A long-term review of posterior colporrhaphy with Vypro 2 mesh

The objective is to study the long-term outcomes of posterior colporrhaphy with composite polyglactin 910-polypropylene mesh (Vypro 2, Ethicon, Somerville, NJ, USA) utilizing an overlay technique. Seventy-eight patients involved in our previous study were contacted 3 years after their initial operation for follow-up (Lim YN, Rane A, Muller R, Int Urogynecol J 16:126–131, 2005). Thirty-seven (47%) returned for follow-up and completed a standardized questionnaire survey, whereas a further 16 (20%) returned their postal questionnaires. Mean age was 61.3 (SD 10.8) years, and follow-up was 35.7 (SD 4.5) months. There were statistically significant improvements in vaginal lump sensation and constipation (p < 0.001) but no differences with defecatory difficulties or dyspareunia. De novo dyspareunia was reported in 27%. On examination, the incidences of mesh vaginal erosion and rectocele recurrence were 30% and 22%, respectively. It appears that posterior colporrhaphy incorporating Vypro 2 mesh with an overlay method is associated with unacceptably high incidence of complications.     

Tension-free vaginal mesh repair for recurrence of pelvic organ prolapse after vaginal mesh procedures: a case report

A 61-year-old woman presented with the chief complaint of a vaginal bulge for 2 years. She had undergone two operations for pelvic organ prolapse. The initial procedure was the Manchester procedure and posterior colporrhaphy, and the second was a vaginal repair with mesh for recurrent rectocele 3 years after the initial surgery. She noticed the vaginal bulge shortly after the second surgery. A gynecological examination revealed a stage III rectocele associated with a 2 cm, firm mass at the posterior vaginal wall. T2-weighted magnetic resonance imaging showed a 2 × 3 cm high-intensity mass located between the vaginal wall and rectum. The recurrent rectocele might have been caused by incomplete support from the mesh, which was not fixed in the vaginal wall, resulting in formation of a mass. The patient underwent complete mesh removal and tension-free vaginal mesh-posterior surgery for the rectocele. The excised mesh had shrunk from a 7 × 5 cm rectangle mesh preoperatively into a firm 2 × 2 × 3 cm mass. No recurrence has been seen for 18 months postoperatively.     

Gluteo-vaginal fistula after posterior intravaginal slingplasty: a case report

In patients with posthysterectomy prolapse of the vaginal vault, the posterior intravaginal slingplasty (posterior IVS, Tyco Healthcare, USA) has been suggested as an alternative to traditional vaginal vault suspensions. The goal of this technique is to recreate the uterosacral ligaments and to reinforce the rectovaginal fascia with the use of prosthetic material. We report the case of a 53-year-old woman with a history of 27 months of perineal suppurative discharge after she underwent a vaginal vault prolapse and rectocele repair using a posterior IVS (Tyco Healthcare®, USA). The IVS tape was reinforced by interposing a rectovaginal monofilament polypropylene mesh (Parietex®, Sofradim®, France). Imaging studies and surgical exploration confirmed infection of the IVS mesh with the formation of a gluteo-vaginal fistula while the rectovaginal mesh was intact.     

