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Pelvic Prolapse in Urology

Vaginal mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft in 138 women: a comparative study.
Deffieux X, de Tayrac R, Huel C, Bottero J, Gervaise A, Bonnet K, Frydman R, Fernandez H
Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan 4;:1-7.

The objective of this study was to compare mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft mesh. We retrospectively analyzed 138 consecutive cases of transvaginal repair of cystocele using synthetic mesh. The study endpoint was the pathological evidence of vaginal erosion. Multiple logistic regression was used to determine independent predictors of vaginal erosion. One hundred and thirty eight women (ages 30-83 years) with cystocele between October 1999 and October 2004, from a French University Hospital, participated in this study. Cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. The median follow-up was 32.1 months (range 7.5-59.9) in the Gynemesh group and 7.1 months (range 1-21.9) in the Gynemesh-Soft group. Vaginal erosion was reported in 27 (20%) of the patients. Anatomically, the success rate was 95% (131/138). There was no statistically significant difference between the Gynemesh and the Gynemesh-Soft meshes [the rate of vaginal erosion of the mesh was 16% (15/89) vs 24% (12/49), respectively, p=0.39]. Univariate analysis only identified age class as factor significantly associated with the probability of vaginal erosion. Multivariate analysis revealed that age class is an independent predictive factor of vaginal erosion (age > 70 years, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3-9.7, p=0.010). Furthermore cystocele stage > 2 (Baden and Walker classification) is a protective factor against vaginal erosion (OR 0.3, 95% CI 0.1-0.8, p=0.016). Thirteen symptomatic patients (13/27, 48%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. Two patients (2/27, 7%) underwent a complete excision of the mesh. The incidence of de novo dyspareunia was 9% in patients with vaginal erosion and 11% in patient without mesh erosion (p=0.85). There was no occurrence of bladder or urethral erosion and no vaginal or pelvic infection. Isolated vaginal erosion of the mesh did not prove to be problematic. Gynemesh-Soft mesh does not decrease the incidence of vaginal erosion. Age > 70 years is an independent predictive factor of vaginal erosion. We recommend that mesh placement by vaginal route should be avoided by women with moderate cystocele. Where possible, total hysterectomy and vertical incision should also be avoided. Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur. A multivariate analysis reveals that the incidence of vaginal erosion is not significantly different between Gynemesh and Gynemesh-Soft meshes. Other factors of erosion are analyzed.

Long-term anatomical and functional assessment of trans-vaginal cystocele repair using a tension-free polypropylene mesh.
de Tayrac R, Deffieux X, Gervaise A, Chauveaud-Lambling A, Fernandez H
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 17;:1-6.

We report a case series of 63 women with cystocele who underwent the same trans-vaginal procedure between October 1999 and October 2002. The polypropylene mesh (GyneMesh, Gynecare, Ethicon, France) was placed from the retropubic space to the inferior part of the bladder in a tension-free fashion. Patients were followed up for 24 to 60 months, with a mean follow-up of 37 months. Fifty-five patients returned for follow-up (87.3%). At follow-up, 49 women were anatomically cured (89.1%), five women had stage 2 anterior vaginal wall prolapse (9.1%), and one had a recurrent stage 3 (1.8%). Functional results and sexual function were also investigated. Fifty-three women had significant improvement in their quality of life (96.4%). There were a total of three cases of local pain around a mesh shrinkage (5.5%) and five vaginal erosions of the mesh (9.1%). Four out of 24 patients had dyspareunia (16.7%). In conclusion, the vaginal repair of anterior vaginal wall prolapse reinforced with a polypropylene mesh was efficient at 2 to 5 years follow-up. However, the first generation of polypropylene mesh we used was responsible for high rates of local complications and dyspareunia. Therefore, the polypropylene mesh has to be improved (lower weight) and the technique has to be documented by a randomized controlled trial before we could recommend its use in clinical practice.

Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: report of early results, outcomes, and patient satisfaction with a new technique.
Rodriguez LV, Bukkapatnam R, Shah SM, Raz S
Urology 2005 Nov;66(5 Suppl):57-65.

