Outcome of Transobturator Anterior Vaginal Wall Prolapse Repair

ARTICLE INFO _________________________________________________________ ___________________ Vol. 39 (4): 506-512, July August, 2013 doi: 10.1590/S1677-5538.IBJU.2013.04.08 IBJU | OUTCOME OF TRANSOBTURATOR ANTERIOR VAGINAL WALL PROLAPSE REPAIR 507 (4). During traditional colporrhaphy, the laterally placed pubocervical fascia is medially plicated; however, this technique is thought to potentially lead to vaginal shortening and narrowing (5). Additionally, 70 to 80% of AVWP cases may have a concomitant lateral defect (6) in which case the sole plication of the pubocervical fascia is not a viable option. Consequently, given these limitations for anterior colporrhaphy, graft augmented repair has gained interest within the field of female pelvic reconstructive surgery. The purpose behind the use of these grafts is to obtain more durable and efficient prolapse repair while preserving sexual function without negative impacts on vaginal length and/or caliber. Many subtypes of grafts have been developed including autologous grafts, allografts, xenografts, and synthetic grafts. Polypropylene synthetic grafts are associated with significant host tissue reaction with a reported incidence of extrusion of up to 45%. Newer light-weight polypropylene grafts have lower rates of graft erosion ranging from 5-15% (7). In order to obtain a satisfactory outcome with the use of xenografts, the graft should be biocompatible, strong, durable, resistant to infection and facilitate host tissue in-growth (8). In 2004, Zheng et al. compared porcine dermis with polypropelene grafts in the repair of full thickness abdominal wall defects in rats. They found decreased adhesion formation and milder inflammatory response with porcine dermis compared with polypropylene grafts (9). The relative safety of biological versus synthetic grafts was further supported by a recent randomized controlled trial (10). Limited data is available regarding anatomical success associated with the use of biological grafts. Porcine dermis for AVWP repair has been recently used with variable outcomes. In most of the reported studies, the graft was secured laterally with delayed absorbable sutures (5-6,11). After gaining popularity as a mode of sling fixation, the transobturator approach was also employed in graft augmented AVWP repairs. The first publication of the use of transobturator four-arm biologic graft in AVWP repair was by Eglin in 2003 (12). We recently reported high short term success with a porcine dermis graft placed via a transobturator approach using the Perigee® kit with InteXene® (American Medical Systems, Minnetonka, MN, USA) (13). The long term anatomic success rate using this type of graft in prolapse repair is still not well known. In this study, we present our intermediate term follow-up of AVWP repair using porcine dermis graft through the transobturator approach in an expanded patient population. MATERIALS AND METHODS After obtaining Institutional Review Board approval, the charts of patients who underwent AVWP repair using the Perigee® with the biocompatible porcine dermis graft (InteXen®) within the Sections of Urogynecology and Pelvic Reconstructive Surgery and Female Urology at the study institution were reviewed. Only patients who completed at least 6-month follow-up were included. All patents had routine preoperative assessment with history, physical exam, and multichannel urodynamics (UDS). UDS were performed with and without prolapse reduction in order to assess for possible occult stress urinary incontinence (2). POP was staged using the POP-Q system in all cases. Cases involving hematuria, lower urinary tract storage symptoms (i.e. urgency, frequency and/or urge incontinence), history of lower urinary tract pathology or intrinsic sphincter deficiency underwent cystoscopy pre-operatively. Topical vaginal estrogen cream was used preoperatively in all patients with urogenital atrophy. AVWP repairs were performed using the Perigee® kit with InteXen®. The technique was previously described (13). In brief, a 16 Fr Foley’s catheter is inserted into the bladder. After infiltration of local anesthesia, an anterior vaginal wall incision is performed from the bladder neck to approximately 2-3 cm to the vaginal apex. Dissection is extended laterally to the lateral vaginal sulcus until the ischial spine and arcus tendineous fascia pelvis are easily palpable bilaterally. The skin puncture sites for the graft introducers are marked. The upper skin punctures are made at the medial border of the obturator foramen at the level of the clitoris and approximately 1.5 cm below the insertion of the adductor longus tendon. The two lower punctures are 3 cm inferior and 2 IBJU | OUTCOME OF TRANSOBTURATOR ANTERIOR VAGINAL WALL PROLAPSE REPAIR 508 cm lateral to the upper ones. The trocar is guided through the obturator membrane and through the paravesical space and is externalized through the vaginal incision on both sides along the arcus tendineus as close as possible to the ischial spine. At this point, cystoscopy is performed to exclude bladder or urethral injury and to assure ureteral patency. The Perigee® arms are then connected to the trocars and brought out through the skin incisions. The InteXen® mesh is then trimmed, its arms’ tensioned loosely, and the graft is secured to the underlying connective tissue using absorbable sutures. The vaginal mucosa is closed, a final mesh adjustment performed, the plastic sleeves of the mesh arms are removed, and the arms are cut flush with the skin. The skin incisions are closed using Dermabond® surgical glue (Ethicon, Somerville, NJ). Vaginal packing and a Foley catheter are left in place for 24 hours postoperatively. If a concomitant suburethral sling is indicated, the sling procedure is performed secondarily through a separate incision. Pre and postoperative management were standardized for all patients. All patients received Figure 1 Flow chart delineates the number of patients recruited. appropriate preoperative antibiotic prophylaxis and were observed in the hospital for at least 24 hours postoperatively. Patients were followed at 2 and 6 weeks, and then 6, 12 and 18 months and yearly thereafter. The 2 week post-operative visit included only brief history, and vaginal examination with POP-Q was performed at the 6-week visit and all subsequent visits.