Pelvic Floor Disorders: Surgical Approach

22. Pelvic Organ Prolapse Suspension

Antonio Longo , Brigitta Boller, Francesco Crafa and Federico Perrone

(1)

European Center of Coloproctology and Pelvic Diseases, Vienna, Austria

Antonio Longo

Email: alongo@neomedia.it

Abstract

It may seem strange for a coloproctologist to propose a new procedure for correcting genital prolapse and therefore it is necessary to relate the background to this initiative; however, this will be limited to the most relevant data. At the European Center of Coloproctology and Pelvic Diseases, Vienna, we examined about 1,000 women affected by disorders of evacuation between the years 1999 and 2001.

22.1 Background

It may seem strange for a coloproctologist to propose a new procedure for correcting genital prolapse and therefore it is necessary to relate the background to this initiative; however, this will be limited to the most relevant data. At the European Center of Coloproctology and Pelvic Diseases, Vienna, we examined about 1,000 women affected by disorders of evacuation between the years 1999 and 2001.

The data we are interested in reporting in order to explain the technique relate to patients with genital prolapse or those who had already undergone surgery for this condition. Of 322 patients, who had previously undergone operations for genital prolapse, 306 (95%) had symptoms of obstructed defecation, with an average Longo obstructed defecation syndrome (ODS) score of 9.5 (range 4–36). Thirty-nine (12%) had impaired fecal incontinence (FI), with an average Wexner incontinence score of 4 (range 1–16) [1]. Only 12 patients (3.7%) had undergone defecography before surgery. A review of the literature shows that only 25% of publications reporting results after correction of genital prolapse, using any technique, quote the effects of the surgery on obstructed defecation and/or FI. Moreover very few studies use a score for ODS or FI preoperatively and postoperatively. This suggests that urogynecologists do not focus enough attention on the rectum and defecation disorders, and that coloproctologists have probably not gone into enough depth in investigating the association between urogenital prolapse and rectal prolapse. In 615 women with varying degrees of genital prolapse who requested examination at our center for ODS or active FI, dynamic pelvigraphy revealed an association between genital prolapse and internal or external rectal prolapse and/or rectocele in 100% of cases.

To determine whether this association is constant, or whether it affects only women with symptoms of obstructed defecation, in collaboration with gynecologists we submitted 25 women with genital prolapse to dynamic pelvigraphy; the prolapse was between 2 and 4° according to the HWS Baden-Walker classification, and the women did not show symptoms of obstructed defecation or active FI. In all 25 women (100%) we found an internal rectal prolapse associated with rectocele. In these patients, dynamic pelvigraphy showed that the rectum was emptied by the extrinsic compression of the uterus and bladder. We have used this observation to provide an explanation for evacuation in some of these patients, although they had a major internal rectal prolapse or rectocele.

From 2000 to 2001, gynecologists submitted the aforementioned group of 25 women, plus a further 23 women with similar clinical characteristics, to traditional operations for urogenital prolapse; preoperative and postoperative assessment of internal rectal prolapse and/or rectocele, including ODS, was evaluated by a coloproctologist. Twenty-nine of these women underwent a colpohysterectomy with anterior colpoplasty (ten women), anterior and posterior colpoplasty with mesh (six women), posterior colpoperineoplasty (eight women, of which five were with mesh). Dynamic pelvigraphy examination performed at 3–6 months in 27 of the women showed the presence of rectal prolapse in all cases. Patients who had undergone posterior colpoperineoplasty showed a significant reduction of the rectocele postoperatively, but a greater degree of rectal prolapse. The most significant finding was that 11/29 (37.9%) had developed de novo ODS, with a Longo ODS score of 4.8 (range 3–22). Twenty-one women were subjected to laparoscopic colposacropexy. In this group, the rectal prolapse was not corrected in any of the women, but in 10 cases it was improved, along with improvement in the rectocele. However, ten patients (47.6%) developed ODS with a Longo ODS score of 4.2 (range 2–32). Postoperative dynamic pelvigraphy of all the patients who had developed ODS showed that rectal emptying was incomplete and began after several attempts of intensive straining. Even those patients who reported normal emptying of the bowel preoperatively needed a greater number of attempts to empty the rectum postoperatively.

