MANAGEMENT OF PELVIC ORGAN PROLAPSE
Prof.Dr. Mohamed Shafik
Urology Department Alexandria University President of Voiding Dysfunction & Urodynamics of the EUA Sector
When to treat ?
• Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse ) • Interferes with the normal activity of the woman • The patient seeks treatment
How to treat ?
• NON-SURGICAL Methods: Limited Role
– PELVIC FLOOR REHABILITATION (pelvic muscle exercises, physiotherapy). – HORMONE REPLACEMENT, both systemic and local. – PESSARY TREATMENT for temporary relief
» During Pregnancy, Pureperium & Lactation » When Operation is Unsafe due to Extreme Senility/Debility and Diseases » Preoperatively » For therapeutic test
How to treat ?
• SURGICAL TREATMENT: RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.
• It is the definitive & curative treatment of Prolapse. • Pre operative pessary/tampoon & or Hormone treatment should be given as indicated. • Meticulous and through examination under anaesthesia should be done before deciding the surgery.
• Depending on type & extent of Prolapse, surgery should be tailor made not only to rectify defect but also to suit individual patient’s requirement. • Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable. • Catheter for more than 48 hrs should be exceptional.
• Strict antibiotic prophylaxis is essential
GOALS OF VAGINAL RECONSTRUCTION
Support of the anterior posterior & superior compartments Urinary function Vaginal Axis and depth
Anatomy is not correlated to function Looks good feels bad, feels good looks bad
Vaginal operations for prolapse
• • • • • • Anterior colporrhaphy Posterior colporrhapry- High / Low Enterocele repair Perineorrhaphy Paravaginal repair Hysterectomy with or without Colporrhaphy / Perineorrhaphy
THE CHALLENGE OF GRADE IV CYSTOCELE REPAIR
ATFP Arcus tendinous fascia pelvis
Endopelvic and Perivesical
GRADE IV CYSTOCELE
URETHRA • 10X1 cm sling of soft Prolene mesh BLADDER • Repair central defect • Repair lateral defect using a 5x5 disc of soft Prolene mesh anchored Transvaginal paravaginal repair
– to the obturator fascia of grade 4 cystocele – sacro-uterine & cardinal ligaments – bladder neck
To sling or not to sling…
• No reliable preoperative testing can predict the functional status of the urethra • Minimal morbidity of the sling • Low urinary retention rate (0% in DUPS) • Prevent the 20-30% incidence of secondary stress incontinence • Reduced incidence of secondary cystocele (19% vs.43%)
Cystoscopy after IV indigocarmine
Exposure obturator fascia
Cystocele 25-30% failure rate
• Need for surrogate material for the central defect • Need for a strong lateral anchor to prevent lateral descent
Restoring weak prerectal fascia and vaginal cuff support
Restoring vault support
Tying the vault suspension sutures
In posterior wall prolapse there is descent of levator plate, widening of levator hiatus, separation of prerectal from perivesical fascia Enterocele Rectocele
POSTERIOR REPAIR USING SOFT PROLENE MESH
Approximation of perineal membrane brings levator together
ABDOMINAL OPERATIONS FOR PROLAPSE
• • • • • • Sling operations Closure or repair of enterocele Sacrocolpopexy Anterior Colpopexy Colposuspension Paravaginal repair
Abdominal Sling operations
• It is a major abdominal operation & Synthetic material is costly.
– – – – Shirodkar’s posterior sling. Purandare’s anterior cervicopexy. Khanna’s sling. Virkud’s composite sling.
Abdominal Colpopexy / Colposuspension
• Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy. • Major abdominal operation & technically difficult. • Sexual function is preserved. • Methods-.
– Sacrocolpopexy. – Ant.Colpopexy. – Colposuspension.
• Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum • Enterocele repair can be done if required
• Corrects ant. vag laxity & stress inc. • Useful at abdominal hysterectomy / for vault prolapse. • Extra peritoneal supra pubic approach if done alone. • Enterocele repair if required. • Vagina stitched to the ileo-pectineal ligaments.
Vault / Colposuspension
• Vault is fixed to the abdominal wall by a facial strip or merseline tape
LAPAROSCOPIC SURGERY PROLAPSE
• Advantages of MIS-small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar • Can all types of prolapse be treated?- Yes. • Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery • However extended period of rest is essential • Expertise is needed
Laparoscopic Cervicopexy/sling Operations
• All types of sling operations can be better performed by laparoscopy • Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair) • Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy