Arab Journal of Urology (2014) 12, 275–284 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com ORIGINAL ARTICLE 3-year results of transvaginal cystocele repair with transobturator four-arm mesh: A prospective study of 105 patients Moez Kdous *, Fethi Zhioua Department of Obstetrics and Gynecology, Aziza Othmana Hospital, Tunis, Tunisia Received 27 January 2014, Received in revised form 1 May 2014, Accepted 24 September 2014 Available online 11 November 2014 KEYWORDS Abstract Objectives: To evaluate the long-term efficacy and safety of transobtura- tor four-arm mesh for treating cystoceles. Genital prolapse; Patients and methods: In this prospective study, 105 patients had a cystocele cor- Cystocele; rected between January 2004 and December 2008. All patients had a symptomatic Transvaginal mesh; cystocele of stage P2 according to the Baden–Walker halfway stratification. We Polypropylene mesh used only the transobturator four-arm mesh kit (SurgimeshÒ, Aspide Medical, France). All surgical procedures were carried out by the same experienced surgeon. ABBREVIATIONS The patients’ characteristics and surgical variables were recorded prospectively. The VAS, visual analogue anatomical outcome, as measured by a physical examination and postoperative scale; stratification of prolapse, and functional outcome, as assessed by a questionnaire TOT, transobturator derived from the French equivalents of the Pelvic Floor Distress Inventory, Pelvic tape; Floor Impact Questionnaire and the Pelvic Organ Prolapse–Urinary Incontinence- TVT, tension-free Sexual Questionnaire, were considered as the primary outcome measures. Peri- vaginal tape; and postoperative complications constituted the secondary outcome measures. TAPF, tendinous arch Results: At 36 months after surgery the anatomical success rate (stage 0 or 1) was of the pelvic fascia; 93%. On a functional level, all the scores of quality of life and sexuality were SUI, stress urinary improved. The overall satisfaction score (visual analogue scale) was 71.4%. There incontinence; QoL, quality of life; * Corresponding author at: Department of Obstetrics and Gynecol- ogy, Aziza Othmana Hospital, 1008 Tunis, Tunisia. Tel.: +216 21 852683 (mobile); fax: +216 71 849136. E-mail address: [email protected] (M. Kdous). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier http://dx.doi.org/10.1016/j.aju.2014.09.007 2090-598X ª 2014 Production and hosting by Elsevier B.V. on behalf of Arab Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). 276 Kdous, Zhioua PFDI, Pelvic Floor were no perioperative adverse events. Mesh erosion was reported in 7.6% and mesh Distress Inventory; retraction in 5.7% of the patients. PPISQ-12, Pelvic Conclusions: If the guidelines and precautions are followed, vaginal prosthetic Organ Prolapse/Urin- surgery for genitourinary prolapse has shown long-term benefits. It provides excel- ary Incontinence-Sex- lent results both anatomically and functionally. However, complications are not neg- ual Questionnaire; ligible and some are specific to prosthetic surgery. PFDIQ, Pelvic Floor ª 2014 Production and hosting by Elsevier B.V. on behalf of Arab Association of Distress Impact Urology. This is an open access article under the CC BY-NC-ND license (http:// Questionnaire creativecommons.org/licenses/by-nc-nd/3.0/). Introduction clinical examination aimed to reproduce the maximum degree of the anatomic prolapse, comprising a static Anterior genital prolapse or cystocele is a relaxation in part (gaping vulva, spontaneous exteriorisation of the anterior vaginal wall, as described by De Lancey organs), and a dynamic part (externalisation during and Richardson [1]. Central and lateral cystoceles are the Valsalva manoeuvre, or examination of SUI by distinguished according to the anatomical mechanism coughing). Perineal testing and evaluation of the anal of connective tissue damage [2]. Lateral cystoceles are sphincter were systematic. Bonney or Ulmsten manoeu- secondary to damage of the vaginal hammock fasteners vres completed the examination if there was SUI. to the pelvic wall at the level of the tendinous arch of the Patients were included if they were aged >50 years; pelvic fascia (TAPF), whereas central cystoceles are sec- had a cystocele of Pgrade II according to the classifica- ondary to the loss of support in the midline by Halban’s tion of Baden and Walker [7], either isolated or fascia [3]. The repair of anterior genital prolapse, associated with prolapse of the other stages, either initial whether or not associated with stress urinary inconti- or recurrent; functional discomfort warranting surgery; nence (SUI), remains the weak point of vaginal surgery, and the consent of the patient. with recurrence rates of 30–50% depending on the tech- Patients were excluded if they had a medical contra- nical methods and reporting authors [4]. indication against the intervention, a urinary or genital Formerly managed by simple subvesical plication or recurrent infection, a history of pelvic