A Randomized Controlled Trial Comparing Fascia Lata and Synthetic Mesh for Sacral Colpopexy

Porcine dermis compared with polypropylene mesh for laparoscopic sacrocolpopexy: a randomized controlled trial

OBJECTIVE

To compare the surgical outcomes 12 months after laparoscopic sacrocolpopexy performed with porcine dermis and the current gold standard of polypropylene mesh.

METHODS

Patients scheduled for laparoscopic sacrocolpopexy were eligible for this randomized controlled trial. Both our clinical research nurse and the patients were blinded as to which material was used. Our primary end point was objective anatomic cure defined as no pelvic organ prolapse quantification (POP-Q) points Stage 2 or greater at any postoperative interval. Our sample size calculation called for 57 patients in each group to achieve 90% power to detect a 23% difference in objective anatomic cure at 12 months (α=0.05). Our secondary end point was clinical cure. Any patient with a POP-Q point greater than zero, or Point C less than or equal to -5, or any complaints of prolapse symptoms whatsoever on Pelvic Floor Distress Inventory-20 or Pelvic Floor Impact Questionnaire, Short Form 7, or reoperation for prolapse were considered "clinical failures"; the rest were "clinical cures." Statistical comparisons were performed using the χ or independent samples t test as appropriate.

RESULTS

As expected, there were no preoperative differences between the porcine (n=57) and mesh (n=58) groups. The 12-month objective anatomic cure rates for the porcine and mesh groups were 80.7% and 86.2%, respectively (P=.24), and the "clinical cure" rates for the porcine and mesh groups were 84.2% and 89.7%, respectively (P=.96). Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire, Short Form 7 score improvements were significant for both groups with no differences found between groups. There were no major operative complications.

CONCLUSIONS

There were similar outcomes in subjective or objective results 12 months after laparoscopic sacrocolpopexy performed with either porcine dermis or polypropylene mesh.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00564083.

LEVEL OF EVIDENCE

I.

Surgical management of pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.

OBJECTIVES

To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process and handsearching of journals and conference proceedings, healthcare-related bibliographic databases, handsearched conference proceedings (searched 20 August 2012), and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Fifty-six randomised controlled trials were identified evaluating 5954 women. For upper vaginal prolapse (uterine or vault) abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse on examination and painful intercourse than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. In single studies the sacral colpopexy had a higher success rate on examination and lower reoperation rate than high vaginal uterosacral suspension and transvaginal polypropylene mesh.Twenty-one trials compared a variety of surgical procedures for anterior compartment prolapse (cystocele). Ten compared native tissue repair with graft (absorbable and permanent mesh, biological grafts) repair for anterior compartment prolapse. Native tissue anterior repair was associated with more recurrent anterior compartment prolapse than when supplemented with a polyglactin (absorbable) mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.08, 95% CI 1.08 to 4.01), however there was no difference in post-operative awareness of prolapse after absorbable mesh (RR 0.96, 95% CI 0.33 to 2.81) or a biological graft (RR 1.21, 95% CI 0.64 to 2.30). Data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment prolapse on examination than for any polypropylene (permanent) mesh repair (RR 3.15, 95% CI 2.50 to 3.96). Awareness of prolapse was also higher after the anterior repair as compared to polypropylene mesh repair (28% versus 18%, RR 1.57, 95% CI 1.18 to 2.07). However, the reoperation rate for prolapse was similar at 14/459 (3%) after the native tissue repair compared to 6/470 (1.3%) (RR 2.18, 95% CI 0.93 to 5.10) after the anterior polypropylene mesh repair and no differences in quality of life data or de novo dyspareunia were identified. Blood loss (MD 64 ml, 95% CI 48 to 81), operating time (MD 19 min, 95% CI 16 to 21), recurrences in apical or posterior compartment (RR 1.9, 95% CI 1.0 to 3.4) and de novo stress urinary incontinence (RR 1.8, 95% CI 1.0 to 3.1) were significantly higher with transobturator meshes than for native tissue anterior repair. Mesh erosions were reported in 11.4% (64/563), with surgical interventions being performed in 6.8% (32/470).Data from three trials compared native tissue repairs with a variety of total, anterior, or posterior polypropylene kit meshes for vaginal prolapse in multiple compartments. While no difference in awareness of prolapse was able to be identified between the groups (RR 1.3, 95% CI 0.6 to 1.7) the recurrence rate on examination was higher in the native tissue repair group compared to the transvaginal polypropylene mesh group (RR 2.0, 95% CI 1.3 to 3.1). The mesh erosion rate was 35/194 (18%), and 18/194 (9%) underwent surgical correction for mesh erosion. The reoperation rate after transvaginal polypropylene mesh repair of 22/194 (11%) was higher than after the native tissue repair (7/189, 3.7%) (RR 3.1, 95% CI 1.3 to 7.3).Data from three trials compared posterior vaginal repair and transanal repair for the treatment of posterior compartment prolapse (rectocele). The posterior vaginal repair had fewer recurrent prolapse symptoms (RR 0.4, 95% CI 0.2 to 1.0) and lower recurrence on examination (RR 0.2, 95% CI 0.1 to 0.6) and on defecography (MD -1.2 cm, 95% CI -2.0 to -0.3).Sixteen trials included significant data on bladder outcomes following a variety of prolapse surgeries. Women undergoing prolapse surgery may have benefited from having continence surgery performed concomitantly, especially if they had stress urinary incontinence (RR 7.4, 95% CI 4.0 to 14) or if they were continent and had occult stress urinary incontinence demonstrated pre-operatively (RR 3.5, 95% CI 1.9 to 6.6). Following prolapse surgery, 12% of women developed de novo symptoms of bladder overactivity and 9% de novo voiding dysfunction.

