A new operation for genitourinary prolapse

Clinical and urodynamic effects of anterior colporraphy and approximation of pubococcygeus muscles in patients with severe cystocele

OBJECTIVE

The objective was to evaluate in a homogeneous series of patients the clinical and urodynamic outcomes following anterior colporraphy and approximation of pubococcygeus muscles for correcting cystocele and genuine stress incontinence (SUI).

METHODS

The authors analyzed the pre- and postoperative clinical and urodynamic data of 56 consecutive, not previously operated, patients underwent anterior colporraphy and approximation of pubococcygeus muscles by the same surgeon. The mean follow-up period was 20 months (range 12-32). Statistical analysis was performed with Wilcoxon matched pairs test and Fisher's exact test.

RESULTS

Four (8%) patients experienced cystocele recurrence at a lesser degree than preoperatively and 2 (4%) patients developed grade II rectocele postoperatively. Recurrence of cystocele occurred only among those patients undergone sacrospinous colposuspension (4 out of 20 vs. 0 out of 32, P=0.018). Manifested and potential genuine stress incontinence (Pot-SUI) treatment was successful in 18 out of 30 (60%) patients. These patients showed a significant increase (P<0.001) of bladder-to-urethra pressure transmission ratio (PTR) values whereas, in those patients who presented recurrence, such an increase did not occur.

CONCLUSION

Anterior colporraphy and approximation of pubococcygeus muscles appears, from our preliminary results to be a safe, effective technique for the primary treatment of cystocele without compromising the other vaginal profiles but should not be considered as the procedure of choice for patients presenting with manifested or Pot-SUI. Long-term follow-up is needed to evaluate whether these results are durable.

Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh

The purpose of this study was to evaluate the effectiveness of the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh in patients with severe (stage III or IV) anterior vaginal prolapse. Thirty-eight consecutive women were enlisted for this prospective study. The procedure consisted of an extensive vaginal dissection to join the vesicovaginal and retropubic space and an anchoring of a polypropylene mesh patch between the two Arcus Tendineus Fasciae Pelvis in a tension-free manner. The mean age of the study group was 63 (33-80) years. The success rate was 87% (33/38) at a mean follow-up interval of 21 (12-29) months. A total of eight (100%) patients were also cured of concomitant stress incontinence (five overt and three occult type) with an additional tension-free vaginal tape (TVT) operation. During follow-up, there were five de-novo stress incontinence cases (16.7%) and four vaginal erosions of mesh (10.5%). Four clinical variables--diabetes mellitus, recurrent anterior vaginal prolapse, chronic cough and vaginal erosions of mesh--were found to have a significant correlation with an unsatisfactory surgical result with large values of hazard ratios found by survival analysis. We concluded that the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh was effective for most, but failed in some patients who had specific risk factors within short convalescence periods. Concomitant stress incontinence can be successfully treated by a TVT operation in combination with the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. However, the anterior colporrhaphy procedure may itself have adverse effects on urethral sphincter function.

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.

Reliability, validity, and gender differences in the quality of life index of the SEAPI-QMM incontinence classification system

PURPOSE

To evaluate reliability and validity of the SEAPI-QMM 15-item quality of life index and assess differences between male and female patients with urinary incontinence.

MATERIALS AND METHODS

Twice pre- and once post-treatment, 315 patients (102 men, 213 women) with incontinence and 35 without incontinence completed the self-directed SEAPI-QMM quality of life index. A voiding diary reported frequency of incontinence episodes with number of pads or type of protection used daily for incontinence. In 30%, the Nottingham Health Profile (NHP) was administered to further validate the measure.

RESULTS

Cronbach's alpha coefficient for the index was 0.91. Domain-specific alpha coefficients ranged from 0.88 to 0.73. Test-retest reliability scores at 5 days gave a reliability coefficient of 0.93. Split half reliability was 0.89. Correlation of the index with the NHP was 0.78 for women, 0.72 for men. Mean scores before and after treatment with medical or surgical management were significantly different in both genders and were sensitive to the presence or absence of use of protection and the type of protection chosen in men. Men with incontinence (61%) reported a high level of impact in the sexuality domain compared to 7% of women.

CONCLUSIONS

The SEAPI quality of life index has a high degree of reliability relating to stability and internal consistency across a wide age range in both genders. There are differences between men and women in life domains most frequently affected by urinary incontinence.

Vaginal paravaginal repair with an AlloDerm graft

OBJECTIVE

This study was undertaken to describe outcomes of a technique of vaginal paravaginal repair that used AlloDerm graft (LifeCell, Branchburg, NJ) in women with recurrent stage II or with primary or recurrent stage III/IV anterior vaginal wall prolapse.

STUDY DESIGN

This was an observational study. Thirty-three women underwent a vaginal paravaginal repair using AlloDerm graft. Anterior vaginal wall prolapse was staged using the pelvic organ prolapse quantification system preoperatively and every 6 months after surgery. Recurrence of prolapse, changes in functional status (urinary symptoms, prolapse symptoms, and sexual activity), and complications were recorded. Objective failure was defined as recurrent anterior vaginal wall prolapse, stage II or greater, and subjective failure as symptomatic recurrent anterior vaginal wall prolapse. Life-table analysis evaluated objective and subjective failure. Risk factors for recurrent anterior vaginal wall prolapse were evaluated.

