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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_894_Библиотеки_им_академика_М_И_Перельмана.pdf
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E. R. Raskin
59. Takano S, Boutros M, Wexner SD. Gracilis transposition for complex perineal stulas: rectovaginal stula and rectourethral stula. Dis Colon
Rectum. 2014;57(4):538. https://doi.org/10.1097/
DCR.0000000000000093.
60. Lefevre J, Bretagnol F, Maggiori L, Alves A, Ferron
M, Panis Y.Operative results and quality of life after
gracilis muscle transposition for recurrent rectovaginal stula. Dis Colon Rectum. 2009;52:1290–5.
61. Wexner S, Ruiz D, Genua J, Nogueras J, Weiss
E, Zmora O. Gracilis muscle interposition for the
treatment of rectourethral, rectovaginal, and pouchvaginal stulas: results in 53 patients. Ann Surg.
2008;248:39–43.
62. Fürst A, Schmidbauer C, Swol-Ben J, Iesalnieks
I, Schwander O, Agha A. Gracilis transposition
for repair of recurrent anovaginal and rectovaginal stulas in Crohn’s disease. Int J Color Dis.
2008;23:349–53.
63. Schloericke E, Hoffmann M, Zimmermann M, Kraus
M, Bouchard R, Roblick U, Hildebrand P, Nolde J,
Bruch H, Limmer S.Transperineal omentum ap for
the anastomotic reconstruction of the rectovaginal
space in the therapy of rectovaginal stulas. Color
Dis. 2011;14:604–10.
64. van der Hagen S, Soeters P, Baeten C,
van Gemert W. Laparoscopic fistula excision and
omenoplasty for high rectovaginal fistulas: a prospective study of 40 patients. Int J Colorectal Dis.
2011;26:1463–7.
65. Mukwege D, Mukanire N, Himpens J, Cadiere
G. Minimally invasive treatment of traumatic high rectovaginal fistulas. Surg Endosc.
2016;30:379–87.
66. Maggiori L, Blanche J, Harnoy Y, Ferron M, Panis
Y. Redo-surgery by transanal colonic pull-through
for failed anastomosis associated with chronic pel-
vic sepsis or rectovaginal stula. Int J Color Dis.
2015;30:543–8.
67. Hallet J, Bouchard A, Drolet S, Milot H, Desrosiers
E, Lebrun A, Gregoire R.Anastomotic salvage after
rectal cancer resection using Turnbull-Cutait delayed
anastomosis. Can J Surg. 2014;57:405–11.
68. Rivadeneira D, Ruffo B, Amrani S, Salinas
C. Rectovaginal stulas: current surgical management. Clin Colon Rectal Surg. 2007;20:96–101.
69. Lamazza A, Fiori E, Schillaci A, Sterpetti A, Lezoche
E. Treatment of rectovaginal stula after colorectal
resection with endoscopic stenting: long-term results.
Color Dis. 2014;17:356–60.
70. El-Gazzaz G, Hull T, Mignanelli E, Hammel J,
Gurland B, Zutshi M.Analysis of function and predictors of failure in women undergoing repair of
Crohn’s related rectovaginal stula. J Gastrointest
Surg. 2010;14:824–9.
71. Lofer T, Welsch T, Muhl S, Hinz U, Schmidt J, Kienle
P. Long-term success rate after surgical treatment of
anorectal and rectovaginal stulas in Crohn’s disease.
Int J Color Dis. 2009;24:521–6.
72. Hull T, Fazio V.Surgical approaches to low anovaginal stula in Crohn’s disease. Am J Surg. 1997;173:
95–8.
73. Ruffalo C, et al. Outcome of surgery for rectovaginal stula due to Crohn’s disease. Br J Surg.
2009;96:1190–5.
74. Shah N, Remzi F, Massmann A, Baixauli J, Fazio
V.Management and treatment outcome of pouch-vaginal stulas following restorative proctocolectomy.
Dis Colon Rectum. 2003;46:911–7.
75. Lambertz A, Luken B, Ulmer T, Bohm G, Neumann
U, Klink C.Inuence of diversion stoma on surgical
outcome and recurrence rates in patients with rectovaginal stula—a retrospective cohort study. Int J
Surg. 2016;25:114–7.
