Tension-free vaginal mesh repair for anterior vaginal wall prolapse

OBJECTIVES: We determined the efficacy of the use of a tension free prolene mesh to correct a grade III anterior vaginal wall prolapse recurrence. METHODS: Twelve women (mean age 65.6 years) with stress urinary incontinence (SUI) (4 type II and 1 type III) and bladder prolapse entered the study. After vaginal incision a pretailored polypropylene mesh was fixed to its four angles by absorbable sutures to the urethropelvic ligaments and pubocervical fascia anteriorly and to the cardinal ligaments and pubocervical fascia posteriorly. When present, a posterior descensus was corrected during the same procedure. SUI was treated with the tension-free vaginal tape procedure (TVT) through a separate vaginal incision over the mid-urethra. RESULTS: All patients were available for postoperative pelvic examination at 3-month intervals, for a mean follow-up of 20.5 months (range 15-32). Nine patients were considered cured (no cystocele recurrence) while in 3 patients a grade 1 asymptomatic cystocele was present postoperatively (asymptomatic). No significant postoperative pain was reported by the patients. CONCLUSIONS: This study confirms that in patients with moderate cystocele a tension-free mesh to support bladder base and neck effectively treats the cystocele. It is particularly recommended in the treatment of previous failure with traditional techniques and when the quality of suspending tissue is poor or defective. A long-term study on a large number of patients is still warranted to confirm and validate its clinical use.     

Biomesh (Pelvicol®) erosion following repair of anterior vaginal wall prolapse

Sparse information is available regarding erosion following biomesh implantation. We report two cases of erosion following anterior vaginal wall repair. In both cases, the operation was performed as a standard cystocele repair where the collagen Pelvicol® mesh was anchored to the pubocervical fascia. Both patients had signs of erosion shortly after the operation, and both had the mesh removed. In one patient, the vaginal epithelium healed spontaneously, whereas the other patient had a delayed healing process. The graft was rejected due to intolerance to the biomesh or an infection. Our study shows that an erosion following implantation of a biomesh may be complicated.     

Long-term outcomes of vaginal mesh versus native tissue repair for anterior vaginal wall prolapse

Introduction and hypothesis

To estimate the risk of repeat surgery for recurrent prolapse or mesh removal after vaginal mesh versus native tissue repair for anterior vaginal wall prolapse.

Methods

We utilized longitudinal, adjudicated, healthcare claims from 2005 to 2010 to identify women ≥18 years who underwent an anterior colporrhaphy (CPT 57420) with or without concurrent vaginal mesh (CPT 57267). The primary outcome was repeat surgery for anterior or apical prolapse or for mesh removal/revision; these outcomes were also analyzed separately. We utilized Kaplan–Meier curves to estimate the cumulative risk of each outcome after vaginal mesh versus native tissue repair. Cox proportional hazards models were used to estimate the hazard ratio (HR) for vaginal mesh versus native tissue repair, adjusted for age, concurrent hysterectomy, and concurrent or recent sling.

Results

We identified 27,809 anterior prolapse surgeries with 49,658 person-years of follow-up. Of those, 6,871 (24.7%) included vaginal mesh. The 5-year cumulative risk of any repeat surgery was significantly higher for vaginal mesh versus native tissue (15.2 % vs 9.8 %, p?<0.0001) with a 5-year risk of mesh revision/removal of 5.9%. The 5-year risk of surgery for recurrent prolapse was similar between vaginal mesh and native tissue groups (10.4 % vs 9.3 %, p?=?0.70. The results of the adjusted Cox model were similar (HR 0.93, 95%CI: 0.83, 1.05).

Conclusions

The use of mesh for anterior prolapse was associated with an increased risk of any repeat surgery, which was driven by surgery for mesh removal. Native tissue and vaginal mesh surgery had similar 5-year risks for surgery for recurrent prolapse.     

