Experience in treating apical pelvic organ prolapse in women using mesh implants

Introduction

Pelvic organ prolapse (POP) is one of the most common gynecological diseases, the incidence of which is steadily augmenting with increasing life expectancy and reaching 56.3–77.0%. POP is most often diagnosed in old and senile age. The social significance of this disease is explained by the fact that up to 47% of patients are women of working age, and POP symptoms significantly reduce the quality of life of patients. Operations for POP are the third among all the indications for surgical treatment. Besides, the high frequency of relapses after surgical treatment should be noted; in particular, before the use of mesh prostheses, the frequency of relapses amounted to 33.0–61.0%. Despite the achievements of modern surgery, the search for the optimal treatment method still continues, which is stipulated by the complex and multifaceted pathogenesis of this disease [1–3].

An important argument that has affected the introduction of mesh implants for the correction of POP is the advances in the investigation of connective tissue failure, which is often hereditary. In particular, researchers discovered a syndrome of connective tissue dysplasia, the symptom complex of which includes POP as one of its clinical manifestations. In this regard, using surgical methods for prolapse treatment based on strengthening the pelvic floor with local tissues or shortening one's own ligaments turned out to be ineffective since correction of the pathology with compromised tissues leads to a relapse of the disease.

The classic method of treating apical prolapse was hysterectomy but currently, it has lost its significance in the treatment of this disease. Moreover, this approach is believed to aggravate the course of prolapse since its implementation can cause injuries to the ligamentous apparatus of the uterus. Historical operations for the treatment of apical prolapse include ventrosuspension according to Doleris-Gilliam, the Baldy-Webster operation and its modification according to McCall, the Elkin operation, ventrofixation according to Kocher, Mackenrodt, Durssen, and the Manchester operation proposed by Donald from Manchester in the late 19th century and improved by Forthergil in 1937.

Polypropylene mesh implants have been widely used in hernioplasty since the 1990s and in pelvic floor surgery since 1996. However, the technique of using a mesh implant to suspend the cervix or upper vagina to the anterior longitudinal ligament of the sacrum was first described in 1958 by Huguier and Scalin and expanded by Lane in 1962 [2]. Numerous clinical studies have confirmed the efficacy of this technology; therefore, interest in it is still growing steadily. Petros (1997) proposed the PIVS (posterior intravaginal slingplasty) technique for correcting apical prolapse in combination with rectocele, based on the principles of prosthetic replacement of the uterine ligament apparatus with a synthetic tape without tension.

The "gold standard" of surgical correction of apical prolapse is mesh technology with abdominal access. According to many authors, laparoscopic sacrocolpopexy using a mesh implant provides efficacy in 78–100% of cases. During the operation, the mesh implant is fixed to the stump of the cervix or the vaginal wall and the longitudinal presacral ligament. Despite its efficacy, this method is not without its drawbacks: during its accomplishment, the risk of injury to the presacral vessels and ureters increases; in the postoperative period, stress urinary incontinence and defecation disorders associated with a decrease in the volume of the small pelvis and impairment of the lower hypogastric plexus are often recorded, especially in obese people [3][4].

It should be noted that there is also a new method for treating apical prolapse in obese patients, namely pectopexy. The essence of the method is to fix the cervix or vaginal stump to Cooper's ligament on both sides using a mesh, which prosthetizes the lost ligamentous apparatus of the uterus. The advantage of the method is the shorter duration of the operation, no conflict with the ureters, and a lower incidence of postoperative intestinal disorders [5–7]. Thus, laparoscopic pectopexy is a promising method for treating POP, significantly improving the quality of life of patients [8].

The aim of the study was to evaluate the results of surgical correction of POP using mesh implants.

Materials and methods

Since 2016, the gynecology department of the Federal Siberian Scientific and Clinical Center of the Federal Medical and Biological Agency of Russia in Krasnoyarsk has introduced into everyday practice operations to correct POP using mesh implants. From 2016 to 2022, the gynecology department performed 567 surgical interventions with mesh implants (Table 1). Of these, 149 cases involved sacropexy, 137 cases involved pectopexy, 197 cases involved sling operations via transobturator access, 5 cases involved sacrospinal fixation, and 79 cases involved complex surgical interventions including combinations of abdominal fixation and loop operations).

Statistical processing of the obtained results was carried out using Microsoft Office Excel (Microsoft Corporation, USA) and SPSS Statistics 24.0. The nature of the data distribution was assessed using the Shapiro-Wilk criterion. For variables, subjected to the law of normal distribution, the mean value and standard deviation were calculated; differences between groups were assessed using the Student criterion. For asymmetrically distributed quantitative variables, the median and quartiles were determined, and differences between groups were assessed using the Mann-Whitney test. The critical level of statistical significance (p) upon testing the null hypothesis was taken to be less than or equal to 0.05.

Results

Pectopexy and sacrocolpopexy were used in patients with apical prolapse. Surgical interventions were performed using standard techniques. In both cases, we used the same mesh implant, namely Gyneflex. In menopausal patients, if indicated, subtotal hysterectomy was performed that enabled more reliable fixation of the implant. In patients of reproductive age, organ-preserving corrections were most often performed.

