Treatment of recurrent cystocele in the Netherlands
IUGA Academy. Evers R. Jun 30, 2018; 213004; 545 Topic: Pelvic Organ Prolapse
R.M.E. Evers
R.M.E. Evers

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545

Treatment of recurrent cystocele in the Netherlands

Evers, R1;Veen, J1; Withagen, M2; Kluivers, K3; van Eijndhoven, H4

1: MMC Veldhoven; 2: UMCU; 3: Radboud UMC; 4: Isala Zwolle

Introduction: The anterior compartement is most vulnerable to prolapse and shows the highest recurrence rate after surgical repair. With the decline of transvaginal mesh for recurrent prolapse in the Netherlands, it’s unclear how clinical decision making is done and what techniques are preferred.

Objective: To evaluate the practice pattern variation in treatment of recurrent cystocele in the Netherlands.

Methods: We conducted a cross-sectional study among members of the ‘Dutch Society for Urogynecology’ who were asked to participate in a web-based survey. A questionnaire was sent by mass mail in November 2017 to 237 members. Non-responders were reminded 2 weeks after the initial survey invitation via a personal email and again after 4 weeks if they still didn’t respond. We developed a questionnaire addressing several cases of recurrent cystocele with varying time interval between relapse and index surgery. Anterior wall prolapse with and without an uterine or vault prolapse were addressed as well.

Treatment preference

The preferred treatment in case of an early recurrent cystocele (1 year after primary surgery) is a transvaginal polypropylene mesh (39.3%). In case of a recurrent cystocele occurs in combination with uterine prolapse the preferred treatment varies between an anterior colporrhapy (AP) again (27.7%), a transvaginal polypropylene mesh (17 %) or a laparoscopic polypropylene mesh (LSCP) (25 %). Most gynaecologist (40,2%) chose LSCP in case of recurrent cystocele with a vault prolapse 40.2 %.

Native tissue repair is preferred (66.1 %) in case of an isolated cystocele relapse or combination with uterine prolapse. However in case of recurrent cystocele with vault prolapse native tissue repair is preferred in 39.3 % of cases. 27.7 % favours the laparoscopic sacrocolpopexy as treatment in that case.

Time course

77.7 % of the respondents think that the relapse time is of importance. 61 % wouldn’t propose a native tissue repair when a recurrence occurs in the first 5 years after index surgery.

Mesh

Since meshes are in negative publicity respondents were asked if their patients still want a transvaginal mesh. Gynaecologists estimate that 0-25 % of their patients still opt for transvaginal mesh. Laparoscopic mesh is more acceptable according tot them; 0-75 % of patients consider this as a good option.

Age

42.9-67.9 % of the Dutch gynaecologists don’t consider age to be important in considering the best option. The remaining group wouldn’t consider a LSCP / TVM an option in women aged over 80.

Conclusions: Dutch gynecologists prefer transvaginal mesh in case of an early isolated anterior wall prolapse and native tissue repair in case of a late recurrence. A combined anterior wall and apical prolapse is preferably reconstructed by a LSCP. In particular after hysterectomy. This is interesting since the LSCP has not proved itself in RCT for recurrent cystocele repair. According to Dutch gynaecologists, a LSCP might be a good solution for recurrent anterior wall prolapse, especially vault prolapse. A RCT comparing LSCP with native tissue repair for recurrent anterior wall prolapse with apical defect is needed.

Table 1 Treatment preference for symptomatic recurrent anterior wall prolapse 1 vs 10 years (y) after anterior collporrhaphy (AP), N=112

UTERUS IN SITU

STATUS AFTER HYSTERECTOMY

Procedure/

treatment of choice

1 y

NO u.p.*

%

10 y

NO u.p.*

%,

1 y

u.p.*

%,

10 y

u.p.*

%,

1 y

NO vvp**

%,

10 y

NO vvp**

%,

1 y

vvp**

%,

10 y

vvp**

%,

AP

22.3

66.1

27.7

60.7

27.7

67.0

17.0

39.3

Site specific repair

8.0

8.9

5.4

9.8

7.1

7.1

3.6

8.0

Transvaginal xenograft

1.8

0

0.9

0

0

0.9

0.9

0.9

Transvaginal mesh

39.3

11.6

17.0

6.3

40.2

13.4

13.4

7.1

LSCP

3.6

0

25.0

10.7

3.6

1.8

40.2

27.7

Robot assisted mesh

3.6

0

8.0

3.6

5.4

0

13.4

8.0

Abdominal mesh

0

0

0

0

0

0

1.8

0

Other;

21.4

13.4

16.1

8.9

16.1

9.8

9.8

8.9

*=uterine prolapse, **=vaginal vault prolapse

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