Pelvic Organ Prolapse andPerineal
Hernias
DanaR.Sands, DanielS.Lavy, andEricA.Hurtado
12
Introduction
As dened by the Joint Report on the
Terminology for Female Pelvic Organ Prolapse
(POP) by the International Urogynecological
Association (IUGA)/International Continence
Society (ICS), pelvic organ prolapse is dened
as an anatomical change (i.e. downward displacement) of the pelvic organs which includes
the uterus and/or the different vaginal compartments involving such organs as the bladder,
rectum, or bowel [1]. Along with POP, urinary
incontinence and bladder and bowel dysfunction
comprise the category of pelvic oor disorders.
Although rarely life threatening, these disorders can have a great impact upon one’s quality of life. Not long ago these disorders were
rarely discussed, and many women suffered in
silence. As medical knowledge has expanded,
growth in understanding these disorders has followed. Once thought to be uncommon, it is now
known that the prevalence of one or more pelvic oor disorders among US women was 25%
among 8368 non-pregnant US women surveyed.
D. R. Sands (*) · D. S. Lavy
Department of Colorectal Surgery, Cleveland Clinic
Florida, Weston, FL, USA
e-mail: sandsd@ccf.org
E. A. Hurtado
Department of Gynecology, Section of
Urogynecology and Reconstructive Pelvic Surgery,
Cleveland Clinic Florida, Weston, FL, USA
Of those women, 2.9% reported prolapse by
answering “yes” to the question, “Do you see or
feel a bulge in the vaginal area?” [2]. In another
study of 479 women presenting for their annual
gynecologic exam, 48% of women were noted
to have Stage 2 POP (1cm within to 1cm past
the hymen), and 2.6% of women were noted to
have Stage 3 POP (greater than 1cm past the
hymen) [3]. Once diagnosed, approximately 1in
9 American women will undergo surgery for a
vaginal prolapse or a related disorder in their
lifetime [4].
POP is thought to begin by having an injury,
such as childbirth that damages the levator ani
muscles. With muscle damage and dropping
of the pelvic oor, the intra-abdominal forces
are placed upon the connective tissue attachments or “ligaments” that suspend the pelvic
organs. Certain individuals with geneticallyprone weakened connective tissue will then
be more susceptible to POP.Promoting factors
such as further vaginal deliveries, advancing
age, and obesity, may also place individuals
at risk for POP. Heavy lifting, straining from
constipation, and previous hysterectomy may
be other risk factors [5, 6]. POP may be graded
by the Baden-Walker halfway system where
grades are made in reference to halfway to the
hymen or halfway past the hymen [7]. POP
may also be graded by the POP quantication
system or POP-Q.It is a system where different points along the anterior vaginal wall, pos-
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_12
205
206
D. R. Sands et al.
terior wall, and apex are measured in reference
to the hymen and categorized into 4 stages [8].
Currently, the POP-Q is the most commonly
used in research since it can measure specic
changes in pelvic support.
Rectocele
The rectovaginal fascia, sometimes named the
rectovaginal septum is a thin structure separating the vagina from the rectum. A rectocele is
dened as a weakness in this rectovaginal fascia
with resulting herniation of the rectal wall into
the vaginal lumen [9]. Age, obesity, and stress
of vaginal delivery can be contributory factors.
Additionally, some rectoceles may be caused by
a paradoxical sphincter response, leading to an
outlet obstruction. Straining to defecate in the
setting of paradoxical contraction of the levator
muscle can result in increased pressure anteriorly
in the rectum, contributing to a rectocele [10].
The normal vagina is supported on three
levels, thus the etiology of rectoceles forms at
these same anatomic levels: high, mid and low
(Fig.12.1a–c). High level rectoceles are due to
weakness at the upper third of the vaginal wall
and cardinal or uterosacral ligaments. These
can be associated with enteroceles, cystoceles
and uterine prolapse, which may need to be
addressed at the same time. Mid level rectoceles
are most common, and are usually secondary
to loss of pelvic oor support due to childbirth.
Low level rectoceles are a result of perineal
body defects secondary to trauma from vaginal
childbirth. Obstetrical injury during childbirth
commonly leads to perineal lacerations and
weakening of bulbocavernous and transverse
perineal muscles [11].
Patients often present with a variety of complaints including obstructive defecation, dyspareunia and most commonly, perineal pressure
[11]. Women may report a need to digitally
reduce the vaginal bulge in order to evacuate their
bowels.
