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New options in reconstructive pelvic floor surgery and surgery in urogynecology
Abstract
The aim of this paper is to provide a brief update review of reconstructive pelvic floor surgery and surgery in urogynecology, including the application of surgical implants.
Review article.
Gynecological and Obstetric Clinic, 1 LF UK and VFN, Prague.
Summarization, compilation and classification of recent findings, opinions and recommendations on new options in surgical procedures of reconstructive pelvic floor surgery and surgery in gynecology, with emphasis on the use of implants and their introduction into common clinical practice.
From the beginning of the 1990s, the view of pelvic floor defects and urinary incontinence in women started to change significantly. The validity of De Lancey's classification of vaginal fixation into 3 basic levels was confirmed, with resulting modifications in surgical procedures. The etiology of pelvic floor defects comprises not only labor trauma or incorrectly performed previous operations (e.g. hysterectomy), but also hereditary influences and changes in the metabolism of the connective tissue. When comparing patients with or without descensus, there is a significant difference in the composition of collagen connective tissue; these findings, and the frequency of recurrence in up to 40% of patients within 3 years after the operations, resulted in the introduction of allogenous implants--meshes in the surgical treatment. These have been used for a long time in surgical treatment of abdominal wall defects, and for the above reasons the polypropylene meshes were introduced in pelvic floor defects surgery, while their safety has been proved in accordance with the principles of Evidence Based Medicine. In gynecology, these materials are already used in the laparoscopic approach to treat female stress incontinence. Pelvic floor defects occur either isolated, or combined (a defect of anterior, posterior or medial segment, or combination of all), while the patients may at the same time suffer from a stress type of urinary incontinence (SI). In surgical treatment of this type of urinary incontinence (TVT, TVT-O, TVT-S) allogenous implants--tapes--are frequently used. The results of studies suggest that one factor affecting the success of the operation using allogenous implants is the surgeon's erudition and experience in pelvic and vaginal surgery, while the long-term effect of the operation also depends on the surgical procedure involved, i.e. on the correct selection of operation methods and decision whether to use an implant or not. The effect of various operations using implants may differ as well, especially there is a difference between operations where the implant is placed freely under the bladder, and those where it is stabilized by fixing the arms of the implant under the lower arms of symphysis. Another factor to consider is the material of the implant used. Material currently recommended according to Evidence Based Medicine is: a lightweight, flexible polypropylene; and according to Amid's classification: type 1, i.e. macro-porous, monofilament material. The advantage of surgical treatment of pelvic floor defect using implants consists in a low percentage of recurrence of the descensus; there is, however, a certain risk of rejection (around 5%) and shrinking of tissues provoked by the implant.
... Up to 40% of patients have been found to have a recurrence in pelvic organ prolapse following surgery. 28 This may be attributed to an underlying connective tissue defect in the pathogenesis of pelvic organ prolapse. 29 Because of this high percentage of women who will need a second surgical intervention for pelvic organ prolapse, there has been a continuous effort to improve surgical procedures and outcomes. ...
... This has led to the use of biological and synthetic mesh for surgical treatment. 2,28,29 Over the last decade, mesh has become popular in pelvic reconstructive surgery. There have been some improvements in mesh development to reduce the complications and adverse effects, such as production of lightweight mesh with less dense and larger pores. ...
Prolapse of the pelvic organs is a common condition encountered in gynecological prac-tice that adversely affects the quality of life of affected women. It affects millions of women worldwide. The principles of treatment of pelvic organ prolapse include restoring anato-my and vaginal function, correcting associated urinary and or fecal incontinence, and pre-venting de novo prolapse and incontinence. There are various treatment options for pelvic organ prolapse. These vary from conservative treatments/mechanical interventions to sur-gery. The choice of treatment depends on severity of symptoms, patient's age, parity, and whether there is the need to conserve the uterus for reproductive function. In conclu-sion, thorough evaluation of symptoms and degree of prolapse is essential in order to pro-vide the best possible treatment and ultimate-ly improve quality of life.
