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.     

Surgery for Pelvic Organ Prolapse: A Historical Perspective

Surgical treatment of pelvic organ prolapse has evolved from the use of pomegranates as pessary devices to contemporary robot-assisted laparoscopic sacral colpopexy. Symptomatic pelvic organ prolapse requires correction of all the defects to achieve optimal outcomes. Factors to consider in selecting the appropriate repair include patient's age; stage of prolapse; vaginal length; hormonal status; desire for uterine preservation and coitus; symptoms of sexual, urinary, or bowel dysfunction; and any comorbidities that influence her eligibility for anesthesia or chronically increase intra-abdominal pressure. There is currently no consensus as to the best surgical approach for advanced pelvic organ prolapse. Reconstructive surgery for pelvic organ prolapse is currently performed by vaginal or abdominal (open, laparoscopic, and robotic approaches) approaches or a combination. It is important to maintain skills in proven procedures such as abdominal sacrocolpopexy and sacrospinous ligament suspension. This paper discusses the historical evolution of surgery for pelvic organ prolapse from antiquity to date.     

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.

     

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the “gold standard” procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.     

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%).     

Sacrospinous hysteropexy: review and meta-analysis of outcomes

Introduction

Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery.

Methods

Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration’s Review Manager software to perform meta-analysis of randomized controlled studies and observational studies.

Results

Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n?=?651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76–5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41–2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy.

Conclusion

Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.

     

Transvaginal sacrospinal colposcopy in treatment of uterovaginal and vaginal wall prolapse

Investigation has been performed upon 29 patients of average age of 62.7 years who have undergone sacrospinous colpopexy because of different degree of uterovaginal prolapse (26 patients) and vaginal vault prolapse (3 patients) after having abdominal or vaginal hysterectomy. In patients with uterovaginal prolapse, 23 of them have vaginal hysterectomy with high ligation of the enterocele sac, anterior et posterior vaginal repair and sacrospinous colpopexy, while 3 patients had conservation of uterus following previous reparation of vaginal walls and cervicosacrocolpopexy. Only in one patient we had intraoperative lession of the bladder with no other intraoperative complications so far. Aveage time duration of the operation was 112 minutes. All patients were scheduled to be seen at 4 weeks, 6 months and 12 months after operation and then yearly therafter. The mean follow-up period was 16.8 months (6-27). We have achieved satisfactory results in 25 patients while 4 patients have bladder instability, 3 patients suffered from urinary infection, 2 have febrile morbidity and 2 bottock pain. Sacrospinous colpopexy can be performed together with vaginal hysterectomy and anterior and posterior vaginal wall repair in patients with marked uterovaginal prolapse because of its high success in avoiding possible vault prolapse and low intra and post-operative complication rates.     

A Retrospective Comparison of Abdominal Sacrocolpopexy with Burch Colposuspension versus Sacrospinous Fixation with Transvaginal Needle Suspension for the Management of Vaginal Vault Prolapse and Coexisting Stress Incontinence

The objective of this study was to compare the surgical outcome of abdominal sacrocolpopexy and Burch colposuspension with sacrospinous fixation and transvaginal needle suspension in the management of vaginal vault prolapse and coexisting stress incontinence. One hundred and seventeen women with vaginal vault prolapse and coexisting stress incontinence were surgically managed over a 7-year period. The first 61 consecutive women who underwent sacrospinous fixation and transvaginal needle suspension comprised the vaginal group, and the following 56 consecutive women who underwent abdominal sacrocolpopexy and Burch colposuspension comprised the abdominal group. Office records were reviewed to assess the presence of recurrent prolapse and urinary incontinence during postoperative follow-up. Objective follow-up was available for 101 women. Mean duration of follow-up was 24.0 ± 15 months for the vaginal group, and 23.1 ± 12.6 months for the abdominal group. The incidence of recurrent prolapse to or beyond the hymen (33% vs. 19%, P = 0.0505) and lower urinary tract symptoms (26% vs. 13%, P = 0.0506) were significantly higher in the vaginal group than in the abdominal group. Our data suggest that the combined abdominal approach has a lower incidence of recurrent prolapse and lower urinary tract symptoms than the combined vaginal approach in managing vaginal vault prolapse and coexisting stress incontinence.     

Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review

Introduction and hypothesis  

A previous version of the Cochrane review for prolapse surgery in 2008 provided two conclusions: abdominal sacrocolpopexy had lower recurrent vault prolapse rates than sacrospinous colpopexy but this was balanced against a longer time to return to activities of daily life. An additional continence procedure at the time of prolapse surgery might be beneficial in reducing post-operative stress urinary incontinence; however, this was weighed against potential adverse effects. The aim of this review is to provide an updated summary version of the current Cochrane review on the surgical management of pelvic organ prolapse.     