Baden-Walker classification grade III-IV (pelvic organ prolapse quantification [POP-Q] system stage III-IV) cystocele is associated with a constellation of abnormalities including urethral hypermobility, lateral defect, central defect, and concomitant vault and posterior wall prolapse. We describe a new transvaginal paravaginal technique to correct this group of abnormalities and report on our early results. We prospectively evaluated patients with high-grade cystocele who underwent repair with the new transvaginal paravaginal repair. Preoperative evaluation included history and physical examination, dynamic pelvic magnetic resonance imaging, urodynamics, and symptom questionnaire. All patients first underwent a distal urethral polypropylene sling surgery. After repair of the central defect of the cystocele, a paravaginal repair of the lateral defect was performed by using a circular 5 cm x 5 cm soft polypropylene mesh attached proximally to the sacrouterine/cardinal ligament, distally to the bladder neck, and laterally to the infralevator obturator fascia. Postoperative evaluation at 3-month intervals included history and physical examination using the POP-Q system, a voiding dysfunction and incontinence symptom questionnaire, the validated short form of the Urogenital Distress Inventory (UDI-6), a validated global quality-of-life question, and a postvoid residual. We performed the repair in 98 patients with a mean age of 65 years (range, 40 to 86 years). Of these, 26% underwent concomitant vaginal hysterectomy, 45% had enterocele repair, and 94% had rectocele repair. There were 2 complications, including transient ureteral obstruction due to bladder wall hematoma and 1 patient who presented with a recurrent enterocele requiring surgical repair. No patient experienced urinary retention. De novo stress urinary incontinence was seen in 3 patients; de novo urge incontinence was seen in 2 patients. Postoperative POP-Q scores showed 85% of patients with stage 0-I, 13% with stage II, and 2% with stage III anterior vaginal wall prolapse. Of patients with preoperative stress urinary incontinence, 70% reported never experiencing symptoms under any circumstances. Quality of life improved from 4.7 to 1 (P < 0.005). Transvaginal paravaginal repair of grade III-IV cystocele using soft polypropylene mesh fixed to the obturator fascia, sacrouterine ligaments, and bladder neck area provides excellent support of the central defect repair as well as repair of the lateral defect. The operation is safe, simple, and outpatient based, and provides excellent anatomic results with minimal complications. Concomitant distal polypropylene sling did not increase the rate of complications and did not compromise results of stress urinary incontinence surgery.

[Factors for voiding dysfunction and cystocele]

Salinas Casado J, Adot Zurbano JM, Dambros M, Virseda Chamorro M, Ramirez Fernandez JC, Moreno Sierra J, Marcos Diaz J, Silmi Moyano A
Arch Esp Urol 2005 May;58(4):316-23.

OBJECTIVES: To evaluate the clinical and urodynamic features of a series of women with post void residual urine (disbalanced voiding) and various degrees of associated cystocele. METHODS: 119 female patients were studied by clinical evaluation, urodynamics, and imaging tests (VCUG). All patients underwent history and genitourological examination (evaluating cystoceles from grade o to 3), neuro-urological examination, and complete urodynamic study. Fifty patients (42%) underwent radiological studies of the upper urinary tract. Disbalanced voiding was defined as existence of post void residual greater than 20% of the voided volume. Urethral resistance was measured by URA. Structural obstruction was characterized by PURR (CHESS classification). Functional obstruction was studied by DURR and perineal EMG (associated with flowmetry). Detrusor contractile power was evaluated by W max, W 80-20, and duration of contraction. Urodynamic terminology and measurements complied with the International Continence Society (ICS) standards. Statistical significance was established at 0.05. Statistical analysis was done by Student's t for quantitative variables, and Pearson's chi-square for non parametric variables. RESULTS: 119 patients were enrolled. Mean age was 55.84 yr. (range 15-87). Regarding post void residual (114 valid uroflowmetry studies), 25 patients were classified as voiding disbalance (21.9%) and 89 as balanced (74.8%). Regarding clinical data, there were only significant differences between groups in voiding difficulty. For uroflowmetry, only the percentile of the Maximal flow (Qmax) showed significant differences (35 vs. 22 for balanced/disbalanced voiding respectively, p = 0.02). Pressure/volume studies demonstrated bladder hyperactivity in 16 cases (64%) in the group of disbalanced voiding and 31 cases (34.8%) in the normal voiding group (p = 0.008), which presented associated with increased urethral resistance (URA)(p = 0.01) . In the pressure/flow study, there were significant differences in the URA (14.7 vs. 25.3, p = 0.001). There were statistically significant differences in the degree of constrictive (0.5 vs. 1.1, p = 0.009) and compressive (0.5 vs. 1.1; p = 0.04) obstruction (Chess classification). There were not significant differences in the analysis of isometric contractility (Wmax), but there were in the isotonic contractility (W80-20) and detrusor contraction duration. These latter differences presented significant association with the degree of cystocele. DURR and perineal EMG data did not show differences between groups. Radiological abnormalities of urethral morphology were statistically different between groups, presenting in 10% of the patients with normal voiding and 50% of the disbalanced voiding group, although there was not statistical association with obstruction (p = 0.64). The existence of cystocele did not show a statistical association with these variables either. CONCLUSIONS: Disbalanced voiding appeared with organic obstruction of the lower urinary tract (constrictive most significantly), as well as detrusor abnormal contractility, but whereas the first was not significantly associated with presence and grade of cystocele, the second showed such association.

