Urogynecology: Evidence-Based Clinical Practice 2nd ed.

10. Management of Prolapse

Kate H. Moore1

(1)

Department Obstetrics & Gynaecology, St George Hospital, Kogarah, New South Wales, Australia

Abstract

Uterovaginal prolapse is very common. The largest epidemiological study to date (n = 1,547 women interviewed, age 15–79) showed that 8.8 % had symptomatic prolapse and a further 23 % had undergone some form of prolapse surgery MacLennan et al. [12].

Uterovaginal prolapse is very common. The largest ­epidemiological study to date (n  =  1,547 women interviewed, age 15–79) showed that 8.8 % had symptomatic prolapse and a further 23 % had undergone some form of prolapse surgery MacLennan et al. [12].

Nonsurgical Management Options

Until recently, the treatment of symptomatic prolapse has been considered to be largely surgical, with vaginal rings offered to those who were unfit for anesthetic. However, the median lifespan of women in developed countries is now around 83 years old, so many women live well into their 90s. Thus, prolapse is becoming more common. Patients with mild symptoms and mild–moderate prolapse often ask whether they “need” surgery.

There are few data to guide such patients. If a patient has mild asymptomatic prolapse, dealing with the precipitating factors (as per Chap. 1), along with a pelvic floor training program (Chap. 6), may be sufficient. One long-term study of women with asymptomatic rectocele who had no treatment over a median of 8 years found that only new-onset constipation provoked worsening of the prolapse on physical exam [26].

As regards the use of physiotherapy, a large RCT of pelvic floor training versus a leaflet about lifestyle advice has just been concluded in 447 women with mild to moderate prolapse (POPQ stage II 74 %, remainder stage III or stage I). In the active group (4–5 physiotherapy visits over 12 weeks) assessed at 6 months, there were highly significant improvements in symptom severity, quality of life test, and desire for further treatment, compared to control. The change in POPQ was moderate (p  =  0.052) [8].

Use of Ring Pessary

In patients with symptomatic prolapse, who decline to have or are totally unfit for surgery, a vaginal ring pessary is very useful in selected cases. The main reasons for which patients are totally unfit for surgery are as follows:

·               Severe respiratory embarrassment, unable to lie flat without dyspnea

·               Transplant patients with pelvic kidney, on immunosuppressive drugs

·               Severe Alzheimer’s disease, unable to tolerate hospitalization

·               Morbid obesity, poor surgical access to the vagina

·               Unstable heart disease

·               Recurrent thromboembolic events, multiple previous stroke

Patients may decline surgery if they are an elderly sole caregiver for an ill husband or if they are sole caregiver for a disabled relative with no suitable respite care. Some women have had unpleasant surgical or anesthetic experiences and do not want another surgical episode. These reasons should be respected, especially if a ring pessary can be easily fitted.

Traditional vaginal ring pessaries (Portex) come in a range of sizes, from 56 to 100 mm diameter. Fitting a ring pessary is like assessing cervical dilatation in labor ward. Insert two fingers into the vagina, spread them apart, and mentally measure the vaginal diameter. In the United States and Australia, Gellhorn pessaries are used for large prolapse, and in the United Kingdom, shelf pessaries are also used. The ring pessary sits anteriorly behind the pubic bone and posteriorly rests on the perineal body.

Hence, if the perineum is very deficient, a ring pessary may not “sit” properly and be extruded during defecation. In a series of 100 patients with prolapse in the United States, 73 % could be fitted satisfactorily [Clemens et al. 5]. A deficient perineum with large introitus was often associated with failure.

In some cases, it may be possible to overcome this by fitting a “double ring,” using the largest ring possible in the upper vagina and the next smaller ring beneath it. This will not solve the problem if the patient has had multiple previous surgeries with scarring/thickening of the walls and vaginal shortening—such women are often very difficult to fit.