... Durante las últimas dos décadas hemos asistido al nacimiento de un gran número de técnicas quirúrgicas en uroginecología (14). Esto ha sido principalmente gracias a la mejor comprensión de la anatomía y fisiología del suelo pélvico, y la aparición de mallas fabricadas con las características apropiadas (15). ...
Objetivo: Revisar la seguridad, eficacia y principales ventajas de la corrección quirúrgica de incontinencia de orina de esfuerzo (IOE), con el nuevo dispositivo TVT-Secur. Método: Entre enero y marzo de 2007 se realizó corrección quirúrgica a 9 pacientes con incontinencia de orina de esfuerzo, a las que se les realizó urodinamia monocanal y medición de presión de retro-resistencia uretral, como parte del estudio y selección preoperatoria. Todas debían tener incontinencia por al menos un año. Se utilizó la técnica de aplicación de cinta suburetral, con el nuevo dispositivo TVT-Secur. Las medias fueron: edad 50 años, IMC 28, paridad 3 hijos e IOE 3 años (rango: 2 a 6 años). Resultados: Se realizaron 6 TVT-Secur aplicando la cinta en "U" y 3 en "V". La media de tiempo operatorio fue de 10 minutos (rango: 8 a 15 minutos). No se registraron complicaciones durante el intraoperatorio y postoperatorio inmediato, temprano y tardío. La escala visual análoga para dolor registrada a las 12 horas fue de 1 a 2. Conclusiones: La técnica de corrección de la incontinencia de orina de esfuerzo por medio de la aplicación de cinta suburetral, con el nuevo dispositivo TVT-Secur, es factible, segura y eficaz. Permite realizar una cirugía con todas las características de mínima invasión. Se trata de un sistema de cinta de tercera generación, con menor invasión que las técnicas antecesoras, ya que sólo requiere una apertura de la mucosa suburetral y no de puntos de salida por piel, dejando sólo 8 cm de cinta. Es un instrumento con gran versatilidad, ya que permite colocar la cinta en "U" como en la técnica de TVT o en "V" como las técnicas trans-obturadoras.
Pelvic floor muscles are like any muscles in the body which is affected by aging process. It is a highly complex structure which is made of pelvic floor muscles (PFMs) and an intricate neural network. This elaborate system must work in a highly integrated. Investigations for PFD in elderly are discussed such as clinical, urodynamic, manometric, imaging, and neurophysiologic assessments. Neurophysiological studies including pudendal nerve terminal motor study (PNTML) and pelvic floor electromyography (EMG) are essential to localize and assess the severity and mechanism of injury. The primary clinical aim during PFD management is to correct the anatomy of pelvic floor in order to preserve or restore its function. As a consequence, patients need careful clinical assessment, appropriate investigations, and counseling before embarking on a well-defined PFMT. When the patient is referred to physical therapy, the typical management process includes assessment of impairments, and determination of prognosis and interventional plan of care
Objective: To evaluate the feasibility, efficacy, safety and main advantages of the stress urinary incontinence (SUI) surgical correction with the new device TVT-Secur. Method: Between January and March of 2007, surgical correction was made in 9 patients. All patients were studied with urodynamic before surgery. All must have the urinary incontinence by more of one year. The new TVT-Secur device was used. The median was: age 50 years old, BMI 28, parity 3, SUI 3 years. Results: Six TVT-Secur were applied in "U" and three in "V". The media surgical time was 10 minutes (8-15 minutes). Complications were not registered during intraoperative and immediate, early or delayed postoperative time. The visual analogue scale of pain was 1 to 2 at 12 hours. Conclusions: The new TVT-Secure technique is feasible, safe and effective in the surgical correction of the SUI. This technique allows to make a minimally invasive surgery. It is a sling system with smaller invasion than the preceding techniques, only requires an opening of the suburethral mucosa and only 8 cm of tape are used. It is an instrument with great versatility, since it allows to place the tape in "U" (like TVT technique) or in "V" (like trans-obturator techniques).
Purpose:
To evaluate the anatomical, functional and post-operative outcomes of polypropylene mesh (Prolift™) in the surgical management of pelvic organ prolapse (POP).