AUTHORS' CONCLUSIONS

Sacral colpopexy has superior outcomes to a variety of vaginal procedures including sacrospinous colpopexy, uterosacral colpopexy and transvaginal mesh. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach.The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse on examination. Anterior vaginal polypropylene mesh also reduces awareness of prolapse, however these benefits must be weighted against increased operating time, blood loss, rate of apical or posterior compartment prolapse, de novo stress urinary incontinence, and reoperation rate for mesh exposures associated with the use of polypropylene mesh.Posterior vaginal wall repair may be better than transanal repair in the management of rectocele in terms of recurrence of prolapse. The evidence is not supportive of any grafts at the time of posterior vaginal repair. Adequately powered randomised, controlled clinical trials with blinding of assessors are urgently needed on a wide variety of issues, and they particularly need to include women's perceptions of prolapse symptoms. Following the withdrawal of some commercial transvaginal mesh kits from the market, the generalisability of the findings, especially relating to anterior compartment transvaginal mesh, should be interpreted with caution.

The use of biological materials in urogynecologic reconstruction: a systematic review

There are numerous randomized controlled trials examining biological materials in urogynecologic surgery. For prolapse surgery, the addition of a biological graft adds no benefit compared with native tissue repairs for rectocele repair. Conflicting data exist regarding cystocele repair. Synthetic mesh repairs provide superior anatomical support for sacral colpopexy and cystocele repair compared with biologic grafts. However, biological and synthetic mesh slings have equivalent success rates for the treatment of stress urinary incontinence. Contrary to prior assumptions that biologic grafts add tissue strength without graft-related complications, there appears to be no benefit to the use of biological materials for prolapse and incontinence surgery.

Prospective study of an ultra-lightweight polypropylene Y mesh for robotic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

To prospectively evaluate the use of a particular polypropylene Y mesh for robotic sacrocolpopexy.

METHODS

This was a prospective study of 120 patients who underwent robotic sacrocolpopexy. We compared preoperative and 12-month postoperative objective and subjective assessments via the Pelvic Organ Prolapse Quantification (POP-Q), the Pelvic Floor Distress Inventory, Short Form 20 (PFDI-20); the Pelvic Floor Impact Questionnaire, Short Form 7 (PFIQ-7); and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 (PISQ-12). Objective "anatomical success" was defined as POP-Q stage 0 or 1 at all postoperative intervals. We further defined "clinical cure" by simultaneously considering POP-Q points and subjective measures. To be considered a "clinical cure," a given patient had to have all POP-Q points ≤0, apical POP-Q point C ≤5, no reported pelvic organ prolapse symptoms on the PFDI-20, and no reoperation for prolapse at all postoperative intervals.

