Sydney Pelvic Floor Health

Prolapse Audit

Traditional prolapse surgery

The reconstructive result after traditional anterior or posterior repair is often disappointing, especially in women with marked levator ballooning and/ or avulsion defects. It seems unrealistic to expect longterm success from a vaginal hysterectomy and repairs in a woman with marked levator impairment- she is very likely to return with recurrent prolapse within a few years, as the underlying problem has not been addressed. Figure 1 shows mathematical modelling of the risk of cystocele recurrence on average 2.5 years after an Anterior Colporrhaphy +/- mesh. It is evident that someone with avulsion and severe ballooning has a recurrence risk of over 80%.

In women with avulsion an anterior repair is highly unlikely to be successful unless augmented with transobturator mesh implants, and even then one would expect recurrence rates in the order of 30-50% as shown in Figure 1. However, in some instances a repair using the patient’s own tissues can be very effective. The best example I know of is a defect- specific rectocele repair. Defects of the rectovaginal septum can be identified on ultrasound (see the chapter on anorectal imaging), and surgical closure of such defects often is very obvious on postoperative imaging (see Figure 2). It is not clear whether a defect- specific repair is possible for the anterior and central compartments. To date there is no solid data proving the concept. Own experience suggests that paravaginal repairs, unless the surgeon performs a procedure that resembles a colposuspension, are unlikely to be successful.

Transobturator/ Pararectal mesh repair

In the past, the main problem with mesh techniques has always been fixation, especially for cystocele. Trans-obturator mesh developed by Rane and Frazer in 2004 provides for anchoring of mesh by extensions that are placed through the obturator foramen (Perigee TM, Anterior Prolift TM). These meshes have been shown to reduce cystocele recurrence (Altman et al., 2011) and may be particularly useful in women with levator avulsion injuries who seem much more prone to recurrence after anterior repair (Wong et al., 2011). Less commonly used are pararectal posterior mesh techniques (Posterior Prolift TM, Apogee TM etc), and there is no evidence that they are superior to traditional repair.

Pelvic floor ultrasound is a very useful method in auditing transobturator mesh repair for large and/or recurrent cystocele. These implants are clearly visible as linear hyperechogenic structures (see Figure 3), although the cranial aspects of a well supported mesh can be obscured by acoustic shadowing arising from a full rectum or a rectocele. Rendering can be used to visualise large parts of both mesh and anchoring arms (Figure 3). Dislodgment of such anchoring arms or lateral plastic anchors (as in the Anterior Elevate TM) is not that uncommon, and of course meshes oftena are highly mobile (and quite useless) if they are not anchored at all. In a retrospective series of 296 patients, we observed a failure of mesh fixation in 38% of patients at a mean of 1.8 years after Anterior Colporrhaphy with mesh. Most were global failures (dislodgment of all anchoring structures) or apical failures, implying dislodgment of lateral and/or apical anchors or fixation, see Video 3). A small minority were anterior failures, implying dislodgment of the mesh from the bladder base, likely due to suboptimal surgical technique (Video 4). Global and apical failures seem associated with hiatal ballooning (see levator biometry) and levator avulsion. Figure 4 shows a comparison of the three forms of cystocele recurrence after mesh.

It is plausible that a larger hiatus subjects anchoring structures to greater loads, increasing recurrence risk. This suggests that in such women, the currently used anchoring techniques are insuffciciently load- resistant and need to be re-engineered. Clearly, ultrasound will have a major role to play in assessing and optimising these new surgical techniques.

n the past, the main problem with mesh techniques has always been fixation, especially for cystocele. Trans-obturator mesh developed by Rane and Frazer in 2004 provides for anchoring of mesh by extensions that are placed through the obturator foramen (Perigee TM, Anterior Prolift TM). These meshes have been shown to reduce cystocele recurrence (Altman et al., 2011) and may be particularly useful in women with levator avulsion injuries who seem much more prone to recurrence after anterior repair (Wong et al., 2011). Less commonly used are pararectal posterior mesh techniques (Posterior Prolift TM, Apogee TM etc), and there is no evidence that they are superior to traditional repair.

Pelvic floor ultrasound is a very useful method in auditing transobturator mesh repair for large and/or recurrent cystocele. These implants are clearly visible as linear hyperechogenic structures (see Figure 3), although the cranial aspects of a well supported mesh can be obscured by acoustic shadowing arising from a full rectum or a rectocele. Rendering can be used to visualise large parts of both mesh and anchoring arms (Figure 3). Dislodgment of such anchoring arms or lateral plastic anchors (as in the Anterior Elevate TM) is not that uncommon, and of course meshes oftena are highly mobile (and quite useless) if they are not anchored at all. In a retrospective series of 296 patients, we observed a failure of mesh fixation in 38% of patients at a mean of 1.8 years after Anterior Colporrhaphy with mesh. Most were global failures (dislodgment of all anchoring structures) or apical failures, implying dislodgment of lateral and/or apical anchors or fixation, see Video 3). A small minority were anterior failures, implying dislodgment of the mesh from the bladder base, likely due to suboptimal surgical technique (Video 4). Global and apical failures seem associated with hiatal ballooning (see levator biometry) and levator avulsion. Figure 4 shows a comparison of the three forms of cystocele recurrence after mesh.

It is plausible that a larger hiatus subjects anchoring structures to greater loads, increasing recurrence risk. This suggests that in such women, the currently used anchoring techniques are insuffciciently load- resistant and need to be re-engineered. Clearly, ultrasound will have a major role to play in assessing and optimising these new surgical techniques.

Figure 1: Prediction of cystocele recurrence (‘probability) based on avulsion, hiatal area and mesh use in 334 women at a mean of 2.5 years postop., in women with avulsion (A) and with intact pelvic floor (B). The effect of mesh, while very substantial in avulsion, seems negligible in those with an intact pelvic floor. Ballooning can be determined on Ultrasound (cm2) or clinically (gh+pb).

Figure 1: Prediction of cystocele recurrence (‘probability) based on avulsion, hiatal area and mesh use in 334 women at a mean of 2.5 years postop., in women with avulsion (A) and with intact pelvic floor (B). The effect of mesh, while very substantial in avulsion, seems negligible in those with an intact pelvic floor. Ballooning can be determined on Ultrasound (cm2) or clinically (gh+pb).

Figure 3: Perigee transobturator mesh as seen in the midsagittal plane (left) and in a rendered volume, axial plane, on the right.

Figure 4: Figure: Anterior (A), apical (B) and global (C) recurrence after AC + mesh. SP= symphy-sis pubis, B= bladder, U= urethra, R= rectum, A= anal canal.

Figure 5: Perigee transobturator mesh as imaged in the midsagittal, coronal and axial plane.

Video 3: Dislodgment of superior anchoring arms of a Perigee transobturator mesh.

Video 4: Dislodgment of the bladder neck from a well supported Perigee transobturator mesh.

Video 5: Excellent postoperative result after suburethral sling and Apogee. The latter is seen as a 'crinkly' hyperechoic line on the left and a plate bridging the hiatus on the right.

Video 6: Severe hiatal ballooning in patient with bilateral avulsion injury. The clinical result is excellent after Perigee and Apogee mesh. The meshes are evident as hyperechoic bands traversing the hiatus at maximal Valsalva.