For example, we know that sacrospinous ligament suspension retroverts the vagina and sets women up for recurrence or development of anterior vaginal wall prolapse. Another example is a Burch colposuspension that anteverts a portion of the vagina and sets patients up for posterior vaginal wall defects in the form of a rectocele and enterocele.
Too much simplification
I also think surgeons and device manufacturers have attempted to simplify what, in reality, is a very complicated clinical picture. So many factors are involved in the identification and appropriate utilization of support structures for a durable prolapse repair.
Since Dr. Shull’s popularization of a high uterosacral suspension, we have had very good long-term success with transvaginal vault repair. Also, over time I have realized that it is possible to mobilize a substantial amount of durable fascial tissue—which is nothing more than the muscular lining of the vagina—to appropriately support the anterior and posterior vaginal walls.
That said, the results are far from perfect. I would estimate our anatomic failure rate at 15% to 20% over the long term.
Does augmentation add complications?
When it comes to mesh, we have to ask: Is it truly going to increase durability? If it is, is that going to be at the expense of a new set of complications such as mesh erosion or extrusion and dyspareunia?
The only way to answer these questions is with a randomized trial with long-term follow-up. At this time, such data are not available.
Are tension-free repair kits the wave of the future?
- It’s not yet time to make these kits the standard, although preliminary data are promising.
KARRAM: Do you think the synthetic mesh repairs now being promoted as tension-free repairs utilizing numerous industry-created “kits” will be the future of prolapse repair?
BRUBAKER: I hope not.
KARRAM: At present, I would say the answer to that question is “no.” However, I was very reluctant to accept synthetic midurethral slings, and they have turned out to be the standard of care.
SHULL: These products are the future for surgeons who allow industry to dictate their practice styles. For those of us who are more skeptical, we will change only after there is adequate scientific information to do so.
Though unproven, kits do have advantages
PARAISO: I agree. Even so, in many ways, these kits make sense. Operative time is greatly reduced and incisions are small, thus offering the advantage of minimally invasive procedures. Preliminary data at 6 months show excellent anatomic outcomes. However, the graft extrusion rate is high with the kit procedures, compared with existing evidence on synthetic mesh erosion associated with abdominal and laparoscopic sacral colpopexy.
In addition, current synthetic materials are not ideal. Long-term sequelae of transvaginal implantation of these meshes are not known. Nor do we have long-term data on sexual function.
By and large, these procedures are blind and involve the transobturator and transgluteal (ischiorectal fossa) spaces—uncharted waters for many gynecologic surgeons. Further, many gynecologic surgeons lack extensive training or experience in sacrospinous ligament suspension, iliococcygeus fascia suspension, and vaginal paravaginal defect repair, which are prerequisites for the kit procedures.
Matching the kit procedure to the patient
As for patient selection, women for whom previous anterior repair (with or without biologic graft), paravaginal defect repair, and apical suspension have failed, and who continue to have asymptomatic anterior vaginal wall prolapse are the best candidates for anterior kit procedures. The best candidates for posterior and apical segment kit procedures are women in whom transvaginal apical suspension has failed, and who are not suited for laparoscopic or abdominal procedures.
The only impediments to widespread adoption of these procedures for years to come will be adverse events or technology so advanced it makes gene modification possible, rendering surgery obsolete.
KARRAM: I think we need better and longer follow-up. Most of the surgeons currently using these procedures are proponents of the repairs, in my opinion, but until results from comparative trials become available, we won’t really know how they compare to conventional repairs.
Bringing up the next generation
- Residents need as much hands-on experience as possible, including cadaveric dissections, urodynamic labs, and urogynecologic clinics—even virtual-reality models.
KARRAM: How do we best train residents in the appropriate evaluation and surgical management of these very common pelvic floor disorders?
BRUBAKER: Carefully and ethically. Encourage them to be good consumers of surgical literature and to resist the urge to constantly demonstrate the “latest and greatest” until we have solid evidence.
PARAISO: Residents can learn from discussions of surgical indications prior to pelvic reconstructive procedures in which they are involved, attendance at urogynecologic clinics, urodynamic lab rotations, and study of urogynecologic learning modules and current clinical textbooks that focus on these surgeries.