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Anterior vaginal wall repair with mesh leads to higher anatomic success rates

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Placement of synthetic mesh to reinforce anterior vaginal prolapse repair is associated with improved anatomic outcomes at two years, a study shows. However, the study also found that improvement in patients’ symptoms is likely regardless of whether mesh is used or not.

In addition, “the use of vaginal mesh for cystocele repair did result in some mesh erosions into the vagina, which in select cases required a second surgical procedure to treat,” Dr. Shawn A. Menefee, in the division of female pelvic medicine & reconstructive surgery, University of California San Diego and Kaiser Permanente San Diego, told Reuters Health.

He said “longer-term follow-up will determine if the addition of synthetic mesh results in better outcomes and outweighs the inherent risks.”

Women in the United States have an 11% lifetime chance of needing surgery to correct pelvic organ prolapse and many of these procedures include correction of anterior vaginal wall defects, Dr. Menefee and colleagues note in the December issue of Obstetrics and Gynecology.

They point out that anterior colporrhaphy has become the standard procedure to correct anterior vaginal wall prolapse, although high recurrence rates and reoperation rates have led some surgeons to perform mesh or graft-reinforced repairs. And published studies to date make it tough to draw reliable conclusions about the use of grafts or mesh for prolapse repair.

This led Dr. Menefee and colleagues to design a randomized double-blind clinical trial to compare the objective success rates and effect on quality of life of three different anterior vaginal wall repairs: traditional anterior colporrhaphy, vaginal paravaginal repair using the porcine dermis graft Pelvicol, or vaginal paravaginal repair using the synthetic polypropylene mesh Polyform.

Participants were women older than aged 18 with at least stage II symptomatic anterior wall prolapse who wanted to have surgery. Seventy-eight of 99 women completed two years of follow up; 24 had colporrhaphy, 26 porcine graft repair, and 28 synthetic mesh repair.

According to the investigators, rates of anatomic failure – defined as anterior prolapse at stage II or greater – were significantly lower with mesh repair (18%) than with graft repair (46%) and standard colporrhaphy (58%).

Nonetheless, all groups had a similar reduction in their prolapse and urinary symptom “severity and degree of bother” and there were no between-group differences in sexual function.

Composite failure rates – a measure which included objective and subjective variables including symptoms of “bulge” and anterior prolapse at stage II or greater – was not statistically different between groups (13% colporrhaphy, 12% porcine graft and 4% mesh).

Two reoperations for anterior prolapse occurred in the porcine graft group and erosion rates were higher in the mesh group compared with the porcine group (14% vs 4%).

“Successful treatment of anterior vaginal prolapse remains one of the most challenging aspects of pelvic reconstructive surgery,” Dr. Menefee and colleagues note in their report.

Dr. Menefee told Reuters Health that it’s not possible to say which approach is better/best for which patient. “The decision of which technique to use for anterior vaginal wall ‘cystocele’ repair,” he said, “depends on several factors including the individual surgeons’ experience; the outcomes and adverse events with each procedure type and patients’ perception of what is important to them (anatomic correction, symptom relief, length of surgery, minimize potential complication and durability of the repair).”

“This decision should be made after detailed counseling of these factors with each individual patient,” Dr. Menefee advised.

Reference:

Colporrhaphy compared with mesh or graft-reinforced vaginal paravaginal repair for anterior vaginal wall prolapse: a randomized controlled trial.

Obstet Gynecol 2011;118:1337-1344.