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PELVIC ORGAN PROLAPSE & ITS
ASSOCIATED COMPLICATIONS
GEOFFREY MAINAR QUE , MD., DPOGS, FPSURPS
Urogynecologist and Reconstructive Pelvic SurgeonObstetrician and Gynecologist
• Incidence• Risk Factors• Classification• Diagnostic Evaluation
• Clinical Evaluation• Laboratory Investigation
• Conservative Management• Surgical Management
• Anterior Vaginal Wall • Posterior Vaginal Wall• Middle or Apical Vaginal Wall
LEARNING OBJECTIVES
• Abnormal descent or herniation of the pelvic organs from their normal attachment sites
• Poorly understood condition that has relatively high recurrence rate (nearly 30%)
• Presently, no surgical form of treatment offers 100% chance of cure
• Many have modified , improvised or developed various surgical techniques all in the hopes of improving outcomes
PELVIC ORGAN PROLAPSE
Womens Health Initiative (WHI) - 16, 616
13,000 or 80% of women 50-79 years oldhave some degree of prolapse
Cystocele - 34.3% Rectocele - 18.3% Uterine Prolapse - 14.2%
Hendrix SL, et al. AJOG, June, 2002. Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity.
INCIDENCE
PREDISPOSE INCITE PROMOTE DECOMPOSE
Genetic (Congenital / Hereditary)
Race (white>african)
Gender (F > M)
Pregnancy & Delivery
Surgery ( such as hysterectomy for prolapse)
Obesity Smoking Pulmonary Disease (Chronic cough)
RecreationalOccupationalActivities (frequent or heavy lifting)
Aging Menopause
Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:723–46. Copyright 1998
PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q)
PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q)
AaAnterior Wall
BaAnterior Wall
CCervix/ Cuff
GHGenital Hiatus
PBPerineal Body
TVLTotal Vaginal Length
ApPosterior Wall
BpPosterior Wall
DPosterior Fornix
POP-Q.exe
Inter-Observer and Intra-Observer Evaluation
Quantitates the Severity of Prolapse
Quantitates the Result of Treatments
POP-Q ICS ADVANTAGE
CLINICAL EVALUATION• “ PALPABLE INTROITAL MASS ”
• Common Complaint • Not specific to one compartment
• COMMONLY ASSOCIATED • Urinary Stress Incontinence• Transient Voiding Dysfunction
• Advance prolapse makes the patient continent due urethral kinking or obstruction
• 15 - 80% occult or unmasked stress incontinence -> benefit with continence surgery
DIAGNOSTIC EVALUATION
CLINICAL EVALUATIONDefecatory Dysfunction i.e, incomplete emptyingSexual Function – Pre / Post Surgery
DIAGNOSIS OF POP CAN ONLY BE MADE BY P.E.Systematic Assessment(Standing,Lithotomy)
Anterior vaginal wallPosterior vaginal wallMiddle or apical compartment
DIAGNOSTIC EVALUATION
ANTERIOR COMPARTMENT PROLAPSE STAGE III
POSTERIOR COMPARTMENT PROLAPSE STAGE II
MIDDLE COMPARTMENT PROLAPSE STAGE III
MIDDLE COMPARTMENT PROLAPSE STAGE III
MIDDLE COMPARTMENT PROLAPSE STAGE IV
LABORATORY INVESTIGATIONBladder testing should be part of initial workup
3 important factsUTI ScreeningPost Void Residual Urine VolumePresence or Absence of Bladder SensationVoided volume with sensation of fullness, voiding diary or by
bladder filling)
DIAGNOSTIC EVALUATION
BLADDER FUNCTION ASSESSMENT is ESSENTIAL prior to ANY form of Surgical InterventionSimple Retrograde Filling Cystometry (Office)Fill the Bladder until subjective fullness while recording
Sensations and Pressure ChangesCough Stress Test – prolapse out and reduced15-80% occult SUI when prolapse is reduced