These observations led us to conclude that: a uterovaginal prolapse should be considered a total pelvic prolapse because it always includes a cystocele and a rectal prolapse, which may be symptomatic of ODS or asymptomatic; conventional techniques are not capable of simultaneously correcting rectal prolapse; de novo ODS can be induced.

From a review of the literature on urogenital prolapses it was noted that about 30% of women undergoing surgery for genitourinary prolapse required a further operation [2]. We therefore concluded that there is considerable room for improvement in conventional surgery for pelvic organ prolapse.

We made some anatomical-functional hypotheses on why it is possible to observe a rectal prolapse without a genital prolapse, but, in contrast, the genital prolapse always involves a rectal prolapse. In fact, the rectum has only two types of ligaments. The lateral ligaments support the lower third of the rectum only. The upper two-thirds section of the rectum is maintained in the normal craniocaudal position by the rear sacral ligaments, which consist of thin connective fibers that lie obliquely and allow discrete movements of the rectum, such as a relaxation and shortening; at the top is the pelvic visceral peritoneum (pouch of Douglas) with the underlying connective tissue elastic fibers covering the anterior intraperitoneal rectum supporting it toward the top, anteriorly; in women, the rectum is connected to the vagina on the posterior fornix by connective muscle fibers, in the middle portion of the oblique fibers, which also allow a reasonable range of motion on the walls of the two organs, and in fact they are connected anatomically. This ligamentous labile structure of the middle and upper rectum means that the descent of the posterior pelvic peritoneum and vagina inevitably drags down the upper and middle rectum, often causing the formation of a loop rectocele and consequently a rectocele dilatation. Therefore, all vaginal prolapses, which involve the pouch of Douglas, always induce a rectal prolapse. Instead, as the uterus and vagina have an extremely strong ligamentous structure, both craniocaudally and laterally, a primary rectal prolapse does not necessarily lead to a genital prolapse.

Another important clinical observation at the European Center of Coloproctology and Pelvic Diseases, Vienna, regards the lower incidence and the severity of disorders of urinary incontinence, ODS and FI in patients who had undergone hysterectomy for benign or malignant diseases of the uterus, compared with patients who had undergone a hysterectomy for genital prolapse. We believe that this difference in incidence can be attributed to major changes in pelvic anatomy induced by the prolapses themselves and the traditional techniques of correction of genital prolapse. Colposacropexy does not correct the rectal prolapse and results in a partial occlusion of the pouch of Douglas. There is also stiffness of the pouch as a consequence of the bridge formed with mesh that runs from the vagina to the sacrum. Furthermore, this technique leaves a large anterior pelvic space where the bladder can expand abnormally, resulting in disorders of micturition. The partial obliteration of the pouch of Douglas and the resulting inelasticity contribute to ineffective straining for evacuation. We think that this might be a cause of de novo ODS, or that it might lead to a worsening of a preexisting ODS.

Colpohysterectomy brings about several problems because of the attachment of the vaginal vault. The suspension of the vaginal vault to the sacrospinous ligament is too low and posterior, and this frequently causes urinary stress incontinence and ODS, as we have often noted. Suspension of the vaginal vault to the uterosacral ligaments causes obliteration of the pouch of Douglas, and straining for defecation becomes ineffective. In addition, the placement of mesh in the rectovaginal septum induces an inelasticity of the anterior rectal wall making it difficult to empty the rectum, and also because this intervention compresses the rectocele resulting in rectoanal intussusception. Further problems of evacuation are created by elevatorplasty, which tends to strangle the rectum.