Methods:
A single-centre observational study of 106 successive patients, who underwent Prolift™ mesh repair (POP ≥ 2) with a median follow-up of 4 years, was performed. Outcomes of interest measured included patient demographics, intra and post-operative complications, concomitant procedures for POP or urinary incontinence. Using the Baden-Walker classification, grade ≥2 prolapses in the operated compartment were deemed as surgical failure. Validated questionnaires including ICIQ-VS and ICIQ-UI were used to assess functional outcome.
Results:
Of the 106 patients, 56 had an anterior, 36 a posterior and 14 a total Prolift™. 101 patients were available for follow-up (median 4 years). 82 women underwent a clinical follow-up whilst 19 underwent a telephonic follow-up. Peri-operative bladder injury was noted in 2 (1.9 %) cases. Six (5.6 %) patients developed mesh exposure post-operatively. Re-operation rates for recurrent prolapse in the operated compartment were 2.8 % (n = 3). At follow-up, prolapse recurrence in the operated compartment was noted in another 7.3 % (n = 6) patients. Combining re-operations for POP and recurrences noted during follow-up, the revised failure rate was 10.1 % (n = 9). De novo prolapse in the non-operated compartment occurred in 19.5 % (n = 16) women.
Conclusion:
Our study demonstrates that Prolift™ vaginal mesh surgery offers anatomical cure rates of 89.9 %. A higher rate of de novo recurrence in the non-operated compartment was noted suggesting that surgical correction in one compartment may exacerbate recurrence in other compartments.
Objective
To review our initial experience with the new system TVT-Secur for the stress urinary incontinence. To evaluate the feasibility, efficacy and main advantages of the surgical correction with the new deviceMethod
Between january and may of 2007, 16 TVT-Secur (Women’s Health & Urology, Ethicon, Johnson & Johnson) were made in patients of the Urogynecology Unit, of Clínica Las Condes. Six TVT-Secur were applied in “V” and 10 in “U”. The median age was 52 years old, BMI 29, parity of 3. All patients were studied with urodynamic before surgery. All must have the urinary incontinence by more of one year and no must have previous surgical correctionResultsThe media surgical time was 10 minutes (8-15 minutes). Complications were not registered during intraoperative and immediate, early or delayed postoperative time. The visual analogue scale of pain was 1 to 2 at 12 hours. All patients were cured. The follow-up was between 1 and 4 months, 2 month media. All patients expressed satisfaction with the surgical results and they would recommend it to other patients in the same conditionsConclusion
According to our initial experience, the new system TVT-Secur is feasible, safe and effective in the surgical correction of the SUI. However, only the long follow-up and the incorporation of new patients to the study, will allow to determine the permanence of these good results in the time
Pelvic organ prolapse affect 50% of parous women over 50 years of age. The lifetime risk of undergoing a single operation for prolapse or incontinence by age 80 is 11.1%. Recurrence rates for classical prolapse surgery are as high as 30%. For this reason various graft materials have been proposed to improve the long-term surgical outcomes. The aim of our study was to investigate the safety and efficacy of posterior colporrhaphy incorporating Vypro II (polyglactin 910-polypropylene) mesh in the treatment of posterior vaginal wall prolapse.
Retrospective study.
Gynaecological and Obstetric Clinic, First Medical Faculty of Charles University and General University Hospital, Prague.
Standard posterior colporrhaphy was performed with levator ani muscles plication. Vypro II (Ethicon, Somerville, NJ, USA) is a type III macroporous mixed fibre lightweight mesh composed of 50% absorbable multifilamentous polyglactin 910 and of 50% non-absorbable multifilamentous polypropylene fibres. This operation was performed in 28 women between March 2003 and November 2005. All patients underwent before surgery, urodynamics, ultrasound and physical examination. 22 women (78.5%) had a previous hysterectomy, 16 women (57%) had previous pelvic surgery for prolapse and/or urinary incontinence. Concomitant surgeries performed included vaginal hysterectomy 7% (n = 2), anterior colporrhaphy 50% (n = 14), anterior colporrhaphy with Vypro II mesh 21.4% (n = 6), TVT 7% (n = 2), TVT O 7% (n = 2), sacrospinous vaginal vault suspension 32% (n = 9). The pelvic organ prolapse was staged in ICS POP-Q system. All women had stage II-IV symptomatic prolapse of the posterior compartment (11 patients 39.2% with stage II, 14 patients 50% with stage III and 3 patients 10.7% with stage IV). All patients were examined always in case of complications and were invited to follow-up 2 months after surgery and once a year. The mean follow-up was 26.2 months (range 2-58), whereas 71% of patients had a follow up longer then 24 months.
