous technique is unknown are
eligible.)

- Pelvic pain or dyspareunia due to levator ani spasm that would preclude a PMT program.

- History of previous synthetic sling procedure for stress incontinence.

- Previous adverse reaction to synthetic mesh.

- Urethral diverticulum, current or previous (i.e., repaired)

- History of femoral to femoral bypass.

- Current cytotoxic chemotherapy or current or history of pelvic radiation therapy.

- History of two inpatient hospitalizations for medical comorbidities in the previous 12
months.

- Subject wishes to retain her uterus. [Both ULS and SLS include removal of the uterus,
if not previously removed]

We found this trial at

sites

Loyola University Medical Center

2160 South 1st Avenue
Maywood, Illinois 60153

(888) 584-7888