The document discusses surgical outcomes for recurrent pelvic organ prolapse (POP). It finds that while anatomical recurrence rates after traditional anterior colporrhaphy for cystocele are high, reoperation rates remain low, suggesting symptoms may not be severe enough to require further surgery. Another study found higher anatomical and symptomatic failure rates when repairing recurrent POP compared to primary POP repairs. For recurrent POP, alternative techniques that provide better long-term durability may be beneficial. Overall, recurrent POP surgery can achieve reasonable anatomic results without mesh and significantly improve symptoms while avoiding mesh-related complications.

1. Chirurgia ricostruttiva fasciale della recidiva
Michele Meschia
Magenta

2. The results of native tissue vaginal POP repair are better than previously
thought with high patient satisfaction and acceptable reoperation rates
There is no difference in anatomic and subjective outcome when native
tissue vaginal repairs are compared with multicompartment vaginal mesh
Mesh exposure is still a significant problem requiring surgical excision in
approximately > 10% of cases
Several studies indicate that greater surgical experience is correlated with
fewer mesh complications

3. Incidence of recurrent pelvic organ prolapse 10 years following
primary surgical management: a retrospective cohort study.
Fialkow MF, Newton KM, Weiss NS. Int Urogynecol J 2008;19:1483-7
Overall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate of
recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)
Kaplan-Meier survival curve of recurrent prolapse within 10 years

4. Reoperation rate for traditional anterior vaginal repair: analysis
of 207 cases with a median 4-year follow-up.
Kapoor DS, Nemcova M, Pantazis K, Brockman P, Bombieri L, Freeman RM.
Int Urogynecol J 2010;21:27-31
Methods:
Retrospective case note review of 207 cases of primary anterior colporrhaphy
with/without other prolapse surgery.
Results:
While the anatomical recurrence rate of cystoceles at 3 months postoperatively
was 12%, the reoperation rate for recurrent cystocele by 50 months was 3.4%.
Comclusions:
While the anatomical recurrence rates for cystocele following traditional anterior
colporrhaphy might be high, the low reoperation rate at more than 4 years (3.4%)
suggests that patient's symptoms might not be bothersome enough to require
further surgery.

5. Prolapse recurrence 5 years after surgery
Compartment Anatomical Symptomatic
Any vaginal 31% 7.4%
site
Anterior 20% 5.5%
Apical 7% 4.2%
Posterior 15% 2.4%
Dietz-Itza, 2007

6. The challenge of recurrent POP
Outcome data from Olsen et al., with a 40% non-return correction factor applied to the known failure
count. Repairing recurrent prolapse by traditional re-suture of native tissues was associated with
approximately 60% higher failure rates, compared with surgical outcome in primary cases (67% v
41%).

7. • Assessment measures must include:
QoL
Degree of bother
Patient symptoms
Quantification of symptoms Relief of symptoms
Prevent de novo
Objective measurements Cure the anatomical
changes
QoL measurements
Prevent complications
No single outcome measure is appropriate in all cases

8. Definition of success
• No prolapse beyond the hymen
• Absence of prolapse symptoms
• Absence of retreatment
88% of women met the definition of success at 1 year
No differences among the 3 groups were noted for any outcomes

9. Primary versus recurrent prolapse surgery: differences in
outcomes.
Peterson TV, Karp DR, Aguilar VC, Davila GW Int Urogynecol J 2010; 21;483-8
Methods:
A retrospective study was performed comparing patients who underwent AC for
recurrent cystocele (group I) and a matched control group who underwent
primary AC (group II).
Results:
At 1 year
Successful anterior vaginal support was obtained in 78.2% of patients in group I
and in 81% in group II (p = 1.000)
At 2 years
42.8% of patients in group I and 71.4% in group II (p = 0.031) had no evidence
of POP
Conclusions:
Alternative surgical techniques that provide better long-term durability may be
beneficial in repair of recurrent anterior wall prolapse.

10. Pelvic Organ Prolapse repair
Surgical failures
• inappropriate choice of procedure (plan of surgery)
• surgeon expertise in pelvic floor repair
• defect in restoring fascial attachments
• inappropriate choice of suture materials
• inadequate control of bleeding (pelvic hemathoma)
• persistent increase in intra-addominal pressure
• poor connective tissue quality Birch C and Fynes MM, 2002

11. Post-op POP in non-treated compartment

12. Development of de novo prolapse in untreated vaginal
compartments after prolapse repair with and without mesh: a
secondary analysis of a randomised controlled trial.
Withagen MI, Milani AL, de Leeuw JW, Vierhout ME. BJOG 2012;119:354-60
Primary outcome
de novo pelvic organ prolapse stage II or higher in the untreated vaginal
compartments at 12 months after surgery.
Results
At 12 months ten of 59 women (17%) in the conventional group versus 29 of 62
women (47%) in the mesh group were diagnosed with a de novo pelvic organ
prolapse stage II or higher in the untreated compartment (P < 0.001, odds ratio
4.3, 95% confidence interval 1.9-10.0).
Additional apical support to a mesh-augmented anterior repair significantly
reduced the de novo prolapse rate.

