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Anterior Compartment Prolapse: Biological Grafts Miss Michelle Fynes MB BAO BCH (Hons) MRCOG DU DipUs
Anterior Compartment Prolapse: Biological Grafts Miss Michelle Fynes MB BAO BCH (Hons) MRCOG DU DipUs
Anterior Compartment Prolapse: Biological Grafts Miss Michelle Fynes MB BAO BCH (Hons) MRCOG DU DipUs
Anterior Compartment Prolapse:
Biological Grafts
Miss Michelle Fynes MB BAO BCH (Hons) MRCOG DU DipUs MD (Research)
Consultant Subspecialist Urogynaecologist

Department of Reconstructive Pelvic Surgery & Urogynaecology St George’s Hospital and Honorary Senior Lecturer St. Georges University of London

and Honorary Senior Lecturer St. Georges University of London Presented to: RCOG Urogynaecology Surgical Masterclass 2012
Presented to: RCOG Urogynaecology Surgical Masterclass 2012
Presented to: RCOG Urogynaecology Surgical Masterclass 2012
Introduction  Assessment and management of anterior vaginal wall defects presents a unique surgical challenge
Introduction
 Assessment and management of anterior
vaginal wall defects presents a unique
surgical challenge
 It is the most common site of initial
prolapse in women and the most common
site of recurrence
Background  POP surgery undertaken in 11% of women  Surgical POP rates will increase
Background
 POP surgery undertaken in 11% of women
 Surgical POP rates will increase with aging
population
 Anterior vaginal wall is both the most common
site of POP (81% of surgical repairs)
Cystocele repair fails most frequently (up to
41%)
 Cystocele repair fails most frequently (up to 41%) Olsen AL. Obstet Gynecol. 1997;89:501 – 506.

Olsen AL. Obstet Gynecol. 1997;89:501506. Jelovsek JE. Lancet. 2007;369:10271038. He. USA 2005 special studies 65+ www.census.gov. Benson JT. Am J Obstet Gynecol. 1996;175:14181421. Nguyen JN. Obstet Gynecol. 2008;111:891898. Nguyen JK. Obstet Gynecol Surv. 2001;56:239246. Maher C. IUJ 2006;17:195201.

Cystocele
Cystocele
 Analysis of “Well women” population
 Analysis of “Well women” population
Cystocele  Analysis of “Well women” population  For women who entered the WHI protocol without

For women who entered the WHI protocol without cystocele. At some point during the study the following type of POP was diagnosed:

during the study the following type of POP was diagnosed:  1 in 4 Cystocele 
 1 in 4 Cystocele  1 in 6 Rectocele  1 in 100 Uterine
 1 in 4
Cystocele
 1 in 6
Rectocele
 1 in 100 Uterine prolapse

Hendrix SL, Clark A, Nygaard I, et al. POP in the Women's Health Initiative: gravity and gravidity.

Am J Obstet Gynecol. 2002;186:11601166.

What’s wrong with anterior vaginal wall support?

What’s wrong with anterior vaginal wall support?  Is the anterior compartment not as well supported
 Is the anterior compartment not as well supported by the levator plate countering the
 Is the anterior compartment not as well supported by
the levator plate countering the effects of gravity &
abdominal pressure as for the posterior
compartment?
 Are the attachments of the anterior compartment to
the pelvic sidewall or to the apex weaker?
 Is the anterior wall more elastic or less dense when
compared with the posterior wall?
 Is the anterior wall more susceptible to damage during
childbirth or weakening with aging or loss of
oestrogen?
George White (1866-1926)  On reviewing the failure of anterior repair: The reason for failure
George White
George White
(1866-1926)  On reviewing the failure of anterior repair:
(1866-1926)
 On reviewing the failure of
anterior repair:

The reason for failure seems to be that the normal

support of the bladder has not been sought for and

restored, but instead an irrational removal of part of the anterior vaginal wall has been resorted to, which could only result in disappointment and failure.

removal of part of the anterior vaginal wall has been resorted to, which could only result
removal of part of the anterior vaginal wall has been resorted to, which could only result
Objectives
Objectives

For successful surgical intervention in women with Cystocele we need to understand:

intervention in women with Cystocele we need to understand:      The anatomy
intervention in women with Cystocele we need to understand:      The anatomy
    