In the case of sacropexy, fixation was performed using a Y-shaped implant; more specifically, the anterior leaflet of the implant was fixed to the anterior wall of the vagina and the stump of the cervix, and the posterior leaflet was fixed to the posterior wall of the uterus and m. levator on both sides. It should be noted that sacropexy is difficult to perform while preserving the body of the uterus but possible. In this case, the anterior leaflet of the implant was divided longitudinally in half and passed through the formed "windows" in the broad ligament of the uterus. Such difficulties did not arise during pectopexy, and the correction was equally effective both with the preserved and removed body of the uterus. However, when performing pectopexy, there were difficulties with laparoscopic correction of posterior wall prolapse. Therefore, in some cases, additional correction was performed through vaginal access (posterior colporrhaphy) that ultimately enabled to achieve adequate correction of genital prolapse.

Comparative analysis showed that laparoscopic pectopexy was a shorter operation, lasting 90±25 minutes, compared to laparoscopic sacropexy, which required 150±36 minutes; statistical significance is p=0.006. The volume of blood loss was minimal, not exceeding an average of 10 ml. Intraoperative complications were not observed in both cases.

The analysis of treatment results showed that the efficacy rate of POP correction by laparoscopic access reached 93.4% (p<0.001), which was comparable with the data presented by other researchers. Relapses of apical prolapse were observed in 6.6% of cases (p<0.001). Predominantly, relapses were caused by detachment of the implant from the attachment site and most often emerged in the first three months of the postoperative period. In some patients, this was caused by a violation of the regimen of limiting physical activity due to a return to heavy physical labor after surgery. In case of relapses, patients underwent repeated surgical interventions using laparoscopic access but the type of surgery most often changed. In particular, patients after unsuccessful sacropexy underwent pectopexy during repeated surgical intervention. We did not perform total excision of the implant due to the high traumatism of this intervention and provided that there was no dysfunction of the pelvic organs under the effect of the implant.

It is worth noting that we did not consider the development of vaginal wall prolapse after correction of apical prolapse with a mesh implant as cases of POP relapse. All patients who underwent POP correction with mesh implants in our clinic were recommended to return for a follow-up examination 6 months after the operation. In the case of the development of vaginal wall prolapse and taking into account the complaints of patients, additional surgical correction was performed using the own tissues of the patient without the mesh implants. Such additional surgical interventions made it possible to achieve the maximum quality of life of patients.

Assessment of postoperative complications revealed that 87.5% of patients after sacropexy noted obstipation in the first 2 months after surgery, with symptoms persisting in 22.9% of cases for up to 6 months (p<0.001). This complication was not diagnosed after laparoscopic pectopexy. Besides, 4.1% of patients after laparoscopic sacropexy noted stress urinary incontinence de novo, which was not manifested after pectopexy. In addition, 37.4% of patients who underwent laparoscopic sacropexy reported dyspareunia, while after pectopexy, dyspareunia was manifested in 6.1% of patients (p<0.001). Concurrently, in 0.64% of cases (p<0.001), such a complication as vaginal wall erosion was recorded; however, it is worth noting that this complication was manifested only after urethropexy.

Discussion

In accordance with the ideas of researchers existing in this period,sacropexy and pectopexy are effective methods of surgical correction of POP [3][4]. In our study, the efficacy rate of POP correction by laparoscopic access reached 93.4% (p<0.001).

One of the serious complications in the correction of POP using mesh implants is the formation of vaginal wall erosions. In our study, such a complication was revealed in 0.64% of cases (p<0.001) and all complications were recorded in patients after urethropexy. No similar cases were recorded after laparoscopic corrections. This can be explained by specific techniques, namely we did not use a uterine manipulator when performing subtotal hysterectomy in patients who were planned to have a mesh implant that eliminated the contact between the vaginal microflora and the implant. In addition, upon fixing the mesh, the sutures were applied in such a way that the thread did not impair the vaginal mucosa.

Another complication of laparoscopic correction of POP is the formation of obstipation in the postoperative period. This was especially characteristic of sacropexy [3]. Almost all patients had disorders with stool and a tendency to constipation during the first 2 months; in 80.0% of cases, this condition was successfully resolved, but in 20.0% of patients, obstipation persisted further (p<0.001). This symptom not only affects the quality of life of the patient but is also a risk factor for relapse of POP. However, patients after pectopexy did not experience such disorders, which could be explained by the absence of implant pressure on the rectum due to different fixation points. Similar data were obtained by other researchers [9][10]

Considering that the correction of POP, in addition to normalizing the functions of the pelvic organs, aims to improve the quality of life, the aspect of the ability to live a sexual life after surgery worried many of our patients. According to Astepe et al., sexual dysfunction was manifested less frequently in patients after laparoscopic pectopexy compared to the group of patients after sacrospinous fixation [7]. In the case of sacropexy, patients had more difficulties due to dyspareunia during sexual intercourse compared to patients who underwent pectopexy. This may be stipulated by the formation of a different vaginal axis, since after sacropexy, the axis is directed craniodorsally, and the tension of the vaginal wall tissues is more pronounced. Meanwhile, after pectopexy, the axis is directed cranioventrally, which corresponds to the normal vaginal axis.

Currently, more than 234 million operations are performed annually in the world for various surgical pathologies, and one of the objective parameters for assessing the treatment efficacy is the development of postoperative complications [11]. The principles for implementing the concept of surgical safety, developed by WHO in 2008, were an undoubted priority of our study.

Conclusion

An analysis of the results of surgical interventions for the elimination of POP has shown that both laparoscopic sacropexy and pectopexy are effective methods of surgical correction of POP but laparoscopic pectopexy seems to be more preferable. The advantages of pectopexy over sacropexy include a shorter duration of surgery, a lower risk of intraoperative injury to adjacent organs, and a lower incidence of postoperative complications.