Topical vaginal estrogen cream (e.g., Ovestin) should be used three times weekly because the ring pessary is a foreign body which may increase desquamation of the vaginal epithelium, leading to a watery creamy discharge (see Fig. 10.1b). It is traditional to change the ring every 4–5 months, to inspect the vagina to ensure no major vaginal inflammation is occurring. In a snugly fitting pessary, when Ovestin is not used, or when the pessary is not changed regularly, there is a recognized incidence of vaginal bleeding. If this occurs, remove the ring, ask the patient to cleanse the vagina with salt baths twice daily for 5–7 days, and apply Ovestin nightly for 3 weeks. If there is an associated purulent discharge, metronidazole 400 mg TDS for 7 days will resolve this.

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Figure 10.1

(a) Portex ring pessary sits anteriorly behind the pubic bone and posteriorly rests on the perineal body. (b) Information diagram about applying Ovestin cream for prolapse

A recent long-term study of 167 women using vaginal ring pessaries up to a median of 7 years showed that over time about 45 % of women may experience bleeding, infection, or both. These women were having the ring changed four monthly; we now teach women to self-insert and remove more often [18].

Surgery for Cystocele

The opening paragraph of the relevant chapter in a World Health Organization monograph on incontinence states that “experts and the majority of published literature suggest the anterior wall is probably the most challenging part of prolapse to cure” Brubaker et al. [4]. This is largely because there are few structures to “anchor” on to. Unlike repair of posterior wall prolapse, in which one can suture onto the sacrospinous ligament or the presacral ligament on the sacral promontory, the pubourethral/pubocervical fascia and paravesical fascia on the undersurface of the pubic rami may be thin and weak. The main surgical options for repair of the anterior wall (also known as the “anterior compartment”) comprise:

·               Anterior colporrhaphy with plication of the pubourethral and vaginal fascia

·               Anterior colporrhaphy with more vigorous plication of subpubic fascia

·               Paravaginal repair (either vaginal or abdominal approach)

·               Use of mesh to reinforce the anterior colporrhaphy

Anterior Colporrhaphy

The anterior colporrhaphy for cystocele is performed as follows (see Fig. 10.2a):

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Figure 10.2

(a) Routine anterior colporrhaphy. (b) Ultralateral Anterior Colporrhaphy. (c) Four-cornered mesh kit

·               Inject local anesthetic with adrenaline into subcutaneous plane of anterior wall.

·               Dissect vaginal epithelium off the bladder and proximal urethra.

·               Plicate the paraurethral and paravesical tissue with a sagittal tier of horizontal mattress sutures, without tension.

·               Trim the redundant vaginal skin sparingly and close.

·               Insert pack and suprapubic catheter.

The Anterior Repair with Extensive Plication (Ultralateral Anterior Colporrhaphy)

·               The procedure starts with same dissection of vagina from bladder.

·               In this case, dissect well back into the pelvis; get under the pubic symphysis.

·               Place delayed absorbable vertical mattress sutures into the pubourethral/pubocervical or paravaginal fascia that borders the levator hiatus (underneath the pubic bone) to plicate this tissue across the midline under moderate tension, thus replacing the bladder into the abdominal cavity.

Closure with trimming of vaginal skin is identical to anterior colporrhaphy.

A similar procedure involving plication of the pubourethral “ligaments” has been recommended by Nichols [16]; see Fig. 10.2b.

The recurrence rate for cystocele after routine anterior colporrhaphy is up to 40 %. Few series of the more vigorous ultralateral approach have been published. The procedure remains popular because of minimal surgical morbidity.

Paravaginal Defect Repair

This has been the subject of several publications in the last two decades, but these often consider it as a treatment for stress incontinence, rather than for cystocele alone. Because effective operations are available for USI, but cystocele remains a difficult area, a long-term follow-up study of paravaginal repair for cystocele alone is needed.

The paravaginal defect can be repaired transabdominally or vaginally. Most gynecologists would be reluctant to perform an abdominal procedure for an isolated cystocele. If cystocele coexists with stress incontinence, then the colposuspension is highly curative of both. Therefore, transabdominal repair of paravaginal defect is not considered further (but see Shull [19]).

The vaginal approach to paravaginal defect repair is somewhat “challenging,” inasmuch as the obturator internus muscle must be identified first by palpation and then by inspection, so the white line of the arcus tendineus fasciae pelvis can be identified. This involves use of specialized illuminated retractors, to deflect the bladder into the midline. To date, no randomized controlled trials have evaluated the vaginal or abdominal paravaginal repair for cystocele.