Surgical management of anterior vaginal wall prolapse: an evidencebased literature review

The aim of this review is to summarize the available literature on surgical management of anterior vaginal wall prolapse. A Medline search from 1966 to 2004 and a hand-search of conference proceedings of the International Continence Society and International Urogynecological Association from 2001 to 2004 were performed. The success rates for the anterior colporrhaphy vary widely between 37 and 100%. Augmentation with absorbable mesh (polyglactin) significantly increases the success rate for anterior vaginal wall prolapse. Abdominal sacrocolpopexy combined with paravaginal repair significantly reduced the risk for further cystocele surgery compared to anterior colporrhaphy and sacrospinous colpopexy. The abdominal and vaginal paravaginal repair have success rates between 76 and 100%, however, no randomized trials have been performed. There is currently no evidence to recommend the routine use of any graft in primary repairs, and possible improved anatomical out-comes have to be tempered againstcomplications including mesh erosions, infections and dyspareunia.     

SIS graft for anterior vaginal wall prolapse repair—a case-controlled study

The purpose of this study was to assess the effect on quality of life and prolapse severity of traditional anterior repair compared to anterior repair with a small intestine submucosa (SIS) graft. This report was designed as a case-control study. The sample of this study consisted of 14 women who underwent traditional anterior repair and 14 women who underwent anterior repair with SIS graft (SG) at a London teaching hospital. All women were assessed preoperatively and at 6 and 24 months postoperatively using a validated prolapse quality of life questionnaire and pelvic organ quantification system (POP-Q). Quality-of-life outcomes included the following: (1) General health perception, (2) Prolapse impact, (3) Role limitations, (4) Physical limitations, (5) Social limitations, (6) Personal relationships, (7) Emotions, (8) Sleep/Energy, and (9) Severity measures. The pelvic organ quantification measurement measured nine specific points relating to the anterior and posterior wall of the vagina, vaginal apex, genital hiatus (GH) and perineal body (PB). At 6-month follow-up, the SG repair group showed significant improvement in all quality-of-life parameters measured. In comparison to traditional repair, it was significantly better in improving role limitations, physical limitations and emotions. Both operations significantly improved prolapse quality-of-life severity measures. SG repair improved all POP-Q measurements significantly, except total vaginal length (TVL), whereas traditional repair improved some measurements (AA, midline point of anterior vaginal wall 3 cm proximal to the external urethral meatus; BA, most distal dependant position of the anterior vaginal wall from the vaginal vault or anterior fornix to AA; C, most distal/dependant edge of cervix or vault; AP, point on midline posterior vaginal wall 3 cm proximal to hymenal ring; BP, most distal/dependant point on the posterior vaginal wall from vault or posterior fornix to AP) but not others (location of posterior fornix (D), TVL, GH and PB). At 2-year follow-up, there was no significant difference between the two groups in terms of quality-of-life outcomes or prolapse severity measurements. Surgery for vaginal prolapse results in marked improvement in quality of life and prolapse severity. The greater improvement seen initially in the SG anterior group was not seen at 2-year follow-up.     

Fibulin-5 expression is decreased in women with anterior vaginal wall prolapse

The aim of this study was to compare fibulin-5 expression in women with and without anterior vaginal wall prolapse. Vaginal tissues were sampled in a standardized fashion from women with (n = 12) or without (n = 10) anterior vaginal wall prolapse. Quantitative real-time polymerase chain reaction was performed to measure mRNA levels of fibulin-5 (FIB-5). FIB-5 protein expression was assessed by immunohistochemistry. There were no significant differences in demographic data between the two groups. FIB-5 mRNA expression was significantly decreased in women with anterior vaginal wall prolapse compared to women without prolapse [(FIB-5 mean ± SD mRNA expression in relative units) 0.01 ± 0.01 vs. 0.09 ± 0.14, P = 0.04]. Fibulin-5 staining intensity was diminished in women with prolapse compared to women without prolapse [intensity score, median (range), 1 (1–2) vs. 3 (2–3), P = 0.04]. Fibulin-5 expression is decreased in vaginal biopsies from women with prolapse. Changes in fibulin expression may play a role in the development of pelvic organ prolapse.     

腹腔镜下阴道残端腹壁悬吊术联合阴道前后壁修补术治疗重度子宫脱垂的疗效观察

目的:探讨腹腔镜下阴道残端腹壁悬吊术联合阴道前后壁修补术治疗重度子宫脱垂的临床效果.方法:回顾分析2017年12月至2019年12月63例重度子宫脱垂(Ⅲ度)患者的手术资料,其中30例行阴道前后壁修补术(A组),33例行腹腔镜下阴道残端腹壁悬吊术联合阴道前后壁修补术(B组).对比分析两组手术指标、不同时点阴道残端水平、...     

Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse?

This study aims to evaluate the changes of overactive bladder symptoms to anterior vaginal wall prolapse repair. Ninety-three consecutive women with symptomatic anterior vaginal wall prolapse ≥ stage II and coexistent overactive bladder symptoms were prospectively studied using a urinalysis, urodynamics, King’s Health Questionnaire (KHQ), Prolapse Quality of Life (P-QOL) questionnaire and pelvic organ prolapse quantification (POP-Q) system before and 1 year after surgery. All women underwent a standard fascial anterior repair. Postoperatively, urinary frequency, urgency and urge incontinence disappeared in 60, 70 and 82% of women respectively (p value < 0.001). The vaginal examination findings as well as the quality of life of the women assessed using KHQ and P-QOL significantly improved after surgery (p value < 0.001). This study has demonstrated that anterior vaginal repair does produce significant improvement in overactive bladder symptoms. A larger longer-term study is required to assess if these changes persist over time.     

阴道前后壁修补术联合阴式子宫全切术治疗中重度子宫脱垂的疗效

目的探究阴道前后壁修补术联合阴式子宫全切术治疗中重度子宫脱垂的疗效及其对性功能的影响。 方法选择芜湖市第五人民医院妇产科自2014年8月至2018年8月收治的中重度子宫脱垂患者60例,随机分为观察组与对照组,每组各30例。观察组行阴式全子宫切除术加阴道前后壁修补术治疗,对照组行单纯阴道前后壁修补术治疗,对比2组围手术期临床指标、术后并发症发生率及复发情况,采用盆腔器官脱垂/尿失禁性功能问卷（PISQ-12）对比2组术前、术后随访6个月的性功能变化情况。 结果观察组平均手术时间、肛门排气时间、住院天数明显短于对照组,观察组术中出血量少于对照组,差异有统计学意义（P<0.05）;观察组术后并发症发生率与对照组差异无统计学意义（P>0.05）;观察组的治愈率为90.00%,好转率为10.00%,高于对照组的80.00%、3.33%,观察组无复发者,对照组复发率为16.67%,差异均有统计学意义（P<0.05）;术后随访6个月后观察组PISQ-12评分为（35.12±3.37）分,低于对照组（38.83±5.62）分,差异有统计学意义（P<0.05）。 结论阴式全子宫切除术联合阴道前后壁修补术治疗中重度子宫脱垂的临床效果较理想,与单纯阴式子宫切除术相比可显著缩短手术时间较短,减少术中出血,提高手术疗效,降低术后复发率,但在改善术后性功能方面并不具有优势。     

Surgery for posterior vaginal wall prolapse

Introduction and hypothesis

The aim was to review the safety and efficacy of surgery for posterior vaginal wall prolapse.

Methods

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence? from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

Results

Level 1 and 2 evidence suggest that midline plication posterior repair without levatorplasty might have superior objective outcomes compared with site-specific posterior reopair (grade B). Higher dyspareunia rates are reported when levatorplasty is employed (grade C). The transvaginal approach is superior to the transanal approach for repair of posterior wall prolapse (grade A). To date, no studies have shown any benefit of mesh overlay or augmentation of a suture repair for posterior vaginal wall prolapse (grade B). While modified abdominal sacrocolpopexy results have been reported, data on how these results would compare with traditional transvaginal repair of posterior vaginal wall prolapse are lacking.

Conclusion

Midline fascial plication without levatorplasty is the procedure of choice for posterior compartment prolapse. No evidence supports the use of polypropylene mesh or biological graft in posterior vaginal compartment prolapse surgery.     

