Outcome after anterior vaginal prolapse repair: a randomized controlled trial

OBJECTIVES: To report 1-year outcomes of a randomized controlled trial comparing polypropylene mesh-reinforced anterior vaginal prolapse repair with anterior colporrhaphy. METHODS: Seventy-six patients with stage II or greater anterior vaginal prolapse were randomly assigned to either colporrhaphy or polypropylene mesh repair. The primary outcome was recurrent stage II anterior vaginal prolapse, and secondary outcomes were effects on quality of life and sexual symptom scores, operative time, blood loss, length of hospitalization, and adverse events. RESULTS: Thirty-eight women had anterior colporrhaphy, and 37 had polypropylene mesh repair. One patient allocated to mesh repair withdrew from the study before surgery. Clinical and demographic data did not differ significantly between the two treatment groups. One year after surgery, optimal and satisfactory anterior vaginal support were obtained in 21 of 38 (55%) of the colporrhaphy group and 33 of 38 (87%) of the mesh group (P=.005). Patients in both groups reported less bother after surgery in both prolapse and urinary symptoms. The rates of de novo dyspareunia were 4 of 26 (16%) and 2 of 23 (9%) in the colporrhaphy and mesh groups, respectively. Two of 37 (5%) patients had vaginal mesh extrusion. Nine anterior colporrhaphy patients would have to have recurrent anterior vaginal prolapse to prevent one vaginal mesh extrusion. Neither serious adverse events nor deaths occurred in either group. CONCLUSION: Anterior vaginal prolapse repair with polypropylene mesh reinforcement offers lower anatomic recurrence than anterior colporrhaphy at one year. However, quality of life and sexual symptoms scores improved in both groups.     

Anterior colporrhaphy versus repair with mesh for anterior vaginal wall prolapse: a comparative clinical study

Purpose

To compare the clinical effectiveness of anterior colporrhaphy versus mesh repair as surgical management of anterior vaginal prolapse.

Methods

Of 50 patients with ≥stage II anterior vaginal prolapse on Pelvic Organ Prolapse Quantification (POPQ) system who were initially approached, 44 consented and underwent surgery. They were randomly recruited into two groups. Group I (23 patients) received anterior colporrhaphy, while group II (21 patients) received soft polypropylene mesh (GYNEMESH*PS, Gynecare, Ethicon, France). Clinical assessment took place preoperatively and postoperatively at definite intervals. Functional and anatomical comparisons were based on comparison between preoperative and 24?months postoperative assessments of symptoms and POPQ stages, respectively. Four patients in total did not complete the follow-up assessments and were excluded.

Results

Both groups showed clinical improvement in their symptoms and POPQ staging at the end of the postoperative follow-up period. Improvement, however, was more significant in the repair with mesh group, as patients in this group reported better improvement of their prolapse symptoms, mainly vaginal bulge/pressure sensation (P?P?P?Conclusion Our data shows that repair with mesh is superior to anterior colporrhaphy with more satisfactory outcome to the patients. Due to the small size of our study and uncertainty of the long-term safety and resilience of the mesh, we recommend larger studies to confirm our preliminary results.     

Transvaginal cystocele repair using tension-free polypropylene mesh at the time of sacrospinous colpopexy for advanced uterovaginal prolapse: a prospective randomised study