Without digital assistance in evacuation,
women complain of increasing degrees of perineal pressure, which can then translate into a
a
c
b
Fig. 12.1 Anatomic levels of rectoceles. (a) High rectocele. (b) Mid rectocele. (c) Low rectocele
12 Pelvic Organ Prolapse andPerineal Hernias
207
cycle of increasing pelvic pressure, stronger
valsalva efforts, increase in size of rectocele
bulge, and a further increasing perineal pressure [9].
Patients may also complain of vaginal looseness and decreased sensation during intercourse
secondary to the progressive enlargement of
genital hiatus. If the rectocele extends beyond the
hymenal ring the patient may present with vaginal ulceration or erosion.
Diagnosis
Physical Examination
Physical examination should be performed in a
prone or supine position. A digital rectal examination and a vaginal examination should be
performed. Typical ndings in a female with
a symptomatic rectocele include a bulge in the
lower posterior vaginal wall.
Various classication tools have been devised
in order to calculate severity of rectocele. The
Baden-Walker system was originally created and
uses the mid-vaginal plane to calculate degree of
prolapse. Anatomic defects are graded from 0–4.
Grade 0 is normal while grade 3 extends beyond
the hymen. The pelvic organ prolapse quantication (POP-Q) system is a clinical tool used to
quantify the degree of prolapse. It provides for
a reproducible method to determine the relative
position of cervix and posterior vaginal fornix in
order to calculate the total vaginal length during
straining maneuvers. POP-Q system uses dened
points to measure degree of prolapse instead of
the underlying organ, which decreases clinician
variability [12, 13].
table. The uoroscopic monitor is connected to a
video recorder, to allow for continuous recording
and review of the entire process. Images are taken
at rest (R), squeeze (S), and throughout push
(P); some advocate for a post-evacuatory lm to
evaluate for complete emptying. Anorectal angle
(ARA), perineal descent (PD), and rectocele
diameter can be measured (Fig.12.2). Rectocele
diameter is the distance between anorectal
axis and the anterior most portion of rectocele
(Fig.12.3) [14].
Fig. 12.2 Measurements of anorectal angle (ARA), perineal descent (1) and rectocele diameter (2) can be obtained
from defecography
Imaging/Anorectal Physiologic Tests
Defecography can be a useful tool to adequately
detect the presence of a rectocele, and to further
evaluate rectocele size, degree of emptying, and
signs of obstructed defecation.
The study is performed by injecting 100–
200 cc of radiopaque paste directly into the
rectum, with the patient lying on the left lateral
position. The subject is then seated upright on
a radiolucent commode on a uoroscopic x-ray
Fig. 12.3 Defecogram (lateral view) rectocele diameter
is the distance between the interpolated anterior anorectal
axis and the anyerior most portion of the rectocele
208
D. R. Sands et al.
Treatment
Nonoperative
The most frequent complaint in patients
with rectocele is difculty with defecation.
Therefore, even after the diagnosis is conrmed, an attempt should be made for conservative treatment prior to surgical intervention.
25–35g ber/day in addition to adequate uid
intake (2–3 L of non-caffeinated nonalcoholic
liquid) is recommended. If the patient is still
experiencing symptoms after 8–16weeks, surgical therapy should be considered. Paradoxical
sphincter reaction (PSR), also termed anismus
or paradoxical puborectalis contraction is a frequent nding in patients with rectoceles. These
patients have incomplete rectal emptying as a
result of lack of relaxation of anal sphincters
and the puborectalis during straining and rectal
evacuation. The relationship between PSR and
rectocele is controversial. Some advocate that
PSR may lead to poor outcomes after rectocele repair [12]. Biofeedback is a viable option
where patients learn to evacuate the rectum with
a normal physiologic response. Success with
this technique is highly variable and depends
on aptitude of the therapist and diligence of
patient. Mimura etal. showed that biofeedback
therapy can lead to major symptom relief in a
minority and partial symptom relief in majority of patients with a rectocele and a feeling
of impaired defecation, thus the initiation of
biofeedback therapy may be a viable rst line
option in patients with both PSR and a large rectocele [15]. Surgical repair is reserved for those
patients with rectocele larger than 4cm, which
do not empty on defecography and have failed
medical therapy symptoms that are attributable
to the defect. Relief of evacuatory symptoms
with perineal or vaginal support maneuvers is a
common nding as well.