[Filling phase abnomalities and cystocele]
Adot Zurbano JM, Salinas Casado J, Dambros M, Virseda Chamorro M, Moreno Sierra J, Ramirez Fernandez JC, Silmi Moyano A, Diaz JM
Arch Esp Urol 2005 May;58(4):309-15.

OBJECTIVES: To evaluate the clinical and urodynamic characteristics of a series of women with lower urinary tract symptoms (bladder filling phase) presenting various rates of cystocele. METHODS: 119 female patients were included in this study; mean age was 55.8 yr. (range 15-87). All patients underwent urogynecologic physical examination (cystocele was graded 0-3) and complete urodynamic study. Urodynamic terminology and measurements comply with the ICS (InternationaL Continence Society) standards. Statistical significance was established below 0.05. Quantitative variables were compared by the Student's t and non parametric variables by Pearson's chi-square. RESULTS: The most frequently reported symptom was urinary incontinence when coughing (77/118, 65.3%), followed by urge incontinence (71 patients, 60.2%). The grade of cystocele was 0 in 31.1%, 1 in 25.2%, and 2 in 26.1%, and 3 in 17.6%. There was a statistically significant association between grade of cystocele and the symptom "vaginal bulge" (p=0.00002). The presence of cystocele did not show any statistical association with lower urinary tract symptoms of the filling phase. Mean cystomanometric bladder capacity was 224.8 ml. Involuntary contractions of the detrusor muscle appeared in 38 cases (21.9%), stress urinary incontinence in 19 (16%), mixed incontinence in 8 (6.7%) and absence of evidence of urinary incontinence in 58 (48.7%). Patients with urgency had a lower bladder capacity than patients without it (p = 0.02), as did patients with urge incontinence (p = 0.02). Nocturia (p = 0.05), urgency (p = 0.02) and urge incontinence (p = 0.01) were significantly associated to bladder capacity. The existence of involuntary contractions was statistically associated with urge incontinence (p = 0.01). Patients with involuntary contractions during the filling phase showed increased diurnal voiding frequency (p = 0.02), as well as patients without a stress urinary incontinence (p = 0.04) and cases without a stress urinary incontinence (p = 0.04). The symptom incontinence with coughing had a significant statistical association with the urodynamic diagnosis of stress urinary incontinence (p= 0.01). Bladder capacity was augmented in grade 3 cystocele (p = 0.003). The existence of cystocele was not associated with bladder hyperactivity (p = 0.65), neither was the diagnosis of a stress urinary incontinence (p = 0.37). CONCLUSIONS: No relationship has been demonstrated between existence and degree of cystocele and functional lower urinary tract symptoms of the filling phase, on the one hand, and urodynamic evidence of bladder hyperactivity and incontinence on the other hand. This could have important therapeutic implications.

