Pelvic Floor Disorders: Surgical Approach

25. Management of Concomitant Middle Compartment Disorders

Neil J. Smart , William M. Chambers and Patricia Boorman

(1)

Exeter Surgical Health Services Research Unit, Royal Devon and Exeter Hospital, Exeter, Devon, UK

Neil J. Smart

Email: drneilsmart@hotmail.com

Abstract

In the traditional “vertical” segregation of the pelvic floor into anterior, middle and posterior compartments, disorders of the middle compartment (uterus, vagina and introitus) were the preserve of gynecologists. This compartmentalized view of the anatomy, assessment, and management of pelvic floor disorders led to clinicians working in isolation, with a detailed understanding of pathologies limited to their area of expertise, often to the detriment of the patient. The modern, horizontally integrated view of the pelvic floor as a whole unit has necessitated multidisciplinary team working and has led to a more detailed and broader assessment process [1]. The aim of this strategy has been to optimize patient management by avoiding repeated clinic attendance and/or operative intervention because of a failure to accurately identify dysfunction of an adjacent organ of the pelvic floor.

25.1 Introduction

In the traditional “vertical” segregation of the pelvic floor into anterior, middle and posterior compartments, disorders of the middle compartment (uterus, vagina and introitus) were the preserve of gynecologists. This compartmentalized view of the anatomy, assessment, and management of pelvic floor disorders led to clinicians working in isolation, with a detailed understanding of pathologies limited to their area of expertise, often to the detriment of the patient. The modern, horizontally integrated view of the pelvic floor as a whole unit has necessitated multidisciplinary team working and has led to a more detailed and broader assessment process [1]. The aim of this strategy has been to optimize patient management by avoiding repeated clinic attendance and/or operative intervention because of a failure to accurately identify dysfunction of an adjacent organ of the pelvic floor.

Multicompartmental dysfunction of the pelvic floor is common, but appreciation of this fact by practicing clinicians had been sporadic at best, despite extensive data in the literature, until the resurgence of interest in pelvic floor disorders over the past decade or so. The Cleveland Clinic in Florida did much to raise awareness in colorectal circles with their seminal publication on a survey of three groups of patients: those with fecal incontinence, those with rectal prolapse, and a control group [2]. Consistent with similar studies on “normal” populations, the control group had incidences of urinary incontinence and genital prolapse of 30% and 12.5%, respectively. Urinary incontinence was present in 53% of those who had had previous surgery for fecal incontinence and 65% in those who had had previous surgery for rectal prolapse. Genital prolapse was similarly more prevalent in the study groups than in controls, being found in 18% of patients with fecal incontinence and 34% of patients with rectal prolapse.

The inevitable consequence of all these developments in our understanding of the basic science underlying prolapse disorders and in advances in service provision is the increased frequency of the diagnosis of multicompartmental pelvic organ prolapse. Indeed, with a greater understanding of the natural history of the disease process, multicompartmental pelvic organ prolapse may even be thought inevitable if only unicompartmental prolapse has been diagnosed at initial presentation, thus raising the prospect of prophylactic surgical measures. Ultimately, if multicompartmental prolapse repair is to be performed, the debate is between sequential and simultaneous procedures. The development of urogynecology as a subspecialty means that anterior and concomitant middle compartment prolapse is often dealt with by the same surgeon. The challenge lies when there is posterior with concomitant middle compartment prolapse, as this traditionally would have required both a colorectal surgeon and a gynecologist. With the development of pelvic floor surgery as a specialty in its own right, the prevailing view is that procedures that simultaneously correct prolapse in both compartments are to be preferred as the outcome from concomitantly performed procedures is not any worse than sequentially performed procedures, the overall time in recovery is reduced by having only one operation and there is a theoretical reduction in the rate of surgical complications. Technical considerations, such as access to the sacral promontory for rectopexy and colpopexy, also tend to favor simultaneous procedures.

The main pathological entities that will be encountered in the middle compartment are vaginal vault prolapse and uterine prolapse. These frequently coexist with posterior compartment disorders (Fig. 25.1). The management strategy for each of these concomitant disorders varies according to the operative approach intended for the posterior compartment surgery. The goals of surgery are, however, the same regardless of the operative approach, namely the restoration of normal anatomy and function of pelvic organs.

