How to use biologics: points of attachment
The other difficulty with comparing the efficacy and safety of biologic grafts for POP is the lack of consensus as to how the graft augmentation should be performed technically. Whereas some surgeons simply place an “on lay” graft over a native tissue repair, others will attach the graft to the endopelvic fascia, while others will attach the graft to specific supporting structures in the pelvis, such as the sacrospinous ligament (SSL) or arcus tendineus fascia pelvis.
Attachment to the SSL
The surgeon may elect to perform a native tissue repair before placement of the biologic graft. Although it is unclear whether this improves the ultimate success of the repair, for large cystoceles and rectoceles this step may facilitate graft placement by reducing the prolapse and keeping it out of harm’s way.
The SSL is a consistently substantial ligament that has been frequently used for direct attachment of the vaginal vault as well as for indirect attachment of the vagina to the ligament with the graft material bridging the gap. Many reconstructive pelvic surgeons use this ligament with biologic grafts as well for either uterine or vaginal vault prolapse. The SSL can be approached through either an anterior or posterior vaginal dissection, depending on which compartment has the more significant prolapse. With either approach, once the initial lateral sharp dissection is accomplished, blunt dissection along the levator ani fascia can usually be performed until the ischial spine is reached. Any overlying tissue should be dissected off the sacrospinous ligament and a suture is placed in the mid-portion of the sacrospinous ligament, at least 3 cm medial to the ischial spine to avoid injury to the pudendal nerve and vessels. The surgeon should also avoid placing sutures above the superior margin of the ligament, to protect the sciatic nerve, which lies over (ventral to) the soft piriformis muscle. We use an automatic suturing device (Capio™ Slim, Boston Scientific Corporation) that throws and captures the suture, although several other instruments can be used for this purpose. Whether the approach is anterior or posterior, a trapezoidal shape of graft is used to cover the defect. The proximal portion of the graft is sutured in the midline with delayed-absorbable or permanent suture to the cervix or vaginal vault. The base of the trapezoid is usually approximately 8 cm, so it can span the distance between the mid-portions of the SSL, and the length of the graft is customized to the patient, with an anterior graft extending to the bladder neck and a posterior graft usually brought down distally to the perineal body. The graft can be attached laterally to the pelvic sidewall at the level of the fascial white line. We use a pulley stitch when attaching the SSL suture to the proximal corner of the graft, which can be used to lift the graft into position, effectively reducing the prolapse. If the vaginal vault is foreshortened and does not reach the level of the SSL, the graft is tailored so that undue tension is not placed on the vaginal apex.
Once the graft has been placed, the vaginal epithelium can be closed with a running or interrupted delayed-absorbable suture. We prefer to trim redundant vaginal epithelium and close the dead space between the vaginal wall and the graft to avoid hematoma formation by including the graft in several of the vaginal wall repair stitches.
Graft use for a sacrocolpopexy
In addition to vaginal prolapse repair, biologic grafts have been used with variable results in other applications, including sacrocolpopexy. In 1 trial, women with vaginal vault prolapse were randomized to either synthetic mesh versus cadaveric fascia lata during robotic sacrocolpopexy. After 1 year, the objective success rate (defined as Stage 0-1 prolapse) was 91% in the synthetic mesh group, compared with only 68% in the fascia lata group.26 In another study, women were randomized to either synthetic mesh or a cross-linked porcine dermis (PelviSoft, Bard).27 There was no significant difference in success rate between these 2 grafts, which is not surprising given the fact that the cross-linking of the biologic graft makes the graft resistant to degredation. It is unclear what advantage there would be to using a biologic graft that does not degrade, since there is abundant literature to support the efficacy and safety of polypropylene mesh in sacrocolpopexy.
As shown by the conflicting findings in the scientific literature, it appears that not all biological grafts are created equal, nor can one extrapolate results from different anatomical compartments. Biological grafts may be useful as an alternative to synthetic mesh in patients with POP who are at risk for failure with native tissue repairs. More robust long-term trials need to be undertaken to help guide the proper use of specific biological grafts in pelvic reconstructive surgery.
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