The management of an advanced multi-compartment prolapse requires a combination of techniques. The objective of this study was to report the anatomical outcomes of a prospective randomised trial comparing tension-free polypropylene mesh-reinforced anterior vaginal prolapse with anterior colporrhaphy at the time sacrospinous colpopexy and posterior fascial plication for the management of massive uterovaginal prolapse. A total of 116 patients with a stage III or IV (Pelvic Organ Prolapse Quantification System/International Continence Society) uterovaginal prolapse were randomised into two groups. The mesh group includes transvaginal cystocele repair using a tension-free polypropylene mesh, while the non-mesh group includes anterior colporrhaphy. All patients in the two groups underwent a sacrospinous colpopexy and posterior fascial plication. The primary outcome was objective success < stage 2 prolapse. The secondary outcomes were reoperation for recurrent prolapse, subjective success rates, patient satisfaction with the surgery and complications. The overall objective success rates (in all compartments) were 79 % (42/53) in the mesh group and 62 % (39/63) in the non-mesh group (p?=?0.043). The objective success rates in the anterior compartment were 85 % (45/53) in the mesh group and 62 % (39/63) in the non-mesh group (p?=?0.006). Three (6 %) patients in the mesh group and 12 (19 %) in the non-mesh group underwent repeat surgery for recurrent pelvic organ prolapse (p?=?0.03). The subjective success rates were 89 % (47/53) in the mesh group and 76 % (48/63) in the non-mesh group (p value?=?0.08). The mean patient satisfaction rates with the surgery were 84 % in the mesh group and 76 % in the non-mesh group (p?=?0.08). The development of a urinary tract infection, right-sided buttock pain (temporary sciatic neuralgia) and new-onset stress urinary incontinence were not significantly different between the two groups. The mesh exposure rate was 8 %. Transvaginal cystocele repair using tension-free polypropylene mesh at the time of sacrospinous colpopexy and posterior fascial plication offers lower anatomic recurrence and less need for further prolapse surgery to correct recurrent pelvic floor defects than anterior colporrhaphy, sacrospinous colpopexy and posterior fascial plication.     

Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device

Objectives  To describe a new surgical procedure for pelvic organ prolapse using mesh and a vaginal support device (VSD) and to report the results of surgery.
Design  A prospective observational study.
Setting  Two tertiary referral Urogynaecology practices.
Population  Ninety-five women with International Continence Society pelvic organ prolapse quantification stage 2 or more pelvic organ prolapse who underwent vaginal surgery using mesh augmentation and a VSD.
Methods  Surgery involved a vaginal approach with mesh reinforcement and placement of a VSD for 4 weeks. At 6 and 12 months, women were examined for prolapse recurrence, and visual analogue scales for satisfaction were completed. Women completed quality-of-life (QOL) questionnaires preoperatively and at 6 and 12 months.
Main outcome measures  Objective success of surgery at 6 and 12 months following surgery. Secondary outcomes were subjective success, complications, QOL outcomes and patients' satisfaction.
Results  Objective success rate was 92 and 85% at 6 and 12 months, respectively. Subjective success rate was 91 and 87% at 6 and 12 months, respectively. New prolapse in nonrepaired compartments accounted for 7 of 12 (58%) failures at 12 months. Two of 4 mesh exposures required surgery. Sexual dysfunction was reported by 58% of sexually active women preoperatively and 23% at 12 months. QOL scores significantly improved at 12 months compared with baseline ( P < 0.0001).
Conclusion  Vaginal surgery using mesh and a VSD is an effective procedure for pelvic organ prolapse. However, further studies are required to establish the role of the surgery described in this study.     

Anterior colporrhaphy: A randomized trial of three surgical techniques

OBJECTIVE: The purpose of this study was to compare outcomes after anterior colporrhaphy with the use of 3 different surgical techniques. STUDY DESIGN: One hundred fourteen women with anterior vaginal prolapse were randomly assigned to undergo anterior repair by one of 3 techniques: standard, standard plus polyglactin 910 mesh, or ultralateral anterior colporrhaphy. Before and after operation, patients underwent physical examination staging of prolapse; the International Continence Society system was used. Symptoms were assessed by questionnaire and visual analog scales. We defined "cure" as satisfactory (stage I) or optimal (stage 0) outcome at points Aa and Ba. RESULTS: Of 114 patients who were originally enrolled, 109 patients underwent operation, and 83 patients (76%) returned for follow-up. Mean age (+/- SD) was 64.7 +/- 11.1 years. At entry, 7 patients (7%) had stage I anterior vaginal prolapse; 35 patients (37%) had stage II anterior vaginal prolapse; 51 patients (54%) had stage III anterior vaginal prolapse; and 2 patients (2%) had stage IV anterior vaginal prolapse. At a median length of follow-up of 23.3 months, 10 of 33 patients (30%) who were randomly assigned to the standard anterior colporrhaphy group experienced satisfactory or optimal anatomic results, compared with 11 of 26 patients (42%) with standard plus mesh and with 11 of 24 patients (46%) with ultralateral anterior colporrhaphy. The severity of symptoms that were related to prolapse improved markedly (preoperative score, 6.9 +/- 2.7; postoperative score, 1.1 +/- 0.8). Twenty-three of 24 patients (96%) no longer required manual pressure to void after operation. CONCLUSION: These 3 techniques of anterior colporrhaphy provided similar anatomic cure rates and symptom resolution for anterior vaginal prolapse repair. The addition of polyglactin 910 mesh did not improve the cure rate compared with standard anterior colporrhaphy.     

Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse

Objective To compare the Burch colposuspension and the anterior colporrhaphy in women with both stress urinary incontinence and advanced anterior vaginal wall prolapse (cystocele).
Design Prospective randomised study.
Setting Secondary referral centre, Urogynaecology Unit, San Gerardo Hospital, Monza, Italy.
Sample Seventy-one women undergoing surgery for primary genuine stress incontinence and concurrent grade 2 or 3 cystocele (descending at or outside the vaginal introitus).
Methods Full urodynamic investigation performed pre-operatively and repeated six months after surgery. Clinical follow up continued for 8 to 17 years.
Main outcome measures Subjective (patient history) and objective (negative stress test result) cure of stress incontinence. Assessment of cystocele recurrence.
Results Thirty (86%) of the 35 evaluable women who had the Burch colposuspension and 17 (52%) of the 33 evaluable women who had the anterior colporrhaphy were subjectively cured (OR 5.6, 95% CI 1.6 to 21.6;   P = 0.005  ). Objective cure rates were 74% (26 of 35) and 42% (14 of 33), respectively (OR 3.9, 95% CI 1.3 to 12.5;   P = 0.02  ). A recurrent cystocele of grade 2 or 3 with or without prolapse at other vaginal sites was recorded in 34% (12 of 35) and 3% (1 of 33) of women, respectively (OR 16.7, 95% CI 2.0 to 368.1;   P = 0.003  ).
Conclusions The Burch colposuspension was better in controlling stress incontinence but it lead to an unacceptable high rate of prolapse recurrence. The anterior colporrhaphy was more effective in restoring vaginal anatomy but it was accompanied by an unacceptable low cure rate of stress incontinence. Neither of the two operations is recommended for women who are suffering from a combination of stress incontinence and advanced cystocele.     

Laparoscopic sacral colpopexy versus total vaginal mesh for vault prolapse; comparison of cohorts

The surgical treatment of vaginal vault prolapse can either be performed by the vaginal or the abdominal (laparoscopic) route. The objective of this study was to compare the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM) for vaginal vault prolapse. This study compared a prospective cohort of LSC with bone-anchor fixation and mesh limited to the apex to a prospective cohort of TVM as treatment modalities in patients with a symptomatic vaginal vault prolapse (pelvic organ prolapse-quantification (POP-Q) point C?≥??3). Primary outcome was failure in the apical compartment after 6 month follow-up, defined as POP-Q stage?≥?II with prolapse complaints or re-treatment in apical compartment. Based on an overall failure in all compartments of 23 % in the LSC group and 57 % in the TVM group, 29 patients would be needed in each group with a power of 80 % and alpha 0.05. Ninety-seven women were included, 45 LSC and 52 TVM. The failure rate of symptomatic vault prolapse was 1 (2 %) in each group (p?=?0.99). The failure rate (POP stage?≥?II) in any compartment was 23 (51 %) in the LSC group and 11 (21 %) in the TVM group (p?=?0.002). Each technique had its own type of complications. Short-term failure rates in the apical compartment after TVM and LSC were similar. In case of anterior or posterior prolapsed, additional mesh insertion or additional vaginal colporrhaphy is indicated in LSC surgery.     

Short-range clinical, dynamic magnetic resonance imaging and P-QOL questionnaire results after mesh repair in female pelvic organ prolapse

Objective

To evaluate clinical, quality-of-life (QoL) and dynamic magnetic resonance imaging (dMRI) results in patients with pelvic organ prolapse (POP) preoperatively, and 4 and 12 weeks after anterior and/or posterior mesh repair.

