This three-dimensional understanding of the pelvic floor is mandatory if one is to assume that blind passage of trocars through potentially dangerous spaces is the wave of the future.
DR. RAZ: You need to be a pelvic surgeon, know your anatomy, and know how to manage complications if you are going to use one of these kits. You should stick to the surgery that works best in your hands. Industry cannot teach you to be a good pelvic surgeon; it takes lifelong experience.
Mesh versus an obliterative procedure—which one wins out?
DR. KARRAM: If you have a patient who is sexually inactive with pelvic organ prolapse, would you prefer a mesh repair or an obliterative procedure? And why?
DR. WALTERS: If the patient is sexually inactive—especially if she is older and definitely will not be in the future—it makes absolutely no sense to perform a mesh-augmented repair. A traditional, somewhat tight, sutured repair works fine in this setting and carries very low risk.
In fact, our group and others have found that, in carefully selected patients, partial colpectomy and colpocleisis procedures (without grafts) have among the highest cure and satisfaction rates of all surgeries we perform for prolapse; they also have relatively low risk.8 Recurrent prolapse after an obliterative procedure is rare; most of the dissatisfaction relates to postoperative voiding difficulties or persistent or de novo urinary incontinence.
DR. KARRAM: I also prefer an obliterative procedure. I see no reason to bring in the cost and potential for complications that mesh repair entails. An obliterative procedure should produce an anatomic success rate close to 100%, with minimal complications. It also can be performed quickly with minimal anesthesia and convalescence.
DR. LUCENTE: My response is based on a clinical study that my associate, Dr. Miles Murphy, has performed, comparing a transvaginal mesh procedure with a LaForte operation for severe pelvic organ prolapse.9 Both patient groups were well satisfied with the result, and success rates were comparable. However, the group that underwent the transvaginal mesh procedure had a shorter operative time.
As a result of these studies, we tend to prefer transvaginal mesh repair. Even though the woman may be sexually inactive, the procedure preserves vaginal function, and we all know that life has a way of being unpredictable. Her situation may change so that she once again desires sexual function.
However, for a very elderly woman—one in her late 80s or 90s—who has severe or extreme prolapse with a very large procidentia and vaginal length measuring, say, 13 cm beyond the introitus, I do prefer an obliterative procedure.
DR. RAZ: I agree. I would not offer a sexually inactive patient an obliterative procedure. You never know what the future will hold.
Mesh repair can be performed safely, provided the surgeon has good knowledge of anatomic landmarks and knows how to manage any potential complications that may arise.