1. Surgical Repair of Anterior Vaginal Wall Prolapse; When, Why, and How I Place Vaginal Mesh Mickey Karram MD Director of Urogynecology The Christ Hospital Professor of Ob/Gyn & Urology University of Cincinnati Cincinnati, Ohio U.S.A

2. Objectives Discuss the anatomy of the anterior vaginal wall, retropubic space, and inner groin Discuss the anatomy of the anterior vaginal wall, retropubic space, and inner groin Review clinical presentation and preoperative evaluation of a patient with symptomatic cystocele Review clinical presentation and preoperative evaluation of a patient with symptomatic cystocele Discuss surgical dissection plans and various techniques to transvaginally repair anterior vaginal wall prolapse with and without mesh Discuss surgical dissection plans and various techniques to transvaginally repair anterior vaginal wall prolapse with and without mesh Review outcomes of suture repairs vs mesh augmented repairs Review outcomes of suture repairs vs mesh augmented repairs

3. Cystocele Ahlfelt states that the only problem in plastic gynecology left unsolved by the gynecologist of the past century is the permanent cure of cystocele George R. White 1909

5. Specific Surgical Goals: Maintain or Create a Well Supported Functional Vagina What is normal vaginal length? What is normal vaginal length? What is normal vaginal caliber? What is normal vaginal caliber? What is normal relationship between perineum and posterior vaginal wall? What is normal relationship between perineum and posterior vaginal wall? What is normal vaginal axis? What is normal vaginal axis? What is the most important aspect of your repair? What is the most important aspect of your repair? How do you determine who needs an augmented repair? How do you determine who needs an augmented repair?

6. Types of Anterior Vaginal Wall Prolapse True cystocele (distention cystocele) True cystocele (distention cystocele) Displacement cystocele Displacement cystocele

7. Etiology of Cystocele Separation of paravaginal attachment of the pubocervical fascia from the white line Separation of paravaginal attachment of the pubocervical fascia from the white line Loss of vagina’s attachment to the cervix Loss of vagina’s attachment to the cervix Tearing of pubocervical fascia that results in herniation of the bladder through this layer Tearing of pubocervical fascia that results in herniation of the bladder through this layer

8. Anterior Vaginal Prolapse “Pubocervical fascia is really vaginal muscularis and adventitia.” Weber And Walters (Obstet Gynecol 1997;89:311-8)

23. Ischiopubic Ramus Ischium Pubic symphysis Ilium Obturator Foramen Obturator Canal

24. Transobturator Landmarks Obturator canal Urethra Safe entry zone of Transobturator needle Adductor longus

29. Vaginal Repair of Enterocele

32. Anatomy of Anterior Vagina

33. How Does a Patient with Anterior Vaginal Wall Prolapse Present Completely asymptomatic Completely asymptomatic Typical symptoms of prolapse with no functional derangements Typical symptoms of prolapse with no functional derangements A variety of functional rerangements without prolapse symptoms A variety of functional rerangements without prolapse symptoms Combination of prolapse symptoms and functional derangements Combination of prolapse symptoms and functional derangements Rarely presents in complete isolation Rarely presents in complete isolation

34. Pre-operative Evaluation History History Good physical exam Good physical exam Objective assessment of lower urinary tract function Objective assessment of lower urinary tract function Cystourethroscopy Cystourethroscopy Imaging studies Imaging studies

35. Anterior and Posterior Vaginal Wall Prolapse Extent of dissection for cystocele repair (lateral to inferior pubic ramus and dissection of bladder base off of vaginal cuff) Extent of dissection for cystocele repair (lateral to inferior pubic ramus and dissection of bladder base off of vaginal cuff) Extent of dissection for rectocele repair (lateral to rectal gutter and proximally to preperitoneal space of cul-de-sac) Extent of dissection for rectocele repair (lateral to rectal gutter and proximally to preperitoneal space of cul-de-sac)

36. Surgical Repair of Cystocele Vaginal approaches (anterior colporrhaphy with vesical neck plication) Vaginal approaches (anterior colporrhaphy with vesical neck plication) Abdominal approaches Abdominal approaches Vaginal paravaginal repairs Vaginal paravaginal repairs Mesh augmented repairs Mesh augmented repairs – Mesh overlay – Trocar based mesh kit – Direct access mesh kit

55. Anterior Vaginal Wall Dissection

66. Next Generation: Elevate Anterior Four point fixation system Four point fixation system – Obturator internus muscle and sacrospinous ligament fixation Only one anterior incision Only one anterior incision – Provides both anterior and apical support

68. Direct Access Mesh Augmentation

69. Native Tissue vs. Polypropylene Mesh

70. Objective Failure

71. Anterior colporrhaphy vs. Polypropylene mesh overlay Anterior colporrhaphy vs. Armed transobturator Polypropylene mesh Objective Failure