Operative
Transvaginal (Posterior Colporrhaphy)
Transvaginal approach is typically the procedure of choice used by most gynecologists. This
technique can involve plication of the levator
muscles and the vaginal muscularis in the midline and resection of redundant vaginal wall [12].
General anesthesia is used and patient is placed
in lithotomy position. Retractors are placed in
the vagina to expose the rectocele and a nger
is used to determine the extent of the defect.
Using electrocautery or scalpel, a transverse or
anchor-shaped mucosal incision is created at the
mucocutaneous border. After submucosal aps
have been raised, lateral mobilization of the rectovaginal septum is undertaken. Allis clamps are
then placed at the edges of the defect of the rectovaginal fascia(muscularis). The rectocele defect
is then closed in either a vertical or horizontal
fashion with absorbable interrupted sutures while
simultaneously depressing the anterior rectal
wall. Excess vaginal epithelium is trimmed and
then re-approximated with absorbable sutures
(Fig.12.4).
This technique has historically provided
good functional results. However, many studies
have reported high rates of sexual dysfunction.
One of the most common forms of sexual dysfunction includes dyspareunia, which has been
reported between 20–50% [9, 16, 17]. This may
be attributed to too tight of a levator plication,
causing vaginal narrowing and dyspareunia
[9, 17]. This led to the evolution of a modied
rectocele repair, where instead of plicating the
levator muscles in the midline, discrete fascial
defects in the rectovaginal septum are closed.
Several studies noted improvement in sexual
dysfunction ranging from 66–92% of patients
[12, 17–19].
Transperineal
The transperineal approach is another approach
that has been shown to have good functional
results [20]. This approach necessitates a prone
jackknife patient position. A U shaped incision
is made in the perineum, and dissection occurs
in the plane between the eternal anal sphincter
(EAS) and vaginal epithelium. An L shaped strip
of posterior redundant vaginal wall is retracted
and resected. The resected vaginal wall is sutured
closed with 3–0 absorbable sutures and the space
between rectal and vaginal walls is closed. Levator
plication is completed to further strengthen the
ab
12 Pelvic Organ Prolapse andPerineal Hernias
209
c
Fig. 12.4 Transvaginal rectocele repair (posterior colporrhaphy). (a) Incision is made in vaginal mucosa, (b) Rectocele
is rediced and lateral rectocaginal fascia is plicated in the midline with interrupted sutires, (c) Excess mucosa is excised
and closed
210
D. R. Sands et al.
rectovaginal septum with or without the use of
mesh. The skin is then completely closed. A randomized controlled trial of 62 patients in 2010
showed statistically signicant improvement in
defecatory symptoms in comparison to the transanal approach. Additionally, patients receiving
transperineal repair with levatorplasty had signicantly greater functional scores than patients
receiving transperineal repair alone or transanal
repair (Fig.12.5) [20].
Transanal
The transanal approach is preferred by colorectal surgeons since they are familiar with this area.
a
In addition, many of their patients have other
concomitant anorectal pathology such as hemorrhoids, ssure, and anterior mucosal prolapse.
Additionally, postoperative pain may be less than
a transvaginal approach [9, 11, 12, 14]. However,
the access to high rectoceles may be limited
in this approach due to the high rates of anal
incontinence as a result of excessive dilation for
proper exposure [11]. The patient rst receives a
mechanical and antibiotic bowel preparation. The
patient is then placed in a prone jackknife position
with buttocks taped apart. The rectum is cleaned
with povidine-iodine and exposure is obtained
with a retractor (e.g. Pratt bivalve). Digital pal-
b
Fig. 12.5 Transperineal rectocele repair. (a) Surgical
repair is performed through a U-shaped perineal incision.
