Check for defecatory dysfunction
If it is necessary for her to manually digitate her vagina or splint her perineum to defecate, I would perform a rectocele repair and perineorrhaphy.
If she is not a candidate for laparoscopic or abdominal surgery because of a history of multiple procedures for inflammatory bowel disease or severe adhesions, has not had a previous transvaginal apical suspension, and has intact pelvic floor innervation, I would perform either uterosacral vaginal vault suspension or sacrospinous ligament suspension with concomitant anterior and posterior repair.
I would consider offering this patient a tension-free vaginal mesh “kit” procedure (with synthetic mesh) if she:
- has failed previous vaginal procedures,
- has multiple comorbidities,
- is not a candidate for laparoscopic or abdominal surgery,
- desires to remain sexually active, and
- is willing to use and has no contraindications to intravaginal estrogen therapy.
If she does not wish to remain sexually active and is not a good operative candidate, I would offer colpectomy and colpocleisis with perineorrhaphy.
Which circumstances pose special challenges?
- Apical suspension is a critical factor in success and durability of the surgery.
KARRAM: Which segment of the pelvic floor do you find most challenging when correcting advanced pelvic organ prolapse?
SHULL: My colleagues and I have reported our experience with several techniques of vaginal repair for prolapse, including sacrospinous ligament suspension, iliococcygeus fascial suspension, and uterosacral ligament suspension. When we analyzed specific sites in the vagina, the anterior compartment always had the greatest percentage of persistent or recurrent loss of support.
Our best success has been with uterosacral ligament suspension.
Vaginal apex is key to success
PARAISO: I also find the anterior segment challenging. However, if I am able to suspend the vaginal apex well, management of the anterior vaginal wall is less challenging. The anterior wall fails because treatment of high transverse cystoceles and anterior enteroceles (less commonly seen) depends on the apical suspension. Many of these defects go untreated because they are often not detected.
BRUBAKER: I agree with Dr. Paraiso. If you get the apex up solidly, you’re usually home free.
KARRAM: Yes. If one can get good, high, durable support to the apex, the other segments of the pelvic floor are much more likely to endure.
Are unaugmented repairs doomed to fail?
- Despite claims to the contrary, reoperation rates are low for most conventional repairs.
- Surgeons may be tempted to adopt graft augmentation techniques to keep up with “Dr. Jones.”
KARRAM: As you know, there has been a recent push to consider augmenting most pelvic organ prolapse repairs with either biologic or synthetic mesh. This approach is based on a perception that conventional repairs without augmentation inevitably will fail. Do you agree with this perception?
SHULL: Not based on my own experience. Mesh has been effectively and safely used for midurethral slings and abdominal sacrocolpopexies, but there are not enough data on the use of allografts, xenografts, or meshes to be able to counsel a patient properly about their safety, efficacy, or long-term effects.
PARAISO: I agree that this perception is being promoted, prompting many physicians to adopt graft augmentation techniques to keep up with “Dr. Jones” or to offer their patients “cutting-edge” treatment. Despite the fact that conventional procedures are often described as having high failure rates, the reoperation rates in most series are low. Nevertheless, augmentation with biologic grafts has been widely adopted without prior investigation or data.
Traditional and site-specific repairs versus graft augmentation
My colleagues and I just presented a manuscript on traditional posterior colporrhaphy, site-specific rectocele repair, and site-specific repair with graft augmentation using a porcine small intestinal submucosa bioengineered collagen matrix.
The anatomic cure rate was substantially higher in the traditional and site-specific groups when compared with the graft augmentation arm, with cure rates of 86% and 78% versus 54%, respectively (P=.02).4
Currently, my indications for a mesh-augmented prolapse repair are:
- Nonexistent or suboptimal autologous tissue
- Need to augment weak or absent endopelvic tissue
- Connective tissue disorder
- Unavoidable stress on the repair (eg, chronic lifting, chronic obstructive pulmonary disease, chronic straining to defecate, obesity)
- Need to bridge a space such as sacral colpopexy
- Concern about vaginal length or caliber
- Denervated pelvic floor
- Recurrent prolapse
Surgeons should not believe that graft augmentation compensates for surgical mediocrity or patient risk factors for pelvic organ prolapse.
The key to success: Maintain the vaginal axis
KARRAM: I don’t believe all traditional repairs are bound to fail. Many factors play into recurrent prolapse. I think most people overlook the fact that the vagina is very sensitive to its axis. Any operation that alters the vaginal axis will seriously weaken the vagina opposite the distorted axis.