Reconstructive laparoscopic prolapse surgery to avoid mesh erosions.

INTRODUCTION: The objective of the study is to examine the efficacy of the purely laparoscopic reconstructive management of cystocele and rectocele with mesh, to avoid the risk of erosion by the graft material, a well known complication in vaginal mesh surgery.
MATERIAL AND METHODS: We performed a prospective, single-case, non-randomized study in 325 patients who received laparoscopic reconstructive management of pelvic organe prolaps with mesh. The study was conducted between January 2004 and December 2012 in a private clinic in India. The most common prolapse symptoms were reducible vaginal lump, urinary stress incontinence, constipation and flatus incontinence, sexual dysfunction and dypareunia. The degree e of the prolaps was staged according to POPQ system. The approach was purely laparoscopic and involved the use of polypropylene (Prolene) or polyurethane with activated regenerated cellulose coating (Parietex) mesh.
RESULTS: The mean age was 55 (30-80) years and the most of the patients were multiparous (272/325). The patients received a plastic correction of the rectocele only (138 cases), a cystocele and rectocele (187 cases) with mesh. 132 patients had a concomitant total hysterectomy; in 2 cases a laparoscopic supracervical hysterectomy was performed and 190 patients had a laparoscopic colposuspension. The mean operation time was 82.2 (60-210) minutes. The mean follow up was 3.4 (3-5) years. Urinary retention developed in 1 case, which required a new laparoscopical intervention. Bladder injury, observed in the same case was in one session closed with absorbable suture. There were four recurrences of the rectocele, receiving a posterior vaginal colporrhaphy. Erosions of the mesh were not reported or documented.
CONCLUSION: The pure laparoscopic reconstructive management of the cystocele and rectocele with mesh seems to be a safe and effective surgical procedure potentially avoiding the risk of mesh erosions.

Introduction

The pelvic organ prolaps (POP) is a common disease, affecting up to 40–50% of the women over the age of 40 years [1]. POP results from weakening of the pelvic floor support, the muscles, the ligaments that support pelvic organs occuring after child-birth, after hysterectomy or due to aging [1].

The impact of the disease both on individual and on the society level is considerable and therefore remains a challenge to the surgeon. Ideally, the goals of the treatment should be accomplished at four levels: anatomical reconstruction of the pelvic floor, regaining normal functionality, avoiding surgical complications and achieving the patients’ satisfaction [2]. Over time there were several open and vaginal mesh reconstructive procedures for the correction of POP described. The risk of complications such as erosions and infections of the mesh observed in the vaginal surgery could be potentially successfully avoided using the laparoscopical approach but only a few clinics perform the laparoscopic approach although it could offer several advantages compared to open or vaginal surgery [3].

Material and methods

Patients

The study was conducted between January 2004 and December 2012 and included a number of 325 patients diagnosed with rectocele and a cystocele and treated in a private clinic in India. All patients received a physical examination. In stress urinary incontinence the clinical diagnosis was confirmed by urodynamic evaluation. The staging of prolapse was made according to the POPQ system [4]:

Stage 0 – no prolapse is demonstrated

Stage 1 – the most distal part of the prolaps is more than 1 cm above the level of the hymen

Stage 2 – the most distal part of the prolapse is 1 cm or less proximal or distal to the hymenal plane

Stage 3 – the most distal part of the prolapse protrudes more than 1 cm below the hymen but protrudes no further than 2 cm less than the total vaginal length (for example, not all the vagina has prolapsed)

Stage 4 – vaginal eversion is essentially complete

In our series, 134 (41.2%) of the women had undergone a prior hysterectomy (total 132 and supracervical 2), 325 (100%) had a repair of rectocele, 187 (57.53%) had a repair of cystocele and 190 (58.46%) had colposuspension (Figure 1 (Fig. 1)).

Figure 1

The surgical procedure (concomitant hysterectomy, rectocele repair, rectocele and cystocele repair, concomitant colposuspension) in laparoscopic mesh surgery

Surgical technique

During the laparoscopic plastic procedure, the bladder is dissected down to the urethrovesical junction and laterally to the lateral pelvic margins. Hemostasis is ensured by electrocautery during the dissection, avoiding the lesions of presacral vessels and nerves. The posterior dissection frees the rectum from the vaginal wall and surroundig tissues.

A preconstucted wide shaped synthetic polypropylene or polyurethane mesh of 10 x 12 cm is introduced into the abdomen through the trocar. The meshes cover the entire defect at the vagina, one at the anterior and eventually one at the posterior wall, depending on the vaginal defect.

The operation area is then reperitonealised (No 0 Vicryl) avoiding injury of the ureters along the lateral pelvic side wall or injury to the bladder during closure (Figure 2 (Fig. 2), Figure 3 (Fig. 3), Figure 4 (Fig. 4), Figure 5 (Fig. 5), Figure 6 (Fig. 6), Figure 7 (Fig. 7), Figure 8 (Fig. 8)).

