THIS LITTLE PIGGY'S ON THE MARKET
G. ARAKLITIS, G. THIAGAMOORTHY,J. E. HUNTER, D. ROBINSON, L. CARDOZO;
King's Coll. Hosp.,London, United Kingdom.
Introduction: In 2011, the Foodand Drug Administration (FDA) issued a statement that mesh relatedcomplications in prolapse surgery were “not rare”. Withincreasing morbidity and legal costs, the use of mesh inurogynaecological surgery is controversial. A Cochrane review in 2016(1) showed that anterior compartment mesh repairs have lowerrecurrence on examination, less repeat surgery for prolapse andpatient prolapse awareness, compared to fascial repair. Permacol is aporcine biological mesh, which promotes cellular infiltration andneovascularisation (2). Its cross-linking properties are thought toincrease durability and tensile strength (2). The biological mesh isless likely to become infected or erode into surrounding visceracompared to synthetic mesh (2). We use it to treat recurrentcystocele. A literature review revealed its use in abdominal hernias,with only a few articles describing its use in the vagina. One ofthese found a significantly lower recurrence rate compared totraditional repair (3). Due to limited studies, the Cochrane reviewis unable to draw any conclusions comparing biological mesh to nativetissue repairs (1).
Objective: To present a case seriesutilising porcine biological mesh - Permacol in the management ofrecurrent anterior vaginal wall prolapse.
Methods: This wasa retrospective study of patients who were identified on the theatredatabase who underwent re-do anterior vaginal wall prolapse repairwith the use of Permacol mesh in a tertiary unit. All patients hadsurgery under general anaesthetic in lithotomy position. A verticalincision is made over the cystocele and the vagina is dissected offthe bladder. The prolapse is reduced with two polydiaxanone (PDS)monofilament absorbable purse string sutures. A sheet of gentamicinsoaked Permacol is cut to size and anchored at six points to form asecondary protection layer to hold back the prolapse. The vaginalepithelium is then trimmed and closed in either a ‘double breasted’over-lapping manner or side to side. All patients were contacted byphone or letter and invited to be examined and complete anInternational Consultation on Incontinence Questionairre - VaginalSymptoms (ICIQ-VS). Pre and post-opearative examination findings weredescribed as ordinal Pelvic Organ Prolapse Quantification system(POP-Q).
Results: Between 2010-2016, we identified 11patients, with a median age of 69 (range 54-75 years), parity of 2and BMI of 27. The median number of previous prolapse surgeries was 3(range 0-15). One patient never had prolapse surgery but had pelvicexenteration for transitional cell carcinoma of the bladder. Fivepatients had a previous total abdominal hysterectomy whilst five hada vaginal hysterectomy. The median hospital stay was 2 days with nooperative complications. The median pre and post-op ordinal stage ofanterior compartment prolapse was 2 (range 2-3) and 0 (range 0-1)respectively, at a median review time of 51 days. Only three patientscompleted the ICIQ-VS questionnaire, pre and post-operatively (table1). Those patients had improved scores and quality of life. Eightpatients were seen more than once post-operatively at median time of487 days (range 176 - 1583 days). These patients had a median ordinalPOP-Q of 2 (range 0-2). Six patients completed the questionnaireprospectively, but did not have pre-operative results. These patientshad a median VS score of 23 (range 2-40), sexual matters score of 2(0-42) and QoL of 6 (range 0-9). Only two patients complained ofprolapse symptoms in the post-operative period.
Conclusions:To our knowledge this is the first case series of the use ofPermacol, for the treatment of anterior vaginal wall prolapse in theUnited Kingdom. The study suggests it can be safely used with noimmediate, short or long-term complications. Our study shows that itimproves prolapse objectively in the short term and subjectively inthe long term. There is an improvement in VS and QoL scores in theshort and long term. One patient who was not sexually active in thepre and first post-operative reviews, subsequently becamesatisfactorily sexually active. We acknowledge the limitations of thestudy, which includes 11 patients, only three with pre and postoperative ICIQ-VS scores. Permacol and other biological meshesdeserve further study in the management of complex recurrent anteriorvaginal wall prolapse, as they are not associated with thecomplications incurred with synthetic meshes.
References:1. The Cochrane Library (2016) 2. Journal of Wound Care (2016);25(6): 320-5 3. The Journal of Urology (2007); 177:192-5