RESULTS

Of the 120 patients, 118 patients completed the 1-year follow-up. The objective "anatomical success" rate was 89 % and the "clinical cure" rate was 94 %. The PFDI-20 mean score improved from 100.4 at baseline to 21.0 at 12 months (p < 0.0001); PFIQ-7 scores improved from 61.6 to 8.0 (p < 0.0001); and PISQ-12 scores improved from 35.7 to 38.6 (p < 0.0009). No mesh erosions or mesh-related complications occurred.

CONCLUSION

The use of this ultra-lightweight Y mesh for sacrocolpopexy, eliminated the mesh-related complications in the first postoperative year, and provided significant improvement in subjective and objective outcomes.

Vaginal mesh - the controversy

Pelvic organ prolapse is a condition that can cause significant symptoms that affect a woman's quality of life. It is the result of defects in the supporting structures of the vagina and, depending on the location and size, can alter the functions of the organs contained within the female pelvis. Approximately 11% of women will undergo surgical intervention for their prolapse or for incontinence in their lifetime. Unfortunately, one third of these will require reoperation for failed procedures. Pelvic floor surgeons have sought to improve these outcomes. Based largely on the success of midurethral slings (MUS), transvaginal mesh has been implanted, and commercial kits developed with the intent of improving these outcomes. In 2008, the Food and Drug Administration (FDA) issued a Public Health Notification in response to possible increased adverse events associated with the use of mesh compared to traditional repairs. The 2011 update required that further study be conducted for the use of transvaginal mesh. In this article, we wish to discuss the background of mesh use and the evolution of the public health warnings, and focus on future prospects.

Surgery for pelvic organ prolapse

OBJECTIVES

: Surgery for pelvic organ prolapse (POP) is common with increasing high-quality evidence to guide surgical practice. Yet many important basic questions remain, including the optimal timing for POP surgery, the optimal preoperative evaluation of urinary tract function, and the postoperative outcome assessment. This manuscript reviews traditional surgical approaches for POP.

METHODS

: Formal and hand-searching of prolapse literature was conducted by the committee on Pelvic Organ Prolapse Surgery for the most recent International Consultation on Incontinence. The committee (authors) was composed of prolapse specialists from around the world. Consensus recommendations were made following literature abstraction.

RESULTS

: Surgical correction of POP can be divided into 2 main categories as follows: reconstructive procedures to correct anterior and posterior wall defects and resuspend the vaginal apex or obliterative procedures to close off the vagina. Reconstructive surgery may use the vaginal route or the abdominal route.

CONCLUSIONS

: In addition to recommendations within the report, the committee reaffirms that in planning surgery, the individual patient's risk for surgery, risk of recurrence, previous treatments, and surgical goals are all considered in deciding on obliterative versus reconstructive procedures, and in deciding whether the vaginal or the abdominal approach will be used for reconstructive repairs.

