Synthetic transvaginal mesh kits have become commonplace in the treatment of pelvic organ prolapse. These devices were quickly adopted by many surgeons in an effort to improve outcomes, particularly in patients who had failed native tissue repairs. Studies have provided mixed results as to the effectiveness of these devices. There may be a lower recurrence rate in the anterior compartment when compared with native tissue repairs; however, mesh erosions occur in 2% to 19% of those treated (109–113). The severity of mesh erosions ranges from subclinical to severe dyspareunia requiring surgical resection. Small mesh erosions are sometimes successfully managed with vaginal estrogen alone. As with anterior compartment procedures, graft materials have been used to improve the success of posterior compartment repairs. One recent systematic review concluded that there is insufficient evidence to evaluate the use of synthetic mesh in the repair of pelvic organ prolapse (114). It is also notable that the U.S. Food and Drug Administration (FDA) has recently released a warning about complications that may arise from the use of transvaginal mesh procedures for pelvic organ prolapse.
The FDA recommendations are that physicians should: 1.
Obtain specialized training for each mesh placement technique, and be aware of its risks.
2.
Be vigilant for potential adverse events from the mesh, especially erosion and infection.
3.
Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder, and blood vessel perforations.
4.
Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication.
5.
Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair).
In summary, transvaginal mesh procedures that are currently in use utilize predominantly synthetic materials. These devices may reduce recurrence of pelvic organ prolapse and are associated with some risk of vaginal mesh extrusion and chronic pain or dyspareunia. Patients should be counseled extensively about the risks and benefits of the use of these devices. Surgeons who use these devices should carefully follow their cases to identify complications.
Abdominal uterosacral colposuspension has been used prophylactically after hysterectomy and therapeutically for apical prolapse with cardinal/uterosacral defects (115). It can be performed through laparotomy incisions or by laparoscopic techniques. For the therapeutic procedure, a no. 1 polypropylene or delayed absorbable suture is placed cephalad and at the same level posterior as the ischial spines, which may be palpated transabdominally or with a vaginal finger to push a vaginal fornix to the spine under observation with a laparoscope. One technique is to place one or two permanent sutures through one ligament, then, after reefing across the culde-sac peritoneum at the sigmoid border, through the contralateral ligament, and then through the fibromuscular tissue just anterior to the vaginal cuff. Tying the suture suspends the vaginal cuff and obliterates any enterocele defect. Another technique employs separate sutures placed at the same level into each uterosacral ligament and anchored anteriorly and posteriorly to the ipsilateral side of the vaginal cuff, similar to procedures performed transvaginally. Cystoscopy is performed after the procedure to document ureteral patency. One study found subjective and objective recurrence rates to be low (12% and 5%, respectively) (115).
Abdominal Approach to Posterior Repair