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Thursday, July 18, 2013

Regenerative Vaginal Surgery

Diagnosis is not the end, but the beginning of practice.
                                                         Martin H. Fischer

During the Kelly1 and White2 era the only building blocks available to the surgeon were the tissues in front of him. Transfer of tissues from distant sites in the body - or from external sites - only became available late in the 20th century. These were called upon when the primary tissue was judged to be inadequate; be it in its healing capabilities or in tissue availability. This was replaced in due course by the primary utilization of the implant materials, ignoring the primary tissue as part of the “reconstructive” process. This lead to the madness - if one can call it that - of the synthetic Mesh “kits”. A halt is called due to complications that occurred.3. A true process of destructive surgery seemed to be the result of this “constructive” process. By simplifying techniques to lines and crosses drawn on the skin and utilization of “minimal invasive” needle techniques, incompetent vaginal surgeons were made to feel competent.4 The resulting complications led to a kneejerk response where all synthetics were to be banned from vaginal surgery - and a leap back to the previous comfort zone of the Kelly era...the conventional colphorrhapy is back! One might ask why was there a departure from these classic native tissue surgical procedures? Was it not the unpredictability of results and the poor results of redo surgery after these untested procedures?
The time has come to reach beyond these “classical” native tissue procedures.
One can treat a complicated problem simplistically or you can simplify a complicated problem. The secret of being a good physician is the ability to simplify a complicated problem. The simplistic manner in which prolapse is being seen and treated by most, lead to the perfect storm we are experiencing at present.5 Focus is being placed on reducing the symptom of a bulging vaginal wall, rather than looking for the origin of the defect that leads to the bulging wall. By attacking the bulge with conventional “native tissue” surgery, or by placing a bridge of implant tissue to do that, involves risks of permanent damage. The art of healing surely involves a diagnostic work-up looking for the origin of the disease that lead to the symptoms which brought the patient to the physician. By treating the origin of the disease the symptom will disappear!
Tissue engineering is an interdisciplinary field that applies the principles of engineering and life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function - or even replace whole organs.6 7 Regenerative medicine holds the promise of regenerating damaged tissues and organs in the body by replacing damaged tissue and/or by stimulating the body's own repair mechanisms to heal previously irreparable tissues or organs.8 Regeneration puts the focus on either protecting or enhancing stem cell tissue engineering. With surgical repair of a wound or defect, continuity is established without regard to the exact replacement of lost or injured tissue. In contrast, regeneration is restoration with an exact copy; not only morphologic continuity, but also functionality.
The ultimate goal should be to improve the repair process with the addition of regeneration principles: this would be regenerative surgery. In regenerative surgery, wound healing is manipulated to increase the mass of healthy native tissue to bring the damaged area back to its original - or as near as possible - normal anatomical and physiological state. The focus here is on enhancing native tissue repair, rather than substituting native tissue, hence regenerative surgery – a manipulation of surgical wound healing in clinical practise since 1997.14 In plastic surgery, regenerative surgery is a recognized branch of regenerative medicine15 16 - as in other diciplines.17
This can be applied to vaginal wall prolapse surgery.
We are now entering what can be called the post mesh era. In this era one can return to the surgical techniques of the past, or improve them.
Native tissue is the primary building block in the reconstructive process. To do this, basic information is needed: what is the defect that led to the prolapsed vaginal wall? If one reconstructs, knowledge of the template of normality that you want to reproduce is essential. Accessibility of the support system in its entirety must be possible, which is best provided through the vaginal route. The origin of the defect that leads to the prolapse must be actively searched for and, when found, treated. To treat the defects in the vaginal wall support system, the existing native tissue and the template of normality in front of the surgeon are the best guides.
Native tissue surgery can be defined as the utilization of native tissue to enable the healing process to close the defective areas that led to the prolapsed vaginal wall, thereby reconstructing the normal support system of the vaginal wall. In defect specific surgery the primary underlying cause is treated resulting in the secondary effect, namely the prolapse being corrected.
Regenerative surgery has two legs to stand on: In the first instance is the replacement of healthy native tissue with unwanted collagen of scar tissue avoided by limiting the damage of the surgical onslaught with careful dissection and repair techniques. Secondly, new native tissue formation is supported by the utilization of biodegradable scaffolds to give temporary support to the repair with further limiting surgical trauma. This scaffold will aid in growth of resident-tissue stem cells. Regenerative medicine is combined with good, safe surgical practises.
Wound healing of the surgical insult to tissues will go through its phases of haemostasis, inflammation, proliferation and remodelling. Good surgical dissection techniques must be mastered in order to limit further tissue damage. The degree to which the regeneration process can lead to normal morphological and functioning tissues will depend on the degree to which the inflammatory stage is stimulated. By reducing the inflammatory stage of wound healing tissue, remodeling through regeneration is allowed with minimal scar tissue formation. Over this we have control.
A few rules will apply in regenerative surgery to enhance wound healing:
·      By respecting, during dissection, the tissue planes as well as the spaces between organs - thereby minimizing tissue trauma - and not putting strain or tension on the native tissue, the surgical insult is kept to its minimum.
·      Wound edges must be approximated but never under tension.
·      Foreign materials, infection, ischemia and tensioned tissue can prolong the inflammatory process with resultant increased scar tissue (collagen I) formation.
·      All these have an additional stimulatory effect on the proteolitic enzymes that break the extra cellular matrix protector, heparan sulfate, down.9
·      The use of biodegradable scaffolds and heparan sulfate analogues can be helpful as augmentation materials for regenerating normal healthy tissue.10

