Using Mesh or Grafts to Augment Repair
The downside of synthetic meshes relates to its permanence. The mesh will be with our patient for the rest of her life, during which time rejection, infection, and especially erosion can occur. Whereas dyspareunia and failure are the major complications of traditional repairs, erosion—or exposure, as it is more frequently called today—is the primary complication associated with the use of mesh.
Our Judgment Call
At this time, we do not have enough data on rectocele repair with grafts or mesh to either uniformly recommend or uniformly reject this new type of repair. We need more evidence-based information to document its long-term efficacy.
However, these augmented procedures are now established in many settings—with observed short-term success—and I believe they should be considered for our more challenging cases.
The key to doing good rectocele repair, I believe, is first being able to identify the anatomy, and second, being able to make the clinical judgment about when and when not to use a mesh or graft. In my practice, for instance, we generally use mesh in patients with recurrences, in patients with very advanced prolapse and poor-quality tissue, and in women with a high risk for recurrence, such as those with chronic constipation, obesity, or jobs that require heavy lifting.
With mesh augmentation, we've taken our success rate to 85%–90% for all vaginal wall repairs, and to 90% for rectocele repair. The erosion rate for rectocele repair probably is about 10%. Most erosions can be managed conservatively, and few require reoperation if identified early. The dyspareunia rate is harder to get a handle on and is something we are still evaluating.
Newer Techniques, Getting Started
Some experienced physicians are now using new needle-guided mesh techniques. These procedures are quick, and some physicians value the fact that the materials come in convenient kits.
In these new techniques, needles are inserted through the transobturator approach and brought out near the ischial spine. The needles are then attached to the arms of the mesh, and the mesh is pulled through. The main disadvantage to this technique lies in the blind passage of needles through fairly long distances and critical areas where the potential for complications could include rectal injury, nerve injury, and bleeding. Another disadvantage is that the kits are relatively expensive.
I would rather attach mesh to a suture that I can see, although—in the right hands—needle-guided mesh techniques are probably safe and may result in better mesh application. Certainly you would want substantive experience and a sound knowledge of pelvic anatomy before proceeding.
Needle-guided techniques aside, the skills needed for mesh and graft augmentation of rectocele repair are logical extensions of the ob.gyn's current skill set. It is helpful, though, to revisit the anatomy in a cadaver lab, to talk with physicians who have had experience with grafts and mesh, and even to arrange preceptorships or visit the operating room to see the techniques performed. Then, as with many surgical procedures, success will depend on your skill, comfort level, and clinical judgment.
ELSEVIER GLOBAL MEDICAL NEWS
Mesh or graft placement for rectocele/enterocele repair is shown. Courtesy Dr. Neeraj Kohli/Dr. John R. Miklos
Rectocele Repair Evolves
Unfortunately, as an avid endoscopic surgeon and infertility specialist, I must admit that the most exciting arena in gynecologic surgery at present belongs to the urogynecologist. Until now, there has been little innovation within the subspecialty, even though it was well known that long-term results were compromised by weakened tissue and external factors. However, on the heels of our increased knowledge of the anatomy of the pelvic floor and the pathophysiology of incontinence and prolapse, techniques are being introduced that attempt to increase efficiency and thus decrease recurrence and the necessity of a second surgery.
I have asked Dr. Neeraj Kohli, chief of the urogynecology division at Brigham and Women's Hospital, Boston, to discuss the nuances of the use of mesh or grafts to augment rectocele repairs. A urogynecologist in the department of obstetrics, gynecology, and reproductive biology at Harvard Medical School. Dr. Kohli will make the case for the use of mesh or grafts in selected patients who in the past would have been treated via site-specific defect repair. I am certain that you will find Dr. Kohli's Master Class in gynecologic surgery to be both intriguing and thought provoking.
Tips for Success
The use of mesh or grafts is not without risk, and part of our technique and surgical process should involve a thorough effort to minimize risk. Here are some tips for avoiding complications:
