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Kit-Specific training is required for mesh kits: appropriate training needed for good outcome for anterior compartment prolapse surgical treatment.

ST. LOUIS - Mesh kits aren't a one-size-fits-all option when it comes to the treatment of anterior compartment prolapse.

A number of kits are available, and unlike many other aspects of surgery in which one product or tool might be relatively equivalent to another, that's not the case when it comes to mesh kits, Dr. Peter M. Lotze said at the conference.

Although the kits all have a shared goal of creating a tension-free environment, they are anchored at different points. The right choice - and the right training - is important for a good outcome.

Dr. Lotze of the department of obstetrics and gynecology at the University of Texas, Houston, who is a practicing urogynecologist, described some of the most frequently used kits in the United States.

The Perigee Prolapse Repair System (American Medical Systems), the Gynecare Prolift Total, Anterior and Posterior Pelvic Floor Repair System (Ethicon), and the Avaulta Plus Biosynthetic Support System - Anterior (Bard Urological) all use a transobturator approach and use the ileococcygeus muscle and the internal obturator muscles as their anchor points, he said. These kits are designed to hold up a cystocele.

The Pinnacle Pelvic Floor Repair Kit and Uphold Vaginal Support System (both from Boston Scientific) and the Elevate Apical and Posterior Prolapse Repair System (American Medical Systems) use an anterior compartment approach, and use the sacrospinous ligament as their principal anchor of support, he said. These kits provide apical support in addition to correcting a cystocele.

The Gynecare Prosima Pelvic Floor Repair System (Ethicon) is the newest kit on the market, and via anterior compartment dissection to the ischial spines, it is placed up against the arcus tendineus fascia pelvis rather than anchoring into it. This kit is marketed for use in stage 1 prolapse, Dr. Lotze said.

Although a prospective observational study that he and his colleagues have submitted for publication suggests that fixation at the sacrospinous ligament is best for patients with a cystocele as well as apical prolapse - because it provides better apical support (see sidebar) - data are generally limited in regard to outcomes with these kits. This is true particularly because most reported cases involved combined repairs, making the findings difficult to interpret. However, existing data do suggest some benefit, and the kits do offer a minimally invasive vaginal approach that can be performed in an outpatient setting, Dr. Lotze said, noting that durability and patient satisfaction need further evaluation in future studies.

In the meantime, one important way to avoid complications is to pay careful attention to mesh tensioning. While the kits are technically considered "tension-free," there is no such thing when a woman is standing up. The bladder, bowel, and vagina all rest on the mesh, creating tension. If you think it's too loose - you probably did it right, Dr. Lotze said.

Conversely, if you think it's a perfect result, your patient will likely be back to have the mesh cut out, because it will contract and cause pain, he said.

Know the anatomy, understand the success of classical surgery, know when to augment, and get training, training, and more training, he advised.

"You've got to be trained on your mesh kits," he said, adding that a "weekend warrior" training course may not be sufficient.

Too often, physicians spoiled by quick and easy sling training sessions insist on pared-down weekend mesh kit training sessions to accommodate their social schedules - or vendors offer such limited training to entice participation. This is the biggest mistake physicians and vendors make, and that cycle needs to be broken, Dr. Lotze said.

In fact, even a full Saturday course may be insufficient, he said, noting that it's unrealistic to think you'll be proficient without additional training. There's nothing to lose by coming back to the next cadaver course.

"Go as many times as it takes. Vendors are happy to send you back - they know you're a long-term investment, so invest in your patients and go back if you need to," he said.

Dr. Lotze disclosed that he is a speaker and researcher for Boston Scientific.

RERATED ARTICLE: Use Sacrospinous Ligament Fixation

Apical support is best achieved by using sacrospinous ligament fixation rather than prespinous fixation when using mesh for the treatment of prolapse.

In a prospective observational study of 100 patients, Dr. Lotze and his colleagues found that on average, vaginal length was between 9.0 and 9.3 cm, and length from the introitus to the level of the ischial spine was about 7.5 cm - a difference of about 1 finger breadth.

Fixation of mesh at the sacrospinous ligament will provide support for about 80% of the total vaginal length; fixation at a level 1 finger breadth below that will provide support for only 58% of the total vaginal length, Dr. Lotze said.

Therefore, using prespinous fixation means that about a third of the apex will not be supported, and in patients with both cystocele and apical prolapse, this approach is more likely to fail.

Testing this in a cadaver lab to see how high they could get with the mesh kits in total vaginal length, Dr. Lotze and his colleagues found that with sacrospinous kits they were able to get to 100% of the total vaginal length, compared with only 60% of total vaginal length using prespinous kits, in most cases.

"So again, this emphasizes that the prespinous kits may not cut it if you have apical prolapse," he said.


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Title Annotation:GYNECOLOGY
Author:Worcester, Sharon
Publication:OB GYN News
Date:Dec 1, 2010
Previous Article:Add cystoscopy to incontinence, vaginal surgery.
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