Finally, analysis of the dynamics of over 5,000 pelvigraphies has suggested the following concept: the uterus and broad ligaments have an important anatomical-physiological role because they divide the pelvis in two compartments: anterior and posterior. During contraction of the abdominal muscles, a normoflected uterus compresses the bladder promoting urination, while the small intestine slides on the uterus towards the pouch of Douglas where it compresses the sigmoid rectum, fostering evacuation. Hysterectomy transforms the pelvis so that it becomes a unique compartment, allowing the bladder to expand abnormally resulting in urinary disorders, and, not infrequently, we have observed enormous bladders compressing the sigmoid posteriorly. In contrast, the sigmoid can also move itself anteriorally, interfering with the bladder filling and normal emptying.

It should not be overlooked that hysterectomy almost always has a traumatic psychological impact on women and that it poses the greatest risks of complications in surgery for genital prolapse. We believe that there is no need to remove the uterus, which in 90% of cases is healthy even if it is prolapsed.

For these reasons, we decided to try to improve surgery for pelvic organ prolapse. Our goal was to obtain the simultaneous correction of prolapse of all the pelvic organs and resolution of the related symptoms. We set out to obtain the most anatomically and minimally invasive correction procedure possible. To understand the anatomical and physiological rational basis of the technique, we will explain some of the concepts. A uterovaginal prolapse is downward displacement of the neck and the uterine body so that it gradually occupies the vaginal lumen, tending to lean outward. The process begins with the introversion of the vaginal vault and cervix. Subsequently, the vagina loses the weak lateral intrapelvic anchors and invaginates on itself, tending to move outward and dragging the rectum and bladder behind it. This results in a complete pelvic prolapse, even though there may be different levels of involvement of the three pelvic compartments. In the early stages of a hysterocele, the formation of cystoceles, rectoceles, or enteroceles may cause compression on the vaginal walls, resulting in weakening or dystrophy. However, the rectocele, cystocele or enterocele might have been present before the genital prolapse and already caused dystrophic vaginal damage. Vaginal dystrophic damage is very common in advanced stages of genital prolapse, especially if it is associated with an elytrocele.

It is extremely important to emphasize that the damage to the vaginal wall is always secondary, never primary, and so correction or strengthening the vaginal walls without correction of the pathology, rectocele and/or cystocele that led to the trophic alterations is not, in our opinion, a rational approach.

It should be noted that rectocele and cystocele may occur without a vaginal prolapse. It remains unclear whether the pressure exerted by a rectocele on the posterior vaginal walls during the effort of evacuation may be a possible or concomitant cause of genital prolapse, as well as a cystocele on the anterior wall. Cystocele and rectocele can certainly cause sliding, with elongation of the anterior and/or posterior vaginal walls, leaving the uterine cervix in place only if the Mackenrodt ligaments resist the sliding. Trophic vaginal damage is often absent or minimal; in addition, our clinical observations led us to believe that if the mechanical insult stops, the dystrophic changes are partially reversible.

The anatomical and pathological observations led us to conceive POPS (pelvic organ prolapse suspension), which is described as follows. A prolapse of the vaginal vault is not possible if the Mackenrodt ligaments are intact. In other words, we found that the stretching or breaking of the Mackenrodt cardinal ligaments is a necessary condition for the occurrence of hysterocele, and that other changes such as lengthening of the uterosacral ligaments, round ligaments, pubocervical ligaments etc. were a consequence of the traction on them caused by the prolapsing uterus.

We concluded that reconstructing the anchor of the vaginal vault to the Mackenrodt ligaments must be the first goal in surgery for pelvic organ prolapse. Other accessory procedures may be useful or necessary to restore the anatomy, and especially to correct sexual, urination, and defecation dysfunctions. In particular, it is possible to add to this basic technique the plastic shortening of the round ligaments in order to prevent uterine retroflexion. In order to achieve optimal correction of internal rectal prolapse and rectocele, a stapled transanal rectal resection (STARR) procedure can also be carried out.

22.2 Introduction

Pelvic floor disorders are an increasing problem in the health care of women. Pelvic organ prolapse is a major cause of morbidity in women, affecting 30–40% of parous women, and its incidence increases with age [13]. Up to 24% of women in the US experience a pelvic floor disorder, and this percentage can be as high as 50% in women over 50 years [4]. Symptomatic pelvic organ prolapse can have an important impact on general health-related quality of life (QoL); it can interfere with physical mobility and sleep, and cause pain, emotional reactions, social isolation, and lack of energy [5].