72. Anterior Colporrhaphy (Ac) Alone Vs. Ac Plus Polypropylene Mesh Anterior Colporrhaphy (AC) Vs. Polypropylene Mesh without AC Objective Failure

73. Anterior colporrhaphy vs. Armed Transobturator Mesh PFIQ-7 PQOL Post-op Quality of Life

74. Mesh Erosion Mean = 10.2% (30/293)

75. Native Tissue Repair vs. Mesh Repair De novo Dyspareunia

76. Anterior colporrhaphy Vs. Armed Transobturator Mesh De novo Stress Urinary Incontinence

77. One study reported a subjective success rate which was similar in both groups (Nieminen 2008) One study reported a subjective success rate which was similar in both groups (Nieminen 2008) Blood loss at transobturator meshes was significantly higher compared to anterior colporrhaphy, reported as blood loss in ml (Nieminen 2008) or Hb change (Nguyen 2008) Blood loss at transobturator meshes was significantly higher compared to anterior colporrhaphy, reported as blood loss in ml (Nieminen 2008) or Hb change (Nguyen 2008)

78. Anterior (Prolift ™ ) for Recurrent Cystocele Two year review 36 women Two year review 36 women Recurrent ant wall prolapse Recurrent ant wall prolapse Success rate 53% Success rate 53% Mesh erosion rate 19% Mesh erosion rate 19% De novo dyspareunia 7/16 43% De novo dyspareunia 7/16 43% Fayyad et al 2010 Fayyad et al 2010

79. Self Styled Mesh vs Anterior Colporrhaphy Three Year Outcome Recurrent anterior Recurrent anterior Objective 14/105 (13%) vs 40/97 (41%) Objective 14/105 (13%) vs 40/97 (41%) Subjective 10% vs 18% (.07) Subjective 10% vs 18% (.07) No difference sexual outcome or quality of life No difference sexual outcome or quality of life Re-operation POP & SUI 11% vs 18% Re-operation POP & SUI 11% vs 18% Mesh erosion 19%: 70% surgery Mesh erosion 19%: 70% surgery Nieminen et al 2010

80. Stress Urinary Incontinence (SUI) Following Prolapse Surgery Meta-analysis 9 trials, 723 women Meta-analysis 9 trials, 723 women Continence procedures employed: Continence procedures employed: – Pubourethral ligament plication – Needle suspension – Colposuspension – Suburethral tapes

81. Prolapse Surgery Without vs. With Continence Surgery

82. The benefit remained (RR 5.45 95% CI 1.8, 16.53) even if data from the ‘CARE’ trial was removed The benefit remained (RR 5.45 95% CI 1.8, 16.53) even if data from the ‘CARE’ trial was removed Performing continence surgery in 94 women with occult SUI prevented 19 (20%) women developing SUI post- operatively Performing continence surgery in 94 women with occult SUI prevented 19 (20%) women developing SUI post- operatively De novo SUI in Women with Pre-operative Occult Stress Incontinence

83. 15%12%

84. Ant Colporrhaphy vs Transvaginal Mesh Altman et al; N Engl J Med 2011; 364:1826- 36 389 patients randomized 389 patients randomized 53 participating hospitals 53 participating hospitals 1 yr anatomic outcome noted 60.8% in mesh group vs 34.5% in AC group 1 yr anatomic outcome noted 60.8% in mesh group vs 34.5% in AC group Higher complication rate in mesh group and higher de novo development of SUI Higher complication rate in mesh group and higher de novo development of SUI

85. Synthetic mesh at anterior repair: ↓ recurrent cystocele on examination Synthetic mesh at anterior repair: ↓ recurrent cystocele on examination This benefit was not translated to a significant difference in patient determined outcomes or re-operation rates for prolapse or incontinence This benefit was not translated to a significant difference in patient determined outcomes or re-operation rates for prolapse or incontinence

86. Conclusions POP + continence Symptom: POP + continence Symptom: –  overall post-op SUI (9 trials) –  post-op de novo SUI (6 trials) –  post-op de novo SUI in women with pre- op occult SUI (4 trials) –  post-op De-novo SUI in women without pre-op symptomatic or occult SUI (1 trial) Adequately powered RCT’s are urgently needed on a wide variety of topics Adequately powered RCT’s are urgently needed on a wide variety of topics

87. How I Manage Anterior Vaginal Wall Prolapse In 2011 Most primary repairs are native tissue suture repairs Most primary repairs are native tissue suture repairs Consider mesh augmentation for massive prolapse recurrent AVW prolapse or AVW prolapse in conjunction with a foreshortened vagina Consider mesh augmentation for massive prolapse recurrent AVW prolapse or AVW prolapse in conjunction with a foreshortened vagina