Repair of vaginal vault prolapse and pelvic floor relaxation using polypropylene mesh

PURPOSE OF REVIEW: Innumerable techniques have been described for vaginal vault prolapse and enterocele repair including abdominal (open, laparoscopic, and robotic) and vaginal techniques. Recently, the use of surgical mesh in pelvic floor surgery has become increasingly popular due to the high incidence of recurrence with primary repairs and no surrogate material. The increasing variety of available materials and techniques, combined with a lack of well conducted clinical trials, make the choice of repair to use difficult. RECENT FINDINGS: This article provides an update review on the different procedures available to the urogynecologist and female urologist for repair of vault prolapse. We will also discuss a new surgical technique for the repair of vault prolapse, which recreates the sacrouterine-cardinal ligament complex and reconstructs the pelvic floor with mesh. SUMMARY: The best approach to vaginal vault prolapse remains unknown. Surgeon comfort and preference as well as proper patient selection remain critical. The use of graft materials in pelvic floor reconstruction should have limited use in a carefully selected patient population. There is a need for well powered, controlled, long-term, randomized studies with patient generated quality-of-life questionnaires comparing the short and long-term outcomes of these techniques.     

Positive symptom improvement with laparoscopic uterosacral ligament repair for uterine or vaginal vault prolapse: interim results from an active multicenter trial

STUDY OBJECTIVE: To evaluate the use of laparoscopic uterosacral ligament repair for long-term patient symptom improvement in patients with uterine prolapse or posthysterectomy vaginal vault prolapse and to evaluate how laparoscopic instrumentation kits facilitate procedure performance for the surgeon. DESIGN: Nonrandomized, prospective, multicenter case series (Canadian Task Force classification II-2). SETTING: Five clinical sites consisting of 4 community hospitals and 1 university medical center. PATIENTS: Seventy-two patients with stage II or worse uterine prolapse (58%, n = 42) or posthysterectomy vaginal vault prolapse (42%, n = 30). One patient with stage I vaginal vault prolapse was included in the group due to her significant symptoms. INTERVENTIONS: Laparoscopic uterosacral ligament repair was performed on all patients; round ligament truncation was also performed selectively on patients with uterine prolapse. Fifty-seven percent (41 patients) had concomitant pelvic procedures. MEASUREMENTS AND MAIN RESULTS: At 12-month follow-up, Pelvic Organ Prolapse Quantification (POP-Q) scores and patient self-reported symptom scores were significantly improved over baseline after laparoscopic repair of pelvic organ prolapse. Positive mean change in POP-Q score was 14.4 (p = .0003) for uterine prolapse repair and 9.28 (p = .017) for vaginal vault prolapse repair. Positive mean change in total symptom score was 20.36 (p <.0001) for uterine prolapse repair and 11.43 (p = .005) for vaginal vault prolapse repair. Surgeons reported a mean procedure time of 31.6 minutes for uterine prolapse repair and 21.7 minutes for vaginal vault prolapse repair. A mean rating of 7.5 was documented for ease of use for the uterine prolapse kit and 4.1 for the vaginal vault prolapse kit on a scale of 1 to 10. CONCLUSION: Laparoscopic uterosacral ligament repair improves symptoms and POP-Q scores over the long term in patients with uterine or vaginal vault prolapse. Laparoscopic instrumentation kits facilitate procedure performance for the surgeon with expedited surgery times.     

