The surgical treatment of apical vaginal prolapse by abdominal sacral colpopexy is known to be effective.
This procedure uses graft material, most commonly permanent synthetic mesh, to suspend the proximal vaginal to the anterior longitudinal ligament of the sacrum. One of the known complications of this procedure, when using permanent grafts, is vaginal mesh erosion. Wu and colleagues from Chapel Hill, North Carolina performed a retrospective study to determine to the risk factors for mesh erosion with and without concomitant hysterectomy as well as any additional factors which may increase the risk.
They reviewed the records of 313 women who underwent an abdominal sacral colpopexy at their institution from 1994-2004. Their general operative technique included the use of preoperative antibiotics and when a hysterectomy was performed, it was done prior to any vaginal suspension. The presacral space was exposed and 3 or four permanent sutures were placed through the anterior longitudinal ligament at the S2-S3 level. The vesicovaginal and rectovaginal spaces were then dissected, and if there was any midline fascial defect of the tissue was redundant, the anterior and/or posterior vaginal wall were imbricated. This was done in order to repair fascial defects, minimize redundant tissue, and decrease the risk of mesh erosion. A “Y” shaped piece of mesh was used, with Mersilene or polypropylene used posteriorly, and Mersilene, polypropylene, or Gore-Tex placed anteriorly. Gore-Tex sutures were used to fix the mesh to the vaginal wall. The peritoneum was closed over the mesh.
Of the patients reviewed 101 (32.3%) had a concomitant hysterectomy, while 212 (67.7%) had a previous hysterectomy (the control group). The groups were similar in respect to age, race, vaginal parity, rates of diabetes mellitus, tobacco use, and body mass index. The hysterectomy group was less likely to be using estrogen therapy. Posterior wall imbrication was similar in both groups, while anterior wall imbrication was more common in the concomitant hysterectomy group. Anterior Gore-Tex mesh was used more commonly in the control group than Mersilene or polypropylene (47.6%, 19.8%, and 9.9%, respectively).
They found they overall vaginal mesh erosion rate to be 5.4%. The rates in the concomitant and previous hysterectomy groups were similar (6.9% and 4.7%, P=0.42, respectively). Mesh erosions were independently associated with anterior vaginal wall imbrication, 8.8% in those who had imbrication vs. 1.4% in those not imbricated, and the use of Gore-Tex mesh anteriorly 8.8% vs. 2.8%. Although the use of estrogen was not independently associated with mesh erosions, it was a significant effect modifier, in that only those undergoing a concomitant hysterectomy that were on estrogen therapy had mesh erosions. Mesh erosions occurred between 1.4 and 70 months postoperatively.
The authors conclude that a concomitant hysterectomy at the time of abdominal sacral colpopexy with permanent graft in women on estrogen therapy was associated with an increased the risk of vaginal mesh erosion. In women not taking estrogen therapy, hysterectomy at the time of abdominal sacral colpopexy was not a risk factor for mesh erosion.
By M. Louis Moy, MD
Am J Obstet Gynecol 2006; 194:1418-1422
Wu JM, Wells EC, Hundley AF, Connolly A, Williams KS, Visco AG
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