Use of Mesh for Cystocele Repair

In 1997, Olsen et al. published a widely cited article showing that 30 % of women who had prolapse surgery in northwest USA ended up having repeat prolapse surgery at some stage [17]. If one reads the article carefully, actually many of the subjects had surgery for incontinence, not prolapse. Also, Olsen did not state whether the repeat surgery was necessarily for a recurrence of the same prolapse or a newly developed prolapse in a different vaginal area. Nevertheless, many gynecologist felt that prolapse surgery needed to be made more durable, and mesh was therefore increasingly employed.

Use of mesh to reinforce the anterior wall has been evaluated by several randomized controlled trials recently. The first compared simple anterior repair, versus anterior repair including use of polyglactin (Vicryl) mesh, versus “ultralateral” anterior repair, in 83 patients reviewed at 2 years. Results (using POPQ and symptom score) revealed that 30 % of the anterior repair group, 42 % of the repair plus mesh, and 46 % of the “ultralateral” repair patients achieved normal vaginal anatomy (POPQ stage 0 or 1). This definition of “cure” is quite strict. The authors pointed out that anterior colporrhaphy often simply does not replace the midpoint of the vagina to a level 3 cm above the introitus. Nevertheless, they concluded that the addition of mesh did not significantly improve cure rates [Weber et al. 25].

An Italian study of polypropylene (Prolene) mesh repair for cystocele in 32 women, at a mean follow-up of 1.5 years, found that dyspareunia was increased by 20 %; 6.5 % of women had mesh erosion. Despite a 94 % anatomical cure rate (using POPQ), the authors concluded that the use of Prolene mesh repair of prolapse should be abandoned because of associated morbidity [Milani et al. 14]. Use of Atrium polypropylene mesh in 64 women with cystocele in Australia yielded 4.7 % erosion rate and recurrence at 2 years in 10 % [Dwyer and O’Reilly 6]. All of these series varied in the selection of patients (primary versus previously failed prolapse surgeries). Over the decade of these published series, the implementation of mesh into a repair had changed. Initially, a square piece of mesh was sutured at the four corners into the vaginal vault, in the manner of Hung et al. [9]. However, a variety of mesh “kits” became available, which are anchored into the vagina by mesh arms protruding from the four corners of the central mesh (See Fig. 10.2c). A high-quality RCT Altman et al. [1] recently showed that in 389 women with primary prolapse, Gynecare Prolift Anterior mesh yielded an 82 % anatomic success compared to 47 % of those having native tissue repair.

These kits were much easier to insert than using the 4-corner suture method; thus, the use of mesh for cystocele repair became increasingly popular. Unfortunately, vaginal mesh is associated with a 5–15 % risk of mesh erosion with a weeping discharge and vaginal discomfort. About 5–10 % of patients experience dyspareunia/apareunia, and some are not able to sit down comfortably. Removal of mesh from the vagina can be quite difficult and sometimes requires more than one operation. In mid-2011, the Food and Drug Administration of the USA issued a product warning regarding the use of vaginal mesh. The FDA was concerned because there had been 1,503 adverse event reports from Jan 2008 to Dec 2010, which was a fivefold increase in such reports over the previous triennium. While this report was perhaps rather strongly worded (see Web site link: http://www.fda.gov), it would seem that use of mesh for primary prolapse repair needs careful discussion with the patient and informed consent must be meticulous. Several authors are currently endeavoring to develop a risk of recurrence score, based upon factors such as a large genital hiatus [23] or a complete avulsion of the subpubic attachment of the levator ani [15], which can be used to select primary prolapse in which mesh would confer a significant advantage. A recent editorial in International Urogynecology Journal, entitled “To mesh or not to mesh?,” gives an excellent summary of the current situation [21].

What Is the Value of Manchester Repair/Retention of a Nonprolapsed Uterus?

In a patient with a cystocele, in whom the cervix is bulky, protuberant, and somewhat elongated, without evidence of actual uterine descent, a Manchester repair may be useful. This comprises anterior colporrhaphy with amputation of the cervix as well as using sutures from the transverse cervical ligaments to enhance elevation of the upper vagina.

