Dr. Christian Fünfgeld on cystocele repair

How widespread are cystocele defects in Germany?

Around 40 percent of all women who have given birth to children suffer from prolapse or descent of the uterus, the bladder or the vagina. 11 percent of the women affected have to undergo prolapse correction. 30 percent of those affected suffer from recurring prolapse.

What symptoms do affected women have to contend with? How much psychological stress does it cause?

Many patients complain of a sagging feeling. They often have bladder dysfunction with bladder emptying problems and urinary incontinence. Bowel emptying problems are also possible. Some patients have to have their prolapse relocated so that they can urinate or empty their bowels.

There are different therapy options available to treat cystoceles. What patients can specifically benefit from mesh implants?

As far as is possible, conservative therapy such as pelvic floor training or the use of a pessary should be attempted in order to relieve symptoms. If these methods do not bring about any improvement or if the condition is too pronounced, the prolapse can be repaired surgically. 

There are different access routes for prolapse surgery. Vaginal access is chosen traditionally. The prolapse can also be repaired with abdominal or laparoscopic surgery in appropriate cases. A hysterectomy, which would have been routinely performed in the past, is usually no longer necessary these days. 

If possible, the patient's own connective tissue is used for stabilisation. A good outcome is achieved through implantation of an artificial mesh in pronounced cases, if there is recurrence or if maximum stability is desired.

You use the mesh implant TiLOOP® Total 6 from pfm medical ag for cystocele correction. How do these new meshes differ from first-generation meshes?

At the beginning, the surgical techniques for the use of alloplastic materials were not yet very sophisticated and the products themselves were really heavyweight. The modern materials are very light, macroporous and are better fixed in place using optimised surgical techniques. This means that adverse events such as erosions through the vagina, pain or dyspareunia can be significantly reduced.

What is special about the TiLOOP® Total 6 implant and the surgical method used?

The TiLOOP® mesh is fixed with six bands at individually adjustable points. Very good stability is achieved through apical and lateral fixation. The originally hydrophobic surface of the polypropylene mesh is made hydrophilic by titanium oxide, which in turn facilitates the formation of fibroblasts.

Are there studies that prove the benefit of TiLOOP® Total 6?

There is now one study for TiLOOP® Total 6 with 289 patients over a period of three years. An observation carried out over 36 months shows that TiLOOP® Total 6 has very long-term stability, with a very low rate of recurrence and an extremely significant improvement in quality of life. We surgeons very much welcome the study. This is because for many of the materials and surgical techniques there are no data which enable us to make any in-depth assessment of the risks and benefits for patients.

What relevance do the study data have with regard to the controversial debate about first-generation mesh implants?

At the beginning, the first-generation alloplastic meshes were used in large numbers as a result of indiscriminate diagnosis and without sufficient training, particularly in the USA. This led to considerable complications. These days, thanks to optimised surgical techniques, refined materials and a differentiated diagnosis, good anatomical and functional outcomes are achieved with the method used here, with a significantly lower rate of complications. We can therefore significantly improve the patients' quality of life. The modern implants have proven particularly reliable in cases of recurrence.

What are the requirements for successful prolapse correction with mesh implants?

A thorough urogynaecological examination should be performed for a differentiated diagnosis prior to any prolapse surgery. After all, not all prolapses are the same! An appropriate surgical procedure and corresponding surgical access route must be chosen for each patient on an individual basis. Many factors play a role in this: from the severity of the prolapse and the symptoms, through the affected compartments, the patient's age, the necessary stability, to any preliminary operations. Given the numerous options available and increased demands on the surgical outcome, a high level of expertise is required of the surgeon. Prolapse correction with alloplastic implants should therefore only be performed by trained specialised urogynaecologists.

(December 2016)

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Dr. Christian Fünfgeld is chief physician for gynecology and obstetrics at the hospital in Tettnang. He also leads the interdisciplinary continence and pelvic floor centre of the clinic.