Vaginal mullerian cyst presenting as a cystocele.
Montella JM
Obstet Gynecol 2005 May;105(5):1182-4.

BACKGROUND: Vaginal cysts occur rarely, are usually discovered incidentally on examination, and can cause a variety of symptoms. CASE: This article discusses a 34-year-old para 2 female with a large anterior vaginal wall cyst that arose at 20 weeks' gestation and was originally diagnosed as a cystocele. The unusual timing of its occurrence and the characteristics of the anterior vaginal wall prompted ancillary testing and reexamination. CONCLUSION: The timing of onset and general characteristics of prolapse as well as defecography and magnetic resonance imaging can be used to aid the gynecologist in diagnosing vaginal cysts instead of the more common condition of vaginal prolapse.

Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse.

de Tayrac R, Gervaise A, Chauveaud A, Fernandez H
J Reprod Med 2005 Feb;50(2):75-80.

OBJECTIVE: To study the ongoing results of the repair of anterior vaginal wall prolapse reinforced with tension-free polypropylene mesh (GyneMesh, Gynecare, Ethicon, Issy-Les-Moulineaux, France). STUDY DESIGN: A case series of 87 consecutive women with anterior vaginal wall prolapse who underwent a transvaginal procedure using polypropylene mesh between October 1999 and August 2002. The mean age (+/-SD) was 62.4+/-13.4 years. Before the operation, patients underwent physical examination staging of the prolapse with the International Pelvic Organ Prolapse staging system. Thirteen women had stage 2 anterior vaginal wall prolapse (14.9%), 59 had stage 3 (67.9%), and 15 had stage 4 (17.3%). The polypropylene mesh was placed from the retropubic space to the inferior part of the bladder in a tension-freefashion. Patients were followed for 9-43 months, with a median follow-up (+/-SD) of 24+/-9.6 months. We defined "cure" as satisfactory (stage 1) or optimal (stage 0) outcome for point Ba in the staging system. RESULTS: Eighty-four patients returned for follow-up (96.6%). At follow-up, 77 women were cured (91.6%), 5 women had asymptomatic stage 2 anterior vaginal wall prolapse, and 2 had a recurrent stage 3 (2.4%). There were no postoperative infections. There were a total of 7 vaginal erosions of the mesh (8.3%); 4 necessitated a second procedure for partial excision of the mesh. CONCLUSION: Vaginal repair of anterior vaginal wall prolapse reinforced with tension-free polypropylene mesh is effective and relatively safe. Vaginal erosion occurred in 8.3% of the study population but was easily manageable, with no sequelae.

Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh.
Hung MJ, Liu FS, Shen PS, Chen GD, Lin LY, Ho ES
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):399-406; discussion 406. Epub 2004 Jun 2.

The purpose of this study was to evaluate the effectiveness of the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh in patients with severe (stage III or IV) anterior vaginal prolapse. Thirty-eight consecutive women were enlisted for this prospective study. The procedure consisted of an extensive vaginal dissection to join the vesicovaginal and retropubic space and an anchoring of a polypropylene mesh patch between the two Arcus Tendineus Fasciae Pelvis in a tension-free manner. The mean age of the study group was 63 (33-80) years. The success rate was 87% (33/38) at a mean follow-up interval of 21 (12-29) months. A total of eight (100%) patients were also cured of concomitant stress incontinence (five overt and three occult type) with an additional tension-free vaginal tape (TVT) operation. During follow-up, there were five de-novo stress incontinence cases (16.7%) and four vaginal erosions of mesh (10.5%). Four clinical variables--diabetes mellitus, recurrent anterior vaginal prolapse, chronic cough and vaginal erosions of mesh--were found to have a significant correlation with an unsatisfactory surgical result with large values of hazard ratios found by survival analysis. We concluded that the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh was effective for most, but failed in some patients who had specific risk factors within short convalescence periods. Concomitant stress incontinence can be successfully treated by a TVT operation in combination with the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. However, the anterior colporrhaphy procedure may itself have adverse effects on urethral sphincter function.