CASE Symptoms point to yet another prolapse recurrence
A 52-year-old woman presents with a bulge and pressure in her vagina. She has undergone 2 prior reconstructive surgeries. The first was a vaginal hysterectomy, anterior and posterior repair, and sling; the second was an abdominal procedure that included a sacrocolpopexy and paravaginal repair.
A physical examination reveals a recurrent 4th-degree cystocele that protrudes 2 cm beyond the hymenal ring. The vault and posterior compartment are well supported, and the patient reports no incontinence, a fact confirmed by urodynamics testing. She asks that you do everything in your power to prevent further recurrence.
How do you proceed?
This patient ultimately underwent anterior colporrhaphy and vaginal paravaginal repair using a decellularized dermal cadaveric implant. She was still doing well 1 year later, with no recurrence.
Despite success stories like this one, the use of graft materials to repair cystoceles and rectoceles is controversial. One reason is the difficulty of interpreting published data, since studies lack uniformity in technique, patient characteristics, graft shape, type of material, attachment sites, and duration of follow-up. Level I evidence that augmented repairs have a clear benefit over traditional repairs is sparse.
Advocates of graft materials argue that native tissue is already compromised—hence, the prolapse—making surgical failure likely.1 They claim graft materials help strengthen repairs, especially in the case of cystoceles. They also point out that adjuvant materials have been used in burns, plastic surgery, and orthopedics for more than 10 years and are generally well tolerated. Their success in hernia repairs prompted their consideration for the pelvic floor.
A pervasive problem, but only 10% to 20% seek help
Roughly 1 of 2 parous women lose pelvic support as they age, but only 10% to 20% seek medical care, with a lifetime risk of surgery for pelvic organ prolapse (POP) of 11% by age 80.2
With women living longer than ever and remaining active later in life, this percentage is likely to rise. Unfortunately, few alternatives to surgical treatment exist, and the reoperation rate for recurrence is 29%, according to a 1995 review.2 If surgical management is the only hope of cure, how can we lower the 29% recurrence rate?
Graft materials may provide part or all of the solution.
Elements of prolapse
Anterior compartment
Central and/or lateral defects can occur in the anterior compartment.
Lateral (paravaginal) defects indicate that the endopelvic connective tissue has separated from the arcus tendineus fascia pelvis. Lateral defects can be repaired vaginally or abdominally.
One study3 found that 67% of women with anterior wall prolapse had paravaginal defects, but no randomized trials have evaluated the clinical benefit of repairing these defects, compared with traditional colporrhaphies.
Central defects involve site-specific defects and/or general attenuation of the endopelvic connective tissue. These are usually repaired vaginally.
Recurrence rates for lateral and central defects range from 3% to 70%.4-8
Two large series of vaginal paravaginal repairs noted the following recurrence rates:
- Shull et al6 found a recurrence rate of 7% to the hymenal ring or beyond.
- Young et al7 observed a recurrence rate for lateral defects of 2%, with recurrence rates as high as 22% for central defects.
In a comparison of 3 techniques for vaginal repair of central defects, using strict criteria to assess anatomic outcomes, Weber et al4 found recurrence rates of 54% to 70%. Other studies show symptomatic recurrence rates of 3% to 22% for cystoceles.5,8
With grafts, both paravaginal and central defects can be repaired. Vaginal paravaginal repairs are not popular due to the technical difficulty involved. With the use of grafts, however, both paravaginal and central defects can be addressed simultaneously with relative ease.
Posterior compartment
Defects in the posterior compartment are less likely to recur. Reported success rates range from 80% to 90%.9,10
Posterior compartment defects include general attenuation of Denonvillier’s fascia or a tear anywhere along the fascia or any of its attachments.
Recurrence rates. Site-specific repairs are thought to minimize complications such as dyspareunia. However, few studies have compared the efficacy of site-specific repairs with that of traditional colporrhaphies. At our institution, women who underwent traditional colporrhaphy had fewer recurrences than controls (33% vs 14%), with no differences in postoperative symptoms such as dyspareunia, constipation, and fecal incontinence.11
Graft materials of questionable benefit. In the posterior compartment, these materials have not been shown to be beneficial, compared with traditional or site-specific repairs. Sand et al12 found no benefit for repairs in which absorbable Vicryl mesh was imbricated, but this randomized trial may have lacked sufficient power to show statistical significance. Large cohorts would be needed to show significant benefit of meshes in the posterior compartment.