Pelvic organ prolapse disorders are also associated with a profound adverse effect on QoL, and there is a significant correlation between impairment of total prolapse QoL (P-QoL) scores and increasing stage of uterovaginal prolapse. The impact of pelvic floor disorders on health-related QoL is similar to the impact of other chronic and debilitating medical conditions such as stroke, cancer, diabetes, and dementia [6]. The lifetime risk of undergoing at least one surgical procedure for prolapse and urinary incontinence can be as high as 18% by the age of 79 years and the reoperation rate for recurrence of these disorders is close to 30% [7]. Over the next 30 years, it is predicted that the demand for services for female pelvic organ diseases will increase at twice the rate of growth of the same population, and that the number of surgical operations carried out for urinary incontinence and pelvic organ prolapse will increase substantially over the next 40 years [8].

The high prevalence of pelvic organ prolapse results in high socioeconomic costs and a significant impact on the QoL of these patients. During the last century, hundreds of surgical procedures were described for the treatment of pelvic organ prolapse; these mainly addressed single compartment prolapse, and they produced contrasting results, underlining the need to continue the search for the ideal surgical treatment. The ideal treatment should correct a rectal prolapse and/or rectal intussusception and derived symptoms, which range from FI to ODS [2]. In addition, the treatment should address middle and anterior compartment prolapses when they are present. The impact of surgical correction of prolapse on symptoms remains unclear. Several studies suggest an improvement in constipation levels [9], while others have demonstrated worsening of symptoms or a significant degree of new-onset constipation [10]. Furthermore, preoperative clinical-instrumental evaluations rarely include anatomical-functional examinations of the rectum, thus neglecting the fact that the rectum is one of the pelvic organs that has a high impact on the dynamics of the pelvis, because it is subjected to mechanical strain on a daily basis. If ODS persists or is created de novo in patients undergoing surgery for pelvic organ prolapse, this often results in intense straining which represents a daily mechanical stress on all the pelvic organs and supporting structures. We do not exclude that this could be a major cause of the high rate of relapse after conventional surgery. For these reasons, we believe that correcting ODS is a prerequisite in order to avoid relapses and improve the QoL. Traditionally, abdominal approaches are preferable to perineal approaches because of the lower longterm recurrence rate and better correction of incontinence [3]. However, when rectal prolapse is treated with posterior rectopexy, although incontinence is improved, the associated constipation tends to get worse after surgery [23]. Occasionally new-onset constipation is a consequence of rectal denervation secondary to posterolateral mobilization and division of the lateral ligaments. Concomitant colonic resection is effective at overcoming this problem, but it risks the occurrence of anastomotic leakage or anastomotic stricture. Moreover, it has been suggested recently that a key role of the sigmoid colon is as a fecal reservoir, and that on another level it helps to maintain fecal continence [4].

Based on these assumptions, we have developed a procedure known as POPS (pelvic organ prolapse suspension). We have developed significant experience in this technique over a long period of time. In this chapter, we describe the surgical technique itself, and preliminary results of statistically processed data.