(b) Redundant vaginal mucosa is retracted and resected.
c
(c) Resected vaginal wall is sutured closed (inferiorly)
and ‘levator’ plicated with sutures. The skin is completely
closed without drainage
ab c
12 Pelvic Organ Prolapse andPerineal Hernias
Fig. 12.6 Transanal rectocele repair. (a) Mucosal ap is created, (b) Rectal wall is plicated, (c) Excess mucosal is
excised and closed
211
pation is used to conrm the size of the rectovaginal defect. Local anesthesia is injected into
the submucosal plane, and a vertical, horizontal
or elliptical incision is created in the anorectal
mucosa depending on the repair. Mucosal aps
are then created, and the rectovaginal fascia is
then plicated with absorbable sutures. Redundant
mucosa is excised and closed with absorbable
sutures (Fig. 12.6). Most studies support high
rates of symptomatic improvement after transanal repair [21]. Despite this, a Cochrane review
found lower recurrence rates when a transvaginal
approach was used compared to transanal repairs,
however the vaginal approach was associated
with signicantly higher blood loss and narcotic
use. The review noted no signicant differences
rior vaginal wall down to the perineal body. The
rectocele is repaired by suturing the superior
fascia of the levator ani from the perineal body
to the uterosacral ligament. The uterosacralcardinal ligaments are then plicated using 2–0
absorbable sutures to the vaginal fornix or the
pubocervical fascia to reconstruct the vaginal
vault. This retrospective matched cohort study
comparing laparoscopic and transanal repair
of rectoceles showed that patients treated with
the transanal repair showed signicantly higher
degree of bowel symptom alleviation sustained
over a longer period of time than patients treated
laparoscopically. However, those treated laparoscopically had a lower rate of post-operative
dyspareunia [23].
in rates of post-operative incontinence or dyspareunia [22].
Cystocele/Anterior Vaginal Wall
Laparoscopic Rectocele Repair Technique
Laparoscopic approach is another method specically designed to address the fascial defects
seen from above the pelvic oor. Thornton etal.
described a technique of laparoscopic repair.
After general anesthesia is induced and entry
into the abdomen is obtained, dissection of the
posterior compartment begin with uterine or
vaginal vault elevation to display the uterosacral ligaments. An incision is then made in the
peritoneum medial to the ureters. The superior
fascia of the levator ani is exposed by dissecting medial to the uterosacral ligaments into the
pararectal space. The rectovaginal space is then
dissected in order to properly expose the poste-
Prolapse
A cystocele (Fig. 12.7) is dened as a hernia
of the urinary bladder, especially one protruding into the vagina [24]. This is also commonly
referred to as anterior vaginal wall prolapse as per
the IUGA/ICS Joint Terminology. Specically, it
has been dened as observation of descent of the
anterior vaginal wall, which is most commonly
thought to represent bladder prolapse [1]. Often
anterior vaginal wall prolapse will include an
apical component such as the uterus or vaginal
vault and is thought to contribute to the size of
the prolapse [25, 26]. Further treatment of the
vaginal apex will be discussed later.
212
Fig. 12.7 Cystocele. Reprinted with permission,
Cleveland Clinic Center for Medical Art & Photography
© 2017. All Rights Reserved
D. R. Sands et al.
some controversy exists as to whether these
different defects exist or are created surgically
during dissection. Apical cystoceles refer to anatomic defects in the superior third of the vagina.
This is thought to be from detachment of the
anterior vaginal wall muscularis from the cervical ring allowing the anterior wall to swing down
like a trap door. In contrast, a medial or midline
cystocele is felt to be from a weakness or thinning of the muscularis in the center of the vaginal
wall. Often, this is said to be associated with lack
of vaginal ruggation. The lateral cystocele may
result from ligamentous or muscularis defects
from the ATFP.This is also known as a paravaginal defect [27].
Diagnosis
Anterior vaginal wall prolapse is thought to
occur from compromise of the support structures
which include the vaginal muscularis (pubocervical fascia), tendinous arch, endopelvic fascia,
and levator ani muscle [27]. The vaginal wall
itself is composed of non-keritatinized epithelium, submucosa consisting of lamina propria,
and a peripheral muscle layer also known as the
muscularis. The muscularis is composed of collagen and smooth muscle, which lies under the
bladder base and neck to the cervical ring [28].
Weakness of the connective tissue is thought to
allow for stretching and is thought to contribute
to POP. Additionally, lack of support to a vaginal compartment can lead to POP. DeLancey
described three levels of vaginal support according to the “hammock theory”. According to this
theory, level 2 support comprised of the arcus
tendineus fascia pelvis (ATFP) gives lateral support to the vaginal wall [29]. Petros etal. instead
describe a system of connective tissue and ligamentous-fascial structures extending from the
posterior pubis to the S3 and S4 sacrum known
as the integral theory. Pelvic symptoms are proposed to come from laxity of these structures
[30].