The anatomy of anterior vaginal wall support Patho-anatomy of Cystocele Classification and types of Cystocele Institute appropriate surgical repair techniques Identify those with high risk of failure based on patho- anatomy

Anatomy Anterior Compartment Support

Anatomy Anterior Compartment Support Trapezoidal support Anterior Vaginal Compartment Illustration From Article by Brincat

Trapezoidal support Anterior Vaginal Compartment

Compartment Support Trapezoidal support Anterior Vaginal Compartment Illustration From Article by Brincat et al 2010

Illustration From Article by Brincat et al 2010

Anatomy Anterior Compartment Support  Anterior vaginal wall resembles a trapezoidal plane because of the
Anatomy Anterior Compartment
Support
 Anterior vaginal wall resembles a
trapezoidal plane because of the ventral
and more medial attachments near the
pubic symphysis and dorsal and more
lateral attachments near the ischial spine
 The trapezoidal anterior wall is suspended
both sides to the parietal fascia overlying
the levator ani muscles at the arcus
tendineus fascia pelvis (ATFP)
Cystocele: Midline Defect  Damage to pubocervical fascia  Fascia stretches and weakens  Bladder
Cystocele: Midline Defect
 Damage to pubocervical fascia
 Fascia stretches and weakens
 Bladder sinks into the middle of the upper
vaginal wall
Cystocele: Lateral Defect  Detachment of fascia from arcus tendineus  Fascia tears away from
Cystocele: Lateral Defect
 Detachment of fascia from arcus tendineus
 Fascia tears away from their attachments to
the sidewalls of the pelvis
Clinical Presentation
Clinical Presentation
Clinical Presentation FIGURE A. A transverse defect with loss of the anterior fornix. FIGURE B. A

FIGURE A. A transverse defect with loss of the anterior fornix.

A. A transverse defect with loss of the anterior fornix. FIGURE B. A cephalad defect with
A. A transverse defect with loss of the anterior fornix. FIGURE B. A cephalad defect with

FIGURE B. A cephalad defect with loss of apical attachment at the level of the ischial spine.

Surgical Intervention - Midline Defect  Disappointing results with “standard” vaginal repair  Recurrence rates

Surgical Intervention - Midline Defect

 Disappointing results with “standard” vaginal repair  Recurrence rates vary with definition of failure:
 Disappointing results with
“standard” vaginal repair
 Recurrence rates vary with
definition of failure: Weber et al
2001 (56%) & Sand et al
2001(43%)
 Mesh kits: commercial success
but significant concerns
regarding mesh erosion,
dyspareunia and other adverse
events
concerns regarding mesh erosion, dyspareunia and other adverse events Anterior Vaginal Wall Fascial Plication
concerns regarding mesh erosion, dyspareunia and other adverse events Anterior Vaginal Wall Fascial Plication

Anterior Vaginal Wall Fascial Plication

Biological Grafts?
Biological Grafts?
“Arcus to Arcus” Graft
“Arcus to Arcus” Graft

Fascial Reconstruction Repairing Enterocele

Level I

Support

Restored

/ / Suture Placement: “6-Point Suspension”
/
/
Suture Placement:
“6-Point Suspension”
I Support Restored / / Suture Placement: “6-Point Suspension” Paravaginal Defect Repair Central Defect Covered
I Support Restored / / Suture Placement: “6-Point Suspension” Paravaginal Defect Repair Central Defect Covered
I Support Restored / / Suture Placement: “6-Point Suspension” Paravaginal Defect Repair Central Defect Covered

Paravaginal Defect Repair

Central Defect Covered

Apical Suspension: Comparing Devices Posterior IVS Apogee Prolift Capio
Apical Suspension: Comparing Devices
Apical
Suspension:
Comparing
Devices
Apical Suspension: Comparing Devices Posterior IVS Apogee Prolift Capio

Posterior IVS Apogee

Prolift

Capio

• Cut suture in 2 to get 2 throws • Remember needle tip
• Cut suture in 2 to get 2 throws • Remember needle tip
• Cut suture in 2 to get 2 throws • Remember needle tip