Study design

Thirty-six patients (mean age 65 years) with symptomatic pelvic floor descent underwent mesh repair. The prolapse was quantified using the POP-Q system. Before surgery as well as 4 and 12 weeks after surgery, the pelvic organ positions were measured on dynamic magnetic resonance imaging during Valsalva manoeuvre in relation to the pubococcygeal and mid-pubic lines to assess surgery outcome. Patients also completed the P-QOL questionnaire to evaluate subjective changes at each visit.

Results

Four and 12 weeks after surgery patients showed improvement of the POP on clinical examination and on dynamic MRI. The latter demonstrated high significance (p < 0.001) especially in bladder and vaginal cuff/cervix positions during maximal straining. All quality-of-life domains and some symptom questions of the P-QOL questionnaire significantly improved (p < 0.05) 12 weeks after surgery.

Conclusion

Significant anatomical and quality-of-life improvement was demonstrated after anterior and/or posterior mesh repair for POP using dynamic MRI and the P-QOL questionnaire.     

Combined anterior vaginal wall mesh with sacrospinous ligament fixation or with posterior intravaginal slingplasty for uterovaginal or vaginal vault prolapse

Objective

To evaluate outcomes of anterior vaginal wall mesh augmentation with concomitant sacrospinous ligament fixation (SSLF) or with concomitant posterior intravaginal slingplasty (IVS) for uterovaginal or vaginal vault prolapse.

Study design

Women with symptomatic uterovaginal or vaginal vault prolapse were randomly allocated to SSLF or IVS. All underwent concomitant anterior repair augmented with self-tailored multifilament polypropylene and polyglactin composite mesh. Before and 2, 12, 24 and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of pelvic organ prolapse at stage II or beyond (−1 cm or greater) at any site of the vaginal wall. Secondary outcomes included perioperative and postoperative complications, symptom resolution, reoperation and mesh exposure.

Results

Twenty-two women were recruited from March 2003 to December 2005. At 3-year follow-up3 (2 posterior and 1 apical) out of 14 (21%) in the IVS group had anatomic recurrences of pelvic organ prolapse, and 1 anterior out of 8 (13%) in the SSLF group. Severe operative complications or reoperations did not occur. The proportions of symptomatic patients, including those with dyspareunia, did not differ between the groups. Erosion of the anterior multifilament mesh was found in 2 out of 22 cases (9%; 95% CI 3-28%).

Conclusion

At 3-year follow-up anterior repair reinforced with a composite mesh with concomitant sacrospinous ligament fixation or with concomitant posterior intravaginal slingplasty allowed feasible support in patients with severe pelvic organ prolapse.     

Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh

OBJECTIVE: To evaluate the effects of prolene mesh on urinary, bowel and sexual function in prolapse surgery. DESIGN: Prospective observational study on consecutive women. SETTING: Two referral uorgynaecological units in Italy. POPULATION: Women requiring prolapse repair for anterior or posterior vaginal prolapse. METHODS: All women were assessed for urinary, bowel, prolapse symptoms and dyspareunia pre- and post-operatively. Urodynamics was performed in selected cases. Surgery consisted of an anterior or posterior repair plus a prolene mesh. Follow up was after 1, 6 and 12 months. The ANOVA test was used for statistical analysis. MAIN OUTCOME MEASURES: Vaginal anatomical restoration, urinary, bowel and sexual function. RESULTS: We recruited 63 women (mean age 63 years) with a mean follow up of 17 months. Anatomically, the success rate was 94%. Thirty-two women had an anterior repair. Among this group, the sexual activity rate did not alter but dyspareunia increased by 20%. Urge and stress incontinence did not change post-operatively but urgency improved in 10% and 13% had vaginal erosion of the mesh. Thirty-one women had a posterior repair. Among this group, sexual activity decreased by 12% and dyspareunia increased in 63%. Constipation improved in 15% and anal incontinence in 4%, and 6.5% of women had vaginal erosion of the mesh and one required mesh removal for pelvic abscess. CONCLUSIONS: Although this study shows good anatomical results with the use of prolene mesh for prolapse repair, there was a high rate of morbidity. We believe that the use of prolene mesh should be abandoned.     