Patients mean age was 63.7 years (range 46-83), mean parity 2.1 (1-3) and mean BMI 30.34 kg/m2 (25-42). There were no operative or early postoperative complications like bowel erosion or rectovaginal fistula. The incidence of rectocele recurrence was 10.7%: 1 case of stage II rectocele and 2 cases of stage III rectocele. The incidence of mesh vaginal erosion was 10.7%. Two cases were resolved by repeated excision in office and by local estrogen and local antimicrobial therapy. The third case required reoperation and mesh exstirpation.
Posterior colporrhaphy with levator ani muscles plication and incorporating a Vypro II mesh was associated with a higher incidence of post-operative complications even if cure rate was quite good.
The aim of this article is to review the incidence and prevalence of complications after prosthetic surgery for POP (pelvic organ prolaps) and USI (urodynamic stress incontinence) and to introduce diagnostic and therapeutic advice into clinical practice.
Review article.
Gynecological and Obstetric Clinic, 1st LF UK and VFN, Prague.
Summary of complications, recent findings, opinions and specific diagnostic and therapeutic recommendations with special focus to vaginal erosion, post-operative voiding difficulties, persisting leakage of urine and de novo urgency.
In the last decade the surgical treatment of female USI by prosthetic slings procedures has been shown to be effective with high cure rate and low morbidity. Similary, prosthetic reconstruction of pelvic organ prolapse through the different compartments has been introduced into clinical practice with good anatomical and promising functional results. The article is structured to the different sections, describing the epidemiology and management of complications after prosthetic slings procedures and after vaginal prosthetic treatment of pelvic organ prolapse. The effect of various operations of pelvic floor and USI using synthetic implants may differ, depending on the material of the implant used. Current recommendation for the implants material: a light-weight, flexible polypropylene; Amid's classification: type 1, i.e macro-porous, monofilament material. The advantage of surgical treatment of pelvic floor defect using implants comprises a low percentage of recurrence of the descensus.
To review our initial experience with the new system TVT-Secur for the stress urinary incontinence. To evaluate the feasibility, efficacy and main advantages of the surgical correction with the new device.
Between January and May of 2007, 16 TVT-Secur (Women's Health & Urology, Ethicon, Johnson & Johnson) were made in patients of the Urogynecology Unit, of Clinica Las Condes. Six TVT-Secur were applied in "V" and 10 in "U". The median age was 52 years old, BMI 29, parity of 3. All patients were studied with urodynamic before surgery. All must have the urinary incontinence by more of one year and no must have previous surgical correction.
The media surgical time was 10 minutes (8-15 minutes). Complications were not registered during intraoperative and immediate, early or delayed postoperative time. The visual analogue scale of pain was 1 to 2 at 12 hours. All patients were cured. The follow-up was between 1 and 4 months, 2 month media. All patients expressed satisfaction with the surgical results and they would recommend it to other patients in the same conditions.
According to our initial experience, the new system TVT-Secur is feasible, safe and effective in the surgical correction of the SUI. However, only the long follow-up and the incorporation of new patients to the study, will allow to determine the permanence of these good results in the time.
We describe a new surgical technique (the vaginal plastron) for the treatment of cystocele by the vaginal route. The technique is based on bladder support by a vaginal strip (6-8cm in length and 4cm in width), isolated from the anterior colpocele, left attached to the bladder, associated with a suspension of this strip by its fixation to the tendinous arch of the pelvic fascia by six lateral sutures (three on each side of the plastron). The vaginal plastron is then covered by tucking it under the anterior colporraphy.
