GEOFFREY MAINAR QUE , MD.

, DPOGS, FPSURPS
Urogynecologist and Reconstructive Pelvic Surgeon Obstetrician 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

 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

Womens Health Initiative (WHI) - 16, 616

13,000 or 80% of women 50-79 years old have 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 Womens Health Initiative:
Gravity and gravidity.

PREDISPOSE
Genetic
(Congenital / Hereditary)

INCITE

PROMOTE

DECOMPOSE

Race
(white>african)

Pregnancy Obesity Aging & Delivery Smoking Menopause Pulmonary Surgery Disease
( such as hysterectomy for prolapse) (Chronic cough)

Gender
(F > M)

Recreational Occupational Activities

(frequent or heavy lifting)

Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:72346. Copyright 1998

Aa
Anterior Wall

Ba
Anterior Wall

C
Cervix/ Cuff

GH
Genital Hiatus

PB
Perineal Body

TVL
Total Vaginal Length

Ap
Posterior Wall

Bp
Posterior Wall

D
Posterior Fornix

Inter-Observer and Intra-Observer Evaluation

Quantitates the Severity of Prolapse Quantitates the Result of Treatments

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

CLINICAL EVALUATION
Defecatory Dysfunction i.e, incomplete emptying
Sexual Function Pre / Post Surgery

DIAGNOSIS OF POP CAN ONLY BE MADE BY P.E.

Systematic Assessment(Standing,Lithotomy) Anterior vaginal wall Posterior vaginal wall Middle or apical compartment

LABORATORY INVESTIGATION
Bladder testing should be part of initial workup

3 important facts UTI Screening Post Void Residual Urine Volume Presence or Absence of Bladder Sensation
Voided volume with sensation of fullness, voiding diary or by

bladder filling)

BLADDER FUNCTION ASSESSMENT is ESSENTIAL prior to ANY form of Surgical Intervention Simple Retrograde Filling Cystometry (Office) Fill the Bladder until subjective fullness while recording Sensations and Pressure Changes Cough Stress Test prolapse out and reduced 15-80% 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

Support of the Anterior Posterior & Superior Compartments Urinary Function

Vaginal Axis and Depth

Bowel Function

Sexual Function

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

ANTERIOR COLPORRHAPHY
Described by Kelly 1913 Closure of central defect Indicated for LARGE cystocele 37 100% success rate

Mesh augmentation increases success rate for recurrent prolapse

COMPLICATIONS
Ureteral Injury kinking of intramural ureters medially or direct ligation rare TIGHT PLICATION could lead to 1. Bladder neck obstruction 2. Voiding dysfunction 3. Urinary retention Vaginal narrowing compromises sexual function Cystocele Recurrence and Stress Incontinence

BURCH COLPOSUSPENSION
Suspend the bladder neck and urethra to the Coopers

ligament bilaterally restoring the support to the distal anterior vaginal wall

Historically regarded as a CONTINENCE procedure Option for early stage Anterior Vag Wall prolapse

Especially for short anterior vaginal wall

Less superior to Ant. Colporrhaphy- (66 vs 97%)

 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

McCALL CULDOPLASTY
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

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

SACROSPINOUS LIGAMENT FIXATION

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

 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

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

ABDOMINAL SACROCOLPOPEXY
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 ( S1S2) 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

COMPARTMENT
ANTERIOR VAGINA

VAGINAL ROUTE
Anterior Colporrhaphy Paravaginal Repair Posterior Colporrhaphy (Fascia,Myorrhaphy, Site Specific Repair) Transanal Repair Lefort Colpocleisis Sacrospinous Ligament Fixation Prespinous Ligament Fixation / BICF USL Suspension USL Plication Mc Call Culdoplasty

ABDOMINAL ROUTE
Burch Colposuspension Paravaginal Repair Sacrocolpopexy Sacrocolpopexy

POSTERIOR VAGINA

MIDDLE / APICAL VAGINA

Sacrohysteropexy Sacrocolpopexy USL Fixation Moschowitz Procedure Halbans Procedure

Vesicocervical

Pubocervical fascia

Vesicouterine Fold

Peritoneal cavity

Uterosacral Cardinal Ligament Complex

Uterine Vessels

Utero tubal- Broad / Round Ligament

Vaginal Cuff

Mc Call Culdoplasty

Anterior Vaginal Wall Dissection

Exposed Pubocervical Fascia

Midline 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

 Abnormal Descent of Pelvic Organs

Introital Mass, Pelvic Discomfort and Heaviness

Multifactorial Etiology Diagnosis thru Pelvic Examination Bladder Testing Should be part of PRE-OP

Evaluation Conservative and Surgical management