Posterior intravaginal slingplasty for vaginal prolapse

Objective To evaluate the results of the posterior intravaginal slingplasty (IVS).Patients and methods From a urogynecology database, 42 patients who had undergone posterior IVS procedures were analyzed. All the selected patients had also had a posterior colporrhaphy (88% with mesh inserted into the rectovaginal space).Results Intraoperatively, there was one complication, a rectum perforation. All patients were followed-up, with a median of 13 months. Recurrent prolapse, grade 3 or 4, developed in 12 patients (29%) which included ten cystoenteroceles (24%), four rectoenteroceles (10%), and three cases of utero/vault prolapse (7%). Repeat surgery was performed in six patients (14%). For utero/vault prolapse, eight patients presented preoperatively with grades 3 and 4 prolapse. On follow-up, three patients had utero/vault prolapse, one of whom did not have utero/vault prolapse on presentation. Therefore, of the eight patients presenting with utero/vault prolapse, only two had repeat prolapse on follow-up, which reflected an improvement of 75%.Conclusion The posterior IVS delivered satisfactory results for vault and posterior compartment prolapse, with a 75% improvement in vault prolapse. It was not possible, however, to separate the effect of posterior IVS and posterior colporrhaphy on the prevention of recurrent prolapse nor on the improvement of difficulty in defecation. Due to the utilization of the now-abandoned vaginal anterior colposuspension procedure for the treatment of anterior compartment prolapse, no conclusions regarding the impact of the posterior IVS on the anterior compartment can be made.This study was approved by the Ethics Review Board of the University of the Free State (no. 124/04).     

Comparison between trans-obturator trans-vaginal mesh and traditional anterior colporrhaphy in the treatment of anterior vaginal wall prolapse: results of a French RCT

Introduction and hypothesis

To compare the efficacy of a collagen-coated polypropylene mesh and anterior colporrhaphy in the treatment of stage 2 or more anterior vaginal wall prolapse.

Methods

Prospective, randomized, multicenter study conducted between April 2005 and December 2009. The principal endpoint was the recurrence rate of stage 2 or more anterior vaginal wall prolapse 12 months after surgery. Secondary endpoints consisted of functional results and mesh-related morbidity.

Results

One hundred and forty-seven patients were included, randomized and analyzed: 72 in the anterior colporrhaphy group and 75 in the mesh group. The anatomical success rate was significantly higher in the mesh group (89 %) than in the colporrhaphy group (64 %) (p?=?0.0006). Anatomical and functional recurrence was also less frequent in the mesh group (31.3 % vs 52.2 %, p?=?0.007). Two patients (2.8 %) were reoperated on in the colporrhaphy group for anterior vaginal wall prolapse recurrence. No significant difference was noted regarding minor complications. An erosion rate of 9.5 % was noted. De novo dyspareunia occurred in 1/14 patients in the colporrhaphy group and in 3/13 patients in the mesh group. An analysis of the quality of life questionnaires showed an overall improvement in both groups, with no statistical difference between them. Satisfaction rates were high in both groups (92 % in the colporrhaphy group and 96 % in the mesh group).

Conclusion

Trans-obturator Ugytex® mesh used to treat anterior vaginal wall prolapse gives better 1-year anatomical results than traditional anterior colporrhaphy, but with small a increase in morbidity in the mesh group.     

Surgical management of posterior vaginal wall prolapse: an evidence-based literature review

The aim of this review is to summarize the available literature on gynecological management of posterior vaginal wall prolapse. A MEDLINE search and a hand search of conference proceedings of the International Continence Society and International Urogynecological Association was performed. Two randomized trials demonstrated that the transvaginal approach to rectocele is superior to the transanal repair in terms of recurrent prolapse. The traditional posterior colporrhaphy with levator ani plication was largely superceded by fascial repairs with similar anatomic success rates but favorable functional outcome. The midline fascial plication may offer a superior anatomic and functional outcome compared to the discrete site-specific fascial repair. Controlled studies are necessary to evaluate whether a sacrocolpopexy combined with posterior mesh interposition is an effective alternative to the transvaginal repair. There is currently no evidence to recommend the routine use of any graft and complications such as mesh erosion, infection, and rejection have to be considered.     

