Download The Surgical Management

*Utrine Prolapse
Vaginal Sugeries
Maryam Ashrafi
* ratio surgery for prolapse vs incontinence: 2:1
* prevalence of 31% in women aged 29-59 yrs
* 20% of women on gynecology waiting lists
* 11% lifetime risk of at least one operation
* re-operation in 30% of cases
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Principles of Pelvic
Reconstructive Surgery
* Restoration of pelvic structures to normal
anatomical relationship
* Restore and maintain urinary &/or fecal continence
* Maintain coital function
* Correct co-existing pelvic pathology
* Obtain a durable result
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Approach
Approach to prolapse surgery include vaginal, abdominal,
and laparoscopic routes or combination of approaches.
Vaginal approach results in:
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fewer wound complications,
less postoperative pain,
shorter hospital stay
Vaginal procedures for prolapse
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Restorative → use the patient’s endogenous support
structures
Sacrosinous Suspension
Uterosacral suspension
Iliococcygeus Fascia Suspension
Compensatory → replace deficient support with some type
of graft
Obliterative → close the vagina
Le fort colpoclisis
Total colpoclisis
Preoperative Evaluation And Preparation
* A thorough pelvic floor history,
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Assessment of bothersome urinary symptoms
and/or defecatory problems .
A thorough speculum and bimanual pelvic
examination
The findings of the examination should be recorded using a
quantitative and reproducible method for recording POP.
Evaluation Of Urinary Dysfunction
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Urinary incontinence
• Reduced stress testing.
• Urodynamics?
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Urinary retention
• Measure PVR
13 to 65 percent of continent women develop
symptoms of SUI after surgical correction of the
prolapse.
Obliterative Procedure
Obliterative surgery corrects prolapse by removing and/or closing off
all or a portion of the vaginal canal (colpocleisis)
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Total colpocleisis
Partial colpocleisis (Le Fort colpocleisis)
Concomitant hysterectomy?
Concomitant stress urinary incontinence surgery ?
Kelly suburethral plication
midurethral sling
Effects of colpocleisis on bowel symptoms
At baseline Bothersome bowel symptom(s) were present in 77% :
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Obstructive (17-26%),
Incontinence (12-35%) and
Pain/irritation (3-34%)
Procedures performed:
partial colpocleisis (61%),
total colpocleisis (39%),
levator myorrhaphy (71%), and
perineorrhaphy (97%).
RESULTS: Of 121 (80%) subjects with complete data,
Mean age was 79.2 +/- 5.4 years and all had stage 3-4
prolapse
The majority of bothersome symptoms resolved (50-100%)
with low rates of de novo symptoms (0-14%).
CONCLUSIONS: Most bothersome bowel symptoms resolve
after colpocleisis, especially obstructive and incontinence
symptoms, with low rates of de novo symptoms.
Sacrospinous Ligament Fixation
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The surgeon should be familiar with the anatomy of
the sacrospinous ligament complex and of the
pararectal space.
Obtaining adequate exposure can be difficult.
The sacrospinous ligament is a cordlike structure that
exists within the body of the coccygeus muscle.
The sacrospinous ligament attaches medially to the
sacrum and coccyx and attaches laterally to the ischial
spine.
Sacrospinous Ligament Fixation
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The pudendal nerve and vessels pass directly posterior to the
ischial spine.
The sciatic nerve lies superior and lateral to the sacrospinous
ligament.
Superior to the ligament lies the inferior gluteal vessels and
the hypogastric venous plexus.
To avoid trauma to these structures, it is important to place
the fixation sutures two fingers medial to the ischial spine.
Complications
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Hemorrhage can result from injury to the hypogastric
venous plexus inferior gluteal vessels, and internal
pudendal vessels.
Postoperative gluteal pain due to pudendal nerves and
the sciatic nerve injury.
Approximately 10% to 15% of patients have transient
moderate to severe buttock pain
Inadvertent proctotomy.
Potential stress incontinence.
Results of sacrospineous Ligament Suspension
for Vaginal Vault Prolapse
Author
No. of patients
Follow-up in
months (range)
Success
Jenkins
1997
50
6-48
88%
Barber
2001
46
3.5-40
90%
Karram
2001
202
6-36
89.5%
Amundsen 33
et al. 2003
6-43
82%
Viviane Diet 133
z 2006
3-55
84%
Total transvaginal mesh (TVM) technique
Prolift Pelvic Floor Repair System™
Complications
* Febrile morbidity
* Urinary tract infection
* Deep hematoma
* Granuloma (without exposure)
* Mesh exposure
* Shrinkage of mesh
Ojectives:
The objective of the study was to assess the
effectiveness and complication rates for the
transvaginal (TVM) technique in the treatment of pelvic
organ prolapse (POP).
Methods:
All enrolled patients underwent prolapse repair surgery
with GYNEMESH PS Prolene Nonabsorbable Soft Mesh
using the TVM technique
Conclusions:
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Five-year results indicated that TVM
provided a stable anatomic repair.
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Improvements in quality of life and
associated improvements in specific
prolapse symptoms were sustained over the
5-year period.
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Mesh exposure was the most common
complication
Of 85 patients:
• 16 comlicated with Mesh exposure
• 9 required partial mesh excision.
• 3 patients with some degree of dyspareunia, (in 8,
preexisting dyspareunia resolved).
• 1 rectovaginal fistula reported and
• 2 reported ureteral injuries, one of which resulted
in a ureteral-vaginal fistula; all resolved after
repair
• 5 required reoperation for prolapse by 5 years
To elucidate the outcome of transvaginal pelvic
reconstructive surgery using
polypropylene mesh (Gynemesh; Ethicon, Somerville, NJ,
USA) for patients with pelvic organ prolapse (POP) stage III
or IV.
RESULTS: The average age of the patients was 64.1 years
and average parity was 3.9
The success rate was 97.4%.
Only one patient (2.6%) had recurrent genital prolapse
(stage II) postoperatively.).
The complication rate was 10.3 %, including
onevaginal mesh erosion (2.6%), one dyspareunia (2.6%) (and
two prolonged bladder drainage (longer than 14 days
Neither long-term nor major complication was identified
CONCLUSION: Transvaginal pelvic
reconstructive surgery with
polypropylene mesh reinforcement is a safe and effective
procedure for POP on 1.5 years' follow- up. It also has
positive influence on quality of life.
Sacrocolpopexy and paravaginal repair
for total pelvic floor prolapse