Vaginal prolapse repair using the Prolift kit: a registry of 100 successive cases

Objectives

To evaluate anatomical, functional outcomes and complications inherent to the treatment of pelvic organ prolapse by implantation of polypropylene mesh, using the Prolift™ kit.

Materials and methods

Single-center observational study of 100 successive patients enrolled in a registry, who underwent Prolift™ prolapse repair. Data on prior treatments, associated procedures and per- and post-operative complications were collected and the patients were seen after 2, 6 and 12 months. Anatomical outcomes were assessed using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system. Function was assessed in terms of urinary and digestive problems, and impact on sex life. Failure was defined as relapse of POP-Q Grade 2 or more.

Results

Of the 100 patients, 32 had an anterior, 14 a posterior, 54 a total Prolift™; 53 had concomitant urinary incontinence surgery. At 6 and 12 months respectively, 8% and 12% of the patients were lost to follow-up. Mean operating time was 39.8 min. With respect to peri-operative complications, there was no bladder or rectal damage but three patients experienced bleeding (≥300 ml) without needing transfusion. POP-Q Grades before surgery were: Grades III-IV cystocele in 65.7% of the anterior Prolift™ patients; Grades II-III rectocele in the posterior; and 77.8% of total were Grade III and 11.1% Grade IV.The incidence of recurrence was 3.6% at Month 6 and 10.2% at Month 12. Significant (p < 0.05) improvements were seen in median scores for the various POP-Q items. With respect to functional problems, stress urinary incontinence was cured in 92% of the patients but 7.7% reported new-onset urinary incontinence after one year. One case of vaginal exposure after one year was observed and major or symptomatic mesh retraction was observed in 8%. New-onset dyspareunia was reported by 11.1% of the patients.

Conclusions

These results confirm the feasibility of using the Prolift™ kit in the repair of prolapse via a vaginal approach and the low per- and post-operative morbidity associated with that technique. Nevertheless, longer-term evaluation is required to confirm the results.     

Laparoscopic Uterosacral Ligament Hysteropexy vs Total Vaginal Hysterectomy with Uterosacral Ligament Suspension for Anterior and Apical Prolapse: Surgical Outcome and Patient Satisfaction

Study ObjectiveTo compare anatomic and clinical cure rates as well as patient satisfaction between uterine-preserving laparoscopic uterosacral ligament suspension and total vaginal hysterectomy with uterosacral ligament suspension in women with apical and anterior prolapse.DesignSingle-center clinical comparative retrospective cohort study.SettingA female pelvic medicine and reconstructive surgery service at a tertiary teaching hospital.PatientsWomen with pelvic organ prolapse who underwent surgical treatment for their condition between July 2010 and December 2015.InterventionsAll women underwent laparoscopic uterosacral ligament suspension or total vaginal hysterectomy with uterosacral ligament suspension for apical and anterior prolapse. Concomitant procedures included anterior and posterior repair, as well as a midurethral sling when indicated.Measurements and Main ResultsPreoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements were obtained. The primary outcome was clinical cure rate. Secondary outcomes included anatomic cure rate and outcomes of site-specific POP-Q points Ba, C, and Bp for the whole cohort. Patient satisfaction was measured using the Patient Global Impression of Improvement questionnaire. During the study period, 106 women underwent transvaginal hysterectomy with uterosacral ligament suspension, and 53 women had laparoscopic uterosacral ligament suspension. At a mean follow-up of 14.7 ± 13.23 months for the vaginal group and 17.5 ± 15.84 months for the laparoscopic group (p = .29), there were significant improvements of POP-Q points Ba, C, and Bp (p < .0001 for all comparisons in both groups). The clinical cure rate was 96% in the vaginal group and 98% in the laparoscopic group (p = .50). The anatomic cure rate was 85.4% in the vaginal group and 93.75% in the laparoscopic group (p = .11) Patient satisfaction was high in both groups.ConclusionIn appropriately selected patients, laparoscopic uterosacral ligament suspension is a valid uterus-preserving option for women with anterior and apical prolapse, associated with high anatomic and clinical cure rates and patient satisfaction.     