Follow-up after polypropylene mesh repair of anterior and posterior compartments in patients with recurrent prolapse

To retrospectively analyze the outcome of surgery in women followed up for 1 year after vaginal repair with the Apogee® (support of posterior vaginal wall) or Perigee® (support of anterior vaginal wall) system. A total of 120 patients with recurrent cystocele and/or rectocele or with combined vaginal vault prolapse were treated by either posterior or anterior mesh interposition depending on the defect. Follow-up after 1 year (±31 days) comprised a vaginal examination with prolapse grading using the POP-Q system, measurement of vaginal length, evaluation of the vaginal mucosa, and exploration for mesh erosions. Postoperatively, 112 (93%) women were free of vaginal prolapse, whereas 8 (7%) had level 2 defects. Erosions occurred significantly more often (p?=?0.042) in patients treated with the Perigee system. Our results suggest that the Apogee® and Perigee® repair systems (monofilament polypropylene mesh) yield excellent short-term results after 1 year.     

Will hysterectomy at the time of sacrocolpopexy increase the rate of polypropylene mesh erosion?

Will total abdominal hysterectomy with concomitant sacrocolpopexy lead to polypropylene (Prolene, Ethicon, Somerset, NJ) mesh erosions? Sixty-seven patients demonstrating a stage 2 or more International Continence Society cystocele, rectocele, and uterine prolapse underwent combined sacrocolpopexy and polypropylene mesh fixation and total abdominal hysterectomy. Surgical failure was noted as prolapse of any of the three pelvic compartments with a stage 2 or more recurrence. Sixty-four patients were available for examination, and none demonstrated mesh erosion or recurrent vault prolapse with a median follow-up of 27 months. Four patients experienced a recurrent stage 2 rectocele without any cystoceles or vault prolapse. Performing abdominal hysterectomy with concomitant sacrocolpopexy with polypropylene extensions does not increase the occurrence of synthetic material erosions in the vaginal vault or the anterior or posterior vaginal walls.     

Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study

The aim of this study was to evaluate the anatomical and functional results of a low-weight polypropylene mesh coated with an absorbable film in prolapse surgery by vaginal route. We have conducted a prospective multicentre study in 13 gynaecological and urological units. There were 230 patients requiring repair for anterior or posterior vaginal prolapse included. The present report is based on the analysis of the first 143 patients evaluated after at least 10 months follow-up. All patients were operated by the vaginal route using a specially designed mesh (Ugytex, Sofradim, France). Prolapse severity were evaluated using the Pelvic Organ Prolapse staging system. Symptoms and quality of life were evaluated preoperatively and during follow-up using the validated Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) self-questionnaires. Mean age was 63 years (37–91). Anterior, posterior and anterior–posterior repair with the mesh were performed in 67 (46.9%), 11 (7.7%) and 65 (45.4%) patients, respectively. With a mean follow-up of 13 months (10–19), 132 patients were considered anatomically cured (92.3%) with a recurrence rate of 9 of 132 for cystocele (6.8%) and 2 of 76 for rectocele (2.6%). Nine vaginal erosions occurred (6.3%), six of them necessitated another procedure by simple excision. The rate of de novo dyspareunia was 12.8%. At follow-up, improvement of PFDI and PFIQ scores were highly significant (p<0.0001). The use of low-weight polypropylene mesh coated with a hydrophilic absorbable film for vaginal repair of genital prolapse seems to decrease local morbidity while maintaining low recurrence rates.     

A 2-year anatomical and functional assessment of transvaginal rectocele repair using a polypropylene mesh

This study reports the 2-year results of an original technique for rectocele repair by the vaginal route, using a combined sacrospinous suspension and a polypropylene mesh. Twenty-six women were successively operated between October 2000 and February 2003. Mean age was 63.7 years [range 35–92]. 19 women had had previous pelvic surgery for prolapse and/or urinary incontinence (73.1%), but none had had a previous rectocele repair. Patients underwent physical examination staging of prolapse in the international pelvic organ prolapse staging system. Eleven women had stage 2 posterior vaginal wall prolapse (42.3%), seven had stage 3 (26.9%) and eight had stage 4 (30.8%). The procedure included a bilateral sacrospinous suspension and a polypropylene mesh (GyneMesh, Gynecare, Ethicon France) attached from the sacrospinous ligaments to the perineal body. We did not perform any associated posterior fascial repair, nor myorraphy. Patients were followed up for 10–44 months, with a median follow-up (±SD) of 22.7±9.2 months. Functional results and sexual function were evaluated using the PFDI, the PFIQ and the PISQ-12 self-questionnaires. Twenty-five women returned for follow-up (96.2%). At follow-up, 24 women were cured (92.3%) and one had asymptomatic stage 2 rectocele. All the patients but one had symptoms and impact on quality of life improved. No postoperative infection of the mesh or rectovaginal fistula was found, but there were three vaginal erosions (12%) and one out of 13 had de novo dyspareunia (7.7%).     

