Surgical Repair of Anterior Surgical Repair of Anterior Vaginal Wall Prolapse; When, Vaginal Wall Prolapse; When, Why, and How I Place Vaginal Why, and How I Place Vaginal

MeshMeshMickey Karram MDMickey Karram MD

Director of UrogynecologyDirector of Urogynecology

The Christ HospitalThe Christ Hospital

Professor of Ob/Gyn & UrologyProfessor of Ob/Gyn & Urology

University of CincinnatiUniversity of Cincinnati

Cincinnati, Ohio U.S.ACincinnati, Ohio U.S.A

ObjectivesObjectives

• Discuss the anatomy of the anterior vaginal wall, Discuss the anatomy of the anterior vaginal wall,

retropubic space, and inner groinretropubic space, and inner groin

• Review clinical presentation and preoperative Review clinical presentation and preoperative

evaluation of a patient with symptomatic cystoceleevaluation of a patient with symptomatic cystocele

• Discuss surgical dissection plans and various Discuss surgical dissection plans and various

techniques to transvaginally repair anterior vaginal techniques to transvaginally repair anterior vaginal

wall prolapse with and without meshwall prolapse with and without mesh

• Review outcomes of suture repairs vs mesh Review outcomes of suture repairs vs mesh

augmented repairsaugmented repairs

CystoceleCystocele

Ahlfelt states that the only problem in Ahlfelt states that the only problem in

plastic gynecology left unsolved by the plastic gynecology left unsolved by the

gynecologist of the past century is the gynecologist of the past century is the

permanent cure of cystocelepermanent cure of cystocele

George R. White 1909George R. White 1909

Specific Surgical Goals: Specific Surgical Goals: Maintain or Create a Well Supported Maintain or Create a Well Supported

Functional Vagina Functional Vagina

• What is normal vaginal length?What is normal vaginal length?

• What is normal vaginal caliber?What is normal vaginal caliber?

• What is normal relationship between perineum and What is normal relationship between perineum and posterior vaginal wall?posterior vaginal wall?

• What is normal vaginal axis?What is normal vaginal axis?

• What is the most important aspect of your repair?What is the most important aspect of your repair?

• How do you determine who needs an augmented How do you determine who needs an augmented repair?repair?

Types of Types of Anterior Vaginal Wall ProlapseAnterior Vaginal Wall Prolapse

• True cystocele (distention cystocele)True cystocele (distention cystocele)

• Displacement cystoceleDisplacement cystocele

Etiology of CystoceleEtiology of Cystocele

• Separation of paravaginal attachment of Separation of paravaginal attachment of

the pubocervical fascia from the white linethe pubocervical fascia from the white line

• Loss of vagina’s attachment to the cervixLoss of vagina’s attachment to the cervix

• Tearing of pubocervical fascia that results Tearing of pubocervical fascia that results

in herniation of the bladder through this in herniation of the bladder through this

layerlayer

Anterior Vaginal ProlapseAnterior Vaginal Prolapse

““Pubocervical fascia is really vaginal Pubocervical fascia is really vaginal

muscularis and adventitia.”muscularis and adventitia.”

Weber And Walters (Obstet Gynecol 1997;89:311-8)Weber And Walters (Obstet Gynecol 1997;89:311-8)

Ischiopubic Ramus

Ischium

Pubic symphysis

IliumObturator Obturator ForamenForamen

Obturator Obturator CanalCanal

Transobturator Landmarks

Obturator canal

Urethra

Safe entry zone of Transobturator needle

Adductor longus

Vaginal Repair of Enterocele

Anatomy of Anterior VaginaAnatomy of Anterior Vagina

How Does a Patient with Anterior Vaginal How Does a Patient with Anterior Vaginal Wall Prolapse PresentWall Prolapse Present

• Completely asymptomaticCompletely asymptomatic

• Typical symptoms of prolapse with no functional Typical symptoms of prolapse with no functional

derangementsderangements

• A variety of functional rerangements without A variety of functional rerangements without

prolapse symptomsprolapse symptoms

• Combination of prolapse symptoms and Combination of prolapse symptoms and

functional derangementsfunctional derangements

• Rarely presents in complete isolationRarely presents in complete isolation

Pre-operative EvaluationPre-operative Evaluation

• History History

• Good physical exam Good physical exam

• Objective assessment of lower urinary Objective assessment of lower urinary

tract functiontract function

• CystourethroscopyCystourethroscopy

• Imaging studiesImaging studies

Anterior and Posterior Vaginal Anterior and Posterior Vaginal Wall ProlapseWall Prolapse

• Extent of dissection for cystocele repair Extent of dissection for cystocele repair

(lateral to inferior pubic ramus and (lateral to inferior pubic ramus and

dissection of bladder base off of dissection of bladder base off of

vaginal cuff)vaginal cuff)

• Extent of dissection for rectocele repair Extent of dissection for rectocele repair

(lateral to rectal gutter and proximally (lateral to rectal gutter and proximally

to preperitoneal space of cul-de-sac)to preperitoneal space of cul-de-sac)

Surgical Repair of CystoceleSurgical Repair of Cystocele

• Vaginal approaches (anterior colporrhaphy Vaginal approaches (anterior colporrhaphy

with vesical neck plication)with vesical neck plication)

• Abdominal approachesAbdominal approaches

• Vaginal paravaginal repairsVaginal paravaginal repairs

• Mesh augmented repairsMesh augmented repairs– Mesh overlayMesh overlay

– Trocar based mesh kitTrocar based mesh kit

– Direct access mesh kitDirect access mesh kit

Anterior Vaginal Wall DissectionAnterior Vaginal Wall Dissection

Next Generation: Elevate AnteriorNext Generation: Elevate Anterior

• Four point fixation systemFour point fixation system

– Obturator internus Obturator internus

muscle and muscle and

sacrospinous ligament sacrospinous ligament

fixationfixation

• Only one anterior incisionOnly one anterior incision

– Provides both anterior Provides both anterior

and apical supportand apical support

Direct Access Mesh AugmentationDirect Access Mesh Augmentation

Native Tissue vs. Polypropylene MeshNative Tissue vs. Polypropylene Mesh

30%

12%

33%

53%

41%

29%

5% 7%

18%13% 12%

9%

Al-Nazer2007a

Ali 2006a Lim 2007a Nguyen 2008 Nieminen2008

Sivaslioglu2008

Native Tissue Polypropylene mesh

Objective FailureObjective Failure

Anterior colporrhaphy vs. Polypropylene mesh overlayAnterior colporrhaphy vs. Polypropylene mesh overlay

Anterior colporrhaphy vs. Armed transobturator Anterior colporrhaphy vs. Armed transobturator Polypropylene meshPolypropylene mesh

Objective FailureObjective Failure

Anterior Colporrhaphy (Ac) Alone Vs. Ac Plus Polypropylene MeshAnterior Colporrhaphy (Ac) Alone Vs. Ac Plus Polypropylene Mesh

Anterior Colporrhaphy (AC) Vs. Polypropylene Mesh without AC

Objective FailureObjective Failure

Anterior colporrhaphy vs. Armed Transobturator MeshAnterior colporrhaphy vs. Armed Transobturator Mesh

PFIQ-7PFIQ-7

PQOLPQOL

Post-op Quality of LifePost-op Quality of Life

Ali 2006a Lim 2007a Nguyen2008

Nieminen2008

Sivaslioglu2008

7%7%

5%

17%

7%

Mesh ErosionMesh Erosion

Mean = 10.2% (30/293)

Native Tissue Repair vs. Mesh RepairNative Tissue Repair vs. Mesh Repair

De novo DyspareuniaDe novo Dyspareunia

Anterior colporrhaphy Vs. Armed Transobturator MeshAnterior colporrhaphy Vs. Armed Transobturator Mesh

De novo Stress Urinary IncontinenceDe novo Stress Urinary Incontinence

• One study reported a subjective One study reported a subjective

success rate which was similar in both success rate which was similar in both

groups groups (Nieminen 2008)(Nieminen 2008)

• Blood loss at transobturator meshes Blood loss at transobturator meshes

was significantly higher compared to was significantly higher compared to

anterior colporrhaphy, reported as anterior colporrhaphy, reported as

blood loss in ml blood loss in ml (Nieminen 2008)(Nieminen 2008) or Hb change or Hb change (Nguyen 2008)(Nguyen 2008)

Anterior (ProliftAnterior (Prolift™™) for Recurrent Cystocele) for Recurrent Cystocele

