Cystocele and rectocele repair: More success with mesh?
Graft materials have been used for years in other types of surgery. Can they reduce the high failure rate of prolapse repairs?
IN THIS ARTICLE
A complex web of support
In the normal pelvis, support of reproductive organs depends on a complex web of muscles, fascia, and connective tissue. To ensure success, prolapse repairs should correct any separation or attenuation of tissue and preserve or enhance tissue resilience.
Risk factors for recurrent prolapse
- Poor tissue (assess tissue quality before and during surgery)
- Impaired healing
- Chronic increases in intraabdominal pressure due to obstructive pulmonary disease, asthma, or constipation
- High-grade cystocele
- Age 60 or above13
Patients with these conditions may benefit from the use of adjuvant materials in the anterior compartment.
Note that women who have had recurrences after earlier repairs may experience repeat recurrence.
Advantages of grafts
Using graft materials, the surgeon can repair all vaginal defects faster and with less effort. In the anterior compartment, a graft can be placed and anchored bilaterally from arcus to arcus tendineus, and posteriorly to the level of the spine, recreating level I support. Graft materials also offer the potential to treat stress urinary incontinence concomitantly using different shaped materials. Two authors have already described their success performing this type of repair.14
Nevertheless, great care and consideration should be devoted to actual and theoretical short- and long-term risks, many of which have not been fully elucidated.
Once a successful material is identified or developed, it may decrease operating time and morbidity in vaginal surgeries. It may also reduce the higher hospital costs normally associated with abdominal procedures.
Types of graft materials
There are 2 types of materials: synthetic or biologic. Synthetic materials can be further classified into permanent or absorbable.
The most widely used biologic materials include allografts such as human freeze-dried or solvent-dehydrated fascia lata (Tutoplast), decellularized human cadaveric dermis (Alloderm, Repliform), porcine dermal xenografts such as Pelvicol or Intexene, and bovine pericardial implants (Veritas).
Soft polypropylene meshes such as Gynemesh and Atrium are commonly used permanent materials, and polyglactin 910 is an absorbable material (TABLE).
TABLE
How successful are adjuvant materials in cystocele and rectocele repairs?
| MATERIAL (SIZE IN CM) | AUTHOR | NO. IN STUDY | RECURRENCE RATE (%) | SITE OF ATTACHMENT | FOLLOW-UP (MONTHS) | COMPLICATIONS |
|---|---|---|---|---|---|---|
| BIOLOGIC MATERIALS | ||||||
| Alloderm 3×7 patch with concomitant sling | Chung29 | 19 | 16 | Pubocervical fascia | 28 | None |
| Intexene 6×8 with sling | Gomelsky et al 200420 | 70 | 9 stage II 4 stage III | Arcus tendineus fascia pelvis | 24 | 1 wound separation |
| Solvent-dehydrated cadaveric fascia lata patch with sling | Gandhi et al 200521 | 76 patch vs 72 no patch | 21 vs 29, respectively (P=.23) | Overlay | 13 | None |
| Alloderm 3×7 trapezoid | Clemons et al 200322 | 33 | 41 stage II 3 symptomatic | Arcus tendineus fascia pelvis | 18 | None |
| SYNTHETIC MATERIALS WITH CONCOMITANT SLINGS* | ||||||
| Marlex 10×3×5 | Nicita 199823 | 44 | 0 | Arcus tendineus fascia pelvis | 13 | 1 vaginal erosion |
| Polyglactin 910 absorbable mesh | Sand et al12 | 80 mesh vs 80 no mesh | 25 vs 43 stage II cystoceles, respectively(P=.02) | Insert in the anterior and posterior colporrhaphy suture line | 12 | None |
| Polyglactin 910 absorbable mesh | Weber et al4 | 26 with mesh + standard repair; 24 with ultra-lateral repair; 33 with standard repair | 58 vs 54 vs 70 stage II, respectively (P=.58) | Overlay | 23 | None |
| SYNTHETIC PERMANENT GRAFTS WITHOUT CONCOMITANT SLINGS | ||||||
| Marlex trapezoid | Julian 199619 | 12 with 12 without | 0 vs 33, respectively | Arcus tendineus fascia pelvis | 24 | 3 vaginal erosions |
| Mixed-fiber mesh (polyglactin 910 and polyester 5×5) | Migliari and Usai 199924 | 12 | 25 | Pubourethral and cardinal ligaments | 20 | None |
| Prolene (Atrium) | Dwyer and O’Reilly25 | 64 anterior 50 posterior | 6 grade II | Tension-free | 29 | 8% vaginal erosion 1 rectovaginal fistula |
| Gynemesh 6×15 | de Tayrac et al 200526 | 87 | 7 stage II 2 stage III | Tension-free | 24 | 8% vaginal erosion |
| Prolene mesh patch | Milani et al 200527 | 32 anterior 31 posterior | 6 stage II | Fixed to endopelvic connective tissue | 17 | 20% anterior, 63% posterior dyspareunia; 13% vaginal erosion (anterior); 1 pelvic abscess (posterior) |
| Prolene mesh (double-wing shape) | Natale et al 2000 28 | 138 | 3 | Tension-free | 18 | 9% vaginal erosion 7% dyspareunia 1 hematoma |
| *Absorbable and permanent. | ||||||
Classification of synthetic materials
- Type 1 grafts are totally macroporous (>75 μm), which allows fibroblast, macrophage, and collagen penetration with angiogenesis. Examples include Prolene and Marlex meshes.
- Type 2 mesh is microporous (<10 μm in 1 dimension). This prevents penetration of fibroblasts, macrophages, or collagen. Gore-Tex is an example of a Type 2 mesh.
- Type 3 mesh is macroporous (>75 μm) with multifilamentous or microporous components. Examples include Mersilene (braided Dacron mesh), Teflon (polytetrafluoroethylene [PTFE]), Surgipro (braided polypropylene mesh), and MycroMesh (perforated PTFE patch).
- Type 4 mesh has a submicron pore size that prevents penetration. Examples include Silastic, Cellgard (polypropylene sheeting), and Preclude pericardial membrane/Preclude dura-substitute.1
2 other important properties are composition of fibers (multifilamentous materials commonly have interstices less than 10 microns) and flexibility (which has a bearing on erosion of the material).1
Bacteria can penetrate pores smaller than 1 μm, whereas polymorphonuclear white blood cells and macrophages need a pore size larger than 10 μm, and capillary ingrowth requires a size larger than 75 microns. Thus, Type 1 offers the advantages of larger pore size and monofilamentous interstices to allow for capillary ingrowth.
Which material is best?
Although the literature is difficult to interpret because of the diversity of studies and other factors, some findings are worth noting:
