• New sling procedures • Correcting site-specific defects • Mesh augmentation
Additional investigations of the transobturator tape procedure are underway.
Correcting site-specific defects in prolapse repair
This repair rationale should become the standard, although it has yet to be widely adopted and procedural refinement and research are continuing.
As early as 1908, site-specific defects in the endopelvic fascia were identified as the likely cause of anterior vaginal segment prolapse. Like hernia repair, which requires closure of the fascial defect, the “cystocele hernia” repair advocated by George White involved reattaching the endopelvic fascia to the arcus tendineus fascia pelvis using a series of interrupted sutures through an abdominal retropubic approach.
Although this view was later abandoned, it resurfaced in the 1980s, when Cullen Richardson described midline, lateral, and transverse defects (FIGURE 1) in the endopelvic fascia as the cause of cystocele and rectocele.15 Richardson advocated diagnosis that identified these fascial defects, along with treatment with site-specific repair.
(In the intervening decades, prolapse was thought to result from generalized weakening or attenuation of the endopelvic fascia that supports the bladder, rectum, or vagina, leading to cystocele, rectocele, or uterine prolapse, respectively. Traditional repairs, still widely performed by most gynecologists, consist of the anterior and posterior colporrhaphy, which involve midline plication of the endopelvic fascia to reduce the prolapse and recreate support by strengthening the weakened fascial layer.)
FIGURE 1 Identify the site of defect
Whether the defect that causes a rectocele or cystocele is transverse, central, or lateral determines the type of repair to be performed. Reprinted with permission from Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol.1993;36(4):976–983.
Excellent cure rates with fewer complications
Site-specific repair (FIGURE 2) has been adopted by many pelvic surgeons, who report excellent cure rates with fewer complications such as dyspareunia, vaginal narrowing, and increased blood loss—all of which are more common with traditional anterior and posterior colporrhaphy.
Traditional colporrhaphy does correct the underlying fascial defect when the “hernia” is in the midline. However, for lateral and transverse defects, traditional colporrhaphy leaves the defect uncorrected and may even create additional tension, resulting in recurrence.
Site-specific repair also is useful in the treatment of enterocele, which has been described as a herniation of the peritoneum through a defect of the anterior and posterior fascial planes at the vaginal apex.16
Widening but not broad acceptance
Although cure rates for site-specific prolapse repair range from 75% to 85%,17,18 the concept has yet to be widely adopted and continues to undergo procedural refinement and research, as well as physician education. With increasing experience and clinical data, it may become the standard for pelvic prolapse repair.
FIGURE 2 Repair the defect to correct the rectocele
Surgical technique for a transverse tear in the rectovaginal fascia: After identifying the defect, place a series of interrupted sutures to reapproximate the fascial edges (copyright Miklos/Kohli).
Mesh augmentation: Useful in selected patients
Although augmentation with mesh or biomaterials is easy to perform, it remains unclear which technique and materials are optimal.
The use of mesh and biomaterials to augment repair of a cystocele, rectocele, or enterocele is slowly increasing, although general surgeons have been utilizing these materials for many years in hernia repair.
Augmentation has been advocated for “pelvic hernias” because of poor long-term cure rates for traditional prolapse surgeries (which range from 40% to 80%—well behind rates of 90% or more for incontinence procedures).
A recent informal survey of the members of the American Urogynecologic Society and International Urogynecologic Association revealed that most pelvic surgeons are using some type of graft or mesh to augment repairs in selected patients.
Synthetic mesh versus autologous and heterologous grafts
Synthetic materials have the advantage of being readily available, cost-effective, and consistent in quality, but they may cause significant complications, including infection, stricture, and erosion. This is especially important in the vagina, which needs to stretch during intercourse and which alters in thickness and other properties during a woman’s lifetime.
In contrast, autologous and heterologous donor grafts provide naturally occurring biomaterials capable of remodeling. Unfortunately, the in vivo tissue response is not yet fully understood. Other disadvantages: Biomaterials may lack consistent tissue properties and can be expensive.
For these reasons, graft materials remain in an early period of evaluation, although their use is expected to rise steadily with increasing experience and new product development.
Limited data on safety and efficacy
Although many pelvic surgeons use graft/mesh materials in prolapse repair, data on their safety and efficacy are limited, partly due to the variety of surgical techniques and materials available. Another factor is the difficulty of obtaining good long-term data with large patient numbers. Most of the literature is comprised of case reports, with few prospective, randomized trials.