Retrospective multicentre study of the new minimally invasive mesh repair devices for pelvic organ prolapse

Objectives  To assess the complications and short-term outcomes of prolapse repair mesh devices used in the management of female pelvic organ prolapse (POP).
Design  Retrospective cohort study.
Setting  Multicentre study involving a tertiary referral urogynaecology unit and two district general hospitals.
Population  329 women who underwent surgical management of prolapse with various prolapse repair mesh devices in the period between January 2005 and December 2006.
Methods  Women were identified from theatre records. An independent clinician performed a case notes review during the period March to May 2007.
Main Outcome Measures  Complication rates and the short-term cure at 3-month follow-up (defined as ≤stage I prolapse on the POP-Q or Baden Walker scoring systems).
Results  A total of 289 women were included: 219 (76%) used the Gynecare prolapse repair mesh devices, while 70 women (24%) used the American Medical Systems prolapse repair mesh devices. Operative complications included: bladder injury (1.6%), rectal injury (1.1%) and two women with serious vascular injuries. Postoperative complications included: buttock pain (5.2%), vaginal erosion (10%), one woman with bladder erosion and two women (0.7%) with serious infection, leading to necrotising fasciitis in one woman. Short-term cure rates in different groups varied from 94 to 100%, depending on vaginal compartment and device used. In total 15 women (5%) had persistent prolapse at 3-month follow up.
Conclusion  The new prolapse repair mesh devices demonstrate excellent short-term cure and low morbidity rates. However, some complications are serious and require highly specialised management. Rigorous evaluation by means of independent, controlled studies is urgently required.     

改良盆底重建术与传统手术治疗盆腔器官脱垂的随访评价

目的:评价经阴道全子宫切除术加改良盆底重建术和经阴道全子宫切除术加阴道前后壁修补术治疗盆腔脏器脱垂的治疗效果。方法:对2007年4月至2011年4月盆腔脏器脱垂Ⅱ～Ⅳ度102例患者进行术后3个月、6个月、12个月、36个月随访,其中经阴道子宫切除术加改良盆底重建术(重建组)65例,经阴道子宫切除术加阴道前后壁修补术(传统组)37例。采用POP-Q分度法,Ⅱ度及Ⅱ度以上判定为复发。结果:重建组2例(3.08%)复发,传统组6例(16.21%)复发,两组复发率差异有统计学意义(P<0.05);重建组复发患者均合并网片侵蚀、外露,剪除外露网片并局部雌激素治疗后放置子宫托,目前疗效满意;传统组复发患者分别行子宫托治疗、改良盆底重建术、Prolift盆底重建术、阴道封闭术,目前疗效满意;重建组35例术后恢复性生活,传统组25例术后恢复性生活,性功能问卷评分均较术前下降(P<0.05),但两组术后性功能评分无显著差异(P>0.05)。结论:改良盆底重建术作为一种新术式,能更好地修补缺陷、实现结构重建和组织替代,其复发率低,尤其是对于Ⅲ～Ⅳ度脱垂患者较传统手术更具优势。术后复发患者首选子宫托治疗,传统组可行网片再次手术治疗,阴道封闭术为最后的选择方法。     

Laparoscopic paravaginal repair of anterior compartment prolapse

STUDY OBJECTIVE: To assess the results of laparovaginal repair of anterior vaginal prolapse in terms of perioperative morbidity and repair durability. DESIGN: Longitudinal study of a consecutive series of women assessed with the pelvic organ prolapse quantification (POPQ) system before and after laparoscopic paravaginal repair of anterior vaginal prolapse (Canadian Task Force classification II-2). SETTING: University hospital in South Australia. PATIENTS: Two hundred twelve women undergoing laparoscopic paravaginal repair for anterior compartment prolapse, with average follow-up of 14.2 months and 10 (4.7%) lost to follow-up. INTERVENTIONS: All women underwent bilateral laparoscopic paravaginal repair that was combined with uterosacral hysteropexy or colpopexy in women with concomitant level I defects (n = 42) and supralevator repair in those with posterior fascia defects (n = 47). Recurrences were treated with graft-reinforced anterior colporrhaphy (n = 18). MEASUREMENTS AND MAIN RESULTS: Nine women (4.2%) had major complications, and there were 61 minor complications. The POPQ assessment on follow-up (mean 14.2 months) gave a prolapse cure of the laparoscopic repair of 76% (95% CI 70.7%-82.1%). Eighteen of 23 women with a residual central defect subsequently had a graft-reinforced anterior colporrhaphy, after a mean interval of 14 months, which increased the cure rate to 84% (95% CI 79.6%-89.3%). CONCLUSION: Laparoscopic paravaginal repair followed by graft-reinforced anterior colporrhaphy for central defects, when necessary, is associated with a low morbidity rate and achieves an anatomic cure rate greater than 80%.     