The Manchester repair (Fig. 10.3) was developed in the 1950s, at a time when anesthetic risks were greater than now. Thus, a simple procedure to remove an offending organ (the bulky protuberant cervix) without the prolonged anesthesia of a vaginal hysterectomy was attractive.

As anesthetic agents/morbidity improved, a concept evolved that if any part of the uterus/vagina was prolapsing, it should be removed/repaired. The extra time required for a vaginal hysterectomy was no longer an anesthetic issue.

In the last decade, greater scrutiny has been given to the concept of “If any part of the uterus prolapses, remove it all.” A gradually increasing perception of vault prolapse has pervaded the urogynecological community. Laparoscopic procedures to suspend the uterus from the presacral ligament in cases of prolapse (laparoscopic hysteropexy) have been the subject of sporadic reports. Because no large clinical trials have been reported, this procedure is not further discussed. Nevertheless, gynecologists have perhaps appreciated that women do not want their uterus removed unless the evidence proves this will give the best result. Inasmuch as we do not know how to predict vault prolapse, a “fallback” approach may be to leave the uterus intact unless it is truly prolapsed.

Of course, the converse argument is that one is leaving a potentially malignant organ (the uterus) in situ. Furthermore, because one cannot guarantee that the cervix is completely removed, Pap smears are still required after Manchester repair.

Nevertheless, the Manchester repair has been used for 60 years and is worth consideration in selected cases.

The Manchester repair is as follows:

·               Inject local anesthetic into the anterior and posterior walls of the cervix.

·               Circumferentially incise the cervix, as for the commencement of a vaginal hysterectomy, but simply amputate the cervix (Fig. 10.3a).

·               Push up the bladder anteriorly.

·               Use curved Kocher’s forceps to clamp the transverse cervical ligaments.

·               Suture with No. 1 Vicryl and place ties on Kryal’s forceps.

·               Perform a posterior Sturmdorf suture to cover the posterior cervix with vaginal epithelium but leave the os patent (see Fig. 10.3b). Then, plicate the transverse cervical ligaments (Fig. 10.3c).

·               Carry out anterior colporrhaphy, but when closing the anterior leaves of the vaginal skin, the lower margin of the skin is again used to cover the cervix, to the level of the os.

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Figure 10.3

Posterior Sturmdorf suture in the Manchester repair. After amputation of the cervix, seen in (a), then the posterior leaf of the vaginal vault is brought up over the posterior cervix, and the Sturmdorf suture is used to fix the vault to the cervix while leaving the cervical os patent (b). The transverse cervical ligaments are then plicated (c) to facilitate elevation of the uterine body within the pelvis

Preoperative Consent Discussion for Anterior Compartment Repairs

Consent discussion involves routine discussion of mode of anesthesia to be chosen and the risks of hemorrhage, infection, and vaginal scarring. The risk of voiding difficulty is small. If anterior repair is performed in isolation, a urethral catheter may be sufficient, especially if no bladder neck buttress suture (described in Chap. 10) is needed. For patients having cystocele repair combined with other procedures, a suprapubic catheter is usual; hence, trial of void protocol should be explained. In patients having mesh inserted, risk of erosion must be explained.

Postoperative convalescence depends on whether other procedures are performed: if an isolated anterior repair, patient should rest for 1 week, then have light duties for 4 weeks, and avoid heavy lifting for another 4 weeks.

Surgery for Rectocele/Deficient Perineum

Before embarking upon a “posterior repair,” check whether the patient truly has:

·               A deficient perineum, requiring perineorrhaphy.

·               An isolated rectocele, requiring posterior colporrhaphy, which may just involve the lower third of the rectum or the hernia may include the mid rectum and the upper rectum. The latter is often associated with enterocele.

·               Or both of the above.

For example, in Chap. 2 (Fig. 2.2b), a patient with an isolated rectocele was shown. As discussed, depending upon symptoms, she may be better served by a transanal repair, with no disruption of her intact perineum (Chap. 8, Fig. 8.5).

Note that the deficient perineum and low rectocele are usually associated with insufficiently repaired obstetric lacerations, whereas the mid/high rectocele is often associated with constipation.

