BERKELEY, CA (UroToday.com) - The lifetime risk of requiring pelvic floor surgery for prolapse is between 10% and 20%, and a significant number of patients require repeat surgery for recurrence. Until a few years ago, we didn’t know what increased the risk for the failure of reconstructive surgery, but we now know the status of the pelvic floor muscle, levator ani, seems to play a major role. Its injury during vaginal delivery, called avulsion, affects nearly 20% of women and seems to be largely responsible not only for the development of prolapse, but for the failure of conventional pelvic floor injury, as well. Therefore we limited our trial only to patients suffering with this kind of injury. We had, for the first time, used pelvic floor ultrasound assessment as entry criteria for pelvic floor surgery. Using this entry criterion, we had shown that if a woman suffers from prolapse and has levator ani injury (avulsion), the failure rate of the conventional surgery is almost 65% within the period of the first year after surgery! And, conversely, if we used mesh in this high-risk group, the likelihood of failure greatly decreased. We found that implementing pelvic floor imaging for pelvic floor assessment enables us to identify patients who will likely be at high risk for the failure of conventional reconstructive surgery. Also, we have shown that there is a group of patients who will benefit from vaginal mesh implantation, and we are even been able to preoperatively identify those patients.
The high risk of failure of conventional pelvic floor reconstructive surgery has a significant impact on patients and on the health care system. By assessing patients prior to receiving treatment, using pelvic floor imaging, we are able to identify women who will benefit from vaginal mesh implantation over a conventional approach and dramatically reduce the risk of repeat surgery. This is a win/win situation for patients and for understanding the reasons behind varying success rates of conventional or less traditional treatments.
Despite the relatively small size of our study, we have achieved significant results. Using a noninvasive assessment approach – which in our case was imaging -- to determine the risk of failure allows us to validate the benefits of non-conventional approaches in a targeted patient group. This saves many patients from the uncertainty of participating in large general population trials, which take time and a great deal of resources. We hope that our results will encourage other smaller centers to follow the path of finding affordable, noninvasive, diagnostic methods to determine the right surgical approach. This level of research diversity will provide timely, more accurate, and reliable results. Most importantly, patients will receive better, faster, and more individualized treatment in the end.
Kamil Svabik as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Obstetrics and Gynecology, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Apolinarska 18, Prague 2, 128 00, Czech Republic
Comparison of vaginal mesh repair with sacrospinous vaginal colpopexy in the management of vaginal vault prolapse after hysterectomy in patients with levator ani avulsion: A randomized controlled trial - Abstract