The use of submucosal small intestinal mesh in laparoscopic sacrocolpopexy and posterior vaginal repair

Sacrocolpopexy for vaginal vault prolapse changes the mechanical axis of the vagina and can result in prolapse of the anterior or posterior vaginal walls. Thirteen consecutive patients were examined before and after surgery using the POP-Q International Continence Society scoring system for genital prolapse. One patient had an intact cervix and therefore underwent sacrocervicopexy, whereas two patients had sacrohysteropexy. The other patients had sacrocolpopexy. Porcine small intestinal submucosal (SIS) absorbable mesh (Surgisis, Cook) was fixed to the posterior vaginal wall. The posterior wall remained well supported following SIS mesh interposition between the posterior vaginal wall and the rectum. Meshes can provide the much-needed support in pelvic reconstruction.     

Operative Therapie des Descensus

Surgery for pelvic organ prolapse is one of the most frequent gynecologic procedures. Pelvic organ prolapse is caused by three factors: high intra-abdominal pressure, connective tissue disorders, and dysfunction of the pelvic floor musculature. There are three anatomic compartments: anterior (anterior vaginal wall, bladder, and urethra), central (uterus, cervix, the apex of the vagina, and cul-de-sac), and posterior wall compartments (posterior vaginal wall and rectum). Vaginal support is provided by the perineal membrane, the arcus tendineus fascia pelvis, the cardinal-uterosacral ligament complex, and the crura of the levator ani muscles. These factors have to be taken into account when planning reconstructive surgery. Reconstruction of defects in the anterior vaginal wall consists of abdominal and vaginal paravaginal repair and anterior colporrhaphy. Abdominal sacral colpoperineopexy, sacrospinous vault suspension, and obliterative surgery are used for repair of defects in the central compartment, while defects in the posterior compartment are reconstructed by posterior colporrhaphy, perineorrhaphy, and culdoplasty (Halban, Moschcowitz and McCall).     

生物补片用于阴道后壁修补术的近期效果初探

目的：初步探讨生物补片用于阴道后壁修补手术的安全性和有效性。方法：2006年1月至5月为阴道后壁膨出6例患者施行生物补片阴道后壁修补术。患者平均年龄55．2岁（40-70岁），体重指数平均27．34（22．60-31．25），POP-Q分度Ⅱ度4例，Ⅲ度2例。结果：6例患者总的手术时间平均65min（30-90min），其中放置补片的平均时间为15min。术中平均出血量60ml（10-100ml）。术后患者平均住院4．7天（3-8天），术中及术后未见并发症。随访6例患者平均15．4个月（14．3-17．9个月），随访时行盆腔检查再次POP-Q分度，结果表明，短期内解剖结构得到较为成功的恢复（Bp点较术前减小，P〈0．05）；并用盆腔器官脱垂-尿失禁患者性生活调查问卷（PISQ）了解患者术后性生活质量，结果表明术后PISQ评分为86．33±8．82，较术前的75．17±13．97上升，虽差异无统计学意义（P〉0．05），但提示不影响患者术后性生活的质量。结论：生物补片可用在阴道后壁膨出修补手术中，术后短期随访，解剖结构均恢复达到客观治愈，且不影响患者术后的性生活质量，但有待更多样本、设置对照组及更长时间的观察和研究。     

One-Year Outcome of Concurrent Anterior and Posterior Transvaginal Mesh Surgery for Treatment of Advanced Urogenital Prolapse: Case Series