Prolift system in the correction of female genital prolapse

Objective:To review the security and effectiveness of female genital prolapse using the new Prolift system.Patient and Method:Prospective study of 41 patients that have been submitted to correction of cystocele and/or rectocele or vaginal cuff, between July of 2006 and May of 2007 in the Urogynecology and Vaginal Surgery Unit of Clínica Las Condes. The period of observation was completed at July of 2007.Result:Anterior Prolift mesh was used in 29 cystocele: 13 degree II, 14 degree III and 3 degree IV. Thirty rectocele: 12 degree II, 16 degree III and 3 degree IV. Five cases of vaginal cuff prolapse (total mesh): 1 degree II and 4 degree IV. The media time of surgery was 40 minutes for anterior Prolift (30 to 50 minutes); 30 minutes (20 to 40 minutes) for posterior Prolift and 60 minutes for Total Prolift. They did not present intraoperative complications. During the immediate postoperative time a case of peri-rectal hematoma was observed in a patient with posterior mesh for the rectocele correction. It was treated with oral anti-inflammatory. During the delayed postoperative time a case of vaginal erosion and mesh exposition (0.5 centimeters) was observed in a case of vaginal cuff prolapse treated with a Total Prolift. Two asymptomatic recidivate vaginal cuff prolapse were registered; degree IV to III and a case degree IV that was recidivate to cystocele degree II. The visual analogue scale of pain in Anterior Prolift was 3-4 at 12 hours, 2 at 24 hours and 1 at 48 hours. In Posterior Prolift was 4-6 at 12 hours, 3-4 at 24 hours and 1-2 at 48 hours. In cases with Anterior and Posterior Prolift and in Total Prolift the results were the same of Posterior Prolift.All patients indicated satisfaction in the follow-up at 30 days. The media follow up in the 41 patients was 7 months (range of 2 to 12 months).Conclusion:According to our experience the correction of the female genital prolapse with Prolift system is safe and effective; nevertheless a long follow-up is required to observe the good results in the time.     

The UK National Prolapse Survey: 10 years on

Introduction and hypothesis

To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey.

Methods

An online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures.

Results

Of 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment.

Conclusion

Basic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

     

TVT-O治疗压力性尿失禁89例的中期随访报告

目的探讨经闭孔无张力尿道中段悬吊术（transobturator vaginal tape inside-out,TVT-O）治疗压力性尿失禁（stress urinary incontinence,SUI）的疗效。方法 2006年3月～2009年6月对89例轻、中、重度压力性尿失禁行TVT-O。采用特制的穿刺器械由阴道内经闭孔穿出,将吊带平铺于尿道中段形成＂吊床＂达到治疗SUI的目的。结果 89例手术顺利,72例行单纯TVT-O,5例合并子宫脱垂行阴式子宫全切术,6例合并阴道前后壁脱垂行阴道前后壁修补术,6例（合并阴道前壁脱垂1例,阴道后壁脱垂5例）行网片悬吊术。未出现膀胱损伤或穿孔、血管、神经损伤,无血肿、尿瘘,无吊带侵蚀,术后出现排尿困难2例。89例随访36个月,完全治愈85例,显著好转3例,无效1例,完全治愈率95.5%（85/89）,显著好转率3.4%（3/89）,联合手术者未见SUI复发或阴道前后壁脱垂复发,72例单纯行TVT-O者性生活未觉明显异常。结论 TVT-O治疗轻、中、重度压力性尿失禁,安全有效。     

Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh

The purpose of this study was to evaluate the effectiveness of the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh in patients with severe (stage III or IV) anterior vaginal prolapse. Thirty-eight consecutive women were enlisted for this prospective study. The procedure consisted of an extensive vaginal dissection to join the vesicovaginal and retropubic space and an anchoring of a polypropylene mesh patch between the two Arcus Tendineus Fasciae Pelvis in a tension-free manner. The mean age of the study group was 63 (33–80) years. The success rate was 87% (33/38) at a mean follow-up interval of 21 (12–29) months. A total of eight (100%) patients were also cured of concomitant stress incontinence (five overt and three occult type) with an additional tension-free vaginal tape (TVT) operation. During follow-up, there were five de-novo stress incontinence cases (16.7%) and four vaginal erosions of mesh (10.5%). Four clinical variables—diabetes mellitus, recurrent anterior vaginal prolapse, chronic cough and vaginal erosions of mesh—were found to have a significant correlation with an unsatisfactory surgical result with large values of hazard ratios found by survival analysis. We concluded that the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh was effective for most, but failed in some patients who had specific risk factors within short convalescence periods. Concomitant stress incontinence can be successfully treated by a TVT operation in combination with the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. However, the anterior colporrhaphy procedure may itself have adverse effects on urethral sphincter function.Abbreviations POPQ Pelvic organ prolapse quantitation - TVT Tension-free vaginal tape Editorial Comment: This article is a case series of 38 patients followed for a mean of 21 months following pelvic reconstructive surgery with concomitant prolene reinforced anterior colporrhaphy. Optimal outcome was achieved in 87% of patients; however, the 10.5% mesh erosion rate and 16.7% de novo stress incontinence rate following this procedure are of concern. Synthetic vaginal mesh reinforcements should be used with caution. More data with regard to long-term sexual function is also needed.     

Operation for recurrent cystocele with anterior colporrhaphy or non-absorbable mesh: patient reported outcomes

Introduction and hypothesis

The aim of this study was to compare patient reported outcomes and complications after repair of recurrent anterior vaginal wall prolapse in routine health care settings using standard anterior colporrhaphy or non-absorbable mesh.

Methods

The study is based on prospective data from the Swedish National Register for Gynaecological Surgery. 286 women were operated on for recurrent anterior vaginal wall prolapse in 2008–2010; 157 women had an anterior colporrhaphy and 129 were operated on with a non-absorbable mesh. Pre-, and perioperative data were collected from doctors and patients. Patient reported outcomes were evaluated 2 months and 12 months after the operation.

Results

After 12 months, the odds ratio (OR) of patient reported cure was 2.90 (1.34–6.31) after mesh implants compared with anterior colporrhaphy. Both patient- and doctor-reported complications were found more often in the mesh group. However, no differences in serious complications were found. Thus, an organ lesion was found in 2.3 % after mesh implant compared with 2.5 % after anterior colporrhaphy (p?=?0.58). Two patients in the mesh group (1.2 %) were re-operated compared with 1 patient (0.6 %) in the anterior colporrhaphy group (p?=?0.58). The infection rate was higher after mesh (8.5 %) than after anterior colporrhaphy (2.5 %; OR 3.19 ; 1.07–14.25).

Conclusion

Implantation of synthetic mesh during operation for recurrent cystocele more than doubled the cure rate, whereas no differences in serious complications were found between the groups. However, mesh increased the risk of infection.     

