Site-Specific Prolapse Surgery. II: Vaginal Paravaginal Repair Augmented with either Synthetic Mesh or Remodelling Xenograft

Abstract

Background: Cystocoele repair has been problematic for several reasons. Pelvic anatomy is extremely complex; the difficulty of curing prolapse increases with time and tissue weakness; and reparative efforts have been confounded by 100 years of mechanically inappropriate surgical strategies. In normal women, the levator plate acts as a dynamic backstop, absorbing most of the Valsalva forces. Conversely, pelvic connective tissue is basically an embryologic mesentery, anchoring the pelvic viscera to the axial skeleton. Main suspensory role is to stabilize the organs over the posterior levator plate, where the levator plate works most effectively. Unfortunately, muscle damage sustained at childbirth is not reparable. Hence, strategies for re-suspending sagging pelvic organs are unduly reliant upon the repaired connective tissue. Anything that either weakens or strengthens the endopelvic fascia therefore assumes great surgical importance. In this respect, prolapse repair is similar to herniorrhaphy, where surgical strategies now address both mechanical and metabolic factors. Objective: To investigate whether tissue augmentation delivered any additional benefit, over and above effective mechanical repair.