The Sacrospinous Vaginal Vault Suspension: Critical Analysis of Outcomes

One hundred and three women with a preoperative diagnosis of a pelvic support defect underwent right sacrospinous fixation of the vaginal apex. The procedure was performed either therapeutically (in 63 subjects with vaginal vault eversion) or prophylactically (40 patients with severe uterovaginal prolapse), and was associated with other reconstructive procedures to repair the coexisting cystocele, enterocele or rectocele. Preoperative and postoperative assessments of each vaginal site were compared and the results in the cure of stress urinary incontinence, if present, were evaluated with regard to the type of surgery performed. The overall rate of satisfactory results in the repair of the superior vaginal defect was 94%, and good anatomic results were achieved in the repair of either enterocele or rectocele. Conversely, the repair of the anterior vaginal wall was not as good as in the posterior and superior vaginal sites. Stress urinary incontinence was successfully managed in 72% of the women using different anti-incontinence procedures.     

Results of cystocele repair: a comparison of traditional anterior colporrhaphy, polypropylene mesh and porcine dermis

PURPOSE: Because traditional anterior colporrhaphy can have a high recurrence rate, we assessed the recurrence rate of 3 methods of cystocele repair, including 1) traditional anterior colporrhaphy, 2) repair using porcine dermis interposition graft and 3) repair using polypropylene mesh. Additionally, we compared the rate of erosion of porcine dermal graft with that of polypropylene mesh. MATERIALS AND METHODS: The records of patients who underwent cystocele repair by the same urologist using porcine dermal graft, polypropylene mesh or traditional repair from January 1999 to August 2005 were reviewed. Data were collected on history, physical examination, outcomes and complications. Using the Baden-Walker system a cystocele of grade 2 or higher on followup examination was considered recurrence. RESULTS: A total of 119 patients underwent cystocele repair from January 1999 to August 2005. Followup was available on 99 patients and it averaged 13.5 months (range 2 to 46). Of the patients 56 (57%) underwent cystocele repair using porcine dermal graft, 25 (25%) received polypropylene mesh and 18 (18%) underwent traditional repair. Of the 99 patients 22 (22%) had cystocele recurrence. Based on the type of repair 36% of patients (20 of 56) with porcine dermal grafts had recurrence compared to 4% (1 of 25) and 6% (1 of 18) using polypropylene and traditional repair, respectively. Mean time to cystocele recurrence was 4.9 months (range 0.5 to 20). A total of 12 patients (21%) had extrusion of porcine grafts through the anterior vaginal wall incision compared to 1 (4%) with polypropylene mesh. CONCLUSIONS: In our patient population the short-term failure rate for anterior vaginal wall prolapse using porcine dermis interposition graft was higher than that for traditional anterior colporrhaphy or polypropylene mesh. In addition, the incidence of vaginal extrusion of porcine graft was unacceptably high. Porcine dermis is a less suitable material for cystocele repair than polypropylene mesh or traditional anterior colporrhaphy. Prospective, randomized trials are necessary to determine the true efficacy and complication rates of these graft materials for anterior vaginal wall prolapse repair.     

Burch bladder neck suspension for cystocele repair: the necessity of combined vaginal procedures for severe cases.

BACKGROUND: Burch operation is an accepted form of bladder neck suspension for small cystoceles. The purpose of the present study was to evaluate the efficacy of Burch repair for severe cystoceles compared with Burch repair along with vaginal procedures. METHODS: A total of 14 patients with severe cystocele (grade III-IV) treated with open Burch operation were evaluated retrospectively. Of these patients, eight were Burch only and the remaining six underwent combined Burch with vaginal repair (anteroposterior vaginal wall plasty and hysterectomy). RESULTS: After a mean follow up of 40 months (range 6-80), cystocele recurred in one patient at 1 month, and rectocele became prominent in three patients, including one who also presented uterine prolapse among the Burch-only group. Conversely, all six patients who underwent the combined operation showed no occurrence of cystocele or rectocele. The proportion of patients not failing treatment was significantly higher in the combined operation group than in the Burch-only group. Intermittent self-catheterization was needed in one patient from the combined operation group for 6 months, but all other patients had restored smooth urination within a few weeks after the operation. CONCLUSIONS: The results suggest that, for severe cystoceles, Burch-only repair is insufficient and combined Burch with vaginal repair should be used to manage various pelvic hypermobility symptoms.     