Transvaginal posterior colporrhaphy combined with laparoscopic ventral mesh rectopexy for isolated Grade III rectocele: a prospective study of 27 patients

Aim The aim of this study was to evaluate prospectively transvaginal posterior colporrhaphy (TPC) combined with laparoscopic ventral mesh rectopexy (LVR) in patients with a symptomatic isolated rectocele. Method Patients with these complaints underwent dynamic and static MRI. All consecutive patients with a Grade III (4 cm or more) rectocele and without internal/external rectal prolapse, enterocele and external sphincter damage were operated on. The patients completed the Obstructed Defecation Syndrome (ODS) score and the Cleveland Clinic Incontinence Score (CCIS). All tests were repeated after treatment. Dynamic disorders of the pelvic floor detected by MRI were recorded. Results In 27 patients [median age 67 (46–73) years], TPC combined with LVR was feasible. Complications were limited to port site infection in two patients. Sexual discomfort (n = 8) due to prolapse diminished in six (75%) patients and in one (4%) de novo dyspareunia developed after treatment. The median follow‐up was 12 (10–18) months. The median CCIS was 12 (10–16) before treatment and 8 (7–10) after (P < 0.0001). The median ODS score was 19 (17–23) before and 6 (3–10) after treatment (P < 0.0001). There was no change in urinary symptoms. Conclusion TPC combined with LVR for obstructed defaecation and faecal incontinence in patients with Grade III rectocele significantly relieves the symptoms of these disorders.     

Sacral colpopexy using mersilene mesh in the treatment of vaginal vault prolapse

We report the efficacy and safety of abdominal sacral colpopexy using Mersilene mesh to treat vaginal vault prolapse. A total of 61 patients underwent sacral colpopexy to treat vaginal vault prolapse of whom 58 were available for evaluation. The procedure utilizes an abdominal approach to expose the vaginal vault and the anterior surface of the first and second sacral vertebrae. A Mersilene mesh is fastened to the anterior and posterior vaginal walls then anchored to the sacrum without tension. Hysterectomy and posterior colporrhaphy were performed as indicated. Concomitant anti-incontinence surgery was performed in 52 patients: 41 underwent Burch colposuspension, and 11 had pubovaginal sling placement. To assess long-term subjective and clinical efficacy, patients completed a questionnaire and underwent pelvic examination at least 1 year following surgery. The resolution of symptoms, objective restoration of normal pelvic support, and urinary continence defined surgical success. Median patient age at operation was 62 years. Previous operations included 29 hysterectomy procedures, five failed sacrospinous fixation, and 12 failed anti-incontinence procedures. The total complication rate was 15%. With a median follow-up of 26 months, complete correction of vaginal prolapse was found in 91% of patients. Vaginal symptoms were relieved in 90% of patients and 88% of patients had resolution of their urinary incontinence. Ninety percent of patients were satisfied with the surgery and would recommend it to others. Sacral colpopexy using Mersilene mesh relieves vaginal vault symptoms, restores vaginal function, and provides durable pelvic support.     

Laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy for the treatment of recto-genital prolapse and mechanical outlet obstruction

Objective Whilst trans‐abdominal fixation +/? resection offers better functional results and lower recurrence than perineal procedures, mesh rectopexy is complicated by constipation. Laparoscopic autonomic nerve‐sparing, ventral rectopexy allows correction of the underlying abnormalities of the rectum, vagina, bladder and pelvic floor. Method A prospective database was used to audit our 7‐year experience of this technique. The recto‐vaginal septum was mobilized anteriorly to the pelvic floor avoiding nerve damage. A prolene mesh was sutured to the ventral rectum, posterior vagina and vaginal fornix and secured to the sacral promontory. Patients were assessed with questionnaires and Cleveland Clinic scores. Results Eighty patients, six males, median age 59 years (range 31–90) underwent laparoscopic prolapse surgery between Jan 1997 and Dec 2005; 55% had full thickness prolapse and 46% rectal anal intussusception. Five had a solitary rectal ulcer. A total of 58% had undergone previous surgery; hysterectomy 33%, posterior colporrhaphy 15%, posterior rectopexy 6%, Delorme's rectal mucosectomy 5% and Birch colposuspension 3%. Half (54%) were incontinent (mean Wexner score 11, range 2–17) and 31% reported symptoms of obstructed defecation; seven had slow transit constipation and underwent resection. The median operative time was 125 min (range 50–210) with one conversion. Median time to diet was 12 h and median length of stay 3 days (1–12). No patient has developed recurrent full thickness prolapse at a median follow‐up of 54 months (30–96). Incontinence improved in 39 of 43 patients (91%); median post‐operative Wexner score 1 (0–9). Obstructed defecation resolved in 20 of 25 patients (80%). Pelvic pain resolved in all but one. Complications occurred in 21%; faecal impaction 4%, wound infection 2%, bleeding 2%, leak 1%, chest infection 1%, retention 1%. Three developed minor evacuatory difficulties and two, urinary stress incontinence. Conclusion Laparoscopic ventral rectopexy is safe with relatively low morbidity. In the medium‐term, it provides good results for prolapse and associated symptoms of incontinence and obstructed defecation.     