22.3 Surgical Laparoscopic Technique

All patients are given an enema on the day of the operation. Antibiotic prophylaxis (2 g cephalosporin) is given to the patients in theater. General anesthesia is used in all cases. The patient is placed in a lithotomy position with both arms near the body with the thighs spread moderately and bent upwards. After appropriate preparation and draping, a Foley catheter is placed in the bladder and a circular anal dilator (CAD) kit for hemorrhoidopexy is introduced through the anus and fixed by four stitches. The extent of rectal prolapse is assessed through a gauze mounted on a Klemmer clamp. The operation positions are: surgeon on the right side of the patient, first assistant to the left side of the surgeon, and second assistant between the legs of the patient. The pneumoperitoneum is established using a subumbilical open technique and a 30° laparoscope is introduced. One 10-mm trocar is inserted under laparoscopic vision into the intersection between umbilical-transversal line in the right side, and a 5-mm trocar is inserted symmetrically in the left side. The procedures include the following steps. (1) Exploration of the peritoneal cavity and then moving the patient to the Trendelenburg position (30°). (2) A vaginal valve is pushed up the anterior fornix for adequate exposure of the pelvic peritoneum. (3) Using a 30 ± 30 cm prolene mesh (Ethicon), V-shaped strips (25 cm long, 2 cm wide) are prepared. (4) The mesh is introduced through a 10-mm trocar, then a 2-cm incision of the peritoneum in the apex of the anterior vaginal fornix is made and the mesh is then fixed using a prolene 0 stitch on the anterior vaginal vault or, if the patient has had hysterectomy, on the vaginal apex. (5) On the right side, 2-cm cutaneous incisions are made 2 cm above and 2 cm posterior to the anterior superior iliac spine. The aponeurosis of the external oblique muscle is incised, and by dissociating the fibers of the internal oblique and transverse abdominus muscles using scissors, the subperitoneum is reached. Forceps are introduced through this incision (we formerly used long Klemmer forceps, but we now prefer Click Line, sec. Cuschieri, with a curved distal part of diameter 5 mm, length 43 cm; Karl Storz Endoscopy [UK] Ltd, Slough, UK) and we can follow the tip of the instrument through the transparency of the peritoneum. (6) By advancing this clamp, under laparoscopic vision, a subperitoneal tunnel is created to reach the anterior fornix of the vagina. The tunnel passes 2 cm above the peritoneal reflection of the colon, 2–3 cm below the insertion of the round ligament in the internal inguinal orifice. Reaching the anterior vaginal fornix, the tip of the clamp is then forced out of the peritoneal incision previously performed, and one end of the V-mesh is taken and pulled out through the subperitoneal tunnel. (7) Repeating the same steps, the left strip of the mesh is pulled out. (8) The mesh is fixed to both of the lateral vaginal fornices by two further stitches of prolene 0. Pelvic organ suspension is achieved by symmetrical traction on both mesh strips (Fig. 22.1). (9) The second assistant advises when the vaginal vault is suspended at the desired level to completely reduce the vaginal prolapse, but avoid excessive tension on the vaginal walls. This adjustment takes place after exsufflation of CO2. (10) A 5-cm length of excess mesh strip is positioned by tunneling the fascia of the muscle, above the incision, and fixed by vicryl 2-0 stitches. The skin is closed with an intradermic suture.

A978-88-470-5441-7_22_Fig1_HTML.jpg

Fig. 22.1

Front (a) and lateral (b) view of the pelvic organ prolapse suspension procedure. A V-shaped mesh is fixed to the anterior and lateral vaginal fornix (ab). The end of strips, the abdominal lateral subperitoneal tunnel, were pulled out through the lateral skin incisions above the iliac crest. A symmetrical traction on both strips reduce the genital prolapse, the cistocele and the rectal prolapse (A1+B1)

In patients who have had a hysterectomy, two separate meshes are used for each side (right and left), and these are then sutured at each side of the vagina, remaining below the perineum, thereby avoiding the possibility of contamination of the mesh due to the opening of the vagina and erosion of the mesh on the top of the stump.

In the event that the vaginal prolapse is prevalent posteriorly, the mesh is fixed on the posterior vaginal fornix; a uterine manipulator is useful because it offers appropriate exposure of the posterior vaginal fornix and the pouch of Douglas.

In patients with advanced cystocele with redundancy and dystrophy of the anterior vaginal wall, the space between the bladder and the vagina is opened and a 5-cm wide, 10-cm long V-shaped mesh is sutured and applied and fixed in the vesicovaginal space. Plication of round ligaments can be added to this basic procedure in order to avoid uterine retroversion.

Any sigmoid rectum intussusceptions are corrected by fixing the mesosigma distal to the left branch of the mesh.