Cystocele—vaginal approach to repairing paravaginal fascial defects

The objective of this study is to determine the efficacy and safety of vaginal approach to repair paravaginal defects in patients with symptomatic cystocele. This was a retrospective study of 66 women with a diagnosis of symptomatic cystocele grade 2 to 4, referred to our unit between January 2002 and March 2005. A clinical evaluation was carried out using the Baden–Walker classification before and after the surgery. The same surgical team performed every surgery. The repair of paravaginal fascial defects was carried out through a vaginal approach, exposing the arcus tendineus. The paravaginal fascial defects were corrected through suspension of vesicovaginal fascia to the arcus tendineus with nonreabsorbable Ethibond 0 sutures. Women were seen for follow-up at 3, 6, and 12 months. The presence of well-demarcated vaginal lateral sulci at grade 0, firmly apposed to the lateral pelvic sidewalls and no anterior relaxation with Valsalva maneuver, were used as criteria for cure. Grade 2 cystocele was diagnosed preoperatively in most women. The mean duration of complaints due to prolapse was 64.6 months. There were no major intraoperative complications. Mean time of inpatient stay was of 4.9 days. The cure rate at 12 months was 91.6%. There were five cases of recurrence of cystocele 6 months after surgery. Surgical repair of symptomatic cystocele through a paravaginal approach is a safe and efficacious technique. Vaginal approach to repair paravaginal fascia defects had a low postoperative morbidity and high cure rate at 12 months (91.6%).     

Anterior Repair Using Bologna Procedure: Long-term Results on Stress Urinary Continence

The aim of this study was to describe the prognostic factors and long-term results on stress urinary continence of the Bologna procedure for bladder neck suspension in women undergoing vaginal repair for large cystocele. This was a cohort study and questionnaire-based outcomes analysis. Subjects were 218 women operated on between 1982 and 1992. Their mean age was 66 years. The Bologna vaginal wall sling was associated with vaginal hysterectomy in 199 cases and with posterior colporrhaphy in 202 cases. Median follow-up was 69 months. Of the 218 patients, 182 were continent at stress (83%). The risk factors were low urethral pressure (<30 cmH₂O, RR = 2.42), severity of preoperative stress urinary incontinence (RR = 2.01 for grade I, 4.03 for grade II and 8.10 for grade III), and an exteriorized cystocele (RR = 0.45). We concluded that the Bologna procedure allows bladder neck suspension during vaginal repair of cystocele, with good results on future continence.     

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.     

Porcine dermis interposition graft for repair of high grade anterior compartment defects with or without concomitant pelvic organ prolapse procedures

PURPOSE: Recent literature suggests that graft interposition may decrease the incidence of cystocele recurrence. We describe our experience with porcine dermis interposition grafts for the repair of high grade cystoceles. MATERIALS AND METHODS: We retrospectively reviewed the charts of all women who underwent surgical repair of high grade cystocele. Prolapse was graded with the Baden-Walker and Pelvic Organ Prolapse Quantitation systems, and all patients were evaluated with multichannel videourodynamics. Concomitant stress urinary incontinence was corrected with a pubovaginal sling and vault prolapse was corrected with iliococcygeus vault suspension. Postoperatively patients were evaluated at 2 weeks, 2 months, 6 months and annually thereafter. RESULTS: A total of 70 patients underwent cystocele repair with a porcine dermis interposition graft. Concomitant procedures included a pubovaginal sling in 65 patients and vaginal vault suspension in 50. Mean followup was 24 months. There were no intraoperative complications. Of the patient 59 (91%) are currently dry. One patient had recurrent vault prolapse without cystocele (C -2), which was successfully repaired with abdominal sacral colpopexy. Six patients (8.6%) experienced recurrent grade II (Ba 0) cystocele but continued to be asymptomatic. Three others (4.3%) had recurrence of grade III (Ba +2) cystocele and elected not to undergo reoperation. Two of 6 de novo rectoceles (grade II, Ap and -1 and Bp 0) were repaired with site specific repairs. Superficial vaginal wound separation in 1 case was successfully treated conservatively. CONCLUSIONS: In cases of high grade cystocele interposition of porcine dermis represents a successful and safe treatment option. Cystocele recurrence is typically low grade and it frequently may not require additional surgery.     