Prevention of complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice

The objective of the study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning adverse events related to surgical procedures involving the use of prosthetic meshes. French and English-language articles from Medline, PubMed, and the Cochrane Database were searched, using key words (mesh; pelvic organ prolapse; cystocele; rectocele; uterine prolapse; complications; adverse event; sacral colpopexy; extrusion; infection). As with any surgery, recommendations include perioperative smoking cessation (Expert opinion) and compliance with the prevention of nosocomial infections (regulatory recommendation). There is no evidence to recommend routine local or systemic estrogen therapy before or after prolapse surgery using mesh, regardless of the surgical approach (Grade C). Antibiotic prophylaxis is recommended, regardless of the approach (Expert opinion). It is recommended to check for pre-operative urinary tract infection and treat it (Expert opinion). The first procedure should be undertaken under the guidance of a surgeon experienced in the relevant technique (Grade C). It is recommended not to place a non-absorbable synthetic mesh into the rectovaginal septum when a rectal injury occurs (Expert opinion). Placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after suturing of a bladder injury if the suture is considered to be satisfactory (Expert opinion). If a synthetic mesh is placed by vaginal route, it is recommended to use a macroporous polypropylene monofilament mesh (Grade B). It is recommended not to use polyester mesh for vaginal surgery (Grade B). It is permissible to perform hysterectomy associated with the placement of a non-absorbable synthetic mesh placed by the vaginal route but this is not routinely recommended (Expert opinion). It is recommended to minimize the extent of the colpectomy (Expert opinion). The laparoscopic approach is recommended for sacral colpopexy (Expert opinion). It is recommended not to place and suture meshes by the vaginal route when a sacral colpopexy is performed (Grade B). It is recommended not to use silicone-coated polyester, porcine dermis, fascia lata, and polytetrafluoroethylene meshes (Grade B). It is recommended to use polyester (without silicone coating) or polypropylene meshes (Grade C). Suture of the meshes to the promontory can be performed using thread/needle or tacks (Grade C). Peritonization is recommended to cover the meshes (Grade C). If hysterectomy is required, it is recommended to perform a subtotal hysterectomy (Expert opinion). Implementation of this guideline should decrease the prevalence of complications related to surgical procedures involving the use of prosthetic meshes.

Medium-term effects of a monofilament polypropylene mesh for pelvic organ prolapse and sexual function symptoms

This report is aimed at describing the effects and complications of a polypropylene mesh in standard gynaecological practice. This is single centre prospective cohort observational study performed at a University affiliated hospital in the UK. It involved the prospective symptom assessment of 41 consecutive patients in 2007 who underwent anterior and/or posterior Avaulta Plus™ or Avaulta™ Biosynthetic Support System (BARD). The validated International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) was completed in the clinic preoperatively. Postal questionnaires were sent to the patients up to 3 years postoperatively. Preoperatively the mean overall Quality of life (QoL) was 19.78 (SD 9.052) and at follow-up was 1.67 (SD 1.0) with p< 0.008. Mean VAS preoperatively was 15.00 (SD 7.566) and at follow-up was 0.44 (SD 0.882) with p< 0.008. A decrease in this score over time, indicates improved symptoms. In select patients, repair with mesh augmentation using Avaulta™ or Avaulta Plus™ is a safe and effective procedure up to 3 years with a median follow-up of 27 months (range 20-36 months).

[Prolapse surgery. With abdominal or vaginal meshes?]

In prolapse surgery several surgical techniques are available. The different open, laparoscopic and vaginal approaches are distinguished by distinct success and relapse rates and operation-specific complications. A safe and optimal therapeutic pelvic floor surgery should be based on the three support levels according to DeLancy and be individually adjusted for every patient. The vaginal approach may be used for all kinds of female genital prolapse and is a comparatively less invasive technique with a short time of convalescence. Apart from stress incontinence there is no need for synthetic meshes in primary approaches and excellent results with low complication and relapse rates can be achieved. An uncritical application of synthetic material is to be avoided in vaginal repair at all times. Abdominal surgical techniques, both open and laparoscopic, present their strengths in the therapeutic approach to level 1 defects or stress incontinence. They provide excellent functional and anatomical corrections and low relapse rates. Abdominally inserted meshes have lower complication rates than vaginal ones.

Robotic-assisted laparoscopic mesh sacrocolpopexy

The current 'gold standard' surgical repair for apical prolapse is the abdominal mesh sacrocolpopexy. Use of a robotic-assisted laparoscopic surgical approach has been demonstrated to be feasible as a minimally invasive approach and is gaining popularity amongst pelvic floor reconstructive surgeons. Although outcome data for robotic-assisted sacrocolpopexy (RASC) is only just emerging, several small series have demonstrated anatomic and functional outcomes, as well as complication rates, comparable to those reported for open surgery. The primary advantages thus far for RASC over open surgery include decreased blood loss and shorter hospital stay.

Is tissue engineering and biomaterials the future for lower urinary tract dysfunction (LUTD)/pelvic organ prolapse (POP)?

