Kaven Baessler

Surgical management of anterior vaginal wall prolapse: an evidencebased literature review

The aim of this review is to summarize the available literature on surgical management of anterior vaginal wall prolapse. A Medline search from 1966 to 2004 and a hand-search of conference proceedings of the International Continence Society and International Urogynecological Association from 2001 to 2004 were performed. The success rates for the anterior colporrhaphy vary widely between 37 and 100%. Augmentation with absorbable mesh (polyglactin) significantly increases the success rate for anterior vaginal wall prolapse. Abdominal sacrocolpopexy combined with paravaginal repair significantly reduced the risk for further cystocele surgery compared to anterior colporrhaphy and sacrospinous colpopexy. The abdominal and vaginal paravaginal repair have success rates between 76 and 100%, however, no randomized trials have been performed. There is currently no evidence to recommend the routine use of any graft in primary repairs, and possible improved anatomical out-comes have to be tempered againstcomplications including mesh erosions, infections and dyspareunia.

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

Introduction and hypothesisA 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.MethodsWe 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.ResultsWe 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).ConclusionThe 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 womens perceptions of prolapse symptoms and functional outcome.

Severe mesh complications following intravaginal slingplasty

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended. LEVEL OF EVIDENCE: III

Abdominal sacrocolpopexy and anatomy and function of the posterior compartment.

Objective To assess the effect of abdominal sacrocolpopexy with obliteration of the pouch of Douglas on anatomy and function of the posterior compartment. Methods We prospectively studied 33 consecutive women with pelvic organ prolapse who had abdominal sacrocolpopexies [expanded polytetrafluoroethylene (Gore-Tex)] with pouch of Douglas obliterations and posterior extensions of mesh, using a standardized questionnaire, urodynamic studies, pelvic floor fluoroscopies, and vaginal-rectal examinations (Baden-Walker classification). Concomitant colpoperineorrhaphy was done if rectoceles remained at rectovaginal examination at the end of sacrocolpopexy. The goal was to correct rectoceles transabdominally. Results Thirty-one women returned for follow-up investigations after 12–48 months (mean 26 months). Mean age was 61 years (range 41–77 years). There was no recurrence of vaginal vault prolapse, enterocele, or anterior rectal wall prolapse. Among 28 preoperative rectoceles, 16 recurred (57%) and one occurred de novo. Defecation problems (outlet constipation) were present in 21 women (64%) preoperatively and persisted or were altered in 12 (57%) after sacrocolpopexy. Grade of rectocele was associated significantly with symptoms of outlet constipation preoperatively, but not postoperatively (P = .002). Conclusion Abdominal sacrocolpopexy with obliteration of the pouch of Douglas and posterior extension of the mesh was effective for vaginal vault prolapse, enterocele, and anterior rectal wall procidentia, but not concomitant rectocele. Twenty-eight percent of women described altered defecation with stool stopping higher in the rectosigmoid colon (“high outlet constipation”), which might have been caused by denervation during rectal mobilization.

Mesh augmentation during pelvic-floor reconstructive surgery: risks and benefits

Purpose of review Synthetic meshes are increasingly used in the surgical management of stress urinary incontinence and pelvic-organ prolapse in an attempt to improve success rates and increase the longevity of repairs. This review describes and analyses complications following pelvic-floor procedures employing synthetic meshes. Recent findings Type I monofilament polypropylene mesh with a large pore size is currently the mesh of choice. Chronic inflammation is a typical host response, whereas acute inflammation and predominant CD20+ lymphocyte infiltration represent an adverse host reaction and may result in defective healing. Mesh properties influence the performance and complication rate. Mesh-related complications after midurethral slings and mesh sacrocolpopexies with monofilament polypropylene are rare. An up to 26% mesh erosion rate and up to 38% dyspareunia rate with vaginally introduced mesh for pelvic-organ prolapse repair has been reported. Concurrent hysterectomy seems to increase mesh erosion rates. Summary Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of synthetic mesh in vaginal reconstructive surgery emerge, its routine use outside of clinical trials cannot be recommended.

Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation.

