2076 A NEW MESH-LESS TECHNIQUE TO REPAIR CYSTOCELES WITH BOTH CENTRAL AND LATERAL DEFECTS

Abstract

INTRODUCTION AND OBJECTIVES: Surgeons commonly use mesh for cystocele repair because the result is more durable than the classical anterior colporraphy. However, mesh repairs are associated with a number of complications. Therefore, we have developed a new technique named the CRISP procedure (Cystocele Repair using Interlocking Sutures of Polypropylene) and we are applying it to patients with central-lateral defects. The objective of this study is to review their functional outcomes. METHODS: All patients received preoperative evaluation with a history and physical examination, POP-Q exam, validated questionnaires (UDI-6, ISS, PFDI-20, PFIQ, and PISQ12), videourodynamics, cystoscopy, and dynamic pelvic MRI. All patients were evaluated postoperatively at 3, 6, 12 and 24 months. A brief description of the procedure is as follows: Indicated anti-incontinence and anti-prolapse procedures were performed concomitantly. A vertical incision is made from the bladder neck to the vaginal cuff and carried out laterally. 2-0 polypropylene sutures are used to incorporate the obturator and perivesical fascia bilaterally for lateral support. Four mattress sutures of 2-0 polypropylene are placed to repair the central defect. The lateral sutures are then interlocked with the central sutures. The lateral sutures are tied, followed by the central ones, thereby reducing the cystocele and creating a supporting net of sutures. The excess vaginal wall is excised in an asymmetric fashion with a rotational flap to cover the line of polypropylene sutures. Statistical analysis was performed using Student T-test using SPSS software and p<0.05 was considered significant. RESULTS: Between 1/2009 and 7/2010, the CRISP procedure was performed on 63 patients. Thus far, our only major complication is a patient who developed ureteric obstruction who was treated endoscopically. Tying the sutures prior to cystoscopy should prevent this complication. Postoperative validated questionnaires results showed improvement in quality of life due to urinary symptoms (improved from a mean of 3.6/6 to 2.0/6 (p=0.0022). PFDI-20 questions 1 to 6 (same as POPDI-6)indicate the level of bother caused by pelvic organ prolapse. The POPDI-6 score improved from 50 to 30.4 (p=0.0115). The vaginal bulge score from the PFDI-20 improved from 1.9/4 to 0.11/4 (p=0.002). CONCLUSIONS: The CRISP procedure is a promising alternative to cystocele repair with mesh. Preliminary data shows significant improvement in symptoms and quality of life, and this has been associated with minimal complications. Longer term data is needed to confirm our preliminary findings.