VAGINAL PARAVAGINAL DEFECT REPAIR WITH AN ALLODERM GRAFT

J. Clemons, MD, V. Aguilar, MD, L. Arya, MD, D. Myers, MD

   Objective: The purpose of this study was to describe outcomes of a technique of vaginal paravaginal defect repair using Alloderm (Lifecell Corp. Woodlands, Texas) graft material in women with or recurrent Stage 2 or primary or recurrent Stage 3 / 4 anterior vaginal wall prolapse.

   Methods: This was a prospective observational study. Between November 1998 and April 2002, 33 women underwent a vaginal paravaginal defect repair using Alloderm graft. Demographic data was recorded. The descent of the anterior vaginal wall was graded using the POP-Q system preoperatively and every 6 months post-operatively. Recurrence of prolapse, voiding dysfunction, and post-operative complications were recorded. Life-table analysis evaluated recurrence of prolapse. Odds ratios were used to identify risk factors for complications or recurrence of prolapse.

   Results: Thirty-one of the 33 women were Caucasian. The mean age was 65.2 years (range 42-83) and mean parity was 2.8 (range 1-6). Thirty women were post-menopausal and 21 used estrogen replacement therapy. Twenty-nine (88%) women had a prior hysterectomy, and 19 (58%) had prior surgery for pelvic organ prolapse. Pre-operatively, 6 women had recurrent stage 2, 24 women had stage 3, and 3 women had stage 4 anterior vaginal wall prolapse. Twenty-five (76%) women underwent concurrent pelvic reconstructive procedures. The mean EBL was 378 ml and there were no transfusions. Only one woman has been lost to follow-up due to death secondary to congestive heart failure.
   The median length of follow-up is 18 months. Post-operatively, 13 women developed asymptomatic stage 2 (not beyond the hymen) anterior vaginal wall prolapse, and one woman developed symptomatic stage 2 prolapse (point Aa +1 cm) with stress incontinence at 28 months. Life-table analysis of the post-operative 6-month interval exams demonstrated that the cumulative probability of the anterior vaginal wall remaining at stage 0-1 was .76 at 1 year and .50 at 2, 3, and 4 years. There were no identifiable risk factors for the development of stage 2-asymptomatic prolapse.
   Seven women (21%) had urinary retention more than seven days. The placement of the Tension-free Vaginal Tape sling along with the Alloderm graft increased the risk of post-op urinary retention (odds ratio 7.3, 95% confidence interval 1.2, 46.1). Complications included: one case of febrile morbidity, one cystotomy, and one anterior wall breakdown secondary to hematoma formation due to heparin therapy. No other erosions or rejections were seen.

   Conclusion: A vaginal paravaginal defect repair with Alloderm graft material in women with recurrent stage 2 or stage 3 / 4 anterior vaginal wall prolapse is safe and has good results within the first 2 years.

   Key Words: graft, reconstructive surgery, prolapse