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I-STOP for Vault Prolapse: Contributing to an Interventional Procedures Guidance for NICE
IUGA Academy. Bach F. Jun 30, 2018; 213274
Topic: Pelvic Organ Prolapse
Fiona Bach
Fiona Bach

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259

I-STOP for vault prolapse: Contributing to an interventional procedures guidance for NICE

Bach, F1; Toozs-Hobson, P1; Brair, A1; Bayli, F1

1: Birmingham Women's Hospital

Introduction Infracoccygeal vaginal vault mesh suspension uses a thin band of mesh inserted through the ischiorectal fossa using a posterior, or occasionally anterior, vaginal approach. Advantages over sacrospinous fixation include not being limited by vaginal length, and over sacrocolpopexy, of avoiding abdominal surgery and therefore general anaesthetic. The video shows the following steps: rectal packing, infiltration, opening the vagina, tunneling to the sacrospinous ligament, trochar insertion via buttocks, mesh placement, suturing and tensioning, suspension of the vault and closure. The UK governing body, NICE (National Institute for Health and Care Excellence), reports that there is currently inadequate evidence of efficacy for this procedure and states audit is paramount (1).

Objective: To share the technique and outcomes of infracoccygeal vaginal vault mesh suspension using I-STOP mesh. To present patient feedback supplied to NICE for their Interventional Procedures Guidance (IPG).

Methods: Retrospective review of British Society of Urogynaecology database, notes and patient questionnaire from Jan 2013 to Aug 2016.

Results: 83 procedures were identified, 72 (87%) had BSUG follow-up and 14 patients responded to the NICE questionnaire. Anatomical outcomes were positive with an average rise of -5.1 for point C on POPQ (#49). There was one intraoperative complication of vaginal buttonholing.

Patient reported outcomes for Global Impression of Improvement (PGI) at 3 months were also positive a shown.

Very much/much better

Success

63 (87.5%)

Little better/no change

Neutral

7 (9.7%)

Slightly worse/much worse very much worse

Failure

2 (2.8%)

One patient who felt “worse” developed an enterocele likely due to pre-existing constipation and after discussion is awaiting laparoscopic sacrocolpopexy. The other patient who reported feeling “worse” had a concomitant bulking agent for USI. On notes review, she was happy with the prolapse but discontented with the perception of increased SUI so reported a negative outcome. Clinically the incontinence was related to urgency and improved with medication. She had a repeat bulking and is now much improved.

Post-operatively one patient developed a haematoma and later developed evacuatory difficulty, dyspareunia, pain around the mesh with severe neuralgic left buttock pain. On PGI she reported feeling “a little better”. An EUA revealed a tight mesh which was divided resulting in cure of pain around the mesh however the prolapse returned and the pudendal neuralgia persisted. One patient developed right-sided loin pain following a treated wound infection. She felt overall “much better”.

Longer term (up to 2 years) follow up for PGI is reassuring.

Success

11 (79%)

Neutral

2 (14%)

Failure

1 (7%)

No patient reported mesh exposure which may be because the mesh is underrun behind intact vaginal tissue rather than beneath a stitch line.

Conclusion: Infracoccygeal vaginal vault mesh suspension appears to be an effective and safe operation for vault prolapse. The patient reported outcome is similar to literature (1) and show a successful prolapse operation using minimal mesh with vaginal approach. It offers a safe alternative to sacrospinous ligament fixation or sacrocolpopexy. As with all surgeries, long-term follow up is required.

References

  1. https://www.nice.org.uk/guidance/ipg581/resources/infracoccygeal-sacropexy-using-mesh-to-repair-vaginal-vault-prolapse-pdf-1899872163618757

Disclosure:

Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Consultant Boston Scientific, Ethicon lectures, Ferring and Astellas).

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