Study ObjectiveTo estimate the safety and efficacy of performing concurrent anterior and posterior transvaginal mesh surgery using a commercially available kit (Gynecare PROLIFT Pelvic Floor Repair System; Ethicon, Inc., Somerville, NJ) for treatment of advanced urogenital prolapse (stage III or higher, Pelvic Organ Prolapse Quantification [POP-Q] system staging).DesignCase control series study (Canadian Task Force classification II-2).SettingMedical school–affiliated hospital.PatientsForty-three patients with severe prolapse, POP-Q stage III (n = 23) or IV (n = 20), underwent surgery and were followed up for more than 1 year. In patients with any prolapse greater than stage I, surgery were considered to have functional failure. The Surgical Satisfaction Questionnaire was used for subjective evaluation at 1 year postoperatively.InterventionsExtensive pelvic reconstructive procedures were primarily performed using a combination of the PROLIFT anterior and posterior pelvic systems (i.e., similar to sparing the intermediate section of the PROLIFT total pelvic system). The concurrent pelvic surgery included sequential vaginal total hysterectomy, perineorrhaphy, and suburethra sling, if indicated. Additional subjective and objective evaluations included POP-Q staging, urodynamic assessment, and preoperative and 12-month postoperative questionnaires.Measurements and Main ResultsObjective and subjective data were available for 42 patients. The subjective cure rate and objective success rate for prolapse at 12-month follow-up was 95.2% and 97.6%, respectively. Mean follow-up was 15.7 months, operation time was 79.2 minutes, operative blood loss was 109.1 mL, and postoperative hospital stay was 4.1 days. Intraoperative and postoperative complications were minor. All patients voided spontaneously before discharge. One mesh extrusion, no wound defective healing, and no rejection were observed. Two patients developed asymptomatic recurrent rectocele (stage II, POP-Q staging) that required no surgical intervention. Urodynamic parameters related to voiding dysfunction improved after surgery. Significant improvements were found using the Incontinence Impact Questionnaire and the Urogenital Distress Inventory.ConclusionUsing concurrent anterior and posterior transvaginal mesh for pelvic reconstructive surgery is a safe and an effective method for treating advanced pelvic prolapse. Mesh-related complications are likely minimal, and mesh protrusion at the apex is likely to not occur. Further studies with longer follow-up are required to evaluate long-term effectiveness.     

Cystocele repair by vaginal approach with a tension-free transversal polypropylene mesh. Technique and results

OBJECTIVE: To evaluate mid term results, tolerance and efficiency of interposition of a tension-free polypropylene monofilament mesh by vaginal approach for the repair of cystoceles. PATIENTS AND METHODS: Fourty consecutive women underwent this new procedure between March 2001 and September 2002. After complete dissection of the cystocele, the polypropylene mesh (Gynemesh), Gynecare, Ethicon, Johnson & Johnson, France), proper cut-out was positioned under the bladder without any fixation. The lateral extensions of the mesh where introduced in the para-vesical spaces in contact with the arcus tendinus fascia pelvis. RESULTS: Before surgery all patients had cystocele of more or equal than grade II according to the POP-Q classification. Eight had grade II cystocele (20%) and 32 had grade III cystocele (80%). Thirty women had associated posterior or median prolapse (82.5%). Thirty women had urinary incontinence (75%). Mean age was 63.9 years (51-78). The procedure was performed without any difficulty in all cases. Duration of a cystocele cure procedure was 20 min +/- 2.2 (16-24). Mean follow-up is 16.4 months +/- 4.7 (12-24). The early complication rate was 7.5% (two vaginal erosions and one complete exposition of the mesh which requires secondary ablation). There was no mesh infection. The success rate was 95%. The satisfaction index overpasses 80% in 95% of our patients 6 months after the cystocele repair. DISCUSSION AND CONCLUSIONS: The interposition of a sub-vesical transversal tension-free polypropylene mesh by the vaginal route seems to be an excellent procedure in the definitive surgical treatment of grades II and III anterior vaginal wall prolapse. This new procedure is simple, mini-invasive, reproducible and efficient with low morbidity and good tolerance.