Bilateral transvaginal sacrospinous colpopexy: Preliminary experience

OBJECTIVE: Our goal was to determine how often a transvaginal sacrospinous colpopexy procedure can be done bilaterally. STUDY DESIGN: Between August 1993 and July 1996, 66 patients were prospectively evaluated for uterine prolapse (19 patients) and posthysterectomy vaginal vault prolapse (47 patients). Twenty-six patients (25 with posthysterectomy vaginal vault prolapse) underwent an abdominal sacral colpopexy. The remaining 40 patients (18 with uterine prolapse, 22 with posthysterectomy vaginal vault prolapse) were preoperatively and intraoperatively assessed for a bilateral sacrospinous colpopexy. All patients with uterine prolapse underwent hysterectomy. RESULTS: In 10 of the 18 (56%) patients with uterine prolapse and in 16 of the 22 (73%) patients with posthysterectomy vaginal vault prolapse, bilateral suspension to the sacrospinous ligament was carried out. Follow-up has ranged from 6 to 40 months, and no recurrent vaginal cuff prolapses have been detected in any patients. In 3 patients, however, all in the bilateral fixation categories, distention cystoceles have developed; one patient has undergone a successful anterior colporrhaphy. CONCLUSIONS: The bilateral suspension is different from the unilateral suspension in that the former requires significant intraoperative judgment in its feasibility and in maintaining the width of the vaginal cuff to allow a bilateral suspension without tension. A bilateral fixation appears more attainable in a patient with posthysterectomy vaginal vault prolapse than in one with uterine prolapse.(Am J Obstet Gynecol 1997;177:62)     

Laparoscopic repair of vaginal vault prolapse by lateral suspension with mesh

Background

To evaluate the long-term outcomes of laparoscopic lateral suspension using mesh reinforcement for symptomatic posthysterectomy vaginal vault prolapse.

Materials and methods

We analyzed in a prospective cohort study all the women treated by laparoscopic lateral suspension with mesh for symptomatic vaginal vault prolapse between January 2004 and September 2010. In this procedure, the mesh is laterally suspended to the abdominal wall, posterior to the anterior superior iliac spine. We performed systematic follow-up examinations at 4 weeks, 6 months and yearly postoperatively. Clinical evaluation of pelvic organ support was assessed by the pelvic organ prolapse quantification (POP-Q) grading system. Main outcome measures were recurrence rate, reoperation rate for symptomatic recurrence or de novo prolapse, mesh erosion rate, reoperation rate for mesh erosion, total reoperation rate.

Observations and results

Of the 73 patients seen at a mean 17.5 months follow-up, recurrent vaginal vault prolapse was registered in only one woman (success rate of 98.6 %). When considering all vaginal sites, we observed a total of 13 patients with recurrent or de novo prolapse (17.8 %). The non-previously treated posterior compartment was involved in eight cases (new appearance rate of 11 %). Of these 13 women, only 6 were symptomatic, requiring surgical management (reoperation rate for genital prolapse of 8.2 %). Four patients presented with mesh erosion into the vagina (5.5 %). Two required partial vaginal excision of the mesh in the operating room (2.7 %). There were no mesh-related infections. The total reoperation rate was 11 %.

Conclusion

Laparoscopic lateral suspension with mesh interposition is a safe and effective technique for the treatment of vaginal vault prolapse. This approach represents an alternative procedure to the laparoscopic sacrocolpopexy.     

Perioperative course and medium-term outcome of the transobturator and infracoccygeal hammock for posthysterectomy vaginal vault prolapse

Objective

To describe the perioperative course and medium-term anatomic and functional outcomes of the transobturator-infracoccygeal hammock for posthysterectomy vaginal vault prolapse repair.

Methods

A prospective consecutive series of 52 women with a stage 2 vaginal vault prolapse or higher that occurred after total hysterectomy who underwent surgery between 2003 and 2007. Principal outcome measures were anatomic cure (stage 1 or lower) and impact on quality of life measured using the pelvic floor distress inventory (PFDI) and pelvic floor impact self-reported questionnaire (PFIQ). Anatomical results were analyzed using χ² and Fisher exact tests, and PFDI and PFIQ scores were analyzed using the Wilcoxon test.

Results

With a median follow-up of 36 months, the anatomic cure rate was 96%. Significant improvements were noted in POPQ-S scores after surgery (P < 0.05). Stress urinary incontinence was cured in 73% of patients and improved in 15% of patients. The PFDI and PFIQ scores were improved (P < 0.05). One mesh extrusion was observed. The rates of mesh contraction and new cases of dyspareunia were 31% and 13%, respectively.

