Dear Bassem,

I do not believe that a midurethral sling (MUS ) is useful for treating anterior low grade POP. Namely, MUS is positioned under the midurethra and serves only for urethral support thus preventing urethral hypermobility causing SUI, and has nothing to do with the anterior compartment prolapse. You should address anterior POP with anterior colporrhaphy which can be performed in 15 minutes under local anesthesia. In case of anterior POP recurrence the mesh interposition is recommended (e.g. Elevate, Perigee..).

Kind regards,

Igor

MUS is not open for me.

MUS when combined with repair of cystocele (ant colporrhaphy) has been shown in one study to reduce the likelihood of recurrent cystocele as compared to a anterior colporrhaphy alone but by itself it is not a treatment of anterior wall prolapse.

MUS reinforces a lax pubourethral ligament (PUL), the prinicipal cause of USI. PUL is not a cause of cystocele. Cystocele is caused by laxity in either by dislocation of the cardinal ligament (CL) &pubocervical fascia (PCF) attachments to the anterior cervical ring and/or dislocation of PCF to ATFP, or TAFP from its insertion into the ischial spine.

If the 15 minute anterior repair involves excision of vaginal tissue, all it will do is shorten the vagina and cause further prolapse.

A vaginal repair with conservation of vaginal tissue is far more preferable.

The problem with mesh sheets such as Elevate is that they are placed into the vesicovaginal space. This glues the vagina to the bladder and eliminates the vesicovaginal space which is importan for normal movement by the pelvic floor muscles. Excess tension by Perigee is a major cause of pelvic pain. Such meshes are difficult to remove surgically.

Bottom line: if the POP is low grade , leave it alone.

I do not fully agree and therefore do not support your statements, Peter.

In case of central cystocele, the anterior colporrhaphy is just sufficient. Acc. to my experiences it could be nicely done in local anesthesia (15 minutes) and the result is good and the vagina is not shorter at all! If this is the case then the technique used is wrong. The tissue is not put under tension - if this is the case, then the recurrence is to be expected.

If the lateral cystocele is the case, then anterior colporrhaphy is not a proper approach. In that case one should do paravaginal repair or use mesh (e.g. Perigee).

In my experience the mesh or mesh contraction does not lead to pelvic pain and does not represent the major cause for pelvic pain.

Usually, mesh is used for older patient, who experience osteomuscular pelvic pain which originates from L4-S1 region (lumbar pain, lumboischialgia etc, fibromialgia). And then it is quite normal, that patient with these problems experience pain (or dyspareunia) if one is inserting mesh in them..

However, I do agree with you, dear Peter, that meshes are difficult to remove surgically.

Bottom line:

1. Listen to the wish of the patient and provide them the least invasive and the most successful surgery at the same time.

2. Avoid mesh procedures in patients in whom the palpation of the pelvic floor bones and muscles during gynecologic examination is painful...

thanks for your comments: the reason behind asking is that I feel that a goo MUS alone can correct low grade (Baden-Walker or POPQ grade 1-2) by just casuing good elevationof the midurethral segment and bladder base.

The concomitant repair of both anteiror POP and SUI could be curative. A study isneeded to answer that

HI all! Thanks for inviting me!!! Now I like the POPQ statement. What is a low grade cistocele? A low grade cystocele at home is a Stage II Ba+1 as our usual case is the IVC + 7….

If it's like Peter said, I fully agree with him, leave it like it is as you will probably change the whole urinary function after correction of the cystocele and besides that stastitically you have 50% chance of having the same defect at mid term follow up with tons of paper stablishing this. But if you decide to correct it, and place a sling for SUI that sling will never be at the bladder base at least if properly positioned. It may be at the miduretha or at the bladder neck, but never at the base. If it's at the bladder base then it will be at the opposite side which is the apex. Like in the old Shlomo Raz's four corner bladder suspension to correct cystoceles. The old guys will remember this. Two sutures close to the bladder neck and two to the bladder base, close to the cervix if present or the cuff.

The paper you mentioned is a quite old one written by P. Sand's group published at Am J Obstet Gynecol 2001;185:1307–13. That paper (to my knowledge) is probably the only one. It doen't make much sense to me but was published.

But let me tell you that from the strict urologic standpoint, the bladder base is the at opposite than the bladder neck and of course the urethra. I really cannot understand how a sling at any place of the urethra can be at the same time at the bladder base in a Stage 2 POP.

