Disappointing long-term results with vaginal prolapse surgery have fueled a search for surgical alternatives. Your patients have much to gain from this quest—considering that more than 1 in 10 women are at risk for undergoing pelvic organ prolapse surgery sometime in their lifetime, and about 30% of them will have a repeat prolapse surgery.1 Moreover, the long-term anatomical outcomes of vaginal surgery are highly variable, with a failure rate for traditional cystocele repairs, for example, of up to 37%.2-4
In the past 10 years, the search for surgical alternatives has turned to the question of whether graft materials could improve the success rate of vaginal repairs. Our colleagues in general surgery have increasingly relied on synthetic grafts for ventral and inguinal hernia repairs. Aware that prosthetic meshes decrease recurrence of hernias and are well-tolerated in the anterior abdominal wall, gynecologists have extrapolated this experience to the repair of vaginal prolapse.5,6 A related development is the widespread use of polypropylene slings to correct stress incontinence. As gynecologists have become more familiar with synthetic grafts for incontinence procedures, the addition of grafts for other types of pelvic surgery has become more appealing.
Which grafts are best for vaginal surgery?
A variety of materials have been used as surgical grafts. In considering graft materials, ask these three main questions: (1) Does the graft improve the function of the repair? (2) Does it make the repair more durable? (3) Does the graft increase the rate of complications? Finding a material that strikes the right balance in answering all three questions is the key to success. Despite advances in technology, the ideal material has not been developed. (Table 1 lists the properties that the ideal material would have.7)
Graft materials for vaginal surgery, many of which are commercially available, can be divided into two main categories: synthetic and biologic. The synthetic are either absorbable or permanent, while biologic graft materials fall into three categories: (autograft, allograft [cadaveric], and xenograft. Autografts are tissues from the same person (fascia lata, rectus fascia); allografts are tissues from another human (e.g., skin or fascia lata), and xenografts are tissues (skin, pericardium, or intestinal submucosa) from another species.
Specifically, pore size that exceeds 75 µm allows leukocytes and macrophages to pass through. In contrast, materials with pore size less than 75 µm are more likely to contribute to chronic bacterial colonization.9 Gynecologists seeking a permanent mesh for vaginal repair will therefore be most interested in Type I materials—completely macroporous mesh (of > 75 µm pore size). An example of a totally microporous graft is Gore-Tex. Due to various postoperative complications with this material, likely due to its architectural properties, it is no longer in use.
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