Correction of cystocele and stress incontinence with anterior transobturator mesh

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Abstract

Objective

To evaluate the effectiveness and safety of anterior transobturator mesh for treating cystocele with or without urinary stress incontinence.

Study design

Eighty-five women with cystocele, with or without USI, underwent anterior transobturator vaginal mesh operation. All patients were examined after 4 months. Seventy-two of them were evaluated via questionnaire after 7 months with respect to complications, the effectiveness of the operation and its influence on their quality of life.

Women with urinary stress incontinence in addition to cystocele (62.5%) underwent suburethral mesh placement with the anterior mesh-arms used like a transobturator sling.

Results

Recurrence of stage 1 cystoceles were seen in 9.6% of patients but no recurrence of symptomatic cystocele was observed. Mesh erosion of the central anterior vaginal wall appeared in 5.9%. Three revisions but no mesh explantation became necessary.

Urinary stress incontinence was cured in 83.3%, while it improved in 9.3%. Urge incontinence was cured in 28.6% of patients and improved in 17.5%. De novo urge incontinence occurred four times and de novo urinary stress incontinence was found in three patients.

Among sexually active women, 27% reported improved intercourse, while 24.3% reported a change for the worse. Quality of life improved in 81.9%, and 95.8% would undergo the procedure again.

Conclusion

Anterior transobturator mesh is a safe method to treat cystocele with or without stress urinary incontinence and yields good initial results.

Introduction

Damage to the fibromuscular layer of the vagina may occur centrally, laterally (paravaginal defect), or to the cervical ring attachment (“cervical ring” or “transverse” defect). All three sites may also be simultaneously damaged. Correct diagnosis of the damaged structures is an essential prerequisite prior to repair. Traditional repairs that excise the herniation and re-approximate the vaginal edges have high recurrence rates, and may shorten or narrow the vagina. Recurrence rates for conventional procedures range from 20% to 30%, leaving considerable room for improvement [1], [2], [3], [4].

By contrast, treatment of urinary stress incontinence (USI) made good progress recently. When introducing the tension-free vaginal tape (TVT), Ulmsten et al. brought up a paradigm shift in the surgery of incontinence [5]. Cure rates ranged between 80% and 90% [6] and a long-term follow-up showed continence rates of 84.7% after 5 years and 81.3% after 7 years [7]. Delorme was the first to use transobturator tape to reproduce the natural suspension fascia of the urethra while preserving the retropubic space [8]. Cure rates turned out to be similar to those with TVT [9], [10], with the transobturator sling being slightly superior with respect to complications [11], [12].

The use of non-absorbable polypropylene tapes in the treatment of stress incontinence resulted in good tissue acceptance in urogynaecologic anatomical structures.

With regard to the vaginal use of meshes, their use as a first line treatment was not recommended initially due to complications such as erosion, prosthesis ablation, and formation of a sinus trajectory [13]. However, the use of alloplastic materials in surgery of the inner pelvis has become more frequent in recent years [14]. Here, one of the main problems was to develop a technique for anchoring the mesh in a stable fashion, and also tension-free and without folds.

Early in 2004, gynecologic surgeons developed a technique for fixing a mesh by means of two arms through the anterior part of the obturator orifice following the transobturator tape procedure. The second step was fixation with a second pair of arms through the posterior part of the obturator orifice. It is not clear who was the first to use this technique, but the results were promising. Nevertheless, publications about results and complications are still rare.

We have been using the anterior transobturator mesh to treat symptomatic cystocele with or without USI since November 2004. Since there were no preformed meshes on the market, we initially had to construct the form by hand. Today, a few slightly different meshes are commercially available. Three of them have been used in this study.

We aimed to investigate the effectiveness and safety of anterior transobturator mesh application for treatment of both USI and cystocele and its influence on quality of life.

Section snippets

Material and methods

Women with symptomatic prolapse related to a cystocele of stage 2 or more, with or without USI, were enrolled into the study. In order to detect other pathologies related to the bladder, uterus or appendages and in order to ensure that the appropriate procedure was performed, women were evaluated preoperatively by history, clinical examination, ultrasound (transvaginal and introital) and urodynamic assessment (Ellipse, Andromeda, Medizinische Systeme GmbH, München, Germany). Multichannel

Results

Between November 2004 and July 2005, we have inserted 85 anterior tension-free vaginal meshes through a transobturator pathway. The mean age of the patients was 62 years (range: 35–83 years, standard deviation: 9.6 years). Following meshes were used: 51 GYNEMESH PS (Gynecare, Somerville, NJ) (handmade form), 3 ULTRAPRO (Ethicon, Somerville, NJ) (handmade form), 15 PERIGEE (American Medical Systems, Minnetonka, MN), 8 PROLIFT (Gynecare, Somerville, NJ), and 8 SERATOM (Serag Wiessner, Naila,

Comment

This is a report of the initial results obtained after correction of symptomatic cystoceles with anterior transobturator mesh and, if required, simultaneous treatment of urinary stress incontinence.

The purpose of using alloplastic material is to restore the endopelvic fascia and to provide strong fibrous tissue to weak areas of the repair site. But which mesh to choose? The answer can only be speculative, but in our experience, ULTRAPRO may not be recommended for repair of the anterior vaginal

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