阴式子宫切除术联合阴道前后壁修补术对子宫脱垂合并阴道壁膨出患者术后疼痛及复发的影响

目的探讨阴式子宫切除术联合阴道前后壁修补术对子宫脱垂合并阴道壁膨出患者术后疼痛及复发的影响。 方法选取2017年1月到2019年1月,安徽省马鞍山市中心医院收治的90例子宫脱垂合并阴道壁膨出患者。采用随机数字表法将其分为对照组和观察组。对照组45例采用单纯阴道前后壁修补术进行治疗,观察组45例采用阴式子宫切除术联合阴道前后壁修补术进行治疗,2组术后随访1年。比较2组治疗后的临床疗效及手术前后视觉模拟评分（VAS）;统计2组围手术期手术相关指标及并发症发生率和随访1年的复发率。采用SPSS 21.0统计软件进行数据分析。 结果观察组总有效率为93.33%,显著高于对照组的71.11%,差异有统计学意义（P<0.05）。与手术前相比,术后3～7 d,2组VAS评分均呈逐渐降低趋势,且术后3、7 d观察组显著低于对照组,差异有统计学意义（P<0.05）。与对照组相比,观察组术中出血量明显较少,差异有统计学意义（P<0.05）;观察组的住院时间、肛门排气时间、手术时间等明显较短,差异有统计学意义（P<0.05）。观察组并发症发生率、随访1年复发率分别为6.67%、2.22%,显著低于对照组的26.67%、24.44%,差异有统计学意义（P<0.05）。 结论阴式子宫切除术联合阴道前后壁修补术治疗子宫脱垂合并阴道壁膨出,可显著改善患者围手术期相关指标的情况,减轻患者术后疼痛,并能降低患者并发症发生率及术后复发率,临床疗效显著。     

Pessary reduction and postoperative cure of retention in women with anterior vaginal wall prolapse

This study aimed to determine whether preoperative pessary reduction of anterior vaginal wall prolapse in patients with elevated postvoid residual (PVR) volumes relieves urinary retention, and if reconstructive pelvic surgery in these patients cures urinary retention. The records of all women with symptomatic anterior vaginal wall and urinary retention (PVR 100 cc) who underwent evaluation and surgical repair of the anterior vaginal wall at our institution between 1996 and 1999 were retrospectively reviewed. All patients underwent a detailed urogynecologic and urodynamic evaluation and had a pessary trial prior to surgery. Cure of urinary retention was defined as PVR <100 cc at 3 months postoperatively. Sensitivity, specificity, positive and negative predictive values for pessary reduction testing were calculated. Twenty-four patients met the inclusion criteria. Two patients (8%) had stage 2, eleven (46%) stage 3, and eleven (46%) stage 4 anterior vaginal wall prolapse. Preoperatively, the use of pessary was associated with relief of urinary retention in 75% patients. In predicting postoperative cure of urinary retention, pessary testing had a sensitivity of 89%, specificity of 80%, positive predictive value of 94%, and negative predictive value of 67%. Nineteen of 24 patients had a PVR <100 cc postoperatively, indicating a 79% cure rate for urinary retention. In women with symptomatic anterior vaginal wall prolapse and urinary retention, use of a pessary is associated with relief of retention in the majority of patients. Furthermore, pessary reduction testing has good sensitivity, specificity, and positive predictive value for postoperative voiding function. Editorial Comment: The authors attempt to address an interesting question, whether preoperative reduction of anterior vaginal wall prolapse with a pessary is predictive of improved bladder emptying following surgical correction of the prolapse. In their small retrospective study they found that a successful pessary test of cure was predictive of resolution of urinary retention following surgery with a positive predictive value of 94%. Interestingly, neither the type of pessary nor the type of surgery seemed to influence these results. In addition, the authors noted a higher rate of continued urinary retention in patients who had undergone a sling for correction of their urinary incontinence. This study supports the use of a pessary test of cure for urinary retention in the face of anterior vaginal wall prolapse prior to surgical correction of such prolapse     

Anterior vaginal wall length and degree of anterior compartment prolapse seen on dynamic MRI