Conclusion

The transvaginal mesh hammock represents a useful treatment for recurrent and major vaginal vault prolapse, and has few complications.     

High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to review retrospectively the functional and anatomic outcomes of women who underwent vaginal repair of enterocele and vault prolapse with the use of an intraperitoneal suspension of the vaginal vault to the uterosacral ligaments in conjunction with fascial reconstruction of the anterior and posterior vaginal wall. STUDY DESIGN: Two hundred two women with advanced symptomatic uterovaginal prolapse or posthysterectomy vault prolapse underwent a standard transvaginal procedure to correct their prolapse between January 1997 and June 2000. Anatomic results were assessed by standardized examination from 6 months to 3 years after the operation. Functional results were assessed subjectively and with standard quality of life questionnaires. The average age of the women was 60.3 years. Follow-up data were available for 168 of the 202 women. Fifty-three percent of the women had their uterus in place and underwent a vaginal hysterectomy. The prolapse repair was a primary procedure in 45.2% of the women and was performed for a recurrence or persistence in 54.8% of the women. Sixty percent and 78.6% of women underwent anterior and posterior repair, respectively. Thirty-five percent of the women underwent an anti-incontinence procedure. RESULTS: Eighty-nine percent of the women expressed satisfaction with the results of the procedure. Ten women (5.5%) underwent a repeat operation (by the authors) for recurrence of prolapse in one or more segments of the pelvic floor. Quality of life assessment revealed a significant reduction in all aspects of daily living, when the short forms of the incontinence impact questionnaire and urogenital distress inventory were evaluated before and after the operation. Major intraoperative complications included 5 cases (2.4%) of ureteral injury, 1 case of a small bowel injury, and 1 case of a pelvic abscess that required abdominal exploratory operation and diversion of the colon. CONCLUSION: High uterosacral ligament vaginal vault suspension with fascial reconstruction would seem to provide a durable anatomic repair with good functional improvement in patients with significant complex uterine or vaginal vault prolapse.     

脱细胞生物组织补片在盆底重建手术中的应用

目的初步探讨脱细胞生物组织补片在盆腔器官膨出患者盆底重建手术中的应用情况。方法选择北京大学人民医院妇科2006年5月至12月期间接受盆底修补和重建手术并应用脱细胞生物补片的盆腔器官膨出患者20例,其中子宫脱垂19例,子宫切除术后阴道穹隆脱垂Ⅱ度1例;合并存在膀胱膨出20例、直肠膨出17例。20例患者中17例同时行阴道前后壁修补术,3例行阴道前壁修补术;阴道前壁置入补片15例,阴道后壁置入补片2例,阴道前壁和后壁同时置入补片3例。结果20例患者总手术时间平均为113．1min（70～180min）,其中放置补片的时间平均为10min。术中出血平均为175ml（50～300ml）。术后恢复良好,平均随访9．3个月（6～12个月）,未发现补片侵蚀阴道黏膜情况,无感染发生。随访期间4例（20％）患者出现盆腔器官膨出复发,3例为膀胱膨出Ⅰ度,复发时间均为6个月复查时,其中2例随访12个月时仍为膀胱膨出Ⅰ度,另1例随访8个月时也为膀胱膨出Ⅰ度,未见加重;1例为膀胱膨出Ⅱ度,复发时间为6个月复查时;所有复发患者均无临床症状。结论脱细胞生物组织补片用于盆底重建手术,方法简单,操作容易,未见补片侵蚀发生,其长期效果有待进一步观察。     

Sacrospinous ligament fixation for massive genital prolapse in women aged over 80 years

