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.     

Raz four-corner suspension for severe cystocele: Poor results

The Raz four-corner suspension for the treatment of severe (grades 3 and 4) cystocele has yielded poor results, and is the subject of this paper. During a 10-month period from June 1988 to April 1989, 27 patients with severe cystocele and genuine stress incontinence were treated by the Raz four-corner suspension. Each patient had full preoperative urodynamic evaluation. Twenty-two patients were available for follow-up examinations at 3.5–4 years. At the 6-week postoperative examination all patients had excellent support of the anterior vaginal wall, including the restoration of the anterolateral vaginal wall sulci. However, within 10 months, 6 patients had recurrence of cystoceles of grade 2 or more. These results led to the abandonment of this procedure. On long-term follow-up examination at 3.5–4 years, 59% (13/22) of the patients had recurrence of cystoceles of grade 2 or more. The possible causes for these poor results are discussed. At present therefore, the Raz four-corner suspension for severe cystoceles is not recommended.     

Mesh-related infections after pelvic organ prolapse repair surgery

The use of vaginal meshes has been an advance in the surgical management of women with pelvic organ prolapse. We reviewed the literature to synthesize the evidence regarding the infectious complications related to this new type of foreign body. We searched PubMed, current contents, and references of initially identified relevant articles and extracted data regarding the incidence, clinical manifestation, and management of vaginal mesh-related infections. The incidence of mesh-related infections and erosion ranged from 0 to 8%, and 0 to 33%, respectively, in the published studies. Various factors influence the development of vaginal mesh-related infectious complications such as the kind of biomedical material (e.g. filament structure, pore size) of the mesh, the type of procedure, the preventive measures taken, and the age and underlying comorbidity of the treated women. Non-specific pelvic pain, persistent vaginal discharge or bleeding, dyspareunia, and urinary or faecal incontinence are the most common manifestation of vaginal mesh-related infection. Clinical examination may reveal induration of the vaginal incision, vaginal granulation tissue, draining sinus tracts, and prosthesis erosion or rejection. Various pathogens have been implicated, including Gram-positive and Gram-negative aerobic and anaerobic bacteria. The management of mesh-related infections in women who underwent pelvic organ reconstruction is combined surgical and medical treatment. Although the use of vaginal meshes has become a new effective method of pelvic organ prolapse surgery clinicians should be aware of the various post-operative complications, including mesh-related infections.     

Diagnosis of cystocele – the correlation between clinical and radiological evaluation

In patients with genital prolapse involving several compartments simultaneously, radiologic investigation can be used to complement the clinical assessment. Contrast medium in the urinary bladder enables visualization of the bladder base at cystodefecoperitoneography (CDP). The aim of the present study was to evaluate the correlation between clinical examination using the Pelvic Organ Prolapse Quantification system (POP-Q) and CDP. Thirty-three women underwent clinical assessment and CDP. Statistical analysis using Pearsons correlation coefficient (r) demonstrated a wide variability between the current definition of cystocele at CDP and POP-Q (r=0.67). An attempt to provide an alternative definition of cystocele at CDP had a similar outcome (r=0.63). The present study demonstrates a moderate correlation between clinical and radiologic findings in patients with anterior vaginal wall prolapse. It does not support the use of bladder contrast at radiologic investigation in the routine preoperative assessment of patients with genital prolapse.Abbreviations CDP Cystodefecoperitoneography Editorial Comment: The authors attempt to correlate the visceral position of the bladder on fluoroscopy to the anterior vaginal wall measurements on POP-Q examination. Consistent with other published reports, they show only moderate statistical correlations. Clinically, the correlations are probably not useful. Thirty-eight percent of women with radiographic cystoceles had no clinically significant prolapse (stage III or IV). Based on their findings the authors conclude that the routine use of radiologic investigation might not be warranted in the preoperative assessment of women with pelvic organ prolapse. This must be interpreted with caution when generalizing their data to all women with prolapse. Only 17% of the women in this study had had prior pelvic surgery. The authors also do not address how cystodefecoperitoneography results affected the diagnosis of enterocele or rectocele. Other authors have shown a significant increase in enterocele diagnosis using cystodefecoperitoneography.     