The fields of tissue engineering and regenerative medicine have seen major advances over the span of the past two decades, with biomaterials playing a central role. Although the term "regenerative medicine" has been applied to encompass most fields of medicine, in fact urology has been one of the most progressive. Many urological applications have been investigated over the past decades, with the culmination of these technologies in the introduction of the first laboratory-produced organ to be placed in a human body.1 With the quality of life issues associated with urinary incontinence, there is a strong driver to identify and introduce new technologies and the potential exists for further major advancements from regenerative medicine approaches using biomaterials, cells or a combination of both. A central question is why use biomaterials? The answer rests on the need to make up for inadequate or lack of autologous tissue, to decrease morbidity and to improve long-term efficacy. Thus, the ideal biomaterial needs to meet the following criteria: (1) Provide mechanical and structural support, (2) Maintain compliance and be biocompatible with surrounding tissues, and (3) Be "fit for purpose" by meeting specific application needs ranging from static support to bioactive cell signaling. In essence, this represents a wide range of biomaterials with a spectrum of potential applications, from use as a supportive or bulking implant alone, to implanted biomaterials that promote integration and eventual replacement by infiltrating host cells, or scaffolds pre-seeded with cells prior to implant. In this review we shall discuss the structural versus the integrative uses of biomaterials by referring to two key areas in urology of (1) pelvic organ support for prolapse and stress urinary incontinence, and (2) bladder replacement/augmentation.

Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review

INTRODUCTION AND HYPOTHESIS

A previous version of the Cochrane review for prolapse surgery in 2008 provided two conclusions: abdominal sacrocolpopexy had lower recurrent vault prolapse rates than sacrospinous colpopexy but this was balanced against a longer time to return to activities of daily life. An additional continence procedure at the time of prolapse surgery might be beneficial in reducing post-operative stress urinary incontinence; however, this was weighed against potential adverse effects. The aim of this review is to provide an updated summary version of the current Cochrane review on the surgical management of pelvic organ prolapse.

METHODS

We searched the Cochrane Incontinence Group Specialised Register and reference lists of randomised or quasi-randomised controlled trials on surgery for pelvic organ prolapse. Trials were assessed independently by two reviewers.

RESULTS

We identified 40 trials including 18 new and three updates. There were no additional studies on surgery for posterior prolapse. Native tissue anterior repair was associated with more anterior compartment failures than polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23-3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29-5.51). There were no differences in subjective outcomes, quality of life data, de novo dyspareunia, stress urinary incontinence, reoperation rates for prolapse or incontinence, although some of these data were limited. Mesh erosions were reported in 10% (30/293). Including new studies on the impact of continence surgery at the time of prolapse surgery, meta-analysis revealed that concurrent continence surgery did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53-3.70; random-effects model).

CONCLUSION

The inclusion of new randomised controlled trials showed that the use of mesh at the time of anterior vaginal wall repair reduced the risk of recurrent anterior vaginal wall prolapse on examination. However, this was not translated into improved functional or quality of life outcomes. The value of a continence procedure in addition to a prolapse operation in women who are continent pre-operatively remains uncertain. Adequately powered randomised controlled trials are needed and should particularly include women's perceptions of prolapse symptoms and functional outcome.

Robotics for Pelvic Reconstruction

Robotic-assisted laparoscopy is increasingly used in female pelvic reconstructive surgery to combine the benefits of abdominally placed mesh for prolapse outcomes with the quicker recovery time associated with minimally invasive procedures. Level III data suggest that early outcomes of robotic sacrocolpopexy are similar to those of open sacrocolpopexy. A single randomized trial has provided level I evidence that robotic and laparoscopic approaches to sacrocolpopexy have similar short-term anatomic outcomes, although operating times, postoperative pain, and cost are increased with robotics. Patient satisfaction and long-term outcomes of both robotic and laparoscopic sacrocolpopexy are insufficiently studied despite their widespread use in the treatment of prolapse. Given the high reoperative rates for prolapse repairs, long-term follow-up is essential, and well-designed comparative effectiveness research is needed to evaluate pelvic floor surgery adequately.

Prolapse surgery: which technique and when?