Objective To assess the feasibility of vaginal sacrospinous ligament fixation for women over 80 years of age with massive vaginal vault or uterovaginal prolapse.
Design Retrospective observational study with long term follow up.
Setting Department of Obstetrics and Gynaecology, Tampere University Hospital, Finland.
Sample and Methods The study group consisted of 25 women with a mean (SD) [range] age of 83 (3) [80-93] years: 13 had posthysterectomy vaginal vault prolapse and 12 had massive uterovaginal prolapse. All underwent vaginal sacrospinous ligament fixation with repair of pelvic floor relaxation. Women with uterovaginal prolapse also underwent concomitant vaginal hysterectomy. The long term outcome was assessed in 19 women. The mean follow up period was 33 (31) [2-113] months.
Main outcome measures Intra- and post-operative morbidity, mortality and recurrence of prolapse.
Results Sixteen of the 25 women (64 %) had no major intra- or post-operative complications. The mean estimated blood loss was 400 (280) mL, and seven women received blood transfusions. Four women (16%) had cardiovascular complications, and one died of pulmonary embolism. All four had a history of vascular disease. One woman had symptomatic recurrence of vault prolapse treated with a vaginal pessary; two women had asymptomatic cystocele and one had an enterocele requiring no treatment. The outcomes were similar for women with or without concurrent vaginal hysterectomy.
Conclusion Transvaginal sacrospinous ligament fixation is an effective treatment for massive vaginal vault or uterovaginal prolapse in aged women. Increased blood loss may elevate the risk of cardiovascular complications especially in elderly patients with a history of vascular disease, thus indicating the importance of intraoperative bleeding control.     

Massive genital and vaginal vault prolapse treated by abdominal-vaginal sacropexy with use of Marlex mesh: review of the literature

Two patients with massive procidentia and 13 patients with posthysterectomy vaginal vault prolapse underwent surgical procedures at Mount Sinai Hospital, Toronto, between May 1978 and February 1986. The standard procedure consisted of an abdominal sacropexy, with use of Marlex mesh to anchor the vaginal vault to the sacral promontory and retroperitonealization of the mesh. In 11 of the 15 patients, one or more concurrent procedures were performed at the same time. There were no intraoperative complications. One serious postoperative complication occurred, and one patient developed recurrent vault prolapse. Follow-up has been from 3 to 93 months with an average of 28 months. In 14 patients (93.3%) subjective and objective improvement was achieved. A review of the literature is presented.     

盆腔器官脱垂应用网片术后疗效观察

目的:评价盆腔器官脱垂应用网片术后的疗效。方法:回顾分析2007年4月～2009年4月收住入院的盆腔器官脱垂病例24例(包括2例子宫切除术后穹窿脱垂,4例合并压力性尿失禁),应用网片盆底重建,评价术后各项客观和主观疗效。以POP-Q评分为客观疗效评价指标,以盆底功能障碍问卷(PFDI-20)为主观评价指标。结果:手术均顺利完成,术后恢复良好,无1例血管损伤、尿道损伤膀胱及直肠损伤。术后随访,无感染,无复发,无性生活障碍,补片侵蚀发生率8.33%,经治疗后好转,子宫脱垂复发2例。尿失禁、肛门坠胀感各1例,经治疗后症状消失。结论:网片用于盆腔器官脱垂的治疗安全,有效,术后并发症少,值得推广,仍需长期随访。     

The use of a xenogenic barrier to prevent mesh erosion with laparoscopic sacrocolpopexy