13. Key points of reconstructive surgery
If the top of the tent caves in, the walls may follow
“ we believe the first step in any
anterior or posterior vaginal
repair is to ensure grade 0
support at superior segment ”
To ensure durable apical support, the
surgeon should establish continuity of
the anterior and posterior vaginal
fascia at the vaginal apex or cervix.
Baden WF, Walker T
Surgical repair of vaginal defects,1992

14. Apical Support
Critical to Cystocele
PCF fixation to USL

15. Bladder Prolapse versus Uterine Prolapse
Summers et al, Obstet Gynecol 2006
60% of bladder descent explained by apical descent
Cervical (Apical) Descent
Bladder Descent

16. Anterior repair
Dissection carried forward to the pubic Ultralateral plication with interrupted stitches
bone using delayed or unabsorbable sutures

17. Posterior repair
The perineal body connects the two
perineal membranes
When it breaks nothing holds the rectum in place

18. Wide genital hiatus is a risk factor for recurrence following
anterior vaginal repair.
Medina CA, Candiotti K, Takacs P. Int J Ob/Gyn 2008; 101:184-7
Methods:
A retrospective cohort study was performed on patients who had undergone an
anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide
genital hiatus (> or =5 cm) or normal genital hiatus (<5 cm). The wide genital
hiatus group (n=35) was compared with the normal genital hiatus group
(n=30)
for surgical failure.
Results:
The rate of postoperative anterior vaginal wall prolapse was greater in patients
with a wide genital hiatus compared with those with a normal genital hiatus
(34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0
24.1]; P=0.02).

19. Permanent suture used in uterosacral ligament suspension
offers better anatomical support than delayed absorbable
suture.
Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL.
Int Urogynecol J 2012; 23:223-7
Methods
Permanent and delayed absorbable sutures were compared for failure of
anatomical support. Failure, defined as recurrent prolapse beyond the hymen,
was evaluated using survival analysis.
Results
Two hundred forty-eight procedures were performed. One percent in the
permanent group had a loss of support beyond the hymen compared to 6% in
the delayed absorbable group (p = 0.034). The number of sutures used did not
differ between patients who failed and those who did not fail.

20. Mission impossible?

21. Successful surgical management of the patient with anatomic
support defects requires accurate preoperative and
intraoperative identification of each defect and specific
reconstructive procedure to correct each defect.
Shull 1992
Intraoperative evaluation of the prolapse can reveal
significant changes as compared with the preoperative
situation. In general, the prolapse is more pronounced
especially in the middle and posterior compartment.
Vierhout 2006

22. Ensure strong apical fixation

23. Obstet Gynecol 2007
Variability in failure rates was observed depending
on site of and grade of vaginal support, p < .05
Grade 2 3
Any site 28.8% 4.8%
Among pts with grade > 2 POP
Anterior 21.3% 3.7% failure rate for symptoms was 10.3%
Apical 7.2% 2.7%
Posterior 6.3% 2.3%

24. Associated defects
Enterocele repair
• Commonly found in association with vault prolapse
• Ligation of hernia sac and obliteration of the pouch of
Douglas

25. Associated defects
Cystocele repar
Midline repair
• Fold sides across middle
• Fixation of PCV to USL remnants
Paravaginal Repair
• Reattach bladder to Obturator
Internus muscle

26. Goal

27. Trocar-guided mesh compared with conventional vaginal
repair in recurrent prolapse: a randomized controlled trial.
Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME.
Obstet Gynecol 2011; 117:242-50
Methods:
Patients were randomly assigned to either conventional vaginal prolapse surgery
or polypropylene mesh insertion.
Results:
97 women underwent conventional repair and 93 mesh repair.
Twelve months post-surgery, anatomic failure in the treated compartment was
observed in 45.2% of patients in the conventional group and in 9.6% in the mesh
group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18).
Patients in either group reported less bulge and overactive bladder symptoms.
Subjective improvement was reported by 80% of patients in the conventional
group compared with 81% in the mesh group.
Mesh exposure was detected in 14 of 83 patients (16.9%).

28. Reoperations –
• Diwadkar et al. – review of original articles/abstracts with ≥
50 patients and 3 months follow-up
TVR SCP MESH KIT
Number of studies/patients 48/7,827 52/5,639 24/3,425
Mean follow-up (months) 33 27 17
Reoperation for POP recurrence 3.9% 2.3% 1.3%
Total reoperation rate 5.8% 7.1% 8.5%
– Reoperation for POP recurrence – TVR > SCP > MESH
– Total reoperation rate (POP+COMP) – MESH > SCP > TVR
– Pain was more common in the SCP and MESH groups
Obstet Gynecol 2009; 113:367-73.

29. Recurrent prolapse surgery
• Reasonable anatomic results without mesh
• Significant symptoms improvement
• No erosions, few infections, quick recovery
• Mesh is expensive, no data to suggest any benefit for
apical or posterior compartment