Figure 2

Laparoscopic bladder dissecting from the anterior vaginal wall exposing the cystocele

Figure 3

Tailored mesh put in the prepared pocket in laparoscopic cystocele repair

Figure 4

Mesh lying in the pocket during laparoscopic cystocele repair

Figure 5

Reperitonealising during laparoscopic cystocele repair

Figure 6

Laparoscopic rectum dissection from posterior vaginal wall exposing the rectocele

Figure 7

Tailored prepared mesh laparoscopically placed during rectocele repair

Figure 8

Reperitonealisation after laparoscopic rectocele mesh repair

Results

The demographic findings of our study are scheduled in Figure 9 (Fig. 9). The mean age was 55 (30–80) years and most of the patients were multiparous (272/325).

Figure 9

Age distribution of the patients in laparoscopic prolapse mesh repair

At clinical examination, all the patients presented with a reducible vaginal lump. Clinical urinary incontinence, confirmed by urodynamic investigation, was observed in 111 cases (34.15%). Other symptoms were constipation and flatus incontinence (19 cases, 5.8%), sexual dysfunction (197 patients, 60.61%) and dyspareunia (136 patients, 41.84%). The mean follow up was 3.4 (3–5) years. We performed the repair of cystocele and rectocele using a polypropylene or polyurethane mesh in all the cases. The complication rate in our series was 1%: one case of bladder injury, one case of persistent urinary retention and 4 cases with recurrence of the pelvic prolaps. The bladder lesion was corrected using absorbable suture and the patient received postoperative antibiotic prophylaxe as well as a protective transurethral catheter. The patient with urinary retention required a laparoscopic reintervention with repositioning of the mesh, avoiding the urethra. The patients with recurrence of the disease complained of necessary digital voiding and sexual dysfunction: These patients underwent a secondary vaginal colporrhaphy. Complications such as erosion or infection of the mesh were not reported in our series.

Discussion

Traditionally the surgical reconstructive prolapse repair was performed by an anterior and posterior plastic colporrhaphy. The recurrence rate of these conventional surgical procedures (20–50%) [5], [6], [7] has led to the use of mesh in pelvic organ prolapse. In 1996 the use of synthetic graft materials in vaginal surgery was described [8]. The synthetic nonabsorbable prosthesis can be divided into [9]:

Type I, totally macroporous prosthesis (polypropylene): the large diameter of these prosthesis (>75 µm) [9] allows the macrophages and fibroblasts to enter the space between the pores and to build the connective tissue, which contributes to the mesh integration to the organism. The macropores enable also the access of the immunological cells, which warrant the resistance against infections [9]. These type of mesh has a risk of adhesions and can induce the development of erosions and fistula [10], [11].

Type II, totally microporous prosthesis (expanded polytetrafluoroethylene, Gore-Tex): the pores are smaller than 10 µm. These meshes are smooth and flexible and not very adherent. The micropores allow the entry of fibroblasts, but not of the macrophages and neutrofiles which are too voluminous for the pores and therefore cannot protect against infections [12].

Type III: Macroporous prosthesis with multifilament or microporous components (Mersilene, Parietex): the pores are larger than 75 µm, organized in multifilamentary threads and the space between the threads are less than 10 µm [9], [13]. The disadvantage of this type of mesh is the risk of infection [13].

Many prospective and retrospective nonrandomized studies [14] have reported good outcomes of vaginal surgery with synthetic grafts (Table 1 (Tab. 1)) [8], [15], [16], [17], [18], [19], [20], but the risk of major complications such as erosions and infections of the mesh remains an important problem both for the patient and the surgeon [21].

Table 1

The surgical outcomes of the different synthetic mesh used in vaginal surgery

The application of mesh techniques in pelvic organe prolapse repair and stress incontinence is steadily growing, despite of the relative lack of evidence-base information to document their safety and long-term efficacy [20]. Compared to the vaginal surgery, the laparoscopic closed insertion of graft material showed a significantly lower risk of mesh-related complications: in our study there were no mesh erosions reported.

The laparoscopical reconstructive approach enables superior visualization with accurate disection and hemostasis. The retrovaginal technique itself without cutting the vaginal wall maintains the normal vaginal integrity, providing natural functionality and sexuality.

This technique also has the advantages of the minimally invasive surgery such as smaller incisions, less pain and morbidity, shorter hospital stay with a faster recovery, quicker return to daily activities and to a normal sexual life.

Conclusion

The laparoscopic reconstructive management of cystocele and rectocele with mesh is a safe and efficient method, which offers the advantages of minimally invasive access and avoids mesh erosions known in vaginal surgery using graft materials. Further studies will be required to determine the long-term efficacy and safety of the proposed laparoscopic reconstructive method.

Notes

Competing interests

The authors declare that they have no competing interests.