The process can be curtailed by either lack of tissue or poor quality of available tissue, necessitating the use of implanted tissue or materials. In the pelvis a third force is at play: variable tensions on the suture lines can lead to early breakdown of the repair or putting tension on the native tissue and thereby stimulating the inflammatory reaction. To counter this temporary splinting or support needs to be provided to keep the native tissue in place until proper strong collagen is being produced to strengthen the previous defective areas.6 In regenerative surgery new tissue can be remodelled under the guidance of a biodegradable synthetic scaffold or biodegradable xenografts. Regenerative surgery will involve technical protection of native tissue and splinting surgical sites of repair.

The first surgeon who attempts to repair the damage that lead to the collapse of the vaginal wall is the most important one. The surgical footprint left behind is not only paramount in the success of the primary surgery, but also may impede secondary surgical reconstructive attempts if the first procedure fails to give an optimal surgical outcome. This is especially true in vaginal surgery and in native tissue surgery. Removed organs and tissues cannot be replaced. The secondary procedure must not be an undo-redo process, but rather an add-on process. The minimal damage caused by following regenerative surgical principles will enhance this. Staged surgery can be a real option in some cases.
By performing defect-specific surgery the vaginal surgeon can approximate the tissue layers closing the defective areas. By manipulating the predictable tissue reactions during the process of wound healing the surgeon can decrease the formation of scar tissue and improve tissue quality and function using tissue regenerating surgical techniques.
Regenerative surgery puts the focus on the surgeon and his/her ability to do surgery on the do-no-harm principles. Guarnieri11 and Desarda12 with inguinal hernia repair done on the same basis as being describe here, already showed that one does not need synthetic materials for lasting effects. With proper knowledge and operative skills native tissue responses can be utilised to good effect. This is what regenerative surgery is all about.
The regenerative ability of a surgeon in tissue handling techniques ultimately will be his/her surgical legacy.

In a sense one could say that with regenerative vaginal surgery the vaginal surgeon is invited back into the vagina. Unfortunately, vaginal surgery is an art practise by many, but mastered by few.

A special thanks to Bianca Visschers and Gideon Nieuwoudt for help provided.

1 Cooke TJ, Gousse AE A historical perspective on cystocele repair—from honey to pessaries to anterior colporrhaphy: lessons from the past.2008 J Urol. Jun;179(6):2126-30.
2 White GR. Cystocele. A radical cure by suturing lateral sulci of the vagina to white line of pelvic fascia. JAMA 1909;80(21) 1707-10.
4 Andri Nieuwoudt Int  Urogynecology J, Surgical Footprints. Then and now. 2008 vol 19 (9) 1187-1188
6 Boennelycke M, Gras S, Lose G Tissue engineering as a potential alternative or adjunct to surgical reconstraction in treating pelvic organ prolapse (2013) Int Urogynecol 24:741-747.
7 Langer R, Vacanti JP (May 1993). "Tissue engineering". Science 260 (5110): 920–6.
8 Mason C, Dunnill P (2008) A brief definition of regenerative medicine.Regen Med, 3(1), 1–5
9 Johan van Neck, Bastiaan Tuk, Denis Barritault and Miao Tong. The book Tissue Regeneration - From Basic Biology to Clinical Application, ISBN 978-953-51-0387-5. Heparan Sulfate Proteoglycan Mimetics Promote Tissue Regeneration: An Overview (2012) 4:69-92
10 Mouritsen L, Kronschnabl M, Lose G. Long-term results of vaginal repairs with and without xenograft reinforcement. Int Urogynecol J. 2010 Apr;21(4):467-73.
11 Guarnieri, Antonio; Moscatelli, Franco; Guarnieri, Francesco; Ravo, Biagio (1992). "A new technique for indirect inguinal hernia repair". The American Journal of Surgery 164 (1): 70–3.
12 Desarda, M. P. (2005). "Physiological repair of inguinal hernia: A new technique (study of 860 patients)". Hernia 10 (2) 143-6.
14 Whitman DH, Berry RL, Green DM  (1997) Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery..J Oral Maxillofac Surg. Nov;55(11):1294-9.
17Orlando G, Wood KJ, et al, (2012) Regenerative medicine as applied to general surgery. Ann Surg. 2012 May;255(5):867-80



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