In 2008, the Society of Gynecologic Surgeons (SGS) systematically reviewed the literature and published clinical practice guidelines on vaginal graft use. The SGS group concluded that nonabsorbable synthetic graft use may improve anatomic outcomes of the anterior vaginal wall, but that there are trade-offs in regard to additional risk. While more randomized studies on new mesh products are being conducted and reported, the data simply are insufficient to determine the anatomic or symptomatic efficacy of these types of grafts, the group said (Obstet. Gynecol. 2008;112:1131-42).
Similar to the SGS review, the Cochrane Collaboration completed a systematic review and concluded that the use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele but that there was insufficient evidence to make recommendations for anterior vaginal wall or apical repair (Cochrane Database Syst. Rev. 2010;CD004014 [doi: 10.1002/14651858.CD004014.pub4]).
Overall, the few randomized trials that have been done illustrate the balance of risks and benefits that the surgeon and patient must weigh prior to considering the use of vaginal mesh or graft for the treatment of anterior wall prolapse.
One study that randomized 202 women to anterior colporrhaphy with or without a low-weight polypropylene mesh showed lower recurrence of anterior wall prolapse at 1 year with mesh than without mesh on physical examination using the Pelvic Organ Prolapse Quantification (POP-Q) system, but no differences in patient symptoms.
In this trial, the cure rate 1 year after surgery (defined as POP-Q stage 0 or 1) was significantly higher after the mesh-augmented repair compared with standard anterior colporrhaphy (62% vs. 93%). The use of mesh was, however, associated more often with stress urinary incontinence (23% vs. 10%). There were no differences in symptomatic outcomes. Mesh exposure was significant in the augmented group, 17% vs. 0% (Obstet. Gynecol. 2007;110:455-62).
In a one-surgeon, randomized controlled trial of 38 women who had traditional anterior colporrhaphy and 37 who had polypropylene mesh repair using the Perigee Transobturator Prolapse Repair System, Dr. John N. Nguyen concluded that repair with polypropylene mesh reinforcement offered lower anatomic recurrence rates at 1 year than did anterior colporrhaphy without mesh reinforcement (Obstet. Gynecol. 2008;111:891-8).
In this study, prolapse and incontinence symptoms improved significantly in both treatment groups.
Overall, the current evidence seems to support the use of synthetic mesh to augment repairs of anterior vaginal prolapse but at the expense of an increased rate of complications, particularly mesh exposure.
In my practice, most recurrent anterior wall prolapses are associated with apical descent as well. In those patients, I recommend a sacrocolpopexy performed laparoscopically. I would reserve the use of transvaginal mesh for women who have recurrent isolated anterior vaginal prolapse with a well-supported apex.
Three-point countertraction aids in the dissection of the vaginal wall.
The first vertical mattress stitch is placed at the vaginal apex during the surgery.
The second horizontal mattress stitch is placed, plicating the fibromuscular wall of the anterior wall.
The plication is complete. Minimal vaginal wall is trimmed prior to closing.
Source Photos courtesy Dr. Dee E. Fenner
Revisiting Anterior Colporrhaphy
According to Dr. Sangeeta Mahajan, any descent of the anterior wall of the vagina or base of the bladder, whether provoked or without straining, can be considered clinically an anterior vaginal wall defect. However, the International Continence Society uses a more precise definition: An anterior vaginal wall defect exists when the urethrovesical junction or any other part of the anterior vaginal wall is less than 3 cm from the hymenal ring.
It is now recognized that anterior vaginal wall prolapse occurs as a result of a specific defect in the vagina's support structure. Epidemiologically, aging, parity, obesity, cigarette smoking, chronic lung disease, congenital defects, white ancestry, and prior hysterectomy or prolapse surgery have been identified as risk factors associated with pelvic organ prolapse. Ultimately, management of anterior wall defects, which may be conservative or surgical, is indicated for the following reasons: discomfort, urinary retention, or genuine stress urinary incontinence.
Although retrospective case series, with a minimum of 1-year follow-up, by R. Porges, S.L. Stanton, and Walter and C. Maher, have documented success rates following anterior colporrhaphy for the treatment of anterior vaginal wall defects, in the range of 80%-100%; prospective studies by P.K. Sand and A.M. Weber demonstrate rates of success at 37%-57%.
Given the obvious challenge in providing success to our patient suffering with an anterior vaginal support defect with resulting prolapse, it is important to review the anatomy, perform proper evaluation, and provide appropriate surgical treatment, including use of graft materials.