Mesh‐free anterior vaginal wall repair: history or best practice?

Abstract

Key content Surgical correction of anterior vaginal wall prolapse is a common gynaecological procedure, with traditional anterior colporrhaphy changing little over the past 100 years. Within the literature, terminology is confusing, both on anatomical structures and classification of anterior vaginal wall prolapse. Synthetic meshes have become available but the evidence to support their use is limited and long‐term adverse effects are not clear. The paravaginal repair is an alternative to consider and can be approached vaginally, abdominally or laparoscopically. Learning objectives To revise the relevant anatomy of the anterior vaginal compartment and the classification of anterior vaginal wall prolapse. To review the evidence for the use of permanent mesh in pelvic floor surgery. To learn about the surgical options for correction of anterior vaginal wall prolapse without the use of vaginal mesh. Ethical issues Should permanent meshes be used for anterior vaginal wall prolapse outside a clinical research setting? Please cite this article as: McCracken GR, Lefebvre G. Mesh‐free anterior vaginal wall repair: history or best practice? The Obstetrician & Gynaecologist 2007;9:233–242.

The role of synthetic mesh in the treatment of pelvic organ prolapse

“…With better understanding of the pelvic anatomy and improvement in surgical techniques, better targeted prolapse repair techniques without the use of mesh may become more popular. We would like to refer the readers to the article by McCracken and Lefebvre 65 published recently in this journal. Before new techniques are introduced widely, well‐designed trials to determine success rates and outcomes are needed.…”

The Use of Tutomesh for a Tension-Free and Tridimensional Repair of Uterovaginal and Vaginal Vault Prolapse: Preliminary Report

“…In general, for elderly patients whose health status precludes prolonged surgery, an obliterative repair closing vagina and affording symptom relief with minimal morbidity is preferred (colpocleisis) while, for those patients with discrete defects in the endopelvic fascia without ongoing risk factors for recurrence, a restorative procedure accomplished by a vaginal approach is rather favored (sacrospinous ligament suspension or iliococcygeus fascial suspension or uterosacral ligament suspension in variable combination with anterior colporrhaphy or paravaginal repair and posterior colporrhaphy). In other circumstances the native tissue repair however is insufficient and a compensatory operation using grafts materials (meshes) became a more reasonable option (abdominal or laparoscopic sacral colpopexy or anterior and posterior total vaginal wall mesh replacement or infracoccygeal IVS sling colpopexy) [ 1 – 3 , 5 – 7 ]. Nonetheless, graft materials, particularly when used by a vaginal approach, may shrink after placement (mesh erosion) or lead to loss of pelvic floor flexibility (dyspareunia) or be site of late infections [ 24 , 25 ].…”

“…Tears in the endopelvic fascia can also cause stretch injury to the innervation of the muscular support. The insertion of the cardinal/uterosacral ligaments into the pericervical ring occurs at the level of the ischial spines and it is the detachment at this level that provides the anatomic rationale for development of posthysterectomy vaginal descent and enterocele (apical prolapse) [ 7 , 8 ]. Surgery is limited to correction of connective tissue tears or breaks and overcorrection needs to be avoided because it can lead to new support problems.…”

The Comparison of Outcomes of Transvaginal Mesh Surgery with and without Midline Fascial Plication for the Treatment of Anterior Vaginal Prolapse: A Randomized Controlled Trial

“…Regarding the midline plication procedure [ 20 ], the vaginal wall was incised vertically, and the muscularis (pubocervical fascia) was dissected from the vaginal epithelium. Then, the vaginal muscularis was plicated with 2-0 vicryl using an interrupted manner.…”