irradiation or of anterior colporrhaphy, more than a third of cystoceles malignant neoplasm of the lower urinary tract, long- recur. Indeed, the traditional colporrhaphy only corrects term corticosteroid therapy or other immune deficiency, the central defects, and furthermore, adds a suture adnexal mass, neurological disorder affecting the stabil- under tension to the poor quality of native tissues. These ity of the bladder (multiple sclerosis, spinal cord injury), disadvantages have led to the development of more reli- or an indication for laparotomy for other causes. able and durable surgical techniques, resulting in the use of various types of mesh in vaginal prolapse surgery. Procedure These materials act as a frame, guiding the development of stronger supporting tissue [5,6]. Lightweight macro- Before surgery a urine sample was cultured, the pelvic porous polypropylene meshes are currently the reference area shaved and a cleansing enema given in all patients. material, and are marketed in the form of sheets or pre- We used the SurgimeshÒ prolapse kit (Aspide Medical, cut kits. France) containing a macroporous monofilament poly- The objective of the present study was to evaluate the propylene mesh of density 27.5 g/m2, and a set of tran- long-term safety and efficacy of cystocele treatment sobturator tape (TOT) coil-type needles. The mesh is using a transobturator four-arm polypropylene mesh. formed by a central portion shaped as a square of 5 cm2 and four lateral arms of 12 cm each. The width of Patients and methods these arms is reduced gradually to reach 5 mm at the ends (Fig. 1). In a prospective study at the authors’ institution patients who had a clinical diagnosis of cystocele and who under- Technique went prosthetic surgery using a transobturator four-arm mesh were enrolled between 1 January 2004 and 31 Spinal anaesthesia was preferred to general anaesthesia. December 2008. Informed consent was obtained from Intravenous antibiotic prophylaxis (2 g cefazolin or all patients and approval was obtained from the Ethics amoxicillin/clavulanate) was routinely administered. Committee of the hospital before the first surgical The patient is placed in the dorsal lithotomy position, procedure. the buttocks slightly overlapping the table, and the All patients were questioned about their gynaecolog- thighs and legs in flexion. A large disinfection with povi- ical, obstetric, surgical and pelvi-perineal history. The done-iodine (or other non-iodised antiseptic in case of Transobturator four-arm mesh for treating cystoceles 277 the mesh after colporrhaphy. Laterally, the dissection is continued as far as possible, reaching the TAPF. This permits a large central and lateral exposure of the cysto- cele. In the space thus released, the implant is inserted between the vagina and bladder. The transobturator phase begins with the preparation of the surgical path by inserting the tip of Mayo scissors (which is concave outward) between the puborectalis muscle and the ischiopubic branch, the relief of which is marked by bone contact with the scissors tip. A deep layer of triangular ligament is opened with a firm move- ment that provides access to the anterior extension of the ischiorectal space. The scissors are then opened and removed. Two skin incisions of 3 mm are made in the genito-femoral crease at the approximate level of Figure 1 The polypropylene mesh, with a central part of 4–5 cm the clitoral hood. The transobturator passage is tracked and four lateral wings of 12–13 cm long and 1 cm width. In front, by palpation between the thumb and forefinger of the the two needles used to make the tract for the mesh. obturator membrane in contact with the ischio-pubic symphysis. The needle is introduced inwards, and punched through the obturator membrane, causing a marked ‘jump’. It must then bypass the ischio-pubic branch, and be brought with direct finger guidance, at the level of the proximal part of the TAFP (Fig. 3). The mesh arms are then attached to the needles and then retracted from the groin incisions. A second pair of inci- sions is then made 3 cm inferior and 2 cm lateral to the superior incisions bilaterally. The needles are equipped in the same way as before, and are always introduced inwards. The needle is directed vertically, under finger guidance, to move behind the internal obturator muscle and emerge below the TAPF near its distal insertion, 1–2 cm distal to the ischial spine apically (Fig. 4). The vaginal finger is used to apply pressure on the levator aponeurosis so that the needle can transfix it. The mesh arms are then attached to the needles and are retracted Figure 2 The patient is placed in the dorsal lithotomy position, buttocks slightly overlapping the table, thighs and legs in flexion. Preoperative aspect, stage IV prolapse. allergy) was used, and a permanent urinary catheter was placed (Fig. 2). The anterior vaginal wall is exposed by traction on the cervix or on the vaginal cuff if there was a previous hysterectomy.