Colpocele anteriore recidivante:Colpocele anteriore recidivante:

- riparazione fasciale- riparazione fascialeMichele MeschiaMichele Meschia

What’s old is new again

Owing to reports of high recurrence, the traditional, plication-based, native-tissue repairs have been seemingly relegated to sideshow curiosity, while, on the other hand, mesh-augmented repairs have been thrust into the spotlight.

Kaplan-Meier survival curve of recurrent prolapse within 10 years

Overall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate ofOverall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate of

recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)

Incidence of recurrent pelvic organ prolapse 10 years following

primary surgical management: a retrospective cohort study.Fialkow MF, Newton KM, Weiss NS. Int Urogynecol J 2008;19:1483-7

Prolapse recurrence 5 years after surgeryProlapse recurrence 5 years after surgery

Compartment Anatomical Symptomatic

Any vaginal site

31% 7.4%

Anterior 20% 5.5%

Apical 7% 4.2%

Posterior 15% 2.4%

Dietz-Itza, 2007

What is cure?

• Any definition of success after POP surgery should include the absence of bulge symptoms

• Many patients with unsatisfactory anatomical results (POPQ stage II) are asymptomatic

• Using the hymen as a threshold for anatomic success seems a reasonable and defensible approach

• Patient perspective of cure must be considered to ensure a mutually agreement on definition of an acceptable outcome

An ideal outcome measure should be clinically relevant

• Inclusion criteria are often poorly specified primary and recurrent cases

different POP classifications

• Outcomes often include only anatomical factors• Inadequate description of the surgical technique (i.e.

concomitant apical support procedures)

• Functional outcome data poorly investigated

Anterior Repair

Reports bias

1-year results of 699 women having had native tissue repair for POP from 2002 to 2005

• 94% subjective satisfaction• 84% had stage 0-1 in any compartment• 1.1% 1-year re-operation rate• 4.7% 5-year re-operation rate

Reoperation rate for traditional anterior vaginal repair: analysis

of 207 cases with a median 4-year follow-up.Kapoor DS, Nemcova M, Pantazis K, Brockman P, Bombieri L, Freeman RM. Int Urogynecol J 2010;21:27-31

Methods:

Retrospective case note review of 207 cases of primary anterior colporrhaphy

with/without other prolapse surgery.

Results:

While the anatomical recurrence rate of cystoceles at 3 months postoperatively

was 12%, the reoperation rate for recurrent cystocele by 50 months was 3.4%.

Comclusions:

While the anatomical recurrence rates for cystocele following traditional anterior

colporrhaphy might be high, the low reoperation rate at more than 4 years (3.4%)

suggests that patient's symptoms might not be bothersome enough to require

further surgery.

Outcome data from Olsen et al., with a 40% non-return correction factor applied to the known failure count. Repairing recurrent prolapse by traditional re-suture of native tissues was associated with approximately 60% higher failure rates, compared with surgical outcome in primary cases (67% v

41%).

The challenge of recurrent POPThe challenge of recurrent POP

Mission impossible?Mission impossible?

Primary versus recurrent prolapse surgery: differences in

outcomes.Peterson TV, Karp DR, Aguilar VC, Davila GW Int Urogynecol J 2010; 21;483-8

Methods:

A retrospective study was performed comparing patients who underwent AC for

recurrent cystocele (group I) and a matched control group who underwent

primary AC (group II).

Results:

At 1 year

Successful anterior vaginal support was obtained in 78.2% of patients in group I

and in 81% in group II (p = 1.000)

At 2 years

42.8% of patients in group I and 71.4% in group II (p = 0.031) had no evidence

of POP

Conclusions:

Alternative surgical techniques that provide better long-term durability may be beneficial in repair of recurrent anterior wall prolapse.

• inappropriate choice of procedure (plan of surgery)

• defect in restoring fascial attachments

• inappropriate choice of suture materials

• inadequate control of bleeding (pelvic hemathoma)

• persistent increase in intra-abdominal pressure

• poor connective tissue quality

Birch C and Fynes MM, 2002Birch C and Fynes MM, 2002

Pelvic Organ Prolapse repairPelvic Organ Prolapse repair

Surgical failuresSurgical failures

Wide genital hiatus is a risk factor for recurrence following

anterior vaginal repair.Medina CA, Candiotti K, Takacs P. Int J Ob/Gyn 2008; 101:184-7

Methods:

A retrospective cohort study was performed on patients who had undergone an

anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide

genital hiatus (> or =5 cm) or normal genital hiatus (<5 cm). The wide genital

hiatus group (n=35) was compared with the normal genital hiatus group (n=30)

for surgical failure.