One-year urodynamic outcome and quality of life in patients with concomitant tension-free vaginal tape during pelvic floor reconstruction surgery for genitourinary prolapse and urodynamic stress incontinence

The aim of the study was to examine the 1-year urodynamic outcome and quality of life in patients who have had concomitant tension-free vaginal tape insertion during pelvic floor reconstruction surgery. The medical notes of a retrospective cohort of 45 patients who had undergone tension-free vaginal tape together with pelvic floor reconstruction surgery were reviewed. The operative information, the results of the urodynamic studies and the change in the quality-of-life scores 1 year after surgery were examined. The quality of life was assessed with both general and disease-specific quality-of-life questionnaires (General Health Questionnaire (GHQ-12), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7)). Patient satisfaction was assessed with the validated Chinese version of the Client Satisfaction Questionnaire (CSQ). Forty-five patients underwent tension-free vaginal tape insertion together with pelvic floor reconstruction surgery. The overall objective cure rate was 43%. There was a significant improvement in the disease specific quality-of-life assessment (UDI-6 score 38.3–15.5; P<0.01) and (IIQ-7 score 15.0–4.0; P<0.01). The patients who had a concomitant cystocele repair had a worse objective cure rate than patients without concomitant cystocele repair (38% vs 67%; P=0.19).Abbreviations SUI Stress urinary incontinence - TVT Tension-free vaginal tapeEditorial Comment: This retrospective cohort study compared objective cure rates (negative stress test and normal cystometry) and quality of life surveys among patients who underwent concomitant tension-free vaginal tape procedures and cystocele repair with those undergoing TVT procedures alone. At 1 year, the reported success rate of the combine procedures was 37% as compared to 67% for those patients undergoing TVT alone. These rates are lower than those reported in most previous studies. Without more information concerning pre- and post-operative urodynamic evaluations and techniques employed in the cystocele repair, it is difficult to explain the differences in outcomes from those reported by other authors. Prospective randomized trials are needed to evaluate the long-term cure rates and complication rates of TVT combined with cystocele repair in order to formulate clinical recommendations for future practice.     

A New Vaginal Procedure for Cystocele Repair and Treatment of Stress Urinary Incontinence

Purpose

Treatment of cystoceles and stress urinary incontinence continues to evolve. We evaluated the efficacy of a new vaginal wall sling procedure for cystocele repair and treatment of stress urinary incontinence.

Materials and Methods

We present our experience with the vaginal wall sling procedure in 36 patients (mean age 67.4 years) with cystocele. Of the patients 16 had undergone a prior pelvic operation. With our technique a vaginal wall tube was created with the base in the bladder neck and fixation to the periurethral tissues or suspension to the suprapubic area.

Results

Success rates were 95 and 82 percent for cystocele and stress incontinence repair, respectively. Mean followup was 17 months. Morbidity was minimal and mean hospitalization was less than 5 days.

Conclusions

This original, simple, noninvasive treatment is applicable for all cystoceles regardless of patient age or sexual activity, and has shown encouraging results. Based on our experience we recommend this procedure for repair of cystoceles and stress urinary incontinence.     

Transabdominal repair of cystocele by wedge colpectomy during combined abdominal-vaginal surgery

The aim of the study was to evaluate the effectiveness of transabdominal wedge colpectomy as surgical treatment for cystocele. One hundred and sixty-three women with either first or second-degree cystocele (Beecham classification), rectocele and concomitant stress urinary incontinence or benign pelvic masses were submitted for a combined operation. Transabdominal repair of the cystocele was performed by wedge colpectomy employing two different absorbable sutures, Vicryl and PDS. The choice of suture was not random but depended on the period at which surgery was performed. Data obtained were analyzed with Student’st-test and Fisher’s exact test. The cystocele cure rate was 90.2% (110 out of 122) at 3-year follow-up and was significantly associated with the preoperative degree, being 95.5% and 76.5% in first and in second degree, respectively (P=0.003). At 1-year follow-up the cure rate was significantly associated with the type of the suture employed (P=0.01). At 2-year follow-up rectocele cure rate was 97.2% and vaginal vault prolapse appeared in 3.5% of cases. Stress urinary incontinence relapsed in 10% of patients after Burch colposuspension. After the operation 94.1% of the women declared normal coitus. In the present series wedge colpectomy was found to be effective in repairing first-degree cystocele, whereas a high incidence of relapse was observed when second-degree cystocele was present preoperatively. The suture material employed influenced the cure rate. EDITORIAL COMMENT: Wedge colpectomy of the anterior vaginal wall has been described by Weinstein and Roberts (1949), Macer (1978) and Drutz (1991) as a means of abdominally correcting anterior vaginal wall relaxation. Although the present authors did not find as high a success rate with the procedure as the previous investigators, they do show that an abdominal approach to cystocele repair is feasible. There are instances when such an approach would be advantageous to avoid repositioning for a vaginal anterior wall repair. The danger of abdominal anterior wedge colpectomy lies in the dissection of the bladder base from the underlying vaginal wall. Dissection in this area must proceed carefully to avoid trauma to the bladder, ureters and, more distally, to the urethrovesical junction. Performed carefully, with attention directed at avoiding these structures, the abdominal wedge colpectomy is a potentially useful procedure to add to the armamentarium of the urogynecologic surgeon.     

Urogenitals prolapse: revision of concepts

The prolapse is the exteriorization of the pelvic organs through the vagina, this condition may affect the quality of life. The prolapse was diagnosed in 50% of multiparous women. It is estimated that a woman throughout her life, has 11% risk of needing surgery for correction of pelvic organ prolapse or urinary incontinence. The prolapse may occur at the anterior vaginal wall (cystocele) at the vaginal, uterus (histerocele) or at the posterior wall (or rectocele enterocele). For the unfit patient obliteratives procedures may be indicated and recontructives for pacients wih good performance status. It is important for reconstructive surgery a correct diagnosis, for the specific defect repair. When indicated, meshes can be used to add strength to the poor quality tissues.     

Solvent-dehydrated dermal allograft (AXIS™) augmented cystocele repair: longitudinal results

Introduction and hypothesis

Surgical repair options for pelvic organ prolapse (POP) include native tissue, allograft, xenograft, and synthetic grafts. Solvent-dehydrated dermal allograft (SDDG) has an improved safety profile. We evaluated the long-term safety and efficacy of SDDG use for cystocele repair.

Methods

A total of 184 patients completed a minimum follow-up of 12 months. Incontinence Impact Questionnaire (IIQ), Urogenital Distress Inventory (UDI), and Visual Analogue Scale (VAS) were used pre and post operatively. Recurrent cystocele grade?≥?II and/or repeat cystocele repair were considered objective failure.

Results

Preoperatively, 17 patients (10%) had grade IV cystocele, 87 (47%) grade III, 70 (38%) grade II, and 10 (5%) grade I. All patients underwent SDDG cystocele repair with/without vaginal sling and/or POP repair and/or hysterectomy. Mean hospital stay was 0.58 days (range 0–4), mean estimated blood loss (EBL) was 111 mL, and mean length of Foley catheterization was 1.85 days (range 0–28). Postoperatively, 113 patients (64%) had no recurrent cystocele, 34 (19%) had grade I, 19 (11%) grade II, and 10 (6%) grade III cystocele. None had grade IV cystocele. Nineteen patients (10.3%) underwent repeat cystocele repair. Thirty-eight patients (21.6%) had postoperative recurrence (recurrent cystocele grade?≥?II and/or repeat cystocele repair). Dermal allograft related adverse events included 1 (0.5%) allograft vaginal exposure, dyspareunia 1 (0.5%), and transient hydronephrosis in 1 (0.5%). There were no vascular, vesical, visceral or neurological injuries.