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Fig. 25.1

Defecating proctogram at rest (left) and on evacuation (right). There is a normal anorectal angle at rest, with a reasonable pelvic lift and good anal canal length (left). There is a small anterior rectocele seen with coughing, which enlarges with evacuation and does not fully empty. There is vaginal vault prolapse and an enterocele that descends to within 4 cm of the anal canal (right)

25.2 Etiology of Middle Compartment Prolapse

The high degree of concordance between pelvic floor pathologies suggests a common etiology to disorders of all three compartments, namely childbirth, particularly with increasing parity, after prolonged labor, and after instrumental deliveries. Middle compartment prolapse (vaginal vault and uterus) is caused by loss of support or weakening of the uterosacral and cardinal ligaments. Hysterectomy in particular is associated with a significantly increased risk of vaginal vault prolapse [3]. Etiological factors other than parity, such as family history, genetics, obesity, and smoking status have been implicated in the development of pelvic organ prolapse [4] and much recent work has focused on the significant role of connective tissue and extracellular matrix metabolism [57]. Increasing age is a significant risk factor in addition to those mentioned above, with estrogen deficiency, particularly after the menopause, the presumed main contributing factor. Hormone replacement therapy (HRT) for more than 5 years may have a protective role in the development of pelvic floor dysfunction in postmenopausal females [8], but it is uncertain whether HRT initiated at the onset of menopause can prevent such prolapse.

25.3 Epidemiology

Population estimates of prevalence and incidence of pelvic organ prolapse are difficult to derive accurately, but are conservatively estimated at a life-time risk of at least one-third of the female population as a whole [9] and possibly up to 50% of parous women. Life-time risk of having surgery for pelvic organ prolapse of any type has been estimated at 11.1%, with a high reoperation rate of 29% [10]. This high rate of reoperation may in part reflect the inadequate assessment of all compartments of the pelvic floor in the past and it is uncertain whether it is representative of modern practice.

25.4 Classification

The International Continence Society has devised a scoring system for vaginal prolapse called the pelvic organ prolapse quantification (POP-Q) system, which defines specific sites on the anterior, posterior, and apical vaginal compartments that are measured with respect to the position of the hymen [11]. An ordinal staging system is derived from the measurements ranging from 0 to 4, where stage 0 denotes no prolapse through to stage 4 denoting complete eversion. Use of this standardized system in both clinical practice and in reporting trials facilitates stratification of patients and comparison between studies of different management techniques.

25.5 Conservative Management

The most conservative option for genital prolapse is vaginal pessary use. A wide range of pessary styles and sizes are available and selection of the most appropriate device usually requires a degree of trial and error. Such an approach can be useful for the aged, highly co-morbid patient, who may have a similarly conservative approach employed for their posterior compartment prolapse. Pessaries are also indicated in those who wish to avoid surgery specifically for their genital prolapse or postoperatively after pelvic reconstructive surgery to prevent recurrence. Pessary care can optimize and facilitate safe long-term use, but may be bothersome for younger patients who often prefer definitive surgical management.

25.6 Transvaginal and Obliterative Surgical Approaches

Operative approaches to genital prolapse in general and vaginal vault prolapse in particular include transvaginal, abdominal (open, laparoscopic, or robotic), and obliterative techniques. When considering the management of vault prolapse, transvaginal approaches, such as ileococcygeus suspension, sacrospinous fixation, and uterosacral ligament suspension are useful for postmenopausal women for whom sexual activity may not be important and in whom a perineal approach for posterior compartment disorders has been selected. Sacrospinous fixation was first described in the 1980s [12] and has been the favored transvaginal approach by many, with the vaginal apex being attached to the sacrospinous ligaments by nonabsorbable sutures. The posterior vaginal dissection may allow repair of concomitant enterocele, but the main limitation of this procedure is the not insignificant incidence of postoperative cystocele formation [13]. The medical literature is replete with a myriad of techniques for transvaginal placement of various mesh types for vault prolapse. The recent announcement by the Food and Drug Administration (FDA) in the USA regarding transvaginal mesh placement, whether biological or synthetic mesh, has cast doubt on whether they should be performed at all [14]. Indeed, in their review the FDA concluded “serious adverse events are NOT rare” and also “transvaginally placed mesh in POP repair does NOT conclusively improve clinical outcomes over traditional non-mesh repair”. This point of view remains controversial and is directly opposed by some authors who point out that there is good evidence to support the use of mesh augmentation and that it has a favorable risk/benefit ratio [15]. Obliterative approaches for vault prolapse such as colpectomy or colpocleisis are reserved for elderly women who are not sexually active, and have high rates of patient satisfaction [16]. Similar to the transvaginal approach, obliterative approaches are a useful adjunct to perineal approaches for posterior compartment prolapse. In view of the aging population in many westernized societies, the obliterative approaches to vault and uterine prolapse are likely to become more widespread [17].