MR Imaging in Posthysterectomy Vaginal Prolapse

In the diagnostic work-up of vaginal prolapse after hysterectomy cystoceles can be identified by sonography, whereas enteroceles and rectoceles can only be suspected in a routine clinical setting. The present pilot study was undertaken to investigate the diagnostic role of magnetic resonance imaging (MRI) in the differentiation of cysto-, entero- and rectoceles in women with posthysterectomy vaginal prolapse. Thirteen women (mean age 61, SD ± 7 years) with posthysterectomy vaginal prolapse underwent MRI (Gyroscan S 15, Philips). A median sagittal image series was obtained with a gradient-echo sequence, fast field echo, both at rest and during Valsalva maneuvers. MRI allowed the identification of cysto-, entero- and rectoceles, and differentiation between entero- and rectoceles in cases with inconclusive clinical findings. These findings make dissection more reliable and improve the outcome of hernia repair. No additional diagnostic information is obtained with MRI compared to ultrasound in the assessment of cystoceles.     

Bladder erosion after 2 years from cystocele repair with type I polypropylene mesh

Type I polypropylene mesh have been widely used in gynaecologic surgery for the treatment of pelvic organ prolapse and stress urinary incontinence. Such devices produced positive results compared to the equivalent non-mesh-based operation but erosions into adjacent viscera, especially the vagina, have also been reported. We describe the case of bladder erosion that manifested two years after the initial cystocele repair surgery and the management adopted.     

Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes

Our aim was to study the anatomic recurrence rates and quality of life outcomes of patients who had undergone either anterior colporrhaphy (AC) or anterior colporrhaphy and vaginal paravaginal repair (AC + VPVR) as part of surgery for pelvic organ prolapse. Chart reviews were used to identify anatomic prolapse recurrence. Phone interviews assessed quality of life outcomes [Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ)] outcomes. There was a trend towards longer time to anatomic recurrence (any compartment ≥grade 2) in the AC group compared with the AC + VPVR group (median 24 vs 13 months, p=0.069). If only patients who had undergone previous surgery were compared, time to anatomic recurrence appeared significantly longer in the AC group (median 41 vs 12 months, p=0.022). There were 55% of women in the AC group and 46% of women in the AC + VPVR group who reported significant bladder or bulge symptoms based on responses to the phone-administered UDI and IIQ (p=0.89). Our retrospective study did not suggest that adding VPVR was superior in terms of anatomic or quality of life outcomes. Prospective assessment of the role of VPVR in the treatment of pelvic organ prolapse is needed.     

The effectiveness of the sacrospinous hysteropexy for the primary treatment of uterovaginal prolapse

The objective of this study was to assess the effectiveness of sacrospinous ligament fixation of the uterus as a primary treatment of uterovaginal prolapse. In this observational study, 133 women underwent a sacrospinous hysteropexy. Data were obtained from their medical records, and standardized questionnaires about urogenital symptoms and quality of life were used. All women were invited for gynecological examination, using the Pelvic Organ Prolapse Quantification score. Ninety-nine women responded by returning the questionnaire (mean age, 59.2 and follow-up time, 22.5 months); 60 of these women underwent gynecologic examination. Eighty-four percent of women were highly satisfied about the outcome of the procedure. Serious complications were rare. The recurrence rate of descensus uteri that needed surgical treatment was 2.3%. The recurrence of cystoceles after surgery was 35%, but there were no differences in urogenital symptoms between women with or without a cystocele.     

Familial tranmission of genitovaginal prolapse

Some females with little to no risk factors develop prolapse, while other females with multiple risk factors do not. It appears that some women may have a predisposition for prolapse in the setting of equivalent risk factors. We identified 10 patients younger than 55 years old with a family history of prolapse. Their average age was 37 years (range 27–51), the mean number of deliveries was 1.8, and their mean birth weight was 8 lbs. Genetic analysis of the inheritance pattern within these families demonstrated that pelvic organ prolapse segregated in a dominant fashion with incomplete penetrance in these families. Both maternal and paternal transmissions were observed. The relative risk to siblings of affected patients was five times that of the risk for the general population. Further investigation of these families may identify a genetic defect responsible for prolapse.