Cut suture in 2 to get 2 throws Remember needle tip

Placement of Capio Sutures
Placement of Capio Sutures
Xenform™ Tissue Repair Matrix
Xenform™ Tissue Repair Matrix
Fetal Bovine Dermis
Fetal Bovine Dermis
Biological Grafts and Cystocele Repair
Biological Grafts and Cystocele Repair
Advantages Disadvantages  Avoid erosion  Cost  Minimise wound healing issues  Anchoring technique
Advantages
Disadvantages
Avoid erosion
Cost
Minimise wound healing
issues
Anchoring technique
Longevity of graft
Improved sexual function
Host versus graft
interaction
Outcome data
Clinical History
Clinical History
 53 yrs Para 3  Referred with recurrent cystocele in 2009  Symptoms 
 53 yrs Para 3
 Referred with recurrent
cystocele in 2009
 Symptoms
 Vaginal bulge &
discomfort worse at
the end of the day
 Urgency & occasional
UI but no SUI
No voiding difficulties
 Past surgery Vaginal Hysterectomy & Pelvic Floor Repair (1980) Posterior repair & sacrospinous fixation
Past surgery
Vaginal Hysterectomy &
Pelvic Floor Repair
(1980)
Posterior repair &
sacrospinous fixation
(2006)
 Examination
Grade 2 cystocele,
Grade 1-2 vault prolapse,
Grade 1 low rectocele
High perineum
Operative Procedures
Operative Procedures
 Anterior colporrhaphy incorporating Arcus to Arcus attachment with Xenoform  Sacro-spinous ligament pudendal
 Anterior colporrhaphy incorporating Arcus to Arcus
attachment with Xenoform
 Sacro-spinous ligament pudendal nerve block
 Low rectocele repair with revision of perineum

Arcus Anchored Acellular Dermal Graft Compared to Anterior Colporrhaphy for Stage II Cystoceles and Beyond

Aim: Compare acellular dermal matrix to standard colporrhaphy for repair cystoceles. Methods: 102 patients with > Stage II anterior prolapse (Aa or Ba 0) underwent anterior colporrhaphy with acellular dermal implant attached to arcus, between 10/2003 and 02/2007 were compared to 89 controls who received standard anterior colporrhaphy. Objective recurrence was defined as > Stage II (Aa or Ba -1). Results: The dermal graft and colporrhaphy groups were comparable in age, parity, BMI and concomitant surgeries except hysteropexy and hysterectomy. Regression was performed for possible confounders. Postoperatively, 14 (19%) recurrences were identified in the dermal graft group vs. 26 (43%) in the colporrhaphy group (p=0.004). Two patients underwent reoperations for cystocele recurrence in the study group versus four in the control group. Time to normal voiding, subjective stress urinary incontinence, EBL and length of hospital stay did not differ between groups. Conclusion: Dermal acellular matrix provides benefit over standard colporrhaphy.

matrix provides benefit over standard colporrhaphy. S Botros, P Sand, J Beaumont, Y Abramov, JJ Miller,

S Botros, P Sand, J Beaumont, Y Abramov, JJ Miller, RP Goldberg IJPFD 2009

Table 1: Concomitant Surgeries

Arcus Graft

Controls

(n=102) (n=89) p-value Hysterectomy 37 (36%) 60 (67%) <0.001 Hysteropexy 33 (32%) 9 (10%) <0.001
(n=102)
(n=89)
p-value
Hysterectomy
37 (36%)
60 (67%)
<0.001
Hysteropexy
33 (32%)
9 (10%)
<0.001
Apical suspensions
0.004
McCall’s
6 (6%)
40 (45%)
Uterosacral
26 (25%)
5 (6%)
Iliococcygeous
7 (7%)
6 (7%)
Sacrospinous vault
17 (17%)
16 (19%)
Compartment Repair - Posterior
88 (86%)
79 (89%)
0.61
Compartment Repair - Anterior
102 (100%)
89 (100%)
--
Incontinence Operation - TVT
10 (10%)
13 (15%)
0.31
Incontinence Operation - TOT
42 (41%)
34 (38%)
0.68

