Pelvic Floor Disorders
Pelvic Floor Disorders (PFD) include a broad array of interrelated clinical conditions that include, urinary incontinence (UI), pelvic organ prolapse (POP), fecal incontinence (FI), sensory and emptying abnormalities of the lower urinary tract and defecatory dysfunction. Beyond the economic costs and general healthcare burden, PFD result in significant psychosocial costs and can have a profound impact on an individual’s quality of life [Landefeld 2008]. The prevalence of PFD increases with age and it is estimated that the growth in demand for services to care for women with PFD will increase at twice the rate of growth of the population over the next 30 years [Luber 2001].
POP is the downward descent of the female pelvic organs (vagina, uterus, bladder and/or rectum) into or through the vagina. Loss of vaginal or uterine support in women presenting for routine gynecology care is seen in up to 43%-76% of women, with 3%-6% of those with descent beyond the hymen and approximately 3% of women developing symptomatic vaginal bulging [Nygaard 2008, Elerkmann 2001, Swift 2000]. POP is a prevalent condition that can substantially affect a woman’s daily living, quality of life, body image, sexual function and family relationships. Treatment options for women with prolapse are complex and often involve treating multiple concurrent disorders of bowel, bladder and sexual function, with the use of a pessary, observation, or a surgical repair. Prolapse of the anterior vaginal wall, or cystocele, is the most common form of POP and the most likely to recur after surgery [Clark 2003].
Other than observation, pessary use is the principal non-surgical intervention available for women with POP. These devices are inserted into the vagina to reduce prolapsed tissue inside the vagina, to provide support to related pelvic structures, and to relieve pressure on the bladder and bowel in order to avert or delay the need for surgery [Wilson 2005, Adams 2004].
A variety of surgeries exist for the surgical correction of POP including: transvaginal native-tissue (non-mesh) repairs, transvaginal mesh repairs and abdominal repairs (sacrolpopexy) using mesh or native tissue which can be performed via laparotomy, or via laparoscopy with or without robotic assistance. Reinforcement of vaginal repairs with synthetic mesh has been widely employed in the hope of improving the effectiveness and durability of vaginal prolapse repairs. Surgical mesh materials used to correct POP can be divided into four general categories: (a) non-absorbable synthetic (e.g., polypropylene or polyester); (b) absorbable synthetic [e.g., poly (lactic-co-glycolic acid) or poly (caprolactone)]; (c) biologic (e.g., acellular collagen derived from bovine or porcine sources); or, composite (i.e., a combination of any of the previous three categories). There is currently no consensus regarding which surgical approach is superior and each has its own risk-benefit profile. Most Female Pelvic Medicine and Reconstructive Surgery (FPMRS) specialists incorporate multiple different approaches in their practice, tailoring the specific technique to the individual patient and her unique characteristics and preferences.
A 2011 Cochrane review evaluated 3,773 participants in 40 trials of different surgical procedures for POP made several conclusions including: 1) abdominal sacrocolpopexy had lower recurrent vault prolapse rates than native tissue repair using sacrospinous colpopexy but this was balanced against longer time to return to activities of daily life and higher complications; and 2) that native tissue repair was associated with more anterior compartment failures than transvaginal mesh grafts (overlay: RR 2.14 (95% CI 1.23-3.74; trocar guided kits RR 3.55, 95% CI 2.29-5.51) [Maher, 2011]. However, there was no difference in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, reoperations for POP or UI although available data for these outcomes was limited. There was a higher rate of complications associated with vaginal mesh compared with native tissue vaginal repairs, including a 10% mesh erosion rate. Another systematic review analyzed the complications and reoperation rates for surgical procedures specifically performed to correct apical POP: native tissue vaginal repairs, sacrocolpopexy and vaginal mesh kits. In this review, the rate of reoperation to correct recurrent prolapse was lowest in those who received transvaginal mesh; however, reoperations for complications as well as the total reoperation rate was highest for vaginal mesh kits compared with vaginal native tissue and abdominal repairs, despite shorter overall follow-up [Diwadkar, 2009].