RESULTS

The mean age was 65.2 years and 93% of the women were white. Preoperatively, 6 women had recurrent stage II, 24 women had stage III, and 3 women had stage IV anterior vaginal wall prolapse. The median length of follow-up was 18 months. Postoperatively, 12 women had asymptomatic stage II anterior vaginal wall prolapse (not beyond the hymen) develop, and 1 woman had symptomatic stage II prolapse develop. Thus, there were 13 (41%) objective failures and 1 (3%) subjective failure. Life-table analysis demonstrated the cumulative probability of an objective failure was 0.24 at 1 year and 0.50 at 2, 3, and 4 years. The cumulative probability of a subjective failure was 0.00 at 1 and 2 years and 0.11 at 3 and 4 years. No risk factors for objective failure were identified. Voiding complaints resolved in 11 of 14 (79%) women (P=.004), incontinence symptoms resolved in 17 of 19 (89%) women (P<.001), and urgency symptoms resolved in 20 of 23 (87%) women (P<.001) (all two-tailed Fisher exact test). Twenty-one women (64%) were sexually active, and none complained of postoperative dyspareunia. Complications included 1 case of febrile morbidity, 1 cystotomy, and 1 anterior wall breakdown secondary to hematoma formation caused by heparin therapy. No other erosions or rejections were seen.

CONCLUSION

Vaginal paravaginal repair with AlloDerm graft in women with recurrent stage II or stage III/IV anterior vaginal wall prolapse is safe and has good subjective but only fair objective success within the first 2 years.

What's new in prolapse surgery?

PURPOSE OF REVIEW

There are very many types of operation for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task when selecting the most appropriate procedure(s) for an individual patient. Currently, the lifetime risk of undergoing prolapse or continence surgery in France is one in 11; up to 30% of patients will require repeat prolapse surgery, and 10% will require repeat continence surgery. Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for a definitive surgical cure. This review looks at the etiology, presentation and current surgical management of genital prolapse in females.

RECENT FINDINGS

There are three primary routes of access in reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) for the repair of anterior, superior and posterior defects; the choice often depends on the surgeon's experience. Of the abdominal repairs, abdominal sacrocolpopexy with mesh remains the 'gold standard'; the retropubic paravaginal repair and laparoscopic techniques have not gained widespread acceptance. The laparoscopic approach appears to be the least utilized, because of the great degree of technical difficulty associated with laparoscopic suturing. Of the vaginal restorative procedures, uterosacral ligament vault suspension and iliococcygeous and sacrospinous fixation have their proponents. However, there is increasing interest in the use of biological prostheses (allografts/xenografts) and synthetic absorbable meshes.

SUMMARY

Randomized controlled trials are required to evaluate the role of surgical procedures in reconstructive surgery, to determine which type of prosthesis is most suitable.

Use of cadaveric solvent-dehydrated fascia lata for cystocele repair--preliminary results

OBJECTIVES

To present a surgical technique in which cadaveric fascia lata is used for cystocele repair.

METHODS

Twenty-one consecutive women (mean age 67 +/- 10 years) with severe cystocele were prospectively enrolled. All patients underwent meticulous clinical and urodynamic preoperative evaluations. Solvent-dehydrated, Tutoplast-processed, cadaveric fascia lata was used for cystocele repair. The fascia was anchored transversally between the bilateral arcus tendineus and the cardinal and uterosacral ligaments. Standard endopelvic plication was performed thereafter as a second layer. Patients with overt or occult sphincteric incontinence underwent concomitant pubovaginal sling (PVS) surgery as well, using the same material. The main outcome measures included recurrent urogenital prolapse, persistent or de novo urinary incontinence (stress or urge), and dyspareunia.

RESULTS

Of the 21 patients, 19 underwent concomitant PVS, 3 concomitant vaginal hysterectomy, and 8 posterior colporrhaphy in addition to their cystocele repair. The mean follow-up was 20.1 +/- 6.7 months (range 12 to 30). No postoperative complications related to the material or technique occurred. None of the patients developed a recurrent cystocele. Two patients (9%), one of whom underwent concomitant posterior colporrhaphy, developed mild recto-enterocele at 4 to 6 months postoperatively. Six patients underwent concomitant PVS for occult sphincteric incontinence. None developed postoperative stress incontinence. Thirteen other patients underwent concomitant PVS for overt sphincteric incontinence. All but two were stress-continent postoperatively. One half of the patients with preoperative urge or mixed incontinence had persistent urge incontinence postoperatively. None of the patients developed postoperative de novo urge incontinence or dyspareunia.

CONCLUSIONS

The use of solvent-dehydrated cadaveric fascia lata for cystocele repair, as well as PVS, is associated with encouraging short and medium-term results. Long-term follow-up is needed to evaluate whether these results are durable.

The use of synthetics in the treatment of pelvic organ prolapse

Despite an improved understanding of pelvic anatomy and organ function and advances in surgical techniques, long-term success rates in pelvic surgery are still variable (3-59%), but can reach up to 92% in the case of associated procedures. The major causes of recurrent pelvic prolapse after corrective surgery are related to patient factors, such as poor tissues, impaired healing processes and chronic pathological increases in intra-abdominal pressure. Other causes of failure are, however, probably related to surgical techniques: the use of weak or insufficient sutures, or suboptimal performance of the surgery. In line with progress in the surgical correction of abdominal hernias, the use of synthetic mesh in pelvic reconstructive surgery also seems to guarantee its reliability, especially when autologous tissue is of poor quality or insufficient quantity. Moreover, the use of artificial mesh may simplify a surgical procedure, reducing operative time and the need for additional techniques. This review evaluates the main properties of synthetic biomaterials, their complications and the most common procedures involved in the use of synthetic mesh: the abdominal sacral colpopexy and transvaginal cystocele repair.

The surgical management of recurrent stress urinary incontinence

Recurrent stress urinary incontinence is a distressing problem. Its causes are multifactorial and the literature continually provides suggestions for changes to the surgical approach. Over 200 surgical procedures exist for the treatment of stress urinary incontinence, and this leaves the practising surgeon with an overwhelming range of choice. This article will review current available techniques for the surgical treatment of recurrent stress urinary incontinence.