OBJECTIVE: To estimate the efficacy of midline fascial plication of the posterior vaginal wall in women with rectoceles and obstructed defecation. METHODS: Prospective evaluation of 38 consecutive women with symptomatic rectoceles (stage II or greater) and obstructed defecation included pre- and postoperative standardized pelvic floor questions, pelvic organ prolapse quantification measurements, validated bowel function questionnaires, defecating proctogram, and patient satisfaction. Reviews were conducted by nonsurgical coauthors. RESULTS: The median follow-up was 12.5 months (range 2.5–26 months). The subjective success rates were 97% (95% confidence interval [CI] 0.83–1.00%) at 12 months and 89% (95% CI 0.55–0.98%) at 24 months. The objective success rates were 87% (95% CI 0.64–0.96%) at 12 months and 79% (95% CI 0.51–0.92%) at 24 months. The average points, Ap and Bp, were significantly reduced from −0.1 (range −2 to 3) and 1.1 (range −1 to 8), preoperatively, to −2.6 (range −3 to −1) and −2.5 (range −3 to 0), postoperatively, respectively (P < .001). Depth of rectocele also reduced postoperatively on defecating fluoroscopy (P < .001). The correction of the anatomical defect was associated with improved functional outcome, with 33 women (87%) no longer experiencing obstructed defecation, and there was a significant reduction in postoperative straining to defecate, hard stools, and dyspareunia (P = .001). The improved anatomical and functional outcomes were reflected in the fact that 97% of the women reported very high patient satisfaction. CONCLUSION: Midline fascial plication is effective in correcting anatomical and functional outcomes associated with symptomatic rectoceles and obstructed defecation. LEVEL OF EVIDENCE: III

Surgical management of posterior vaginal wall prolapse: an evidence-based literature review

The aim of this review is to summarize the available literature on gynecological management of posterior vaginal wall prolapse. A MEDLINE search and a hand search of conference proceedings of the International Continence Society and International Urogynecological Association was performed. Two randomized trials demonstrated that the transvaginal approach to rectocele is superior to the transanal repair in terms of recurrent prolapse. The traditional posterior colporrhaphy with levator ani plication was largely superceded by fascial repairs with similar anatomic success rates but favorable functional outcome. The midline fascial plication may offer a superior anatomic and functional outcome compared to the discrete site-specific fascial repair. Controlled studies are necessary to evaluate whether a sacrocolpopexy combined with posterior mesh interposition is an effective alternative to the transvaginal repair. There is currently no evidence to recommend the routine use of any graft and complications such as mesh erosion, infection, and rejection have to be considered.

A validated self-administered female pelvic floor questionnaire

Introduction and hypothesisThe aim of this study was to validate a self-administered version of the already validated interviewer-administered Australian pelvic floor questionnaire.MethodsThe questionnaire was completed by 163 women attending an urogynecological clinic. Face and convergent validity was assessed. Reliability testing and comparison with the interviewer-administered version was performed in a subset of 105 patients. Responsiveness was evaluated in a subset of 73 women.ResultsMissing data did not exceed 4% for any question. Cronbach’s alpha coefficients were acceptable in all domains. Kappa coefficients for the test–retest analyses varied from 0.64–1.0. Prolapse symptoms correlated significantly with the pelvic organ prolapse quantification. Urodynamics confirmed the reported symptom stress incontinence in 70%. The self and interviewer-administered questionnaires demonstrated equivalence. Effect sizes ranged from 0.6 to 1.4.ConclusionsThis self-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion and due to its responsiveness, can be used for routine clinical assessment and outcome research.

Australian pelvic floor questionnaire: a validated interviewer-administered pelvic floor questionnaire for routine clinic and research

The aim of this study was to design and validate an interviewer-administered pelvic floor questionnaire that integrates bladder, bowel and sexual function, pelvic organ prolapse, severity, bothersomeness and condition-specific quality of life. Validation testing of the questionnaire was performed using data from 106 urogynaecological patients and a separately sampled community cohort of 49 women. Missing data did not exceed 2% for any question. It distinguished community and urogynaecological populations regarding pelvic floor dysfunction. The bladder domain correlated with the short version of the Urogenital Distress Inventory, bowel function with an established bowel questionnaire and prolapse symptoms with the International Continence Society prolapse quantification. Sexual function assessment reflected scores on the McCoy Female Sexuality Questionnaire. Cronbach’s α coefficients were acceptable in all domains. Kappa coefficients of agreement for the test–retest analyses varied from 0.5 to 1.0. The interviewer-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion in a typical urogynaecological clinic.

Selection of patients in whom vaginal graft use may be appropriate

Introduction and hypothesisThe recent rapid and widespread adoption of the use of mesh, and mesh-based surgical kits for pelvic organ prolapse (POP) repair surgery has occurred largely unchecked, and is now being subjected to critical analysis and re-evaluation.MethodsThere have been multiple driving forces for this phenomenon, including aggressive marketing by surgical device manufacturing companies, contagious hype among pelvic surgeons and regulatory processes which facilitated relatively rapid marketing of new devices.ResultsPatient-related factors such as indications for mesh use, expected risks and benefits relative to mesh implantation, and appropriately selected outcome measures have been slow to be defined.ConclusionsThis manuscript reviews the currently available literature in the use of grafts and mesh in POP surgery with a focus on identifying situations where graft use may be appropriate for an individual patient. It also identifies specific clinical situations where mesh use may not be recommended.