PURPOSE OF REVIEW

More answers are nowadays available about certain aspects of pelvic organ prolapse (POP) treatment. In this overview some of those aspects are addressed that were considered important and published in 2010.

RECENT FINDINGS

When stress urinary incontinence (SUI) is present concomitant with POP the strategy is still to perform an additional procedure for SUI. If there is no SUI the tendency is only to correct the POP. With masked SUI no firm conclusions can be drawn.The studies that look at mesh for POP provide some careful conclusions. Absorbable biomeshes do not have many benefits over repairs without mesh in the long term. Nonresorbable mesh tends to give better results but also higher complication rates and should be applied with care.A last item is how to perform a sacrocolpopexy. Laparoscopic sacrocolpopexy is a well tolerated but time-consuming and difficult procedure to treat prolapse. Comparison with other conventional techniques is lacking. Robotic surgery has the potential of enhancing the widespread introduction of laparoscopic procedures.

SUMMARY

With these findings a better evidence-based choice for surgical technique can be made with regards to POP with or without SUI, the kind of mesh to use and which sacrocolpopexy technique should be chosen.

Use of composite grafts in abdominal sacrocolpopexy

OBJECTIVE

: The ideal graft material for pelvic reconstructive surgery remains undetermined. The purpose of this study was to present data on novel composite biologic/synthetic grafts during use in abdominal sacrocolpopexy.

METHODS

: A case series of 90 patients undergoing abdominal sacrocolpopexy with composite biologic/synthetic grafts was conducted. The primary outcome was graft erosion. Assuming a 3% risk of reoperation for mesh erosion, the number needed to treat with a composite graft in order to avoid erosion risk from a synthetic-only graft was calculated. The cost of a composite graft was compared to reoperation costs for mesh erosion of a synthetic-only graft.

RESULTS

: Zero patients (N = 90) undergoing abdominal sacrocolpopexy with a composite biologic/synthetic graft experienced graft erosion. Based on existing data, thirty-three patients would need to be treated with a composite graft to avoid one mesh erosion from a synthetic-only graft. If a $500 composite graft is used, the cost of reoperation performed abdominally is higher.

CONCLUSIONS

: This study introduces a novel biologic/synthetic composite graft that offers the advantage of low erosion risk during use in abdominal sacrocolpopexy. Combined grafts may also be cost-effective. Future research should focus on exploring the role of these durable, yet low erosion risk grafts to potentially promote improved safety for our patients and cost savings for society.

Systematic review of the efficacy and safety of using mesh in surgery for uterine or vaginal vault prolapse

INTRODUCTION AND HYPOTHESIS

The aim of this study is to estimate efficacy and safety of mesh in surgery for uterine or vault prolapse.

METHODS

Seventeen electronic databases were searched for relevant studies that were published from 1980 onwards.

RESULTS

Fifty-four studies involving 7,054 women were included. For sacrocolpopexy (average follow-up 23 months), the risk of clinical recurrence ranged from 0% to 6%, persistent symptoms ranged from 3% to 31% and mesh erosion from 0% to 12%. For infracoccygeal sacropexy (average follow-up 13 months), the risk of clinical recurrence ranged from 0% to 25%, persistent symptoms from 2% to 21% and mesh erosion 0% to 21%. Limited evidence was available for sacrocolpoperineopexy and uterine suspension sling to draw reliable estimates.

CONCLUSIONS

Sacrocolpopexy was associated with a low risk of recurrence but with a relatively high risk of mesh erosion. Ranges of estimates for outcomes for other mesh techniques were wide.

Clinicopathological study of patients requiring reintervention after sacrocolpopexy with xenogenic acellular collagen grafts

PURPOSE

We describe the operative and histopathological findings of patients requiring reintervention because of symptomatic vault prolapse or graft related complications following sacrocolpopexy using xenografts.

MATERIALS AND METHODS

A total of 13 patients underwent secondary sacrocolpopexy because of failure (8) or vaginal revision (5) because of a graft related complication after the initial sacrocolpopexy with porcine dermal collagen (9) or small intestinal submucosa (4). Outcome measures were operative findings and histology of specimens obtained at reintervention. Sections were semiquantitatively scored for the presence of infection, foreign body reaction and fibrosis by a pathologist blinded to the outcome and graft type.

