USE
OF CADAVERIC FASCIA LATA TO CORRECT GRADE IV CYSTOCELE
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SÍLVIO H.M. ALMEIDA, ÉMERSON P. GREGÓRIO, EUFÂNIO E. SAQUETTI, HORÁCIO A. MOREIRA, FREDERICO FRAGA, MARCO A.F. RODRIGUES
Section of Urology, Department of Surgery, State University of Londrina, Paraná, Brazil
ABSTRACT
We describe a modification of the cadaveric prolapse repair and sling – CaPS technique that uses the sling surgery principles to correct grade IV cystocele. In this modification, the central and paravaginal defects reconstitution are performed using cadaveric fascia lata fixed over rectus abdominis muscle, eliminating the need of pubic fixation by screws, as proposed by the original technique. The modification described, besides presenting the benefits of CaPS, i.e., not using impaired tissues to reconstruct vesical support, and lower risks of perineal hypercorrection, also reduces the probability of complications of bone fixation.
Key words:
bladder; bladder diseases; prolapse; surgery; prostheses and implants;
voiding dysfunction
Int Braz J Urol. 2003; 29: 48-52
INTRODUCTION
In
grade IV cystocele bladder exteriorization occurs beyond the vaginal introitus,
representing the maximum degree of anterior vaginal wall prolapse (1).
It is a frequent medical problem, and it is difficult to correct because
it shows a large incidence of recurrence, with urinary incontinence and
posterior vaginal wall prolapse induction (1).
Although it may develop as the only feature
of a pelvic prolapse, grade IV cystocele generally occurs combined to
other defects such as enterocele, rectocele, vaginal vault prolapse or
uterine prolapse. In this context a weakness of pubocervical fascia occurs,
with loss of bladder support (central defect), or in its attachment to
the pelvic wall (lateral defect) (2). The surgery should try to repair
these defects, since simple anterior colporraphy shows high recurrences
rates (2).
Using weakened structures to correct prolapse
shows approximately 50% of recurrence and development of urinary incontinence.
Analogous to abdominal wall hernia repairs, flaps of varied organic and
synthetic materials have been used to correct perineal defects (3,4).
Also, because of the risk of incontinence development, combined sling
procedure has been proposed to correct the prolapse (3). Kobashi et al.
described cystocele repair with a cadaveric fascia lata segment that reinforces
vesical support in its central portion and laterally acts as a sling fixed
to pubis through small screws, technique known as CaPS (4).
The aim of this paper is to describe a modification
of this technique, attaching the fascia with sutures tied over rectus
abdominis muscle aponeurosis substituting pubis screws, eliminating thus
the risks of bone fixation and screw cost (5).
SURGICAL TECHNIQUE
The
patient is placed in lithotomy position under spinal blockade. A Foley
catheter empties the bladder (Figure-1) and the vagina is medially incised
1 cm from urethral meatus, progressing to levator ani muscles. Through
blunt dissection or with scissors all vesical wall is freed until the
identification of pubocervical fascia (Figure-2).
The fascia used is obtained in a tissue
bank (frozen and irradiated) and defrost during the surgery, resting in
saline. In a T-fashioned segment, of about 8 x 6 cm, Vicryl™ 0 sutures
are positioned at the ends of the superior portion that works as a suburethral
sling. The sling has an 8 cm extension with 2 cm width. The sutures are
elevated through cystopexy needles passage, and tied medially over the
rectus abdominis muscle aponeurosis as in classic sling procedure. The
remainder of the fascia, a 6 cm square, rests over bladder base. Using
a haemostatic clamp between the fascia and the urethra, pressure over
the bladder is avoided. The square portion of the fascia is laterally
attached with 2 Vicryl™ 3-0 sutures in the level of pubocervical
fascia initially in one side, adjusting fascial width when tying the contralateral
side. The adjustment of these sutures is done without tension, and the
central extremity is fixed as well with 2 Vicryl™ 3-0 sutures to
levator ani muscles (Figure-3).
Cystoscopy is performed and, if there is
any doubt about ureteral damage, and the ureteral meatus have not been
catheterized yet, it may be done now. Redundant vaginal mucosa is resected
and sutured with 2-zero simple catgut, or in presence of additional defects,
such as rectoceles or vaginal vault prolapse, we may proceed to their
correction (Figure-4).
A suprapubic cystostomy is positioned with
a Foley 12F catheter maintained for 24 hours. If there is urinary retention,
the catheter remains for additional 48 hours and, if necessary, intermittent
catheterism is performed. For patients with large postvoid residual before
the surgery, advanced age, or detrusor contractility impairment, the catheter
is closed in the first postoperative day and removed when postvoid residual
is under 50 mL.
COMMENTS
Support
provided by the sling is essential to the success of grade III or IV cystocele
correction. The anterior wall defect is not only central, but also by
the separation of pubocervical fascia at the arcus tendineus level. Sling
not only lift the bladder neck, but corrects lateral defect as well due
to the scaring process.
Numerous studies have demonstrated the presence
of occult urinary incontinence with 59% to 83% rates in urodynamic studies
performed after cystocele reduction; thus urodynamic investigation is
advised to investigate incontinence and voiding dysfunctions that may
develop due to pelvic descent (5).
Using allogenic graft, as cadaveric fascia
lata, favors the benefits of sling procedure combined to prolapse correction.