When referring to cytoceles, they may be
divided into different sub-categories though
Treatment
Medical
When discussing treatments, non-surgical
options should be offered to all patients. There is
some controversy as to whether pelvic oor muscle exercises can improve mild prolapse but no
evidence supports its use with prolapse at higher
stages. With moderate to advanced prolapse, a
pessary can be offered. They are often made of
silicone in numerous sizes and several different
shapes that are either supportive or space occupying. Observation may also be offered to patients
without signicant voiding dysfunction.
Surgical
Often, patients opt for surgical management
as many do not wish to use a device that must
be removed and cleaned periodically. Surgical
repair of the anterior vaginal wall can be broken into reconstructive and obliterative surgery.
Obliterative surgery will be discussed with apical repairs. Within the reconstructive approach,
surgery may involve native tissue repair, biological grafts, or synthetic mesh. Traditionally,
anterior repair (colporrhaphy) has been used to
address anterior vaginal wall prolapse. This technique involves making a midline incision from
the bladder neck to the apex through the vaginal
epithelium. A split thickness dissection of the
12 Pelvic Organ Prolapse andPerineal Hernias
Fig. 12.8 The muscularis layer is plicated in the midline
with either interrupted or a running suture. Reprinted with
permission, Cleveland Clinic Center for Medical Art &
Photography © 2017. All Rights Reserved
anterior vaginal wall is then performed out laterally favoring more muscularis on the side of the
bladder rather than the vaginal epithelium. Once
completed, the muscularis layer is then plicated
in the midline with either interrupted or a running suture (Fig. 12.8). Permanent suture may
also be used but is often used as the rst layer in
a 2-layer technique to decrease the risk of suture
exposure in the future. The plicated tissue is also
often attached to the apex to address any possible
apical cystoceles. Site-specic repairs are performed in a similar fashion. However, the muscularis is then attached to the separated structure
such as a paravaginal repair where the muscularis
is reattached to the ATFP. Native tissue repairs
have been criticized due to their low success rate,
which has been reported to be as low as 30–57%
[31, 32]. However, many of these early studies that are often quoted do not address apical
defects and used strict anatomic criteria that may
not have reected patients’ symptoms.
In an effort to improve outcomes, it was felt
that biological grafts would be more successful
by reinforcing the weakened muscularis layer
213
and attaching laterally and apically to address
potential site-specic defects. Multiple products have been used including cadaveric skin,
cadaveric fascia lata, porcine skin, porcine small
intestine submucosa, porcine bladder, and bovine
pericardium among others. Different processing techniques have also been used from freezedrying to cross-linking to other special patented
techniques. Success rates have been difcult to
discern due to the paucity of randomized trials and the multitude of products. For example,
success rates with cadaveric dermis have varied
from 42 to 84% at 2years [33]. Currently, further
studies are underway to determine if biological
graft augmentation leads to superior outcomes.
Mesh suspension of the vaginal apex, also
known as sacrocolpopexy, has been performed
for decades. Due to the good success obtained
with this technique and the low success rates
with anterior repairs, surgeons began using synthetic mesh in the anterior compartment to mimic
these results. Many early reports demonstrated
improved success rates. However, new complications arose with the most common being mesh
exposure where mesh passes through the vaginal
epithelium. Although rare, severe complications
such as mesh erosion into the bladder and rectum have also been reported [34, 35]. Many of
the original studies were hand-sewn with attachment similar to biological graft augmentation. In
one of the few randomized controlled trials, 202
women were randomly assigned to traditional
anterior repair or anterior repair augmented with
a self-tailored low-weight monolament polypropylene mesh. Recurrence of anterior wall prolapse occurred in 38.5% of the traditional anterior
repair group versus 6.7% in the group with mesh
at 1 year. Though mainly asymptomatic, mesh
exposure was found to be 17.3% [36].
As early success rates with mesh augmentation appeared to be superior to native tissue
repair, several companies started producing
transvaginal mesh kits with standardized placement via the use of trocars passing through the
transobturator space and/or sacrospinous ligament. The rst kit to market in 2005 was the
Prolift™, which could be placed for anterior