In the 1950s, the standard repair of low rectocele (posterior colporrhaphy) and deficient perineum (perineorrhaphy) involved plication of the edges of the levator ani, known as “levatorplasty.” In 1959, Jeffcoate [10] published a series revealing that 50–60 % of patients undergoing this procedure experienced dyspareunia, especially when the levatorplasty is extended upward to repair a defect of the middle third of the rectum (pre-rectal fascia).

Subsequent anatomical studies revealed that the rectovaginal septum is a sheet of fibroelastic tissue between the rectum and vagina, which is often torn during parturition or repeated straining at stool. Repair of this layer does help to correct rectocele but does not cause dyspareunia. Much has been written about this subject, which is beyond the scope of this text. See Nichols and Randall [16] for full discussion.

A Repair for Mid–Low Rectocele and Deficient Perineum

·               Inject local anesthetic into the subepithelial plane of the posterior vaginal wall.

·               Decide the lateral margins of the repair.

·               The final opening should admit two or three fingers easily.

·               A midline vertical incision is made, up to the apex of the rectocele.

·               The vaginal skin is dissected off the rectovaginal septum.

·                      If a low rectocele only, and levatorplasty is desired by the surgeon, dissect out as far laterally as possible, to reach the medial margins of the levator ani and the terminal ends of the bulbocavernosus and transverse perineal muscles in the lower vagina/perineum.

·                      The fascia of the rectovaginal septum is closed over the low rectocele using mattress sutures laterally from left to right.

·                      Interrupted sutures of No. 1 Vicryl are taken deeply through the medial borders of the perirectal fascia and levator ani from left to right, to tighten the muscles and fascia over the defect in the lower rectal wall (Fig. 10.4).

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Figure. 10.4

∎posterior colporrhaphy

·               The perineum is then reconstituted, by placating medial fibers of the pubococcygeus muscles and reuniting torn fibers of the superficial transverse perineal muscles.

·               The redundant vaginal mucosa is excised with care.

·               The vaginal epithelium is closed.

The concept of site-specific defect repair of the rectovaginal septum has become more widely accepted since its introduction in the early 1990s. In brief, anatomical dissections have indicated that lateral or “hockey-stick”-shaped tears in the rectovaginal septum (also known as the fascia of Denonvilliers) are important in the genesis of rectocele and that specific reconstitution of this layer is an important part of rectocele repair. The septum should also be re-attached to the perineal body (during its reconstitution). For full details, see Grody [7]. Certainly, in mid and high rectocele, such site-defect repair is important (Fig. 10.5).

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Figure. 10.5

Example of site-specific defect repair (Reprinted from Grody [7, p. 969])

Surgery for Enterocele

This is one of the most controversial areas in urogynecology. At the level of the pre-membership registrar, the question is whether to perform:

·               A routine posterior colporrhaphy with ligation of the enterocele sac

·                                   A vaginal sacrospinous fixation

·                                   An abdominal sacrocolpopexy using mesh attached to the sacrum.

·                                   The judgment as to which is best depends upon:

·                                   The frailty of the patient

·                                   Whether the patient wishes to be sexually active

·                                   Whether the enterocele is primary or follows previous surgery

·               Whether a concomitant vaginal or abdominal procedure is required

·               Whether previous vaginal repair has rendered the vaginal introitus firm, so that a vaginal procedure would necessitate reentry into an adequately built-up perineum

In a frail patient who does not wish sexual activity, posterior colporrhaphy with enterocele sac ligation is appropriate, unless this is a recurrent large enterocele, in which case sacrospinous fixation is probably necessary.

In a fit, sexually active woman with a primary enterocele, the vaginal approach via sacrospinous fixation would be chosen by most surgeons. Others would argue that the higher long-term failure rate of the sacrospinous fixation indicates that, especially in younger women, an abdominal sacrocolpopexy should be performed. In our unit, we would not normally undertake an abdominal incision in an active young woman, as a primary procedure. In the case of recurrent enterocele (after previous repairs, but certainly if a sacrospinous fixation has failed), abdominal sacrocolpopexy is generally chosen, unless the woman is quite elderly/frail and prefers to have a repeat vaginal sacrospinous fixation (after appropriate counseling). The other choice in a frail woman is colpocleisis (obliteration of the vagina). Note that vaginal mesh kits are available for use in the posterior vaginal wall but yield an unacceptably high risk of dyspareunia and are not considered further in this pre-membership textbook.

