Diagnosis and Management of Complex Pelvic Floor Disorders in Women

Vaginal Approaches

Numerous techniques for pelvic organ prolapse repair have been described, though most repairs can broadly be divided into vaginal and abdominal procedures. Vaginal surgery is consistently associated with shorter operative times, less postoperative pain, and a shorter length of stay than abdominal approaches. All prolapsing compartments can be addressed vaginally using a patient’s own tissue, often called a “native tissue repair.” The vaginal apex is suspended from either the uterosacral ligament (USL) condensations or to the sacrospinous ligaments (SSL). Sutures are placed through these structures and tied to hold the vaginal vault in place, often at the time of concomitant enterocele, cystocele, or rectocele repairs. A recent randomized trial comparing USL and SSL repair showed composite functional and symptomatic success was 60% at 2 years and did not differ by technique [24]. While overall success may appear low, symptomatic vaginal bulge was present in only 17% to 19% of women at 2 years and only 5% underwent re-treatment with surgery or pessary during follow-up. Similar outcomes have been demonstrated for isolated cystocele repairs plicating the pubo-cervical fascia (anterior colporrhaphy). Cited failure rates have been as high as 70% [25], though this depends on the definition of success. When symptoms of bulge and/or prolapse beyond the hymen are used, success rates are closer to 89% at 2 years [26]. In one study comparing mesh-augmented cystocele repair with native tissue anterior colporrhaphy, 49% of women had a successful composite outcome at 2 years of grade 0 or 1 prolapse and no symptoms of bulge without the use of mesh graft [27]. Despite lower anatomic success rates, anterior colporrhaphy consistently relieves symptoms of bulge with low retreatment rates.

The high failure rates of native tissue vaginal repairs, especially in women with high-grade or recurrent prolapse, led to an interest in graft-augmented repairs. Furthermore, anatomic studies showed that up to 88% of cystoceles were associated with a lateral defect, or tearing of the pubocervical fascia from the pelvic sidewall (arcus tendineous fascia pelvis) [28]. Plicating the already weak fascia centrally would not repair an underlying lateral defect resulting in treatment failure. Replacing this weak fascia with a graft and anchoring it laterally and proximally should result in better anatomic and functional outcomes. These patches can be made from autologous tissue (rectus fascia), donor allograft material (fascia lata), xenografts (porcine dermis, bovine pericardium), or synthetic mesh. Initial studies using cadaveric dermis grafts for recurrent stage II or stage III/IV pelvic organ prolapse resulted in 50% failure at 4 years, but symptomatic failure was only 11% [29]. Further publications utilizing cadaveric tissue patches showed lower rates of cystocele recurrences of 0 to 17% between 20 and 56 months of follow-up [30].

As interest in patch repairs became popular, the use of synthetic mesh was applied to tension-free mid-urethral tapes for SUI. Studies were also showing rapid cadaveric and xenograft graft metabolism, graft extrusion, and early failure in some women [31]. This led to the use of larger pieces of synthetic mesh for prolapse repair, as it had been for abdominal wall and inguinal hernia repairs. Ultimately large-pore, light-weight polypropylene mesh was seen as the most favorable material and large randomized studies were performed to compare outcomes. Theoretically, a synthetic material would provide a replacement for the weakened and torn pubocervical fascia and not be subjected to enzymatic degradation. Altman et al published a widely cited randomized trial comparing native tissue vs. synthetic mesh showing that improvement in the composite primary outcome (no prolapse on the basis of both objective and subjective assessments) was more common in the mesh group (61% vs. 35%) at 1 year. Mesh placement was associated with longer operative times, higher blood loss, and 3.2% of women underwent secondary procedures for vaginal mesh exposure [27]. While there is still debate on the routine use of transvaginal mesh placement, current recommendations generally limit its use for recurrent or high grade pelvic organ prolapse (> Stage III), and possibly those at higher risks for recurrence. The American Urological Association has supported the FDA recommendation that patients undergo a thorough consent process and that surgeons are properly trained in pelvic reconstruction and mesh placement techniques. Furthermore, surgeons placing transvaginal mesh should be equipped to diagnose and treat any complications that may arise subsequent to its use.