Chapter 22: Use of Graft Materials in Reconstructive Surgery

INTRODUCTION

Pelvic organ prolapse (POP) and urinary incontinence are common conditions that impose substantial physical, social, and economic burdens on aging women. In a population of ambulatory women presenting for routine gynecologic care, 35% and 2% of patients had stage two and stage three prolapse, respectively.¹ The US National Health and Nutrition Examination Survey (NHANES) of noninstitutionalized women aged 20 years and greater found that 2.9% of women reported seeing or feeling a bulge outside the vagina and that 15.7% of women had at least moderate to severe urinary incontinence.² Further, the NHANES report identified that the proportion of women with at least one pelvic floor disorder such as prolapse or incontinence increased incrementally with age, ranging from 9.7% in women 20 to 29 years to 49.7% in those aged 80 years or older.

While nonsurgical interventions for incontinence and POP including pelvic floor muscle therapy, behavioral changes and pessaries are commonly employed, POP and incontinence are among the most common indications for surgery in postmenopausal women. In a seminal article, Olsen et al. estimated that the lifetime risk of a prolapse or urinary incontinence operation in a US health maintenance cohort was 11.1%.³ Later, in another health maintenance organization cohort, Fialkow et al. similarly identified a lifetime risk for surgery as 11.8%.⁴ Estimate for surgery among a managed-care population in Western Australia was 19%.⁵ Unfortunately, the need for repeat surgical repair is also high with approximately 13% to 29% of women undergoing an additional operation within five years of their primary surgery.^3,6

Surgeries for prolapse treatment may be categorized as obliterative or reconstructive. Obliterative procedures such as a colpocleisis or LeFort partial colpocleisis close off the vaginal canal either completely or partially and elevates the pelvic viscera back into the pelvis; these procedures are usually reserved only for elderly women who are no longer sexually active and who are often medically compromised. An obvious disadvantage to these procedures is the elimination of the future possibility of vaginal intercourse.

For most women with symptomatic POP, reconstructive surgery will be chosen as the means to correct the prolapsed vagina while maintaining—or improving—sexual function and relieving associated pelvic floor symptoms. These reconstructive surgical procedures may be approached vaginally, abdominally, or laparoscopically, and all may utilize graft materials to replace or augment native tissue. National or insurance databases suggest that the preferred route for primary prolapse repair is vaginal, with approximately 80% to 90% of operations performed vaginally.^3,7 Compared with open abdominal procedures, a vaginal approach generally has shorter operating time, shorter length of admission, less patient morbidity, and less cost. On the other hand, traditional vaginal approaches to prolapse repair often have higher rates of recurrent prolapse than an abdominal sacral colpopexy, a mesh repair with an abdominal approach.⁸ Randomized trials of various anterior colporrhaphy techniques with and without use of mesh for ...