Conclusions

These results indicate that SDDG augmented cystocele repair is a safe procedure, with low morbidity, and it’s success is comparable to other techniques.

     

Vaginal mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft in 138 women: a comparative study

The objective of this study was to compare mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft mesh. We retrospectively analyzed 138 consecutive cases of transvaginal repair of cystocele using synthetic mesh. The study endpoint was the pathological evidence of vaginal erosion. Multiple logistic regression was used to determine independent predictors of vaginal erosion. One hundred and thirty eight women (ages 30-83 years) with cystocele between October 1999 and October 2004, from a French University Hospital, participated in this study. Cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. The median follow-up was 32.1 months (range 7.5-59.9) in the Gynemesh group and 7.1 months (range 1-21.9) in the Gynemesh-Soft group. Vaginal erosion was reported in 27 (20%) of the patients. Anatomically, the success rate was 95% (131/138). There was no statistically significant difference between the Gynemesh and the Gynemesh-Soft meshes [the rate of vaginal erosion of the mesh was 16% (15/89) vs 24% (12/49), respectively, p=0.39]. Univariate analysis only identified age class as factor significantly associated with the probability of vaginal erosion. Multivariate analysis revealed that age class is an independent predictive factor of vaginal erosion (age > 70 years, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3-9.7, p=0.010). Furthermore cystocele stage > 2 (Baden and Walker classification) is a protective factor against vaginal erosion (OR 0.3, 95% CI 0.1-0.8, p=0.016). Thirteen symptomatic patients (13/27, 48%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. Two patients (2/27, 7%) underwent a complete excision of the mesh. The incidence of de novo dyspareunia was 9% in patients with vaginal erosion and 11% in patient without mesh erosion (p=0.85). There was no occurrence of bladder or urethral erosion and no vaginal or pelvic infection. Isolated vaginal erosion of the mesh did not prove to be problematic. Gynemesh-Soft mesh does not decrease the incidence of vaginal erosion. Age > 70 years is an independent predictive factor of vaginal erosion. We recommend that mesh placement by vaginal route should be avoided by women with moderate cystocele. Where possible, total hysterectomy and vertical incision should also be avoided. Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur. A multivariate analysis reveals that the incidence of vaginal erosion is not significantly different between Gynemesh and Gynemesh-Soft meshes. Other factors of erosion are analyzed.     

Preoperative screening for latent stress incontinence in women with cystocele

A preoperative urodynamic investigation with and without a vaginal pessary ring including simultaneous urethrocystometry and urethral pressure profiles in supine and standing position during coughing was evaluated in 41 continent women with cystocele. Following the application of the vaginal pessary ring, loss of urine was demonstrated in six patients, in whom a negative urethral closure pressure was found only when the pessary ring was inserted, suggesting that latent stress incontinence might become manifest after surgical repair of the cystocele. These patients were all continent during the follow-up period of 12–18 months after Manchester repair combined with urethrocystopexy. The remaining 35 patients with normal urodynamic registrations with and without an inserted pessary ring had no signs of urinary incontinence during the follow-up period after the Manchester repair. Thus, the present urodynamic screening was found to be valuable for preoperative selection of an adequate surgical method in order to avoid postoperatively manifest stress incontinence after anterior colporaphy.     

Operative technique for the repair of posthysterectomy vaginal prolapse

The operative technique of our own modified sacral colpopexy with a fascial strip for the repair of posthysterectomy vaginal prolapse is described. The complete removal of the enterocele is important. The fascial strip remains extraperitoneal. Only absorbable sutures have been used. Excellent vaginal support was achieved in all cases operated on with the method described. Possible cystocele and rectocele must be corrected separately prior to sacral colpopexy.     