PREOPERATIVE URODYNAMIC EVALUATION is recommended in patients with POP to detect occult or unmasked SUI
● Observation● Pelvic Floor Rehabilitation● Use of Mechanical Devices ( i.e, pessaries)● Surgery
Unfortunately, there is little evidence - based information with scarcity of rigorously conducted trials comparing various therapeutic approaches
MANAGEMENT
SexualFunction
Vaginal Axis and
Depth
BowelFuncti
on
Support of the Anterior
Posterior & Superior
Compartments
UrinaryFunction
GOALS OF PELVIC RECONSTRUCTIVE SURGERY
3 LEVELS OF PELVIC SUPPORT
Levels of pelvic support ( from Delancey JOL, Anatomic aspects of vaginal eversion after hysterectomy. AJOG 1992; 166: 1719,
● Depending on the Severity and Extent of Prolapse
● SURGERY usually involves combination of repairs addressing the ANTERIOR, POSTERIOR, MIDDLE / APICAL VAGINA AND PERINEUM
● Concomitant surgery for bladder neck and anal sphincters
SURGICAL MANAGEMENT
ANTERIOR COLPORRHAPHY• Described by Kelly 1913• Closure of central defect • Indicated for LARGE cystocele• 37 – 100% success rate
• Mesh augmentation increasessuccess rate for recurrent prolapse
SURGICAL MANAGEMENT
COMPLICATIONS• Ureteral Injury kinking of intramural ureters medially or• direct ligation rare
• TIGHT PLICATION could lead to 1. Bladder neck obstruction2. Voiding dysfunction3. Urinary retention
• Vaginal narrowing compromises sexual function• Cystocele Recurrence and Stress Incontinence
BURCH COLPOSUSPENSIONSuspend the bladder neck and urethra to the Coopers
ligament bilaterally restoring the support to the distal anterior vaginal wall
Historically regarded as a CONTINENCE procedureOption for early stage Anterior Vag Wall prolapseEspecially for short anterior vaginal wallLess superior to Ant. Colporrhaphy- (66 vs 97%)
BURCH COLPOSUSPENSION COMPLICATIONS
• Bleeding from pelvic veins during retropubic dissection or vaginal suture placement
• Overcorrection of UVJ may lead to bladder outlet obstruction with urinary retention ( 4-5%)
• De novo urge incontinence (11-17%)• Alteration of Vaginal axis predisposes to vault prolapse,
enterocele and rectocele
POSTERIOR COLPORRHAPHY
• Close the posterior wall herniation by re-approximation of the medial edge of the levator muscles over the midline
• 76 – 96% - LONG TERM anatomic cure rates Maher 2006
• Transvaginal route is superior to Transanal route in terms of recurrent prolapse
• Midline plication offers superior anatomic and functional outcome as compared to site specific repair
POSTERIOR COLPORRHAPHY COMPLICATIONS
Hemorrhage Ureteric injury Rectal injury Pain with Defecation Sexual Dysfunction
MIDDLE /APICAL COMPARTMENT Many operations have been described Vaginal route enjoys the advantage of being
easily performed, repair of other associated site of prolapse and with faster recovery
Abdominal route is associated with longer vaginal length
SURGICAL MANAGEMENT
Primarily an APICAL support procedure
Used to treat or prevent enterocele formation
Internal stitches have been placed from one USL to the other incorporating the peritoneum and tied obliterating the cul de sac
External stitch is tied suspending the vaginal cuff
SURGICAL MANAGEMENT
McCALL CULDOPLASTY
• 89 – 100% success rates• Risk of ureteric injury• McCall Culdoplasty was more effective than either simple
closure of the peritoneum or Moschcowitz over a 3 year follow up in preventing enterocoele