Porcine skin collagen implants to prevent anterior vaginal wall prolapse recurrence: a multicenter, randomized study

PURPOSE: We evaluated the efficacy of the Pelvicol porcine collagen implant for preventing recurrent anterior vaginal wall prolapse in women undergoing primary surgery for pelvic organ prolapse. MATERIALS AND METHODS: This was a prospective, randomized, multicenter trial in 206 women with stage II or greater anterior vaginal wall prolapse (point Ba -1 or greater) according to the pelvic organ prolapse quantification system. The patients were randomly assigned to undergo anterior vaginal repair or the same procedure with Pelvicol implant reinforcement. SPSS software was used for data analysis. RESULTS: A total of 201 women were available for surgical outcome analysis, including 98 and 103 in the implant and no implant groups, respectively. All completed the 1-year followup visit. Most women were satisfied with the postoperative condition with a significant decrease in the visual analog scale score in each group (p <0.001). Anatomical anterior recurrence (point Ba greater than -1) was observed in 7 women (7%) in the implant group and in 20 (19%) in the other groups (OR 3.13, 95% CI 1.26-7.78, p = 0.019). Additionally, there were 11 women (3 and 8, respectively, or 5%) with posterior recurrence and 6 (3 per group or 3%) with unsatisfactory results at the upper vaginal segment. One patient who received a porcine implant had vaginal extrusion of the mesh 1 month after surgery. CONCLUSIONS: Our data show that the Pelvicol implant can be easily and readily used to augment and reinforce anterior colporrhaphy. The prolapse recurrence rate was considerably lower in the implant group compared with outcomes in patients treated with simple anterior repair.     

Abdominal sacral colpopexy with Mersilene mesh.

INTRODUCTION: This study focussed on abdominal sacral colpopexy with Mersilene mesh to correct total vaginal vault prolapse. Our aim was to describe and explain our operative modifications. MATERIALS AND METHODS: From 1992 and 1999, we performed sacrocolpopexy on 25 patients for vaginal vault prolapse. We proposed a change by interposing a mesh between the vaginal vault and the sacral promontory shaped as an inverted 'V'. RESULTS: No intraoperative or postoperative complications were encountered; to date the outcome of all patients was satisfactory. CONCLUSION: Based on the results of the follow-up, this new surgical approach of abdominal sacral colpopexy can be considered as effective surgery for vaginal vault prolapse.     

直肠阴道疝Y型补片修补与悬吊的初步研究

目的探讨应用倒“Y”字形补片对直肠阴道疝进行修补,并行骶前阴道悬吊术的临床效果。方法从门诊盆底功能不全的患者中,选择具有具有直肠阴道疝的妇科患者共8例作为研究对象。常规缝合直肠阴道疝的疝囊,应用到“Y”型补片加强阴道后壁,并将阴道顶端悬吊于第2～3骶骨的前筋膜处。结果直肠阴道疝修补均成功,手术时间（110．0±16．9）min,出血（91．6±52．0）ml,排气时间（33．5±5．8）h,住院时间（6．8±0．7）d。所有患者术后1年,POP—Q评估均为。度。1例患者术后出现补片排斥反应,出现阴道腐蚀。结论直肠阴道疝应用倒Y型补片修补并行骶前阴道悬吊术效果确切,消除了临床症状,比单纯的修补效果佳,不易复发,加强了盆底功能,对防止复发及盆腔脏器的脱垂具有重要意义。．     

Uterine-preserving POP surgery

Introduction and hypothesis

To review the safety and efficacy of uterine preservation surgery.

Methods

Every four 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

A wide variety of surgical options remain for women presenting with uterine prolapse without contraindications to uterine preservation. However, long-term data are limited and the need for subsequent hysterectomy unknown (grade C). Sacrospinous hysteropexy is as effective as vaginal hysterectomy and repair in retrospective comparative studies and in a meta-analysis with reduced operating time, blood loss and recovery time. However, in a single RCT there was a higher recurrence rate associated with sacrospinous hysteropexy compared with vaginal hysterectomy (grade D). Severe prolapse increases the risk of recurrent prolapse after sacrospinous hysteropexy. In consistent level 2 evidence sacrospinous hysteropexy with mesh augmentation of the anterior compartment was as effective as hysterectomy and mesh augmentation with no significant difference in the rate of mesh exposure between the groups (grade B). Level 1 evidence from a single RCT suggests that vaginal hysterectomy and uterosacral suspension were superior to sacral hysteropexy based on reoperation rates, despite similar anatomical and symptomatic improvement (grade C). Consistent level 2 and 3 evidence suggests that sacral hysteropexy (open or laparoscopic) was as effective as sacral colpopexy and hysterectomy in anatomical outcomes; however, the sacral colpopexy and hysterectomy were associated with a five times higher rate of mesh exposure compared with sacral hysteropexy (grade B). Performing hysterectomy at sacral colpopexy was associated with a four times higher risk of mesh exposure compared with sacral colpopexy without hysterectomy (grade B).

Conclusion

While uterine preservation is a viable option for the surgical management of uterine prolapse the evidence on safety and efficacy is currently lacking.     

Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse

PURPOSE: Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with durable success rates. However, it is associated with increased morbidity compared with vaginal repairs. We describe a minimally invasive technique of vaginal vault prolapse repair and present our experience with a minimum of 1 year followup. MATERIALS AND METHODS: The surgical technique involves 5 laparoscopic ports: 3 for the da Vinci robot and 2 for the assistant. A polypropylene mesh is attached to the sacral promontory and vaginal apex using polytetrafluoroethylene sutures. The mesh material is then covered by peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction and morbidity with a minimum of 12 months followup. RESULTS: A total of 30 patients with post-hysterectomy vaginal vault prolapse underwent robotic assisted laparoscopic sacrocolpopexy at our institution and 21 have a minimum of 12 months followup. Mean followup was 24 months (range 12 to 36) and mean age was 67 years (range 47 to 83). Mean operative time was 3.1 hours (range 2.15 to 4.75). All but 1 patient were discharged home on postoperative day 1 and the 1 patient left on postoperative day 2. Recurrent grade 3 rectocele developed in 1 patient, 1 had recurrent vault prolapse and 2 had vaginal extrusion of mesh. All patients were satisfied with outcome. CONCLUSIONS: The robotic assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a decreased hospital stay, low complication rates and high patient satisfaction with a minimum of 1 year followup.     

Where to for pelvic organ prolapse treatment after the FDA pronouncements?

Introduction

With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management.

Methods

A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance.

Results

Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient’s lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery.

Conclusion

Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.     

Management of patients with rectocele

The main objective of this article is to review the management of patients with posterior vaginal wall prolapse. The posterior vaginal wall is inconsistent both in terms of correlating patient symptoms to objective findings and correlating correction of anatomic defects to symptom relief. Therefore, the management of patients with pelvic organ prolapse is challenging and emphasizes the need for surgeons to clearly communicate expectations of surgical repair. Despite these limitations, surgical repair of pelvic organ prolapse in properly selected patients can provide symptomatic relief and improvement in their quality of life and functional status. Review of the literature suggests that traditional posterior colporrhaphy without levatorplasty has superior objective outcomes compared with site-specific posterior repair (grade B), there is a higher dyspareunia rate reported when levatorplasty is employed (grade C), the transvaginal approach is superior to the transanal approach (grade A), there is no benefit of mesh overlay or augmentation of a suture repair (grade B), and while modified abdominal sacrocolpopexy results have been reported, data on how these results would compare with traditional transvaginal repair are lacking. Further studies are needed to optimize the care of patients with posterior vaginal wall prolapse.     

Ligament shortening compared to vaginal colpopexy at the time of hysterectomy for pelvic organ prolapse

Introduction and Hypothesis

The performance of a colpopexy at the time of hysterectomy for pelvic organ prolapse is a potential indicator of surgical quality. However, vaginal colpopexy has not been directly compared with the classic technique of ligament shortening and reattachment. We sought to test the null hypothesis that there is no difference in prolapse recurrence between the techniques.

Methods

We performed a retrospective chart review of 330 vaginal hysterectomies performed for prolapse, comparing symptomatic and/or anatomic recurrence rates between patients having a vaginal colpopexy (uterosacral ligament suspension or sacrospinous ligament suspension) and those having ligament shortening and reattachment. Clinically relevant variables significantly associated with recurrence in a univariate analysis were used to create a multivariable logistic regression model to predict recurrence.

Results

With a mean follow-up of 20 months, there was no significant difference between symptomatic and/or anatomic recurrence rates: 19.4 % of patients (41 of 211) having colpopexy vs. 11.8 % of patients (14 of 119) having ligament shortening (p?=?0.07). Baseline prolapse stage was higher in patients having colpopexy (median 3, IQR 2?–?5) than in those having ligament shortening (median 2, IQR 1?–?3; p?≤?0.0001). In the multivariable logistic regression analysis, the procedure performed was not associated with recurrence (OR 1.57, 95 % CI 0.79?–?3.12). A baseline prolapse of 4 cm or greater was associated with recurrence (OR 2.63, 95 % CI 1.32?–?5.22), as was the time since hysterectomy (OR 1.02 per month, 95 % CI 1.01?–?1.04).

Conclusions

When compared with vaginal colpopexy, selective use of the ligament shortening technique at the time of vaginal hysterectomy was associated with similar rates of prolapse recurrence. Preoperative prolapse size was the factor most strongly associated with recurrence.

     

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.     

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.     

Perineal hernia extruding into the labium majus after multiple surgeries for pelvic organ prolapse

A 78-year-old woman presented with a large bulge in the right labium majus. She had a previous history of two anterior and posterior vaginal wall prolapse repairs, a vaginal hysterectomy for uterovaginal prolapse, a sacrospinous ligament fixation for vaginal vault prolapse, and a LeFort partial colpocleisis for recurrent vault prolapse. Magnetic resonance imaging (MRI) revealed an anterior perineal hernia containing small bowel. Surgery was performed to close the pelvic floor defect through a perineal approach, and polypropylene mesh was used as a bolster. The hernial sac contained small bowel with very thin adhesions. Over 6 months of follow-up, there was no recurrence of the hernia or mesh complications. Perineal hernias after gynecological surgeries for benign diseases are rare. The indications for repair and the optimal surgical approach are not well described.