• New sling procedures • Correcting site-specific defects • Mesh augmentation
That said, initial data suggest a significant improvement in cure rates, compared with traditional techniques, with minimal short-term complications. Long-term results and complication rates are not yet available.
What existing studies show
A variety of synthetic materials have been used in surgical correction of cystocele. In the largest series to date, Flood and colleagues19 reported their 12-year experience with 142 women undergoing a modified anterior colporrhaphy reinforced with Marlex (Davol, Cranston, RI) mesh: 100% success in correcting cystocele and a 74% success rate for urinary stress incontinence, with a mean follow-up of 3.2 years and no significant intraoperative complications.
In a prospective randomized trial of 125 patients utilizing absorbable polyglactin 910 mesh (Vicryl) (Ethicon, Somerville, NJ) to augment standard anterior colporrhaphy, Koduri et al20 reported a failure rate of 13% in the colporrhaphy-alone group compared to 1% in the colporrhaphy-mesh group at the 1-year follow-up. Subjectively, both groups improved equally.
Clemons et al21 used a human dermis graft to treat advanced recurrent cystocele in 33 women, with a follow-up of 18 months. They noted 13 (41%) objective failures and 1 (3%) subjective failure. Complications included 1 case of febrile morbidity, 1 cystotomy, and 1 anterior wall breakdown secondary to hematoma formation caused by heparin therapy. No other erosions or rejections were seen.
Most effective applications
Graft/mesh augmentation may be most effective in posterior vaginal segment reconstruction and rectocele repair, as it obviates the need for levatorplasty in patients with poor rectovaginal fascia. A variety of synthetic materials have been used for posterior wall reconstruction in small series.
Mersilene mesh
Mersilene mesh (Ethicon) was used by Fox and Stanton22 to augment traditional rectocele repair in 29 women followed for 14 months. Most of the women had undergone previous rectocele repair with recurrence of their prolapse. All women with stage II and stage III vault prolapse were corrected, with an increase in stage I prolapse from 20% to 27%. All women with stage II and stage III rectocele were corrected, with a decrease in stage I prolapse from 36% to 7%. The only significant intraoperative complication was a cystotomy. One mesh became infected postoperatively, requiring removal.
Cadaveric dermal graft
Recently, Kohli and Miklos23 reported their experience with 57 patients undergoing augmented rectocele repair using a cadaveric dermal graft (FIGURE 3) over a 2-year period. Average follow-up was 11 months. Average patient age in the follow-up group was 63.6±10.9 years (range: 33–79 years) and average parity was 2.8±1.5 (range: 0–7). No major intraoperative complications (hollow viscous injury, blood loss greater than 500 cc, or transfusion) or post-operative complications (infection, abscess, or hematoma) were noted. No graft-related complications such as rejection, erosion, infection, and fistula formation were noted during the follow-up period.
Using previously accepted Pelvic Organ Prolapse Quantification (POP-Q) parameters for success, Kohli and Miklos found 54 of 57 women (95%) to have surgical cure at follow-up. These authors have also described the use of a dermal graft in the repair of a complicated rectovaginal fistula.24
FIGURE 3 Placement of mesh augmentation
Augment enterocele/rectocele repair by attaching the mesh apically, laterally, and distally (copyright Miklos/Kohli).
Future outlook
Further data on the efficacy and safety of graft/mesh augmentation—including identification of the optimal technique and ideal material—are necessary before this approach can be widely adopted. However, in selected patients, it represents a significant advance in the surgical treatment of pelvic prolapse.
The author is a preceptor for American Medical Systems, Gynecare, CR Bard, and Mentor and a consultant for Boston Scientific.