S Botros, P Sand, J Beaumont, Y Abramov, JJ Miller, RP Goldberg IJPFD 2009

Table 2: Postoperative Outcomes

Anterior recurrence (Aa or Ba to -1) Anterior recurrence (Aa or Ba to 0) Anterior recurrence (Aa or Ba past 0) Posterior recurrence (Ap or Bp to -1) Posterior recurrence (Ap or Bp to 0) Apical recurrence (c or d to -1) Postoperative UUI 1 Postoperative SUI 1 Postoperative dyspareunia 1 (n=21 missing)

Estimated Blood loss (mls) (n=11 missing)

Length of Hospital stay (days) (n = 3 missing)

Arcus Graft Controls (n=72) (n=61) p-value N (%) N (%) 14(19%) 26 (43%) 0.004 7
Arcus Graft
Controls
(n=72)
(n=61)
p-value
N (%)
N (%)
14(19%)
26 (43%)
0.004
7 (10%)
14 (23%)
0.04
3 (4%)
2 (3%)
1.0
9 (13%)
4 (7%)
0.25
4 (6%)
3 (5%)
1.0
6 (8%)
6 (10%)
0.69
26 (41%)
11 (22%)
0.04
14 (22%)
5 (10%)
0.10
7 (14%)
8 (19%)
0.49
Mean (SD)
Mean (SD)
246 (161)
288 (182)
0.10
Median (range)
Median (range)
1 (0– 11)
1 (1 – 4)
0.24

1 n=64 arcus graft and 50 controls with subjective follow-up

S Botros, P Sand, J Beaumont, Y Abramov, JJ Miller, RP Goldberg IJPFD 2009

Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal
Efficacy and safety of using mesh or grafts in surgery for anterior and/or
posterior vaginal wall prolapse: systematic review and meta-analysis.

Jia X, Glazener C, Mowatt G, MacLennan G, Bain C, Fraser C, Burr J. Health Services Research Unit, University of Aberdeen

OBJECTIVES: To systematically review the efficacy and safety of mesh/graft for anterior or posterior vaginal
OBJECTIVES: To systematically review the efficacy and safety of mesh/graft for anterior or posterior
vaginal wall prolapse surgery.
SELECTION CRITERIA: Randomised controlled trials (RCTs), nonrandomised comparative studies,
registries, case series involving at least 50 women, and RCTs published as conference abstracts from 2005
onwards.
ANALYSIS: 3 groups: anterior, posterior, anterior +/- posterior repair (not reported separately).
RESULTS: 49 studies (N=4569) mesh/graft POP repair. Median follow up 13 months (R 1-51) For Anterior
repair, short-term evidence that mesh/graft (any type) significantly reduced objective prolapse recurrence
rates compared with no mesh/graft (relative risk 0.48, 95% CI 0.32-0.72).
GRAFTS PROLAPSE RECURRENCE EROSION RATE Non-absorbable synthetic (8.8%, 48/548) Non-absorbable (10.2%, 68/666)
GRAFTS PROLAPSE
RECURRENCE
EROSION RATE
Non-absorbable synthetic
(8.8%, 48/548)
Non-absorbable
(10.2%, 68/666)
Absorbable synthetic
(23.1%, 63/273)
Absorbable synthetic
(0.7%, 1/147)
Biological graft
(17.9%, 186/1041)
Biological graft
(6.0%, 35/581).
CONCLUSIONS: Evidence for most outcomes was too sparse to provide meaningful conclusions. Rigorous long-term RCTs
CONCLUSIONS:
Evidence for most outcomes was too
sparse to provide meaningful
conclusions.
Rigorous long-term RCTs are required
to determine the comparative efficacy
of using mesh/graft.

BJOG 2008

Conclusions  Arcus to Arcus and SSF with Acellular Cadaveric Graft repair for ≥Stage 2
Conclusions
 Arcus to Arcus and SSF with Acellular
Cadaveric Graft repair for ≥Stage 2
Cystocele versus standard ultra-lateral
anterior vaginal repair is associated with a
56% reduction in cystocele recurrences and
46% reduction in recurrence to hymenal ring
at a mean follow-up of 15 months
 Lack of specific complications and objective
reduction in prolapse requires further
evaluation
Role of fascial plication with augmentation using biological graft?
Role of fascial plication with
augmentation using biological graft?