CHOICES OF NATIVE TISSUE REPAIR

I Wayan Megadhana1

1
Obstetrics and Gynecology Department, Faculty of Medicine Udayana University,

Udayana University/Sanglah General Hospital Denpasar, Bali, Indonesia

Abstract

Background Pelvic reconstructive surgery is mostly done for pelvic organ prolapse

(POP), a pelvic floor disorder that has affected women’s health worldwide, since the

dawn of humanity. Despite conservative treatment, 11% of women will require

surgical intervention by age 80 years old. Then, the surgeons are faced with options

of surgery that has evolved over the past few decades.1

Treatment of pelvic organ prolapse is commonly surgical, aiming to restore the

anatomy of structures supporting the pelvic organs, reduce the symptoms, restore

sexual function, prevent recurrence and improve quality of life. The surgical repair

techniques are classified as native tissue repair (NTR) when only pelvic organ

support tissue are used, and augmented repair (AR) when some other material

(prosthesis or graft) is used to reinforce the defective support system.2

Discussion Although a large number of surgical repair techniques for POP have been

described, treatment of this condition continues to be a clinical challenge for

urogynecological surgeons.3 There is high-quality evidence to support the use of

native tissue reconstructive repairs as surgical treatment of bothersome symptomatic

prolapse of all compartments. NTR have high rates of success. 4 A prospective

comparative study reported a success rate of 35% for anterior colporraphy based on a

combined anatomical and functional definition as recommended recently. 5 Vaginal

mesh augmentation has provided anatomic benefits and decreased prolapse awareness

but is associated with higher rates of de novo stress urinary incontinence, bladder

injury and reoperations compared with NTR. The indications for the use of a mesh

during POP surgery have been widely debated after the Food and Drug

Administration (FDA) of the USA provided a second warning on the adverse effects

of TVM surgery in 2011. Mesh surgery expose to serious complications, introduces

risks not present in traditional non-mesh surgery and even if mesh may provide more

anatomic benefit, symptomatic result is not better. 6 The FDA noted that erosions are

the most common mesh-related complications and they can lead to symptoms such as

bleeding, pelvic pain and dyspareunia or apareunia.7

Conclusion For mild, first-episode POP, after failure of conservative measures,

native tissue repair should be performed, unless the surgeon believes that a mesh-

augmented repair is indicated. If an apical defect exists, ASC is an excellent option,

especially if the patient is sexually active. Although its use is controversial,

transvaginal mesh should be reserved for complex cases at high risk of failure, such

as multicompartment or recurrent prolapse. Transvaginal mesh should only be used in

the hands of trained and experienced surgeons. Patient factors, such as age and co-
morbidities, sexual activity and risk factors for recurrence including severity of

disease, pelvic floor muscle weakness, constipation, and so on and patient preference

should always guide the decision-making process.

Keywords: Pelvic Organ Prolapse, Native Tissue Repair, Transvaginal-Mesh,

Pelvic Reconstructive Surgery, Urogynecology

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