The surgical management of anterior vaginal prolapse is controversial with limited and often conflicting data available. The traditional vaginal repair for cystocoeles was first described by Kelly in 1913, and in controlled trials has a 57% chance of curing cystocoeles. An abdominal approach is also feasible with the abdominal paravaginal repair having a success rate of up to 97%. But the abdominal approach may carry significant complications – including ureteric obstruction, bleeding, haematomas and abscess formation.
No randomized control studies have evaluated and compared the abdominal, laparoscopic or vaginal route of repair in isolation. Goldberg and co – workers demonstrated in a case control study in women with anterior prolapse and stress incontinence, that the addition of a pubovaginal sling to the anterior colporrhaphy significantly reduced the recurrence of a anterior prolapse from 42% in the control group to 19% in the anterior repair and sling group. Which begs the question – does the addition of type 1 soft mesh to a vaginal repair make the procedure more robust, with an acceptable complication rate? It has already been established that the type 1 large pore prolene mesh is extra – ordinarily well tolerated in the vagina with very few long term complications. Workers have proposed that a tension – free mesh buttress may serve as a scaffold for collagen ingrowth and so reduce the incidence of repair failure.
The ProliftR and PerigeeR systems have been developed for this purpose and allow minimally invasive vaginal techniques anchoring a mesh hammock in situ by means of mesh extensions emerging through the obturator foramen. These novel procedures have no long – term follow up data in the published literature at present, and the results of studies are awaited with interest. The use of mesh would be particularly useful where conventional techniques have already failed, in large defects or in individuals with obstructive pulmonary disease or other predisposing causes of prolapse.
The surgeon should bear in mind that a certain percentage of women develop stress incontinence following anterior repair procedures. About 15% - 20% may need urinary continence procedures, and all patients having anterior repairs must be councelled to this effect.