RESULTS

Reinterventions for failure and graft related complications were performed a median of 33 and 15 months, respectively, after the initial operation. Pathology of porcine dermal collagen failures (6) revealed local degradation associated with a minimal foreign body reaction. Porcine dermal collagen remnants were surrounded by minimal fibrosis and neovascularization. Small intestinal submucosa implants of failures (2) were entirely replaced by collagen rich and moderately vascularized connective tissue. Pathology of 3 erosions (all 3 porcine dermal collagen) revealed a locally degraded implant that was surrounded by histiocytes and a polymorphonuclear infiltrate. Pathology of 2 early infections, both small intestinal submucosa, revealed a massive polymorphonuclear infiltration with the implant material remodeled and replaced by loose connective tissue.

CONCLUSIONS

In these clinical recurrences porcine dermal collagen implants were usually locally degraded but still recognizable several years after implantation. Small intestinal submucosa implants were fully replaced by connective tissue. Therefore, the cause of recurrence remains unclear. Porcine dermal collagen erosions displayed features of infection and degradation.

Surgical management of pelvic organ prolapse in women

BACKGROUND

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse.

OBJECTIVES

To determine the effects of the many different surgeries used in the management of pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Forty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model).

AUTHORS' CONCLUSIONS

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

Abdominal, laparoscopic, and robotic surgery for pelvic organ prolapse

Abdominal correction of pelvic organ prolapse remains a viable option for patients and surgeons. The transition from open procedures to less invasive laparoscopic and robotic-assisted surgeries is evident in the literature. This article reviews the surgical options available for pelvic organ prolapse repair and their reported outcomes. Procedures reviewed include apical support (sacral, uterosacral, and others), and abdominal anterior and posterior vaginal wall support. Long-term follow-up and appropriately designed studies will further help direct surgeons in deciding which approach to incorporate into their practice.

Minimizing the cost of surgical correction of stress urinary incontinence and prolapse

OBJECTIVES

To compare the operative costs associated with the use of incontinence kits, with or without biomaterials, with surgeon-tailored prolene mesh (STPM) in the treatment of stress urinary incontinence (SUI) with or without pelvic organ prolapse.

METHODS

All operations for uncomplicated SUI with or without pelvic organ prolapse were reviewed from 2007-2008. Operative billing sheets including operative time, hospital cost, and the insurance billing statement were obtained and reviewed. Surgeon payment was not included in the analysis. Hospital stay was also compared.

RESULTS

For patients with SUI alone, there was a significant difference in the hospital cost and the insurance billing statement between STPM and commercial kits (CK). On average, the insurance billing statement for STPM was $2220 less per case as compared with CK. For patients with SUI and anterior compartment prolapse, there was a significant difference in the hospital cost and the insurance billing statement between STPM and CK. On average, the insurance billing statement for STPM was $4770 less per case as compared with CK. For patients with SUI and anterior and posterior compartment prolapse, the difference in hospital cost and insurance billing statement approached statistical significance. The insurance billing statement for STPM on an average was $5600 less per case as compared with CK. There was no significant difference in operative time or hospital stay.

CONCLUSIONS

The use of STPM for the treatment of incontinence with or without prolapse is significantly less costly for the hospital and the patient and/or insurance as compared with CK. The use of STPM did not increase operative time or postoperative hospital stay when compared with prefashioned kits.

[Vaginal pelvic repair. Always with mesh or not?]

Several surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.

[Vaginal descensus and prolapse. Which operative technique?]

Despite the high prevalence of genital prolapse, there are only few studies so far fulfilling the strict criteria of evidence-oriented data acquisition. On the one hand, this complicates the definition of reliable therapy recommendations, on the other hand, it sounds a note of caution in the application of therapy approaches which are new and have not yet been evaluated adequately.The systematic assessment of common therapy concepts for female genital prolapse and its accompanying pathologies has led to a better understanding of the functional and anatomical background within the last few years. Thus, any invasive anatomical correction should strictly be used with the aim of functional improvement and with evidence of persisting effectivity. Under this premise, traditional methods of vaginal and abdominal prolapse repair still come into use. The choice of the operative technique arises from carefully differentiated, interdisciplinary diagnostics and surgery should be performed in experienced centers.