• Two year review 36 womenTwo year review 36 women

• Recurrent ant wall prolapseRecurrent ant wall prolapse

• Success rate 53%Success rate 53%

• Mesh erosion rate 19%Mesh erosion rate 19%

• De novo dyspareunia 7/16 43%De novo dyspareunia 7/16 43%

Fayyad et al 2010Fayyad et al 2010

Self Styled Mesh vs Anterior ColporrhaphySelf Styled Mesh vs Anterior ColporrhaphyThree Year OutcomeThree Year Outcome

• Recurrent anteriorRecurrent anterior

Objective 14/105 (13%) vs 40/97 (41%) Objective 14/105 (13%) vs 40/97 (41%)

Subjective 10% vs 18% (.07)Subjective 10% vs 18% (.07)

• No difference sexual outcome or quality of life No difference sexual outcome or quality of life

• Re-operation POP & SUI 11% vs 18%Re-operation POP & SUI 11% vs 18%

• Mesh erosion 19%: 70% surgery Mesh erosion 19%: 70% surgery

Nieminen et al 2010Nieminen et al 2010

Stress Urinary Incontinence (SUI) Stress Urinary Incontinence (SUI) Following Prolapse SurgeryFollowing Prolapse Surgery

• Meta-analysis 9 trials, 723 womenMeta-analysis 9 trials, 723 women

• Continence procedures employed:Continence procedures employed:– Pubourethral ligament plication Pubourethral ligament plication

– Needle suspension Needle suspension

– Colposuspension Colposuspension

– Suburethral tapesSuburethral tapes

Prolapse Surgery Without vs. With Continence SurgeryProlapse Surgery Without vs. With Continence Surgery

• TheThe benefit remained (RR 5.45 95% CI benefit remained (RR 5.45 95% CI

1.8, 16.53)1.8, 16.53) even if data from the ‘CARE’ even if data from the ‘CARE’

trial was removedtrial was removed

• Performing continence surgery in 94 Performing continence surgery in 94

women with occult SUI prevented 19 women with occult SUI prevented 19

(20%) women developing SUI post-(20%) women developing SUI post-

operativelyoperatively

De novo SUI in Women with De novo SUI in Women with Pre-operative Occult Stress IncontinencePre-operative Occult Stress Incontinence

187

1093

103

751

56

420

De-novo SUI De-novo OAB De-novo VoidingDysfunction

15% 12% 12%

Ant Ant ColporrhaphyColporrhaphy vs vs Transvaginal MeshTransvaginal Mesh

Altman et al; N Engl J Med 2011; 364:1826-Altman et al; N Engl J Med 2011; 364:1826-3636

• 389 patients randomized389 patients randomized

• 53 participating hospitals53 participating hospitals

• 1 yr anatomic outcome noted 60.8% in 1 yr anatomic outcome noted 60.8% in mesh group vs 34.5% in AC groupmesh group vs 34.5% in AC group

• Higher complication rate in mesh group Higher complication rate in mesh group and higher de novo development of SUIand higher de novo development of SUI

• Synthetic mesh at anterior repair: Synthetic mesh at anterior repair:

↓ recurrent cystocele on examination↓ recurrent cystocele on examination

• This benefit was not translated to a This benefit was not translated to a

significant difference in patient significant difference in patient

determined outcomes or re-operation determined outcomes or re-operation

rates for prolapse or incontinencerates for prolapse or incontinence

ConclusionsConclusions

• POP + continence Symptom:POP + continence Symptom:– overall post-op SUI (9 trials)overall post-op SUI (9 trials)

– post-op de novo SUI (6 trials)post-op de novo SUI (6 trials)

– post-op de novo SUI in women with pre-post-op de novo SUI in women with pre-

op occult SUI (4 trials)op occult SUI (4 trials)

– post-op De-novo SUI in women without post-op De-novo SUI in women without

pre-op symptomatic or occult SUI (1 trial)pre-op symptomatic or occult SUI (1 trial)

• Adequately powered RCT’s are urgently Adequately powered RCT’s are urgently

needed on a wide variety of topicsneeded on a wide variety of topics

How I Manage Anterior Vaginal How I Manage Anterior Vaginal Wall Prolapse In 2011Wall Prolapse In 2011

• Most primary repairs are native tissue Most primary repairs are native tissue

suture repairssuture repairs

• Consider mesh augmentation for massive Consider mesh augmentation for massive

prolapse recurrent AVW prolapse or AVW prolapse recurrent AVW prolapse or AVW

prolapse in conjunction with a prolapse in conjunction with a

foreshortened vaginaforeshortened vagina