SAFETY, EFFICACY, CONTROVERSIES ANDCHALLENGES IN VAGINAL MESH REPAIR IN PELVIC ORGAN PROLAPSE
Waikato Hosp.,Hamilton, New Zealand.
Introduction: Pelvic organprolapse is a frequent cause of physical & psychological distressto affected women adversely affecting their quality of life.Traditional prolapse repair has high failure rates as attenuatedtissues are utilized & paravaginal defects remain uncorrected.This results in poor patient satisfaction and repeated surgeries withassociated risks and morbidity.
Mesh repair aims to overcome thesedeficiencies but has been associated with varying success &morbidity. Patients and the press often associate serious long-termcomplications following mesh repair for Pelvic organ prolapse withnewer techniques and implants.
Objective: To review worldliterature focusing on evolution of techniques and technology andtheir impact on results of surgery and complications of variousmethods of prolapse repair.
To determine efficacy and safety ofvarious systems used, and determine the efficacy and safety ofvaginal mesh repair using polypropylene monofilament mesh (Gynemesh)to repair para vaginal defects in patients with symptomaticcystocele.
Methods: Review world literature focusing onchallenges and controversies over time, how technologicalimprovements and refinements in surgical techniques have tried toaddress these, the results of surgery, and complications of variousmethods of prolapse repair. This is followed by a retrospective studyof all patients with symptomatic cystocele treated.
In our study,patients were assessed using POP-Q scores ± urodynamics asappropriate. A customized tension-free Gynemesh was fixed to thesacrospinous ligament, arcuate line & suburethrally using PDSsutures. Postoperative pain assessments were done using VisualAnalogue Score.
Patients were followed up at 1, 6 and 12 months.Efficacy of repair, morbidity, and impact on quality of life wererecorded and analyzed.
Results: There is a wide variationof techniques, rates of successful repair and complicationsworldwide. Improvements in our understanding of the functionalanatomy, physiology and mechanisms of prolapse have led torefinements in surgical techniques. Improvements in technology havetried to address some of the challenges with varying degrees ofsuccess. In our study, of the 118 women, 4 presented withprocidentia, 25 with stage 2 & 89 with stage 3 prolapse. 15patients had Urinary stress incontinence in addition to prolapse, and38 had a previous surgery (34 with previous hysterectomy, 14 withprevious repair, 10 with both). The median follow-up was 18 months.112 patients felt improvement in symptoms and quality of life.16patients had transient micturition problems (12-USI, 2-urinaryretention, 1-urgency) and were managed conservatively in all but 1(needed Monarch sling). 1 wound infection and 3 mesh exposures werenoted and these required excision of the exposed mesh. There were noclinical recurrences of prolapse. Complications decreased withincreasing experience with use of the technique.
Conclusions:Improvements in our understanding of the mechanism of prolapse,technological advancements and refinements in surgical techniqueshave led to changes in the management of prolapse over time butsignificant challenges remain. Paravaginal mesh repair is a safe,simple surgery, and provides excellent anatomic results with fewcomplications.