Master Class

Using Mesh or Grafts to Augment Repair


 

The concept of using grafts or mesh for rectocele repair—as well as for other hernias of pelvic organ support—makes sense. Their use can restore correct anatomical support by recreating and/or augmenting the fascial layer, enabling us to provide additional stability to traditional repairs of the posterior vaginal wall that too often may incorporate weak tissue.

Our general surgery colleagues have reduced their failure rate for hernia treatment by almost 50% by augmenting their procedures with mesh or grafts.

It was reported almost a decade ago that women have an 11% risk of needing surgery for prolapse or urinary incontinence by age 80 years—and that at least one-third will need a second surgery. Over the last 5 years, new surgical procedures for incontinence have raised our incontinence success rates to nearly 90%. Our success rate for prolapse using traditional techniques, meanwhile, remains in the 50%–70% range.

We're looking for a better mousetrap, and mesh or graft augmentation is likely to be it. Certainly, it is worth considering.

The Shortcomings of Our Traditions

Our underlying concepts of prolapse have changed. We used to think of prolapse strictly as the result of weakness in the vaginal wall and subsequent stretching. Our traditional repair technique was, simply put, to tighten the weakened tissue and narrow the vaginal wall.

The next stage in our thinking was that we were actually dealing with hernias—that is, with discrete breaks (site-specific defects) in the tissue. Our practice then progressed to opening up the vaginal mucosa, finding the defect, and closing it. This was the origin of the anterior paravaginal repair for cystocele and the posterior site-specific repair for rectocele.

There are pros and cons to both traditional ways of thinking. For instance, finding the defect and closing it are theoretically fine, but our assumption here is that the intact tissue is strong. That's not always the case. Sometimes it's hard to find the defect. And sometimes we may even create it.

Often when we're looking for better tissue to use for a central repair, we gravitate toward more lateral tissue and end up bringing too much tissue to the midline, causing dyspareunia. Or we move up in our search for tissue—that is, into the enterocele tissue—and we do our best with tissue that often is of poor quality. This may well result in a recurrence, which we often attribute to “poor protoplasm” or failure of the patient to adhere to our postoperative instructions.

And in either case, with traditional plication techniques or traditional site-specific techniques, we usually are not altering the patient's underlying risk factors for prolapse or for recurrence after surgery. Constipation; obesity; nerve or muscle damage; and occupational risk factors, such as heavy lifting are among the many remaining factors that, without strong tissue and stability, can put our repair in jeopardy.

Our most recent evolution in thinking, therefore, has been to look at our general surgeon colleagues' use of mesh and grafts to more successfully treat hernias, and to think that maybe we can do the same thing.

Choosing Donor or Synthetic Grafts

The use of grafts or mesh alleviates many of the challenges we have faced with our traditional techniques. One real benefit, for instance, is that we can extend mesh up into the enterocele and create strong tissue in a place where we previously would have worked with weak peritoneum.

A variety of graft and mesh products is available to the clinician. (See box.) The question of which materials are better is still much debated among physicians, however. The advantage of donor grafts, of course, is that they are biologic, which should significantly alleviate or even eliminate problems of erosion and rejection. The downside is that the materials are expensive and can contract over time. We also do not yet fully understand the in vivo response to these grafts. In some cases, the body may chew up the graft; in other cases, the graft may be encapsulated through an inflammatory reaction.

The advantage of synthetic meshes is that they are readily available, have more consistent material strength, and are permanent. There also is a great variety of materials to choose from—something that we should certainly view as a benefit and take advantage of. Synthetic meshes come in different weaves, with various degrees of pliability, strength, softness, and thickness. Such variables are important to consider, because the mesh we use in the vagina must be both strong enough to maintain the integrity of our repairs and flexible enough to accommodate sexual function.

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