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Graft use in Prolapse Surgery
Over the past few decades there has been growing interest and investigation in graft use for surgical correction of prolapse and incontinence. The initial work stems from the general surgery literature, where they realized many years ago that abdominal hernia repairs had much higher cure rates when a graft was used to repair the hernia. This only makes common sense, and we have recently seen more and more data supporting graft use in pelvic floor prolapse surgery. With traditional repairs (ie not using grafts to augment our repairs) we are relying on repairs in which we are suturing weak tissue to weak tissue, under tension (which goes against all basic surgical principals!). It's no wonder that we have poor cure rates! Today, very few abdominal wall hernias are repaired without a graft and we are now seeing similar trends in prolapse surgery. We have known for many years that abdominal sacralcolpopexy has the highest cure rate for vault prolapse, and that most likely is because a graft is used and we are not relying on the patients own tissue to hold up. As stated above and in our posterior repair section, we began using grafts back in 1998 and have done much of the research and initial work in the field of graft use for rectocele repairs. We have seen a substantial increase in cure rates (>90% compared to 60% with traditional repairs) and much better anatomic outcomes. There has been work done for several years in placement of anterior vaginal wall grafts for cystoceles, however the difficulty has been in finding a minimally invasive approach to attach the grafts up higher in the vagina to the sidewall and to have a good strong attachment point and obtain anatomic restoration. We feel that grafts should be considered in patients that have had previous failed operations, older patients with poor tissue or patients with large defects or severe prolapse. Up until recently, these techniques were very invasive and fraught with high complication rates such as bleeding, bladder and/or nerve injury, graft rejection, and poor anatomic outcomes.
Transobturator Approach - New, Safer Technique
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In the early 2000’s, the transobturator space was initially described for the safe placement of slings to treat stress urinary incontinence. Dr. Moore and Miklos were two of the first surgeons in the United States to utilize this technique and bring this new technology to the US. They have also been involved with the largest study in the world (Dr. Moore is one of the principal investigators for the worldwide study and is the Principal/Lead US Investigator directing centers such as Harvard and Cleveland Clinic in the study ) studying this space for the treatment of stress incontinence and have found it to be a much safer, less invasive approach than other approaches to date, with excellent cure rates for SUI. Dr. Moore just returned from Copenhagen and Montreal (2005) where he presented the results of those studies and he and Dr. Miklos’ research, which showed cure rates in the range of 90% for the TOT sling. The TOT sling has rapidly become one of the most common forms of treatment for stress incontinence in the world.
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