We evaluated the short-term functional and anatomical results of the first 47 patients to have undergone this treatment between October 1997 and June 1998. The average age of the patients was 69 years. Cystoceles were associated with urinary stress incontinence in 38.3% of cases, with hysterocele or prolapse of the vaginal dome in 87.2% of cases, with an elytrocele in 19.1% of cases and a rectocele in 70.2% of cases. Of the 45 patients having had a hysterectomy combined with the vaginal plastron or in their past history, 44 (99.77%) had a Richter sacro-spino-fixation and 17 (38%) had a Campbell procedure combined with the vaginal plastron. All patients underwent a posterior perineorraphy with myorraphy of the elevators.
Average follow-up was 16.4 months with extremes of 6-26 months and concerned 46 patients (one patient was unavailable). Ninety-three percent of the cystoceles were considered treated. One case of imperfect anatomical outcome was noted (persistence of stage 1 cystocele in one patient) together with two other cases of failure of the treatment of cystocele (relapse to stage 2 cystocele).
Proposed as a curative treatment of cystocele and combined with the Richter fixation, the plastron provides a surgical solution to the problem of cystocele relapse arising after vaginal treatment of prolapse by sacro-spino-fixation alone (10-20% according to Richter). Short-term results are encouraging, however, medium- to long-term results (36-60 months) are necessary in order confirm the usefulness of this surgical technique.
Over a 2-year period 45 patients with bilateral paravaginal support defects underwent vaginal paravaginal repair. Postoperative evaluations were conducted and anatomic outcome was determined by vaginal examination, with grading of vaginal wall support. Functional outcome was assessed by a standardized quality of life questionnaire, voiding dairy and standing stress test with a full bladder. Thirty-five patients had long-term follow-up with a mean of 1.6 years (range 1-85). The recurrence rates for displacement cystocele, enterocele and rectocele were 3% (1/35), 20% (7/35) and 14% (5/35), respectively. In no patients did vault prolapse develop or recur. Subjective or objective evidence of persistent stress urinary incontinence was found in 57% of patients (12/21). Vaginal paravaginal repair is a safe and effective technique for the surgical correction of anterior vaginal wall prolapse but has limited applicability in the surgical correction of genuine stress incontinence.
The purpose of this study was to evaluate the independent effect of suburethral sling placement on the risk of cystocele recurrence after pelvic reconstructive operation.
One hundred forty-eight women with cystoceles to or beyond the hymenal ring underwent pelvic reconstructive operation, with or without incontinence procedures, and were evaluated at 12 and 52 weeks after operation with a standardized pelvic examination. Rates of recurrent prolapse, at all sites, were statistically compared between subjects with and without suburethral slings. A multiple regression analysis was used to determine the independent effect of sling placement on the risk of recurrent cystoceles.
Suburethral sling placement was associated with a 54.8% reduction in the mean rate of postoperative cystocele recurrence (P =.004). This protective effect was observed as early as 12 weeks and remained significant at 1-year follow up (42% vs 19%). A markedly reduced risk of cystocele recurrence was observed when women with sling procedures were compared with all other women, with those women who underwent other incontinence operations, and even with those women who had undergone prolapse repair with no incontinence procedure. The protective effect of the sling procedure remained highly significant (odds ratio, 0.29; P =.0003), even after controlling for potentially confounding variables in a multiple logistic regression model.
Suburethral sling procedures appear to significantly reduce the risk of cystocele recurrence after pelvic reconstructive operation, in contrast with the effect of retropubic urethropexy and needle suspensions. These findings should be considered when the surgical treatment of stress incontinence that accompanies pelvic organ prolapse is being planned.
Pelvic organ prolapse and stress urinary incontinence increase with age. The increasing proportion of the aging female population is likely to result in a demand for care of pelvic floor prolapse and incontinence. Experimental evidence of altered connective tissue metabolism may predispose to pelvic floor dysfunction, supporting the use of biomaterials, such as synthetic mesh, to correct pelvic fascial defects. Re-establishing pelvic support and continence calls for a biomaterial to be inert, flexible, and durable and to simultaneously minimize infection and erosion risk. Mesh as a biomaterial has evolved considerably throughout the past half century to the current line that combines ease of use, achieves good outcomes, and minimizes risk. This article explores the biochemical basis for pelvic floor attenuation and reviews various pelvic reconstructive mesh materials, their successes, failures, complications, and management.