Igor I also agree with you regarding meshes. Feedback in this topic is essential these days. Use of meshes in the right patient and for the right patient is no doubt advantageous both for patiens and surgeon. Moreover in our local reality where uterine sparing surgery is our local standard of care, stage IV is the usual case, patient should be discharged the morning after if not the same day and you have to go vaginally as almost no complex laparoscopic or robotic facilities are available at vast majority of our hospitals

Thanks again for inviting me

The treatment will depend on patient's age, obstetrical history and how much she is incapacitated by the defect. I agree with 'Leave it alone' approach as suggested by Peter Petros if patient is not troubled by the existing vaginal wall prolapse. However, if surgical repair is to be done, the repair of anterior POP will depend upon type of underlying defect. In central defect it is site specific repair with attaching pubocervical fascia to pericervical ring and paravaginal repair in lateral defects. I am not aware of dislocation of cardinal ligament causing anterior POP, as suggested by Peter Petros. Mid urethral sling is not going to help, unless there is associated urethral hypermobility.

Hi Veena

It is not well known that the cardinal ligament (CL) inserts laterally to the cervix but then it reflects anteriorly to attach to the anterior cervical ring where it becomes attached to the pubocervical fascia (PCF) . At childbirth, the CL can become ruptured to dislocate from PCF and cervical ring. The anterior vaginal wall then rotates downwards like a trapdoor, so the bladder prolapses down. This is known as a high rectocele or transverse defect. The classical clinical sign of this is prolongation of the vaginal epithelium on the lateral side of the cervix. If you grasp the vagina 2cm lateral to the cervix with Allis forceps and bring them together on the anterior aspect of the cervix, , you will reduce the cystocele.

Have a look at www. pelviperineology.org "Wagenlehner F, Petros PEP, Gunnemann A, Richardson PA, Sekiguchi Y Cardinal ligament - a live anatomical study, Pelviperineology 2013; 32: 72-76 "

We have found that reinforcing the CL with the TFS also restores the depth of the sulcus. We attribute this to re-attachment of ATFP by the TFS anchor to its insertion point at Inman's point, just above the ischial spine.

Best wishes

Peter Petros

Further comments for Bassem Wadie

Dear Bassam

I think that in some cases what you say may be correct.

We have found that the two main causes of cystocele are lateral defect , dislocation of pubocervical fascia (PCF) from ATFP and high transverse defect, dislocation of PCF from the cervical ring.

In my experience, isolated lateral defect is rare. If we find such a defect, we insert a TFS sling which pulls the laterally dislocated PCF upwards to re-attach it to the ATFP.

The insertion point of ATFP is directly above the pubourethral ligament (PUL).

So in such lateral defect cases with intact PCF/cervical ring attachment, a MUS may well elevate a lateral (distal) cystocele.

The role of repair in any prolapse depends on the symptomatology, Its a quality of life issue. Further the mesh repairs give a good good anatomical support, the long term complications as the mesh erosion is a problem.

Split facial repair gives good support if patient is symptomatic, If she is asymptomatic, why repair?

Hi Bassem

That is a very interesting perspective and the answer is not really 100% clear

I will try and discuss it from an anatomical perspective.

From an anatomical perspective, a midurethral sling repairs only a damaged pubourethral ligament (PUL)

Originating immediately above the PUL is the ATFP ligament. The anterior vaginal wall attaches distally to ATFP, much in the way that a sheet attaches to two washing lines..

De Lancey has shown that the ATFP dislocates proximally from its attachment to the ischial spine, not distally. So the ATFP is usually intact distally

My experience accords with this. It is the detachment of vagina from ATFP which causes lateral defect, not detachment with of the ATFP itself

SO it can be concluded that a MUS may possibly elevate the distal vagina to some extent, but it cannot repair cystocele per se.

I agree with Sanjay about a Split facial repair . It is a much neglected technique which really does exactly the same thing as mesh without the problems which mesh gives. What it does is to produce a double layer which prevents descent of the cystocele. My experience  with it is descrbed in my textbook "The Female Pelvic Floor", 3rd Ed Springer 2010.

Peter:

Thanks a lot for this informative answer. I am running a prospective study and I am having difficulty in getting good quality high evidence level kind of references. I hope when we start to present our data I can share with you and anyone interested in the subject