Lack of effect of concomitant stage II cystocele repair on lower urinary tract symptoms and surgical outcome after tension-free vaginal tape procedure: randomized controlled trial

Introduction and hypothesis

The aim of this study was to compare the lower urinary tract symptom changes and surgical outcome between the tension-free vaginal tape (TVT) procedure with and without concomitant stage II pelvic organ prolapse (cystocele) repair in a randomized clinical trial setting.

Methods

Patients with urodynamically proven stress urinary incontinence (SUI) and asymptomatic stage II cystocele were randomly and equally allocated to either a TVT and concomitant cystocele repair group or TVT only group. SUI was corrected with TVT in all cases. The cystocele repair procedure was performed with Gynemesh®. Lower urinary tract symptoms and surgical outcome were assessed at postoperative year 1. Lower urinary tract symptoms were assessed with the American Urological Association Symptom Score (AUASS) questionnaire, uroflowmetry, and postvoid residual (PVR).

Results

The cure rate of TVT only and the concomitant repair group was 87 and 91 %, respectively (p?>?0.05). Cystocele was cured in all patients in the concomitant repair group. After the operation, the total AUASS were 6.4 and 8.4 in the TVT only group and concomitant repair group, respectively, with no statistical difference. There was no difference in the change in peak flow rate (Q_max) and PVR between the two groups. The prevalence of postoperative mixed incontinence was not different between the two groups.

Conclusions

In patients with stage II cystocele and SUI, there was no difference in the surgical outcome and lower urinary tract symptoms between the TVT sling only group and concomitant repair group. Cystocele repair can be safely omitted in patients with stage II cystocele.     

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

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

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.     

Anatomic and Functional Outcome of Vaginal Paravaginal Repair in the Correction of Anterior Vaginal Wall Prolapse

Over a 2-year period 45 patients with bilateral paravaginal support defects underwent vaginal paravaginal repair. Postoperative evaluations were conducted and anatomic outcome was determined by vaginal examination, with grading of vaginal wall support. Functional outcome was assessed by a standardized quality of life questionnaire, voiding dairy and standing stress test with a full bladder. Thirty-five patients had long-term follow-up with a mean of 1.6 years (range 1–85). The recurrence rates for displacement cystocele, enterocele and rectocele were 3% (1/35), 20% (7/35) and 14% (5/35), respectively. In no patients did vault prolapse develop or recur. Subjective or objective evidence of persistent stress urinary incontinence was found in 57% of patients (12/21). Vaginal paravaginal repair is a safe and effective technique for the surgical correction of anterior vaginal wall prolapse but has limited applicability in the surgical correction of genuine stress incontinence.     

Treatment results using a mixed fiber mesh in patients with grade IV cystocele

PURPOSE: We determined the efficacy of a modification of the 4-corner bladder and bladder neck suspension procedure using mixed fiber mesh to correct grade IV cystocele. MATERIALS AND METHODS: We evaluated 15 women with a mean age of 67 years who had severe anterior vaginal wall prolapse, of whom 3 had concurrent enterorectocele. Previously 5 patients had undergone repair of anterior vaginal wall prolapse and 2 had undergone procedures for stress urinary incontinence. In 10 patients type II stress urinary incontinence was diagnosed with urethral hypermobility and abdominal leak point pressure greater than 90 cm. water. No patients with intrinsic sphincter deficiency were enrolled in the study. A mixed fiber mesh was positioned using a modification of the 4-corner bladder and bladder neck suspension technique. Patients with concurrent enterorectocele underwent simultaneous formal repair of the posterior descensus. RESULTS: All patients were available for postoperative pelvic examination at 3-month intervals. Mean followup was 23.4 months (range 18 to 39). Of the 15 women 13 were continent (dry) at followup. No recurrent cystocele was evident, except in 1 patient who presented with segmental posterior bladder prolapse. In 2 patients new onset enterorectocele developed 6 months after mesh implantation. CONCLUSIONS: Our study confirms that the addition of mesh to the classic 4-corner bladder base and neck suspension procedure effectively treats incontinence and cystocele. We recommend this method for cases in which traditional techniques have previously failed and when the quality of suspending tissue is poor or defective, as in connective tissue disease. However, the risk of worsening enterorectocele or its new onset must be considered.