Transischioanal trans-sacrospinous ligament rectocele repair with polypropylene mesh: a prospective study with assessment of rectoanal function

Introduction and hypothesis

Despite good anatomical outcomes of pelvic organ prolapse (POP) repair by the vaginal route using synthetic mesh, complications limit their use. Clinical data are needed to generalize prolapse mesh repair by the vaginal route. The current study aims to evaluate midterm rectoanal function and clinical outcomes after transischioanal rectocele repair using a medium weight polypropylene mesh.

Methods

Between March 2003 and June 2004, 230 patients with stage II–IV anterior and/or posterior POP were included in a prospective multicenter study. The current study is based on the analysis of the 116 patients who underwent a rectocele repair via the infracoccygeal route through the sacrospinous ligament. Anatomical cure was defined when rectocele was at stage <II in the Pelvic Organ Prolapse Quantification (POP-Q) system. Postoperative functional results were evaluated using the self-administered Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ).

Results

Of the 116 patients who received a posterior mesh with two arms via the infracoccygeal route through the sacrospinous ligament, midterm anatomical results were available for 78 women representing 67 % (78/116) of the operated patients. The mean follow-up was 36 (± 8.1) months. No rectal injury occurred during surgery. The objective success rate was 94.8 % and subjective (by patient satisfaction) was 93.23 %. Colorectal-Anal Impact (CRAI) and Colorectal-Anal Distress Inventory (CRADI) scores were both significantly decreased at midterm follow-up in comparison with baseline (42.7 at baseline vs 11.4 at 24- or 36-month follow-up, p?=?0.001 for CRAI, and 81.1 vs 34.4, p?<?0.001 for CRADI) highlighting the benefits of rectocele repair on colorectal-anal function.

Conclusions

Polypropylene mesh with two arms via the infracoccygeal route through the sacrospinous ligament has good anatomical results at midterm follow-up with significant improvement in symptoms and quality of life and is associated with few complications. Obstructive symptoms reported in cases of rectocele can be improved by transvaginal mesh repair.     

What is the Gold Standard for Posterior Vaginal Wall Prolapse Repair: Mesh or Native Tissue?

Reports in the literature of high recurrence rates after native tissue repair for pelvic organ prolapse led to the development of alternative techniques, such as those using synthetic mesh. Transvaginal mesh (TVM) delivery systems were implemented in search of better outcomes. Despite reported recurrence as low as 7.1 % after posterior colporrhaphy, mesh kits were developed to correct posterior compartment prolapse. There is a paucity of data to substantiate better results with TVM for rectocele repair. Three randomized controlled trials comparing native tissue repair to synthetic mesh reported posterior compartment outcomes and two of these failed to show a significant difference between groups. Complications of TVM placement are not insignificant and mesh extrusion was reported in up to 16.9 %. Based on currently available data, native tissue repairs have similar outcomes to synthetic mesh without the risks inherent in mesh use and remain the standard of care for the typical patient.