For details of colpocleisis and enterocele sac ligation, see standard gynecology texts such as Te Linde [22].

Vaginal Sacrospinous Fixation

This involves the following:

·               Assess where the apex of the vagina will lie by grasping the apex with an Allis forceps, then reducing it into the vagina, placing it at the level of the ischial spine.

·               Leave about 2 cm of vaginal tissue intact at the apex so as to be able to run the two pulley sutures under this segment of intact vagina (this segment will then be fastened to the sacrospinous ligament; see Fig. 10.6).

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Figure. 10.6

Insertion of the pulley stitch to vaginal apex, and attachment to sacrospinous ligament

·               Dissect the posterior vaginal wall, as for commencement of posterior colporrhaphy.

·               Just to the right of the midline, dissect deep into the perirectal space.

·               Gently dissect with the index finger a window in the rectal pillar, allowing one to palpate the ischial spine directly; then, gradually enlarge the window to admit both index and third fingers.

·               Insert the two pulley sutures (1 nylon and 1 PDS) onto sacrospinous ligament at a point two fingerbreadths medial to the ischial spine (to avoid the pudendal nerve and vessels).

Older textbooks feature suture placement under direct vision, using a Miya hook. A much simpler technique is to use a Schutt arthroscopic needle holder (also called a Caspari needle holder) shown in Fig. 10.7. The thread is fed through the device and caught between the two fingers as it emerges from the ligament. The Cappio disposable device is similar.

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Figure 10.7

(a) and (b) Arthroscopic needle holder (manufactured by Zimmer). With close-up of open jaws that encircle the sacrospinous ligament

·               Before tying down the pulley sutures, commence closure of the apex vaginal skin for about 3 cm (this section will become inaccessible once the pulley sutures are tied down).

·               Also, ensure that rectovaginal septum repair sutures or levatorplasty sutures have been inserted appropriately and held out of the way of the pulley sutures.

·               After tying down the pulley sutures, tie off the mid or low rectocele repair sutures, then complete closure of posterior vaginal mucosa.

·               At the perineum, insert appropriate perineorrhaphy sutures before closing perineal skin.

·               Insert vaginal pack and suprapubic catheter.

Preoperative Consent Discussion for Vaginal Sacrospinous Fixation

Consent discussion involves the following:

·               Risk of buttock pain (6 %) (chronic 1 %)

·               Risk of de novo stress incontinence (2.6 %)

·               Risk of de novo dyspareunia (2.7 %)

·               Risk of de novo fecal incontinence (4 %)

·               Risk of de novo cystocele (8 %) (if no concomitant anterior repair)

These risks are derived from 293 cases [Lovatsis and Drutz 11]. The success of the procedure is variable depending upon method of assessment, for example, 88 % success at 6 weeks on strict anatomical criteria (no prolapse below the mid vagina [20]) or 97 % at 1 year (symptomatic prolapse or an asymptomatic prolapse at or beyond the introitus).

Because many patients having a sacrospinous fixation also require other procedures, we find it helpful to draw a diagram of the anatomical defects (see Fig. 10.8a for a patient with enterocele, rectocele, and cystocele) and then superimpose an outline of the surgical procedures on this diagram (see Fig. 10.8b for a patient undergoing sacrospinous fixation with anterior and posterior repair).

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Figure 10.8

(a) Diagram of the anatomical defects for a patient with enterocele, rectocele, and cystocele. (b) Outline of the surgical procedures for a patient undergoing sacrospinous fixation with anterior and posterior repair

Abdominal Sacrocolpopexy

This involves the following:

·               A Pfannenstiel or vertical midline incision (depending on previous scars and obesity).

The vagina is elevated with a probe wrapped in gauze.

The peritoneum over the vaginal vault is incised, abdominally.

·               The bladder is reflected forward from the anterior vaginal wall.

