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Pelvic Organ Prolapse (POP) surgery : native tissue repair vs prosthetic surgery. Compared outcomes
IUGA Academy. Ettore G. Jun 30, 2018; 213032; 475 Topic: Pelvic Organ Prolapse
Giuseppe Ettore
Giuseppe Ettore

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475

Pelvic Organ Prolapse (POP) surgery: Native tissue repair vs prosthetic surgery. Compared outcomes

Ettore, G1; Ettore, C1; Benintende, M1; Torrisi, G1

1: ARNAS Garibaldi Nesima

Introduction: An extensive review of medical literature shows that there are currently no proven benefits with the use of transvaginal mesh and that mesh use is associated with more adverse events and consequently potential reoperations(1); therefore the indications for use of synthetic mesh are a cause of argumentation.

Objective: determine the safety and effectiveness of native tissue repair compared to transvaginal mesh for POP in women, with at least a 3-year follow-up.

Materials And Methods: The clinical observational study was conducted on patients undergoing primary or secondary surgery for POP in the period between June 2012 and January 2017 at our secondary referral Uro-Gynaecological Unit. We recruited a cohort of 437 women, 350 patients underwent native tissue surgery and 87 patients undergoing prosthetic surgery. The patients underwent an accurate pre-operative workup. The surgical techniques for native tissue repair were: vaginal hysterectomy, colposuspension, according to McCall modified, or Sacrospinous fixation, colporrhaphy according to Lahodny (1st step), posterior repair according to Richardson, perineal body reconstruction. Prosthetic surgery included Single-incisionmesh surgery for anterior, apical or posterior POP. Forty nine patients were implanted with Elevate Anterior/posterior mesh and 38 patients with the Uphold system. The primary objective is to determine the anatomical outcome, the second objective is to determine the differential effects on other outcomes such as urinary and bowel functions. Statistical analysis of the results using Student's t test or chi-square test, where appropriate, was performed at a significance level of p=0.05.

Results: The characteristics of the patients are reported in tab.1; no significant differences were apparent between the two groups of patients. A follow-up at 3 year was available for 142 patients underwent native tissue surgery and for 75 patients underwent prosthetic surgery. The cure rate was 81.5% (74-87.5%) for native tissue repair and 84% (70-92%) for transvaginal mesh (95% confidence intervals, no significant difference), with a re-treatment rate of 2.8% and 2.04% respectively. Anterior vaginal wall defects and apical defects were the most common site of POP recurrence, both for native tissue repair and for prosthetic surgery (tab.1) Major complications of tissue native repair were two cases of pelvic hemoperitoneum (1.4%). Major complications of transvaginal mesh use were: two cases of pelvic hematoma (4%) and two cases of bladder injury (4%). The vaginal extrusion rate of the mesh was (4/49, 8%). We also report satisfactory results regarding functional outcomes for both surgical techniques, but a higher rate of de novo urinary stress incontinence (14%) for prosthetic surgery, as shown by data in Tab. 2.

Table 1: Patients data (n=191)

Age (mean + SD) 64.2 + 8.5

Parity (mean + SD) 3.2 + 1.4

BMI (mean + SD) 27 + 3.3

Diabetes 30 (16%)

Hypertension 72 (38%)

Delivery

spontaneous vaginal 114 (61.5%)

instrumental 71 (37.4%)

Caesarean section 6 (3%)

Physiological menopause 150 (79%)

Pre-surgery POP-Q stage

Stage 2 19 (10%)

Stage 3 133 (70%)

Stage 4 39 (20%)

Previous pelvic surgery 20 (10%)

Anatomic recurrence at 3 years after surgery

Native tissue (n=142) Mesh (n=49)

Stage 2 21 (15%) 5 (10.2%)

Stage 3 5 (3.5%) 3 (6%)

Site of recurrence

Anterior 19 (73%) 5 (62%)

Anterior/apical 6 (12%) 2 (25%)

Anterior-apical-posterior

4 (15%) 1 (12%)

Re-treatment 4 (2.8%) 1 (2.04%)

Tab.2 Functional symptoms before/after surgery Native tissue Transvaginal mesh

Before

After

Before

After

UI – stress

49 (34%)

17 (11%)

16 (32%)

13 (26%)

UI – urge

14 (10%)

3 (2.3%)

1 (2%)

1 (2%)

UI – mixed

18 (13%)

8 (6%)

6 (12%)

0

Voiding dysfunctions

30 (22%)

3 (2%)

9 (18%)

1 (2%)

Anal Incontinence

9 (7%)

3 (2%)

0

0

De novo UI - urge

/

9 (7%)

/

1 (2%)

De novo UI – stress

/

8 (6%)

/

7 (14%)

Conclusions: Improved anatomical outcome is an insufficient criterion to use mesh in POP reconstructive surgery, especially in the presence of adequate demonstration of comparably successful functional outcomes without mesh. The choice of prosthetic vaginal surgery rather than native tissue surgery needs to be made on a case-to-case basis, according to the individual variables, expectations and anatomical defects .

Reference:

1) European Urology 7 2 ( 2 01 7 ) 4 2 4 – 4 3 1

Disclosure:

Work supported by industry: no.

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