The current status of laparoscopic sacrocolpopexy: a review

CONTEXT

Pelvic organ prolapse (POP) is a common problem in women that causes morbidity and a decreased quality of life. Sacrocolpopexy can treat women with vaginal vault prolapse (VVP), multicompartmental POP, and/or a history of failed prolapse procedures. Abdominal sacrocolpopexy (ASC) is the gold standard for VVP and is superior to vaginal sacrocolpopexy, with fewer recurrent prolapses and less dyspareunia. Vaginal prolapse repairs, however, are often faster and offer patients a shorter recovery time. Laparoscopic sacrocolpopexy (LSC) aims to bridge this gap and to provide the outcomes of ASC with decreased morbidity.

OBJECTIVE

This review evaluates the recent literature on LSC as a therapy for POP.

EVIDENCE ACQUISITION

A PubMed search of the available English literature on LSC was performed. The reference lists of selected articles were reviewed, and additional on-topic articles were included. Some 50 articles were screened, 22 articles were selected, and the reported outcomes from 11 series are presented in this review.

EVIDENCE SYNTHESIS

Laparoscopic experience with POP has advanced tremendously, and LSC results from >1000 patients in 11 series support this. Conversion rates and operative times have decreased with increased experience. Mean operative time was 158 min (range: 96-286 min) with a 2.7% conversion rate (range: 0-11%) and a 1.6% early reoperation rate (range: 0-3.9%). With a mean follow-up of 24.6 mo (range: 11.4-66 mo), there was, on average, a 94.4% satisfaction rate, a 6.2% prolapse reoperation rate, and a 2.7% mesh erosion rate. Several centers have demonstrated that excellent outcomes with LSC are reproducible in terms of operative parameters, durable results, minimal complications, and high levels of patient satisfaction.

CONCLUSIONS

LSC upholds the outcomes of the gold standard ASC with minimal morbidity. Longer prospective and randomized trials are needed to confirm these results.

Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence

OBJECTIVES

To report anatomic and functional outcomes 2 years after sacrocolpopexy in stress-continent women with or without prophylactic Burch colposuspension.

METHODS

In the Colpopexy and Urinary Reduction Efforts (CARE) trial, stress-continent women undergoing sacrocolpopexy were randomized to receive or not receive a Burch colposuspension. Outcomes included urinary symptoms, other pelvic symptoms, and pelvic support. Standardized pelvic organ prolapse quantification examinations and validated outcome measures including the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire were completed before surgery and at several postoperative intervals, including at 2 years.

RESULTS

This analysis is based on 322 randomized participants; certain analyses were done with a subset based on data availability. Most were Caucasian (94%), with a mean age of 62±10 years (mean±standard deviation). Two years after surgery, 41.8% and 57.9% of women in the Burch and control groups, respectively, met the stress incontinence endpoint (presence of symptoms or positive cough stress test or interval treatment for stress incontinence, P=.020). The apex was well supported (point C within 2 cm of total vaginal length) in 95% of women, and this was not affected by concomitant Burch (P=.18). There was a trend toward fewer urgency symptoms in the Burch group (32.0% versus 44.5% no Burch, P=.085). Twenty participants experienced mesh or suture erosions.

CONCLUSION

The early advantage of prophylactic Burch colposuspension for stress incontinence that was seen at 3 months remains at 2 years. Apical anatomic success rates are high and not affected by concomitant Burch.

CLINICAL TRIAL REGISTRATION

(www.clinicaltrials.gov), ClinicalTrials.gov, NCT00065845.

LEVEL OF EVIDENCE

I.

Surgical management of pelvic organ prolapse in women: a short version Cochrane review

BACKGROUND

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse.

OBJECTIVES

To determine the effects of the many different surgeries in the management of pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding.

MAIN RESULTS

Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated.

AUTHORS' CONCLUSIONS

Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.

Abdominal sacral colpopexy: surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.