The peritoneum is entered in the pouch of Douglas.

·               The rectum is deflected to the left so that the peritoneal incision is extended up along the right paracolic gutter toward the sacral promontory.

·               The peritoneum over the sacral promontory is carefully incised and spread open, taking care not to injure the presacral vessels.

·               A wide-pore mesh such as Vipro-II is fashioned into a Y-shape by the surgeon (Fig. 10.9).

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Figure. 10.9

Y-shaped mesh inserted over the vaginal vault; the long end of the “Y” is attached to the presacral ligament (Reprinted with permission from Baggish and Karram [3]. Copyright 2001, Elsevier)

·               The bottom of the Y (both leaves) is attached over the apex of the vagina with nonabsorbable sutures.

·               The top single leaf of the Y is run laterally up to the presacral ligament over S1.

It is attached to the ligament by nonabsorbable sutures.

The peritoneum is closed over the mesh entirely.

·               The pouch of Douglas is closed to prevent further enterocele, by a Moscovitch or Halban’s procedure:

·               The Moscovitch procedure involves a spiral suture around the edges of the pouch of Douglas to close it circum­ferentially.

·               The Halban’s procedure involves a series of left to right sutures in the sagittal plane that close the anterior and posterior leaves of the pouch of Douglas.

·               The pouch of Douglas is drained.

·               At end of abdominal procedure, assess the lower vagina:

·                      A low cystocele may indicate anterior repair.

·                      A low rectocele or deficient perineum may indicate colporrhaphy or perineorrhaphy.

·                      Vaginal pack and choice of catheter depending upon whether low vaginal procedures were undertaken.

Preoperative Consent Discussion for Abdominal Sacrocolpopexy

Consent discussion involves the following:

·               If the patient has a need to digitate to evacuate the stool preoperatively, which may persist in up to half of the cases (Baessler and Schuessler [2], n  =  33).

·               Careful management of constipation (Chaps. 6 and 8) must be undertaken preoperatively.

·               Complications (from Valaitis and Stanton [24], n  =  41) include:

·                      New or worsened detrusor overactivity (7 %)

·                      New or worsened stress incontinence (12.5 %)

·                      Dyspareunia (9.7 %)

·               The success rate varies from 88 % at 2 years Valaitis and Stanton [24] to 100 % cure of enterocele at 2 years but persistent rectocele in 48 % (Baessler and Schuessler [2]; this picture is quite complex as not all preoperative rectoceles were corrected).

The Cochrane Review concluded that abdominal sacrocolpopexy conferred a lower rate of recurrent vault prolapse versus vaginal sacrospinous fixation (relative risk 0.23, 95 % CI, 0.07–0.77) and less dyspareunia, but there was no significant increase in reoperation rates between the two operations (i.e., the recurrences must not have been bothersome). Furthermore, the vaginal sacrospinous fixation was quicker, cheaper, and allowed earlier return to activities of daily living [Maher et al. 13].

Note: The subject of uterine prolapse is dealt with in standard gynecological textbooks and is not discussed here. If the uterus prolapses to the mid vagina, then vaginal hysterectomy is generally indicated, which may be a part of any of the procedures in this chapter. Procedures to suspend the vault (McCall’s culdoplasty, etc.) should always be considered. If the uterus descends within the upper vagina, the decision for removal should be based upon gynecological considerations (menorrhagia, etc.), tempered by a discussion of the patient’s wishes. The option of Manchester repair has been described.

Conclusions

The median lifespan of women in the Western world is currently about 83 years and is gradually increasing. Hence, prolapse is likely to increase. Although the last two decades have shown improved techniques in the management of prolapse, the Cochrane Collaboration criticizes a serious lack of randomized controlled trials of new interventions. Several procedures have been mentioned only briefly in this chapter because little objective data were available. It is hoped that in the next decade, more objective studies including comparative results will be published. The advent of “mesh kits” for cystocele repair has given better anatomic cure rates at the expense of troublesome mesh erosion/ dyspareunia, so their use in primary cystocele repairs requires careful evaluation and discussion with the individual patient. In the case of recurrent cystocele, they are a useful option.

References

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