At the end of the procedure, through the CAD, an evaluation of the rectal prolapse is performed. If a residual rectoanal prolapse and/or an anterior rectocele persists, then a STARR procedure is performed.

Indications for an approach by laparotomy are: previous Wertheim hysterectomy, or other complex operation in the pelvis performed via laparotomy; if hysterectomy for fibromatosis is planned; if a mesh for the reinforcement of the anterior vaginal wall and vaginoplasty is necessary.

The laparotomy technique is performed using the same steps as the laparoscopic approach, and the access to the pelvis is obtained by using a previous laparotomy incision (Pfannenstiel or umbilicus pubic incision).

The patient is discharged about 2-3 days after surgery.

22.4 Preliminary Results

From September 2001 to December 2010, we enrolled 486 consecutive women with symptomatic pelvic organ prolapse. The most frequent surgical complications were wound infections and postoperative rectal bleeding in 24 of 226 patients; these complications were associated with the STARR procedure. One patient developed acute postoperative bowel obstruction caused by twisting of the sigmoid colon on the fixing points. One patient developed left renal colic with ureteropyelodilatation caused by urethral kinking due to traction of the mesh on the overlying peritoneum. It was resolved by placing a transurethral catheter in the bladder for 30 days. The anatomotic STARR dehiscences were treated conservatively. The overall rate of surgical complications was 14.3%. Patients were discharged on average after 2.7 days (range 2–16). The mean catheterization time was 30 hours, and the incidence of urinary retention was 3.1%.

Of the 486 patients enrolled in the study, 482 were followed-up at 1 month, 426 at 3 months (of which 404 underwent a repeat dynamic pelvigraphy), 390 at 6 months, 304 at 1 year, 242 at 3 years, and 144 at 5 years. Defecation urgency (7.2%) was the main complication reported at 1 month, and this was resolved in all patients within 3 months. Postoperative pain was slight, on average. No cases of de novo dyspareunia were reported, and all 26 patients who reported this affliction preoperatively were cured or showed significant improvement.

When evaluated clinically, the anatomical results and pelvic organ prolapse stage were excellent. In particular, hysterocele was well corrected in 100% of patients. However, in 29 patients (5.97%) there was a residual grade I cystocele, and in 19 patients (3.9%) there was a grade I posterior colpocele. Pelvigraphy confirmed the excellent anatomical results: in 31.2%, a residual modest rectocele was observed; in 3.9%, a residual posterior colpocele grade I was evident; in 18 patients, a residual rectoanal intussusception was detected, and 10 of these patients also had a residual rectocele, and then underwent STARR for symptoms of ODS.

In 23.76% of patients, a deep pouch of Douglas was residual, but paradoxically in this subgroup the average postoperative ODS score was 1.4, while the same score was at least 3.03 for the group as a whole. In fact, the depth measurement of the pouch of Douglas was compared with the vaginal vault, which was often a little higher than the norm: the measurement of the distance of the pouch of Douglas to the pubococcygeal line was found to be normal in 93.5% of patients. There was a significant improvement in the descent of the perineum, especially in patients who underwent the STARR procedure.

We found six patients (1.23%) with vaginal prolapse relapse; five of these patients had previously undergone hysterectomy. All recurrences occurred within 6 months of surgery and we found that in all cases the cause was detachment of the vagina from the mesh. Four patients underwent reoperations to restore the suture between the vaginal vault and the mesh, using a prolene 0 continuous suture.

After the follow-up at 6 months we did not record any cases of relapse. Colposcopy detected only one case of moderate erosion of the mesh, and this was treated by removing the portion of the mesh that had emerged through the vagina.