In addition, avoids the risk of using an already weakened tissue to reconstruct
pelvic structures, and avoiding the potential complications of using synthetic
material (4,5). Another benefit of this technique is to avoid excessive
correction of anterior vaginal wall that may incline to the development
or the increase of posterior wall prolapse.
The techniques used in large cystoceles,
anterior colporraphy and needle suspensions, lead to 24% to 87% of failure
to treat continence and prolapse recurrence (4). After a mean follow-up
of 6 moths we observe 65% of incontinence cure rate and 12% of incontinence
improvement (5). The modification proposed shall present similar results,
since it just simplifies the surgery without altering its basic principles.
Until this moment this modification was successfully used in 4 patients,
followed with a mean follow-up of 9 months (3-24 months).
One of the main issues raised about using
cadaveric fascia lata is the possible risk of transmitting infectious
diseases. Recently, the DNA content of 4 types of human fascia lata commercialized
in the USA was analyzed, and all the tested material presented human DNA
segments. It was concluded, however, that additional tests should be performed
to assess the integrity of this genetic material and eventual risks (6).
The main concern is that transmission of viral diseases by prions (slow
acting viruses) could happen. Although there was no determination of this
phenomenon until now, the theoretical risk is 1 to 3.5 million (6).
There is only 1 case of HIV transmission
from negative donor reported in the literature. It happened in 1985, and
the recipients of solid organs acquired the virus, but those that received
fascia lata and tendons remained HIV-negative (6). The risk of acquiring
HIV in organ transplantation from a screened donor is about 1 to 1,667,6000
to 1 to 8 millions which, comparatively, is lower than the risk of HIV
transmission by blood transfusion (1 to 440,000 to 1 to 660,000) (6).
Even if the risk is small, all patients should be informed about it.
REFERENCES
- Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR, Luber KM, et al.: Female stress urinary incontinence clinical guidelines panel summary report on surgical management of female stress urinary incontinence. J Urol. 1997; 158: 875-80.
- Safir MH, Gousse AE, Rovner ES, Ginsberg DA, Raz S: 4-Defect repair of grade 4 cystocele. J Urol. 1999; 161: 587-94.
- Cross CA, Cespedes RD, McGuire EJ: Treatment results using pubovaginal slings in patients with large cystoceles and stress incontinence. J Urol. 1997; 158: 431-4.
- Kobashi KC, Mee SL, Leach GE: A new technique for cystocele repair and transvaginal sling: the cadaveric prolapse repair and sling (CaPS). Urology 2000; 56: 9¯14.
- Chung SY, Franks M, Smith CP, Lee JY, Lu SH, Chancellor M: Technique of combined pubovaginal sling and cystocele repair using a single piece of cadaveric dermal graft. Urology 2002; 59: 538-41.
- Gallentine ML, Cespedes RD: Review of cadaveric allografts in urology. Urology 2002; 59: 318-24.
____________________
Received: July 15, 2002
Accepted after revision: December 10, 2002
_______________________
Correspondence address:
Dr. Sílvio H.M. de Almeida
Rua Paes Leme, 1081 / 301
Londrina, PR, 86010-520, Brazil
Fax: + 55 43-337-1800
E-mail: salmeida@sercomtel.com.br
Sling
procedures have been consolidated lately as the ones which yield the best
and most longstanding rates of cure for urinary stress incontinence. The
genital prolapses associated certainly represent an additional challenge
for the appropriated treatment of these patients, rendering the use of
larger flaps an attractive alternative that may promote the cure of both
conditions simultaneously.
The search for synthetic and biological
material to substitute autologous fascia aims at yielding these procedures
less invasive, the post-operative period less painful, and reducing the
chance of complications related to the donor site.
Cadaveric fascia lata has been treated through
several chemical and physical processes that include freezing lyophilization,
gamma radiation, antibiotic therapy, povidine, acetone, and hydrogen peroxide;
usually these treatments are combined. The aim of these treatments is
to destroy any infectious agent that could exist in the donor.
The authors raise the question about the
risks of HIV transmission, and mention the possibility of prions involvement
in the etiology of diseases as Creutzfeldt-Jakob syndrome (mad cow disease).
Although the rarity of the event is evident in the reports in literature,
it is important to point out that, independently of the sterilizing technique
used, intact DNA is found in various fascia lata commercially available,
according to Hathaway & Choe study recently published (1). The possibility
of transmission of disease through genetic material present in these fasciae,
as well as the mechanism through which this infection would occur are
not yet known. It is convenient to comment that the quality of fascial
tissue available depends on the treatment it was submitted to in order
to be sterilized. Recently, it became evident that some cadaveric fasciae
commercially available demonstrated tensile resistance markedly inferior
to autologous fasciae, and there are reports in the literature of early
disruption of these materials, yielding failure to the surgical procedure.
Certainly these evidences cannot be minimized
by the simple fact that we do not have many case reports of diseases transmitted
this way. We think that the choice of the biologic material should come
from a joint decision of the practitioner and the patient, after appropriate
information of the facts aforementioned.
Reference
1. Hathaway JK, Choe JM: Intact genetic material is present in commercially
processed cadaver allografts used for pubovaginal slings. J Urol. 2002;
168: 1040-3.
Dr. Luis Augusto Seabra Rios
Hospital do Servidor Público
Estadual de São Paulo
São Paulo, SP, Brazil