The objective of the study was to determine the relationship between midsagittal vaginal wall geometric parameters and the degree of anterior vaginal prolapse. We have previously presented data indicating that about half of anterior wall descent can be explained by the degree of apical descent present (Summers et al., Am J Obstet Gynecol, 194:1438–1443, 2006). This led us to examine whether other midsagittal vaginal geometric parameters are associated with anterior wall descent. Magnetic resonance (MR) scans of 145 women from the prior study were suitable for analysis after eight were excluded because of inadequate visibility of the anterior vaginal wall. Subjects had been selected from a study of pelvic organ prolapse that included women with and without prolapse. All patients underwent supine dynamic MR scans in the midsagittal plane. Anterior vaginal wall length, location of distal vaginal wall point, and the area under the midsagittal profile of the anterior vaginal wall were measured during maximal Valsalva. A linear regression model was used to examine how much of the variance in cystocele size could be explained by these vaginal parameters. When both apical descent and vaginal length were considered in the linear regression model, 77% (R ² = 0.77, p < 0.001) of the variation in anterior wall descent was explained. Distal vaginal point and a measure anterior wall shape, the area under the profile of the anterior vaginal wall, added little to the model. Increasing vaginal length was positively correlated with greater degrees of anterior vaginal prolapse during maximal Valsalva (R ² = 0.30, p < 0.01) determining 30% of the variation in anterior wall decent. Greater degrees of anterior vaginal prolapse are associated with a longer vaginal wall. Linear regression modeling suggests that 77% of anterior wall descent can be explained by apical descent and midsagittal anterior vaginal wall length.     

A new needle suspension procedure for genuine stress incontinence and anterior vaginal wall prolapse

A new suspension method was developed for the correction of anterior vaginal wall relaxation and genuine stress incontinence. This procedure suspends the anterior vaginal wall to the anterior rectus fascia, and in doing so gives support to the bladder neck, anterior vaginal wall and vaginal apex. The procedure is performed at the time of vaginal hysterectomy or correction of anterior vaginal wall relaxation. The authors present their experience with this technique in 31 patients.Editorial Comment: Numerous types of surgery for the simultaneous correction of stress incontinence and cystocele and/or procidentia have been described in the literature. Some have proved more efficient for the correction of stress incontinence and others for the correction of disturbed pelvic support. The authors use the known method of needle suspension for the correction of stress incontinence, but for the new purpose of correction of cystocele/procidentia and stress incontinence. If necessary, vaginal hysterectomy can be performed with the originally planned intervention. As the criterion of an efficient outcome for the correction of genital statics, the author uses a vaginal depth of greater than 5 cm, which is less than normal. The successful correction of genital statics after 24 months was reported to be 93%, which is an extremely favorable result, resembling the success rate achieved by much more complicated surgeries (e.g. sacrospinous vault fixation or fixation of the vagina to the sacrum). The successful correction of stress incontinence in 82% of patients after 24 months is also favorable, and comparable to the results achieved by other surgical methods of needle suspension for the correction of stress incontinence.     

Overt rectal prolapse following repair of stage IV vaginal vault prolapse

Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.     

Porcine skin collagen implants for anterior vaginal wall prolapse: a randomised prospective controlled study

Introduction and hypothesis

The effect of a Pelvicol® graft compared with a conventional anterior vaginal repair was evaluated in this randomised controlled study.

Methods

Only patients with a stage II or higher (Ba?≥??1) defect were included.

Results

Thirty-one patients were allocated to a conventional anterior repair; 30 to Pelvicol® graft. At 12 months follow-up, four patients among controls (15%) and two in the graft group (7%) had objective recurrence. Among controls, the difference at 3 months follow-up in Ba was 6.0 cm when compared with the position of Ba prior to surgery. In the graft group, the difference was 7.0 cm (P?P?Conclusions The implantation of a Pelvicol® graft does not improve the POP-Q stage.     

阴道后壁脱垂与修复的研究进展

阴道后壁脱垂是常见的盆腔底部支持组织缺陷,它的发病率在伴有阴道前壁和阴道顶部位缺损的女性中达50％.阴道后壁脱垂的亚型包括：直肠膨出、肠疝、乙状结肠膨出、会阴疝,或者上述情况同时出现.直肠膨出是指直肠前壁通过阴道后壁向前突出,而肠疝指的是肠管经过DOUGLAS盲端（死胡同）突出至腹膜囊.肠疝解剖学上的研究表明,来自宫骶韧带的骨盆内层筋膜或者阴道前壁和或者后壁筋膜的分离,这导致阴道粘膜与盆腔腹膜直接接触.