Preliminary results regarding the effectiveness of the technique on urination disorders were recorded in terms of the number and percentage of patients who reported the symptom preoperatively and postoperatively (6 months). Urogenital distress inventory scores are currently being analyzed statistically. However, it is evident that there is a dramatic fall in the percentage of patients affected with these disorders. Symptoms of ODS were present in 70.98% of patients; it is important to note that 32% of these patients had been diagnosed with irritable bowel syndrome and 9.6% had reported slow transit constipation or dolichocolon. The Longo ODS score fell from a mean of 14.55 to a mean of 3.03. Taking into account the 52 patients with fecal or gas incontinence, 18 had an external rectal prolapse and marked anal sphincter hypotony, average 12.5 (range 0–25), and 24 had a rectoanal intussusception. Transanal ultrasonography excluded injuries in the continuity of the anal sphincters, even in 22 patients who presented with a thinner rectal wall. A total of 25 of 52 patients showed complete successful treatment immediately after surgery, the 18 patients with an external rectal prolapse showed improvement up to 1 year after surgery, and 12 were referred for biofeedback. However, almost all patients with FI showed improvement. Therefore, in all cases, active FI or sphincter hypotony was secondary to rectal prolapse. The functional results obtained had a very favorable impact on the QoL for patients: they were able to resume normal activities, with improvements in discomfort, anxiety, and depression.

22.5 Conclusions

We are aware that, in the opinion of urogynecologists, the proposed technique could prompt several arguments and questions, and be subject to many doubts. For this reason, we want to collect data for a sufficiently long follow-up period and include many more patients to support our claims.

In light of the results and feedback we have received from colleagues who have used the POPS procedure, we can confirm that POPS, performed when necessary in conjunction with STARR, has produced more effective results than those reported in the literature for traditional techniques, both transvaginal and colposacrosuspension procedures. We believe that correction of the rectal prolapse and rectocele, which are always associated with a genital prolapse, is a fundamental in this surgery. In fact, the high rate of constipation, residual and de novo, reported in the literature is probably due to the failure to correct the rectal prolapse. Certainly, the occlusion of the pouch Douglas, which is involved in some conventional procedures, including colposacropexy and plication of the uterosacral ligaments, contributes worsening of ODS. Also, Douglassectomy often results in rigidity of the peritoneal pouch, and adversely affects physiological defecation.

The high percentage of ODS in patients undergoing conventional surgery for pelvic organ prolapse may be the cause of the high recurrence rate. In fact, patients with ODS have to strain more for evacuation, causing more mechanical stress to the pelvis. When the pouch of Douglas is occluded, the stress is mainly in the middle and anterior compartments. Therefore, it might be a cause of partial or total recurrence.

We reiterate that rectocele is certainly a primary disease of the rectum, and dilatation is due to a thinning or disappearance of the muscular tunics of the distal rectum; posterior colpocele and related anatomical and structural alterations of the posterior vaginal wall must be considered secondary alterations. Therefore applying a mesh between the rectum and vagina, while restoring the look of the vagina, does not solve the cause and symptoms of ODS, but increases the rate of dyspareunia and complications. In addition, if the rectocele continues to push on the mesh it will bring about recurrence of the colpocele and erosion of the mesh. For these reasons, STARR improves ODS by resecting the rectocele and restoring muscular continuity, in addition to correcting the rectocolpocele.

Any excessive posterior vaginal redundancy can be corrected by stretching and suturing the posterior vaginal fornix to the subperitoneal mesh of the POPS. The preservation of the uterus, suspending it in a natural position, produces significant surgical, functional and psychological benefits. In fact, all the complications related to surgical hysterectomy are avoided; the uterus will continue to divide the pelvis into two compartments and modulate straining for evacuation and urination, and at the same time preventing excessive dilation of bladder. Finally, we found that hysterectomy is a serious psychological trauma for women that can affect their sexual activity.

In conclusion, we believe that the procedure we have proposed, given the results, is excellent for use in patients with elongated vagina walls that retain a good trophism. Our proposal must be seen as a contribution from a coloproctologist to a gynecologist to enable better comprehension of the role of the rectum in pelvic floor surgery. We have emphasized that the genital apparatus also functions as an anatomical support for the bladder and rectum and, therefore, inevitably a genital prolapse results in serious anatomical and functional alterations of these organs. Obviously, the gynecologist remains the specialist for pelvic organ prolapse referral, but we have shown that it is essential to have greater multidisciplinary collaboration.

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