Pelvic Prolapse - Evaluating The Effects Of Pelvic Floor Reconstruction On The Outcomes Of Slings

Main Category: Urology / Nephrology
Also Included In: Women's Health / Gynecology
Article Date: 02 Jul 2008 - 8:00 PDT

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ORLANDO, FL (UroToday.com) - Two different groups evaluated the effects of pelvic floor reconstruction on the outcomes of slings. While the UCLA group showed no evidence of any effect of posterior repair on slings outcomes (Abstract #1300), work from Virginia Mason in Seattle suggested a possible protective effect of anterior repair on sling results (Abstract #1299). Clearly, a randomized study involving patients with similar demographics and degrees of prolapse and incontinence would be necessary to demonstrate this with certainty.

A multicenter trial evaluating the safety and short term efficacy of the Perigee system was presented by Dr. Karny Jacoby (Abstract #1301). 8 U.S. sites implanted 108 patients with the type I polypropylene mesh for anterior compartment repair and reported a 93% success rate (defined as anterior compartment POP-Q of Stage 0 or 1) in 57 patients who had 12 month follow up. Mean blood loss was < 70cc, intraoperative complication rate was low (one bladder perforation and one hematoma requiring transfusion), 8.3% experienced vaginal extrusion, and 10 patients (9.2%) underwent device-related revision due to vaginal extrusion, pain, recurrent or persistent prolapse, and bladder perforation.

Dr. Joseph Costa presented an overview of the incidence and management of graft complications following synthetic graft reinforcement of prolapse repair experienced at his institution in 240 patients over a four year period, 132 of whom underwent anterior repair alone, 31 of whom underwent anterior-posterior repairs, and 77 of whom underwent isolated posterior repairs (Abstract #1303). While the overall success rate of the repairs was reported to be 96.7%, 10% (24) experienced graft exposure in the vagina, with 11 (4.6% of the group) requiring excision which occurred between 0.5 and 11 months postoperatively. Major complications related to the mesh included bleeding requiring reoperation, rectovaginal fistula, and urinary retention requiring suprapubic cystostomy. Patients who were sexually active were more likely to require excision, but many patients who were not sexually active were managed successfully with observation.

A topic of frequent discussion is whether or not an anti-incontinence procedure should be performed at the time of repair of large prolapse. To address this question, Dr. Victor Nitti's group from New York retrospectively reviewed the charts of patients who underwent transvaginal repair of POP-Q Stage 3 or 4 prolapse and examined the impact of their urodynamic protocol on the postoperative stress incontinence (SUI) and obstruction rates in this cohort of patients (Abstract #1304). Of 55 patients who denied SUI, 24 had no urodynamic or occult SUI and did not receive a sling. 2 (8.3%) subsequently required a sling.

31 of those who denied SUI symptoms demonstrated SUI and underwent a sling. 3 (9.7%) required intervention for obstruction and one for SUI. Of the 50 patients who described preoperative SUI, 10 did not demonstrate objective SUI and did not undergo a sling. 3 (30%) required subsequent sling placement. 40 confirmed urodynamic or occult SUI and received a sling. Of these, 3 (7.5%) required intervention for obstruction. The group concluded that the risk of requiring intervention for obstruction in patients receiving a sling without demonstrable SUI is equivalent to the risk of requiring intervention for SUI if no sling is placed in a patient who has no symptoms of or demonstrable SUI. However, in those patients who report clinical SUI, irrespective of whether SUI is demonstrated, intervention for SUI is recommended.

ABST #1299: Effect of Concurrent Cystocele Repair on Outcomes Following Transvaginal Cadaveric Fascia Lata Urethral Sling Placement, by David E. Rapp, MD, et al.

ABST #1300: The Effect of Posterior Compartment Repair on Outcome of Sub-Urethral Sling, by Christian O. Twiss, MD, et al.

ABST #1301: Multi-Center Trial Evaluating the Intra-Operative Safety and 6 and 12-Month Efficacy of the Perigee System, by Robert D. Moore, MD, et al.

ABST #1303: Incidence and Management of Graft Complications in Patients with History of Synthetic Mesh Repair for Pelvic Organ Prolapse, by Joseph A. Costa, MD, and Steve E. Goldwasser, MD

ABST #1304: Managing the Urethra at the Time of Transvaginal Pelvic Organ Prolapse Repair: A Urodynamic Approach, by Katie N. Ballert, MD, et al.

Presented at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Kathleen C. Kobashi, MD

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