Results:

The rate of postoperative anterior vaginal wall prolapse was greater in patients

with a wide genital hiatus compared with those with a normal genital hiatus

(34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0

24.1]; P=0.02).

Ensure apical fixationEnsure apical fixation

The cumulative reoperation rates were highest among women who had an isolated anterior repair (20.2%) and significantly exceeded reoperation rates among women who had a concomitant apical support procedure (11.6%; P<.01).

32.8% (95% CI 30.4-35.1) had a colporrhaphy without colpopexy

Role of apical support

Eilber et al, Obstet Gynecol 2013

Fairchild et al, Am J Obstet Gynecol 2015

3244 women underwent POP surgery

1557 hysterectomies performed for POP

Use of colpopexy was independently associated with a surgeon specializing in urogynecology (OR 8.2, 95% CI 5.156-12.923).

Repair of recurrent AVW prolapse

• Midline PCF plication• Bilateral fixation of PCF to USL

remnants• Bilateral re-attachment of PCF

to the ATFP proximal to the

ischial spine

Enterocele repair

• Commonly found in association with vault prolapse• Ligation of hernia sac and obliteration of the pouch of

Douglas

Associated defectsAssociated defects

Permanent suture used in uterosacral ligament suspension

offers better anatomical support than delayed absorbable

suture.Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL.

Prospective series of 248 women• 1% vs 6% loss of support beyond the hymen, p=0.034 Int Urogynecol J 2012

Reattachment of the endopelvic fascia to the apex during anterior colporrhaphy: does the type of suture matter?Zebede S, Smith AL, Lefevre R, Aguilar VC, Davila GW.

230 patients were reviewed (permanent vs absorbable suture)

• Statistically significant improvement in anterior wall anatomy Ba (-2.68±0.65cm vs -2.51±0.73cm, p=0.03) with permanent suture• Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure.

Int Urogynecol J 2013

Type of suture

Poor tissue quality

Khaja et al IUJ 2014 25:181–187

5 year cumulative risk of any repeat surgery• Vaginal mesh: 15.2% (5.9% risk of mesh revision/removal)• Native tissue: 9.8% p<0.0001

5-year risk of surgery for recurrent prolapse• Vaginal mesh: 10.4%• Native tissue: 9.3% p=0.70

27,809 anterior prolapse surgeries • 20,938 (75.3 %) native tissue repairs • 6,871 (24.7 %) vaginal mesh

Trocar-guided mesh compared with conventional vaginal

repair in recurrent prolapse: a randomized controlled trial.Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME.

Methods: Patients were randomly assigned to either conventional vaginal prolapse surgery

or polypropylene mesh insertion.

Results:

97 women underwent conventional repair and 93 mesh repair.

Twelve months post-surgery, anatomic failure in the treated compartment was

observed in 45.2% of patients in the conventional group and in 9.6% in the mesh

group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18).

Patients in either group reported less bulge and overactive bladder symptoms.

Subjective improvement was reported by 80% of patients in the conventional

group compared with 81% in the mesh group.

Mesh exposure was detected in 14 of 83 patients (16.9%).

Obstet Gynecol 2011; 117:242-50Obstet Gynecol 2011; 117:242-50

The UK national prolapse survey: 5 years on.

Jha S, Moran P.Int Urogynecol J 2012; 22:517-28Int Urogynecol J 2012; 22:517-28

5 years ago

Current

Procedure of choice for recurrent anterior vaginal wall prolapse

Ant. colporraphy

Graft + fascial plication

45%

34%

21%

56%

Recurrent prolapse surgery

• Reasonable anatomic results without mesh• Significant symptoms improvement • No erosions, few infections, quick recovery• Mesh complications remain a challenging issue

The fear of unknownThe fear of unknown

Thus conscience does make cowards of us allThus conscience does make cowards of us all

Hamlet: Act III, scene 1, line 82 Hamlet: Act III, scene 1, line 82

The decision to perform a mesh augmented POP repair is often

a difficult one for even the most experienced pelvic surgeon

Pelvic organ prolapse (POP) surgery: the evidence for the repairsPelvic organ prolapse (POP) surgery: the evidence for the repairsAlex Gomelsky, David F Penson and Roger DomochowskiAlex Gomelsky, David F Penson and Roger Domochowski

BJU 2011; 107:1704-1719 Review articleBJU 2011; 107:1704-1719 Review article