STUDY OBJECTIVE: To assess the efficacy of a xenogenic barrier in preventing vaginal mucosal erosion and the use of a collagen-coated polypropylene mesh in preventing small bowel obstruction with laparoscopic sacrocolpopexy for the treatment of severe vaginal prolapse. DESIGN: Prospective longitudinal study (Canadian Task Force classification II-1). SETTING: Private urogynecology clinic. PATIENTS: A total of 31 consecutive post-hysterectomy patients with severe apical vaginal prolapse (pelvic organ prolapse quantification [POP-Q] stages 2-4). INTERVENTIONS: Laparoscopic sacrocolpopexy, in conjunction with other laparoscopic and/or vaginal procedures, was used to correct pelvic floor disease. A Y-shaped polyester multifilament mesh, with a resorbable collagen coating, was used for the implant. The inner surfaces of the Y-shaped synthetic mesh had porcine dermal strips attached to act as a buffer/barrier for the vaginal wall. MEASUREMENTS AND MAIN RESULTS: A total of 29 (94%) of 31 patients were cured at 12 months (defined as POP-Q < stage II). There were no more failures in the 28 patients followed-up at 24 months. Two patients had recurrent apical prolapse (Point C = -1 and 0). There were no small bowel obstructions and no vaginal mesh erosions during the 2-year follow-up. There was significant improvement in the sexual and quality of life questionnaires after repair. CONCLUSION: Laparoscopic sacrocolpopexy is an effective treatment for apical vault prolapse. There were no cases of vaginal erosion in the first 2 years of follow-up with the "combination" biosynthetic mesh. It is suggested that the interposition of a collagen barrier between the synthetic mesh and the vaginal mucosa prevents erosion. Biosynthetic engineering appears promising in aiding the prevention of the most common complication in pelvic floor reconstructive surgery with permanent implants. The use of permanent synthetic mesh plays an important role in the success of sacrocolpopexy, removing the dependence on the use of poor in situ tissue seen in classic and site-specific repairs. The use of biologic barriers developed specifically for certain actions may be useful in minimally invasive vaginal repair surgery.     

阴道穹窿膨出与尿失禁的关系

压力性尿失禁(SUI)是老年女性常见疾病。国外大量研究证实,阴道穹窿膨出与尿失禁有密切关系。分娩损伤,绝经后激素水平低下,主韧带-宫骶韧带复合体薄弱,妇科手术后的盆底损伤,以及长期咳嗽、便秘等引起腹压增加的疾病是阴道穹窿膨出的病因。阴道支持结构的薄弱及破坏导致阴道穹窿膨出,阴道穹窿膨出的患者,11%有SUI症状。近年来,阴道穹窿膨出的发病率逐年上升,针对病因积极预防和治疗阴道穹窿膨出,可使广大中老年妇女免受尿失禁的困扰,提高生活质量。现就阴道穹窿膨出与尿失禁关系的研究及治疗进展进行综述。     

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement

OBJECTIVE: Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. MATERIALS AND METHODS: Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. RESULTS: The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. CONCLUSION: Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.     

Laparoscopic sacrocolpopexy for severe vaginal vault prolapse: five-year outcome

STUDY OBJECTIVE: To assess the efficacy of the laparoscopic sacrocolpopexy in the treatment of severe vaginal prolapse. DESIGN: (Canadian Task Force classification II-1). SETTING: Private clinic. PATIENTS: Fifty-one consecutive posthysterectomy patients with severe vaginal prolapse (Baden-Walker Grade 3 or 4). INTERVENTIONS: The patients were treated by laparoscopic sacrocolpopexy in conjunction with other laparoscopic and/or vaginal procedures, as indicated. MEASUREMENTS AND MAIN RESULTS: Of the 43 patients seen at 5-year follow-up, 3 had recurrent vaginal prolapse (objective cure rate 93%). In the patients with recurrence, the polypropylene mesh had torn partially or completely from the vaginal apex. When the posterior strip of mesh was extended to the perineal body, there were fewer recurrences of posterior compartment defects. Postoperatively, two patients had a partial small bowel obstruction secondary to bowel adherence to the mesh. Four patients had mesh erosion at the vaginal apex: two responded to local treatment, and two required vaginal flaps to cover the defect. CONCLUSION: Laparoscopic sacrocolpopexy can be used safely with cure rates similar to abdominal sacrocolpopexy. Extending the mesh to the perineum appears to decrease posterior vault defects. There is a protracted learning curve. Patient recovery is greatly enhanced, in most cases requiring only an overnight hospitalization.     

Abdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series

OBJECTIVES: To audit the clinical outcome of abdominal vault suspension (sacrocolpopexy, hysteropexy or cervicopexy) using non-absorbable mesh, without burial by closure of the peritoneum. DESIGN: A case series. SETTING: Urogynaecology units of four hospitals. POPULATION: One hundred and twenty-eight women having open or laparoscopic sacrocolpopexy (121), hysteropexy (6) or cervicopexy (1) using non-absorbable mesh for vault prolapse. METHODS: Patients had suspension of the vault, uterus or cervix from the sacral promontory using a monofilament polypropylene mesh. The pelvic peritoneum was not closed over the mesh. Patients were followed up every six months. MAIN OUTCOME MEASURES: Incidence of bowel complications as a consequence of the mesh; cure rate of prolapse and incidence of other post-operative complications; rate of re-operation for prolapse or incontinence. RESULT: After a median follow up of 19 months (1.5-62), there were no bowel complications as a result of non-burial of mesh. Three patients had asymptomatic vaginal mesh erosion, which required minor surgical intervention. Ninety percent of patients had good resolution of their prolapse symptoms while 10% of patients required further surgery. CONCLUSION: Leaving the mesh uncovered by the pelvic peritoneum was not associated with complications. It appears safe to perform vault suspension without closing the peritoneum.     

Selecting suspension points and excising the vagina during Michigan four-wall sacrospinous suspension

OBJECTIVE: To describe the variations in the location of the vaginal apex and the length of vagina excised in women undergoing the Michigan four-wall sacrospinous suspension for posthysterectomy vaginal vault prolapse. METHODS: A prospective observational study of 76 women who had the Michigan modification sacrospinous suspension performed between 1998 and 2001 for posthysterectomy vaginal vault prolapse was carried out. Demographics and preoperative, operative, and postoperative findings were noted, including the pelvic organ prolapse quantification score. The locations of the suspension points relative to the hysterectomy scar were recorded. The amount of vagina excised at surgery and the pre- and postoperative vaginal lengths are reported. RESULTS: The mean length and standard deviation of vagina excised was 4.6 +/- 2.5 cm. The apex created at sacrospinous fixation was at the hysterectomy scar in only seven women (9%). It was most often situated behind the hysterectomy scar, in 58 cases (76%); it was situated in front of it in 11 (14%). In seven women no vagina was excised, and in the remaining 69 women a mean length of 5.1 +/- 2.2 cm was removed. The mean vaginal lengths were 9.7 +/- 1.7 cm preoperatively and 9.4 cm +/- 0.8 postoperatively, a 0.3-cm difference. CONCLUSION: When one performs the Michigan modification sacrospinous suspension, the chosen suspension points are often not at the hysterectomy scar, and in women with large prolapses excess vagina frequently is excised without compromising postoperative vaginal length.     

The use of prosthetics in pelvic reconstructive surgery

With an ageing population, increasing numbers of women are presenting with pelvic floor disorders. The lifetime risk of undergoing prolapse or incontinence surgery in the USA is 1 in 11. With a recognized reoperation rate exceeding 30% for prolapse surgery, attempts are being made to improve our primary surgical outcomes. The introduction of synthetic and biological prostheses have been proposed to reduce recurrence rates whilst maintaining vaginal capacity and coital function. The role of synthetic prostheses is well established for use in continence surgery in the form of midurethral slings and for abdominal sacrocolpopexy to correct vault prolapse. However, postoperative morbidity-specifically the risk of mesh erosion-has limited their use for vaginal prolapse surgery. Biological prostheses have been introduced to offer an alternative for use in these repairs. While these grafts largely obviate the problem of erosion there are concerns regarding longevity, and only short-term outcome data are currently available. The role of prosthetics in pelvic floor surgery is an evolving and controversial field. Current and future research should be directed at evaluating the safety and efficacy of specific products and comparison of subjective and objective outcome parameters to standard surgical techniques for pelvic organ prolapse.     

