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153 - 08-04
"Patient-Tailored" Mesh Graft for Anterior Compartment Repair Using Vertessa Lite Mesh: Just Enough But Not Too Much

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Matthew E. KArlovsky, M.D.: Phoenix, AZ

Purpose: Pelvic Organ Prolapse affects women as they age. The desire to address symptomatic anterior prolapse with transvaginal mesh kits to bolster the repair, though more anatomically successful than native tissue repair, had its usage decelerated due to the FDA Bulletin of 2011 and complications of mesh that may involve large mesh loads and  injury due to kit trocar usage. Small, tailored made mesh grafts that are intra-operatively sized to the patient’s anterior compartment after colporraphy may offer the benefit of mesh reinforcement while minimizing mesh load and avoiding trocar passage. I investigated the short term success rate, extrusion rate, and graft size required in a consecutive series of patients electing mesh repair for their symptomatic cystocele with “patient-tailored” mesh grafts.

Results: Mean age and BMI were 65.3 and 30.66. Mean pre-operative Baden Walker grade and POPQ stage were 3.1 and 2.7. Mean graft size was 3.4 cm length x 5.3 cm width. There were 5 simultaneous transvaginal hysterectomies, and 10 concomitant midurethral mesh slings. Follow up range was 1.5 months to 9 months. Mean and median follow up were 4.6 months and 4 months. Mean post-operative Baden Walker grade and POPQ stage were 0.2 and 0.2.  There was one extrusion noted at 12 weeks of 2 mesh fibers in an area of granulation tissue that was previously treated with silver nitrate topical by the gynecologist at 6 weeks post operatively. The mesh fibers were excised in the office. No other extrusions were noted.  Phone call follow-up of the 8 sexually active patients revealed 5 to be sexually active and 4 to have no dyspareunia. The one patient who had dyspareunia was not the one with the extrusion.

Materials & Methods:  Sixteen consecutive patients with symptomatic cystocele underwent reconstruction with patient tailored graft from Vertessa Lite mesh (Caldera Medical Inc., Agoura Hills, CA) sized to the anterior compartment after midline plication. Mean preoperative statistics include age, BMI, Baden-Walker cystocele grade, POPQ stage, mean graft size (Length cm x Width cm), and number of cases involving transvaginal hysterectomy or slings were recorded. Vertessa Lite mesh consists of a blue colored, light weight (23.8 gm/m2) polypropylene type 1 mesh that is 0.275 mm thick, and appears to have a “square type” weave whose pore size is 1300 μm, with an interstitial pore size 170 μm. The post-plication anterior compartment length and width were measured with an intraoperative ruler and the graft was then cut from a 10 cm x 20 cm pre-packaged Vertessa Lite mesh. Its four points when then sutured to the pelvic side wall fascia, and the proximal vaginal apex and distal bladder fascia. Mean and median post-operative follow up, post-operative BW stage and POPQ stage were recorded, as well as incidence of extrusion and dyspareunia.

Conclusions: “Patient-tailored” mesh grafts for anterior compartment repair are feasible, and can achieve a desired compromise between use of mesh and reduced mesh implant load. In short term follow up, there was excellent post-operative anterior support, with 1 minor extrusion which may have been caused by silver nitrate topical. Of those patients who were sexually active, one reported dyspareunia. In the age of concern over transvaginal mesh kits with large mesh implant loads and potential FDA device reclassification, tailor made small mesh grafts may become a popular option. Further follow up is warranted to validate long term success rates and potential long term extrusion rates.