ST. LOUIS – A new surgical approach that addresses the anatomical cause of anterior vaginal wall prolapse has much higher success rates than do standard midline and paravaginal repairs that simply reduce the bulge, preliminary results in more than 500 patients suggest.
Success rates with the new procedure, which involves transverse defect repair, have been 91%-95% based on preliminary reports, compared with 40%-60% with traditional colporrhaphy – and even less when the complications associated with the increasing use of synthetic mesh come into play, Dr. S. Robert Kovac reported at an international pelvic reconstructive and vaginal surgery conference, which was sponsored by the Society of Pelvic Reconstructive Surgeons.
The findings regarding the new technique, which have been submitted for publication, need to be confirmed in additional studies. However, it appears that the approach, which does not require plication, trocars, or synthetic mesh, is quite promising for improving outcomes, Dr. Kovac said, adding that the key to successful treatment is finding the cause of the problem, understanding it, and treating it correctly.
“It’s not the material you use, it’s the technique you use,” he said.
In one study of 276 patients who had undergone multiple surgeries for repair and 122 patients undergoing primary repair, success rates using the new transverse repair technique were 91% at 12 months in 150 patients whose surgery involved sutures only, and 92% at 12 months in the remaining patients who were treated with Surgisis Biodesign (Cook Medical Inc.), said Dr. Kovac, the John D. Thompson Distinguished Professor of Gynecologic Surgery and director of the center for pelvic reconstructive surgery and urogynecology at Emory University, Atlanta.
The success rate was greater than 95% in a separate study of 122 patients with stage III or IV prolapse who underwent primary repair using Surgisis Biodesign and were followed for 12 months, he said.
The new transverse defect repair technique involves reattaching the pubocervical fascia to the pericervical ring to correct the transverse defect. This is followed by providing apical support to the iliococcygeal fascia and then to the retroperitoneal uterosacral ligaments at the level of their insertion at S2-S3.
The theory behind this approach to anterior vaginal wall prolapse is based on anatomical childbirth studies that provide “very, very strong evidence” demonstrating that transverse defects, and not midline or paravaginal defects, are the cause of cystocele, he explained.
The reason failure rates are so high with traditional colporrhaphy is because the source of the problem is not treated, he said, noting that despite consistently poor results, 80% of gynecologists are still using “this 100-year-old technique,” Dr. Kovac said.
Dr. Kovac teaches the use of Surgisis Biodesign for cystocele repair to visiting surgeons. Payment is made by Cook Medical to the department of gynecology and obstetrics at Emory University.