Jelovsek 22/12/08 11:34 Page 76
Urogynecology
success in randomized trials.
30–33
A good example of why it is important to The proportion of subjects with functional failure was 15% and was not
consider treatment success by evaluating both patient symptoms and objective significantly different between groups. This illustrates that objective success
success is best illustrated by a trial of different methods of performing this does not necessarily equate with subjective success. There was no
procedure by Weber et al.
32
This trial is commonly cited as a reason for significant change in the rate of dyspareunia one year after surgery and
abandoning traditional vaginal repair for POP and is often misinterpreted. there were no differences between groups.
Weber et al. performed a three-armed randomized trial comparing different
methods of anterior colporrhaphy. They used a very strict objective measure of More recently, commercially available vaginal mesh kits that use trocars to
success (Aa and Ba points at -3 or -2cm; POP-Q stage 0 or 1). Only 30% of place permanent mesh, xenograft, or composite mesh transvaginally have
gained popularity. Despite the widespread use of surgical-mesh-introducing
devices, there are very limited safety and efficacy data. The variety of graft
Anterior colporrhaphy is a surgical
types and how they affect different vaginal compartments makes it
challenging to interpret the published literature in this area. A recent
technique to repair anterior vaginal
systematic review on the use of grafts in POP repair by Sung et al. concluded
prolapse that involves the central
that the use of biologic grafts in the posterior vaginal wall was not superior
to native tissue repair for either anatomical or functional outcomes and the
plication of vaginal muscularis and
use of synthetic grafts does not appear to improve anatomical outcomes over
adventitia overlying the bladder.
posterior colporrhaphy alone. The use of synthetic, non-absorbable mesh in
the anterior compartment, however, may improve anatomical outcomes.
42
One large randomized trial comparing anterior colporrhaphy with and
patients with a standard anterior colporrhaphy had an optimal or satisfactory without a synthetic non-absorbable graft for prolapse of the anterior
result. Anterior colporrhaphy with polyglactin 910 mesh overlay had a 42% compartment conducted by Hiltunen et al.
43
demonstrated a significantly
optimal or satisfactory result. Ultralateral plication during anterior colporrhaphy lower recurrence of stage two or greater POP-Q one year after surgery in the
had a 46% optimal or satisfactory result. No differences were seen in mesh augmentation group compared with the traditional anterior repair
anatomical or functional outcomes and most patients reported satisfaction. group. Consistent with other trials in this area, however, patient symptoms
This study is often interpreted as only 40–50% of anterior vaginal prolapse were not significantly different between groups.
being successfully repaired during anterior colporrhaphy. An often overlooked
fact from this trial is that the majority of the patient’s symptoms improved using The potentially higher success rates resulting from commercially available
all three methods and most patients viewed the surgery as a success. This is not vaginal mesh kits are accompanied by a higher complication rate. Mesh erosion
surprising since most women become symptomatic of prolapse when the and/or infection are the most common complications (5.8%), although
vaginal wall protrudes to or beyond the hymen (Aa and Ba points at 0 or +1 vesicovaginal or rectovaginal fistulas are a rare (0.2%) but serious
and above), which is a more realistic definition of success (not used in this trial). complication.
44
A recent meta-analysis by Diwadkar et al. comparing traditional
vaginal surgery, sacral colpopexy, and transvaginal repairs using vaginal mesh
Another method of repairing anterior vaginal wall prolapse includes the kits to support the vaginal apex demonstrated re-operations in the office and
paravaginal defect repair. This procedure involves re-approximating under anesthesia were highest in the mesh kit group, due to higher rates of
detached lateral vaginal tissue that has torn from the lateral supporting mesh erosion and fistulas. This rate of complications requiring re-operation and
arcus tendineous fascia pelvis to correct anterior vaginal prolapse. The the total re-operation rate are highest for vaginal mesh kits in spite of a lower
paravaginal repair has a 67–100% success rate for the repair of anterior rate of prolapse recurrence and shorter overall follow-up.
44
It is data such as
vaginal prolapse. Although this can be accomplished using a vaginal or
retropubic approach, the vaginal approach may result in a high rate of
hemorrhage requiring transfusion.
34–36
We recommend the Capio suturing
device or free suture placement for the vaginal paravaginal repair.
The potentially higher success rates
resulting from commercially available
Posterior Vaginal Wall Prolapse
Posterior colporrhaphy has anatomical cure rates of between 76 and
vaginal mesh kits are accompanied by a
96%.
37–39
Early techniques involved plication of the levator animuscle and,
higher complication rate.
although this was highly effective in the treatment of posterior vaginal wall
prolapse, it was associated with unacceptably high rates of dyspareunia.
37–40
Currently, most gynecologists perform a midline fascial plication or site-
specific repair. A randomized trial comparing three techniques for the these that led the US Food and Drug Administration (FDA) to issue a public
treatment of rectocele found that midline fascial plication and site-specific health notification regarding the serious complications associated with
rectocele repair provide superior anatomical outcomes to site-specific transvaginal placement of surgical mesh.
45
Should these complications occur,
rectocele augmented with a cross-linked porcine small intestinal submucosa mesh removal can be technically difficult, but it does appear to be safe with
xenograft, with similar functional outcomes between the groups.
41
After few complications and good relief of symptoms.
46
Patients and surgeons
one year, those subjects who received graft augmentation had a should decide whether they would rather live with a few more traditional
significantly greater anatomical failure rate (46%) than those who received repair failures due to recurrent prolapse or a few more surgical complications
site-specific repair alone (22%) or traditional posterior colporrhaphy (14%). from the use of trocar mesh kits that require re-operation.
76 US OBSTETRICS & GYNECOLOGY
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