(Cruikshank and Kovac 1999)
• Prophylactic McCall Culdoplasty at the time of vaginal hysterectomy for vaginal prolapse is the routine practice
SURGICAL MANAGEMENT
McCALL CULDOPLASTY
Described by Ritcher in 1968 SSL is used as anchoring point to suspend the vaginal apex 64 – 99% success rate 37% recurrence rate of the anterior vaginal wall due to
posterior displacement of the vault BICF decreases the rate of cystocele recurrence Paraiso et al 1996
SURGICAL MANAGEMENT
SACROSPINOUS LIGAMENT FIXATION
Vascular injury particularly to the inferior gluteal and pudendal vessels which are located superior and posterior to the ligament
7% - neural injury or entrapment and may result in gluteal pain and numbness
High recurrence rate of anterior vaginal wall prolapse
SACROSPINOUS LIGAMENT FIXATION COMPLICATONS
BILATERAL ILIOCOCCYGEAL FIXATION● Similar to SSLF but uses Iliococcygeus muscle fascia just
anterior to the ischial spine as an anchorage site to suspend the vaginal apex
● Bilateral suspension maintains the normal alignment of vaginal canal
● 91 % versus 94% COMPARABLE SUCCESS RATE and concluded that these procedures were equally effective for vault prolapse with less morbidity Maher 2001
SURGICAL MANAGEMENT
ABDOMINAL SACROCOLPOPEXY
SURGICAL MANAGEMENT
● Designed to correct the vaginal vault or on women who have failed prior vault suspension
● Vaginal apex is suspended to anterior longitudinal ligament of sacrum ( S1- S2) using a synthetic mesh
● Sacrohysteropexy is performed on women who desire uterine preservation● 78 – 100% success rate● Maintains normal vaginal axis and caliber
COMPLICATIONS● Procedure of choice in those who have other indication for
laparotomy i.e, oophorectomy or simultaneous retropubic urethropexy for USI
● Hemorrhage from presacral vessels can occur during the sacral component of the procedure
● 5 – 7% Vaginal erosion rate● Small asymptomatic vaginal opening, to infection, abscess
or fistula
ABDOMINAL SACROCOLPOPEXY
COMPARTMENT VAGINAL ROUTE ABDOMINAL ROUTE
ANTERIOR VAGINA Anterior ColporrhaphyParavaginal Repair
Burch ColposuspensionParavaginal RepairSacrocolpopexy
POSTERIOR VAGINA Posterior Colporrhaphy(Fascia,Myorrhaphy, Site Specific Repair)Transanal Repair
Sacrocolpopexy
MIDDLE / APICAL VAGINA
Lefort ColpocleisisSacrospinous Ligament FixationPrespinous Ligament Fixation / BICFUSL SuspensionUSL PlicationMc Call Culdoplasty
SacrohysteropexySacrocolpopexyUSL FixationMoschowitz ProcedureHalbans Procedure
Pelvic Organ Prolapse Stage IV
Vesicocervical Pubocervical fascia
Vesicouterine Fold
Peritoneal cavity
Uterosacral Cardinal Ligament
ComplexUterine Vessels
Utero tubal- Broad / Round
Ligament Vaginal Cuff
Mc Call Culdoplasty
Anterior Vaginal Wall Dissection
Exposed Pubocervical
FasciaMidline Plication
Anterior Colporrhaphy
Vaginal Apex
Genital Hiatus
Dissection of Posterior Vaginal
Wall
Extending laterally until Ischial Spines are palpated
Bilateral Iliococcygeal
Fixation
Suspending the Vaginal Apex
Midline Plication
Posterior Colporrhaphy Perineorrhaphy
Before Surgery
Post Surgery
POP GIRLS of PGH
Abnormal Descent of Pelvic OrgansIntroital Mass, Pelvic Discomfort and HeavinessMultifactorial EtiologyDiagnosis thru Pelvic ExaminationBladder Testing Should be part of PRE-OP
EvaluationConservative and Surgical management
Summary