25.7 Abdominal Operative Approaches: Open and Minimally Invasive

The abdominal approach to correction of vault or uterine prolapse was first described in the 1960s [1819] and involves the placement of a suspensory prosthesis, either synthetic or biologic, between the vaginal vault and the sacral promontory in the retroperitoneal plane. Abdominal approaches to correction of vault or uterine prolapse, whether open, laparoscopic, or robotic, are optimal when an abdominal approach has been selected for correction of the posterior compartment. In patients with uterine prolapse, the role of uterine preservation and suspension versus hysterectomy, either via vaginal or abdominal routes, remains contentious with no clear consensus emerging from the literature [20]. Open sacrocolpopexy has been reported to have better outcomes than transvaginal sacrospinous fixation in terms of correction of prolapse, recurrence, postoperative stress urinary incontinence, and postoperative dyspareunia. Laparoscopic sacrocolpopexy has equivalent outcomes in terms of prolapse correction when compared with open surgery, but is associated with reduced blood loss and shorter lengths of stay [21]. The laparoscopic approach has become the favored approach for many gynecologists in Europe, with over 20 years of experience behind it as a technique. Complications such as L5/S1 discitis [22] due to tack misplacement and mesh erosion [23] are well described and appropriate strategies for prevention and management now exist [2426]. There remains debate about which mesh is optimal for this type of surgery, and this is covered in detail in Chapter 27. As laparoscopic experience has grown among the wider surgical community, other minimally invasive techniques such as single port surgery have also been described in small numbers [27], although long-term follow up is lacking.

Since the advent of the Da Vinci® system onto the market in 1999, robotic sacrocolpopexy for pelvic organ prolapse has disseminated rapidly across the USA with minimal evidence to support its use. The past 5 years has seen numerous single institution case series or retrospective cohort studies that all purport to demonstrate at least equivalent outcomes to laparoscopic sacrocolpopexy, but only two have reported long-term outcomes [2829]. Only one small randomized trial (from the Cleveland Clinic) is currently available and its authors concluded that “robotic-assisted sacrocolpopexy results in longer operating time and increased pain and cost compared with the conventional laparoscopic approach” [30]. Results from the multicenter ACCESS trial, which also compares laparoscopic and robotic surgery, are awaited [31]. The trial may not, however, deliver the answer many clinicians are looking for since its primary outcome measure is cost of the procedure rather than a patient-focused outcome such as rate of recurrence, complications, or severe postoperative pain.

25.8 Synchronous Approaches

Synchronous approaches to middle and posterior compartment prolapse via the abdomen have become more prevalent since the wider recognition of multicompartmental prolapse as a common phenomenon has occurred. Small, single-institution case series of open abdominal procedures with short follow-up first appeared approximately 15 years ago, mainly in the gynecological literature. Cundiff et al. [32] were among the first who reported good clinical and radiological outcomes on 19 patients with vault prolapse, perineal descent, and associated rectoceles or enteroceles who had a sacrocolpoperineopexy. This involved dissection of the rectovaginal septum to the perineal body and mesh placement in this plane, which was sutured to the perineal body, the length of the vagina, and to the sacrum. Marinkovic and Stanton [33] utilized a similar open abdominal approach for 12 patients with triple compartment prolapse, but added an anterior mesh in order treat the cystocele. Objectively assessed clinical outcome and patient satisfaction scores were reported as being good with a median of 39 months follow-up. Within the colorectal literature, detailed functional outcome after open repair in 29 patients with a median 26-month follow-up was reported by Lim et al. following sacrocolporectopexy, which involved suspension of the vaginal vault with a “Y”-shaped mesh combined with fixation of the free edges of the mesh to the rectum, which had been mobilized posteriorly [34]. Significant improvements in global pelvic floor distress inventory scores were noted postoperatively.

The open abdominal approach for concomitant middle and posterior compartment prolapse coincided with the adoption of laparoscopy by the colorectal community, several decades after gynecologists had pioneered its use. Laparoscopic approaches for rectal prolapse were first described in the early 1990s, and many subsequent studies have demonstrated benefits in comparison with open surgery, particularly in terms of reductions in perioperative morbidity and length of hospital stay. Initial reports describing the laparoscopic management of multicompartmental prolapse replicated the open technique. Sagar et al. [35] reported functional outcome on ten patients after laparoscopic sacrocolporectopexy to be improved in a similar manner to their open cohort [34]. This technique, however, necessitated posterior rectal mobilization, which had become associated with worsening constipation. D’Hoore et al. [36] had advocated anterior rectal mobilization only in their seminal paper on laparoscopic ventral rectopexy, in order to avoid this troubling complication that can often be worse than the disease being treated. Subsequently, several minor modifications of the laparoscopic ventral mesh rectopexy technique have been proposed, including mesh fixation to the posterior and/or anterior vaginal wall [37], or with concomitant posterior colporrhaphy [38] as methods for dealing with multicompartmental prolapse. The majority of authors have reported excellent outcomes in terms of prevention of prolapse recurrence, but mesh-related complications and their management remain a concern [39]. The good outcome associated with this minimally invasive approach has been demonstrated most notably in the elderly with low morbidity and recurrence rates [40].

25.9 Summary

The management of concomitant middle compartment prolapse should be tailored to the individual patient and is influenced by the approach taken to the posterior compartment. Elderly and/or comorbid patients may benefit from conservative or obliterative strategies. Patients fit enough for surgery are likely to be best managed by an abdominal approach that synchronously corrects the prolapse of both compartments by suspension to the sacral promontory. Laparoscopic techniques are associated with equivalent outcomes to open surgery in terms of recurrence, but with low rates of morbidity.

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