The use of graft materials in vaginal pelvic floor surgery.

OBJECTIVE: To review recent literature on graft materials used in vaginal pelvic floor surgery. METHODS: A Pubmed-search ("anterior vaginal wall" or "cystocele"), ("posterior vaginal wall" or "rectocele") and ("vaginal vault" or "pelvic prolapse") and ("mesh" or "erosion" or "graft" or "synthetic") from 1995 to 2005 was performed; recent reviews [Birch C. The use of prosthetics in pelvic reconstructive surgery. Best Pract Res Clin Obstet Gynaecol 2005;19:979-91 [1]; Maher C, Baessler K. Surgical management of anterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct 2005 (May 25) [Electronic Publication] [2]; Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:84-8 [3]; Altman D, Mellgren A, Zetterstrom J. Rectocele repair using biomaterial augmentation: current documentation and clinical experience. Obstet Gynecol Surv 2005;60:753-60 [4] were added. RESULT: There are few prospective randomized trials that prove the benefit of implanting grafts in vaginal pelvic floor surgery. Many articles are retrospective case series with small sample sizes or incomplete outcome variables. Serious complications such as erosions are often not mentioned. Inconsistent or unclear criteria for anatomic cure make it difficult to compare outcomes. Quality of life issues such as dyspareunia, urinary or bowel symptoms are often ignored. CONCLUSION: Due to a lack of well-designed prospective randomized trials, recommendations for using graft materials in vaginal reconstructive surgery cannot be made. At this time, grafts should have limited use in a carefully selected patient population.     

Vaginal reconstruction following supra-levator total pelvic exenteration

BACKGROUND: There are several available techniques for neovaginal reconstruction following exenterative gynecologic surgery. However, all methods are associated with prolonged operative time and increased morbidity. The Apogee and Perigee vaginal vault and prolapse repair systems are innovative and minimally invasive procedures that may prove to be effective in controlling the levator defect and reconstructing the vagina in patients undergoing supra-levator pelvic exenteration. CASE: We present a patient who underwent supra-levator total pelvic exenteration for treatment of recurrent squamous cell carcinoma of the cervix. Vaginal reconstruction was performed with the Apogee and Perigee systems utilizing the porcine mesh (InteXen) from American Medical Systems. The patient did well without any postoperative vaginal or small bowel complications. CONCLUSION: The Apogee and Perigee systems comprise an innovative technique for vaginal vault reconstruction and prolapse repair. These systems may prove useful in reconstruction of the pelvis following ultra-radical pelvic procedures for recurrent gynecologic malignancies.     

Abdominal sacrospinous ligament colposuspension

BACKGROUND: When an abdominal approach is chosen for repair of pelvic prolapse, a paravaginal repair is often used to correct lateral cystoceles and a retropubic urethropexy to correct genuine stress incontinence. If concomitant vaginal vault prolapse exists, an approach for vaginal vault support, which can be done through the space of Retzius, would be beneficial. We describe an abdominal approach to the sacrospinous ligament. TECHNIQUE: The space of Retzius is accessed and important anatomic landmarks, including the obturator canal and neurovascular bundle, paravaginal veins, bladder, and ischial spine, are identified. The sacrospinous ligament complex is palpated and exposed. The superior posterolateral vaginal wall is then fixed to the complex. Often a bilateral repair is possible. EXPERIENCE: Fifty-five women at two centers had abdominal sacrospinous ligament colpopexies for vaginal vault prolapse. All had other repairs for pelvic organ prolapse. No follow-up operations were needed for recurrent vault prolapse, over an average of 23 months follow-up. CONCLUSION: An abdominal approach to the sacrospinous ligament complex can be used, providing pelvic reconstruction surgeons with an alternative technique for vaginal vault support when other space-of-Retzius procedures are required.