general principles of prolapse repair bob l. shull, m.d. professor of gynecology department of...

General Principles of General Principles of Prolapse RepairProlapse Repair

Bob L. Shull, M.D.Bob L. Shull, M.D.Professor of GynecologyProfessor of Gynecology

Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyScott and White Memorial Hospital and ClinicScott and White Memorial Hospital and Clinic

Texas A&M Health Science CenterTexas A&M Health Science CenterTemple, TexasTemple, Texas

USAUSA

At the completion of the lecture the At the completion of the lecture the participant will know: participant will know:

1.1. The similarity of pelvic support defects to The similarity of pelvic support defects to a herniaa hernia

2.2. The requirements for evaluation of The requirements for evaluation of anatomic defects and functional anatomic defects and functional complaints in planning a surgical strategycomplaints in planning a surgical strategy

3.3. Each compartment of the pelvis may Each compartment of the pelvis may exhibit specific support defectsexhibit specific support defects

Learning ObjectivesLearning Objectives

AnalAnalIncontinenceIncontinence

Pelvic OrganPelvic OrganProlapseProlapse

UrinaryUrinaryIncontinenceIncontinence

Pelvic Floor DisordersPelvic Floor DisordersPelvic Floor DisordersPelvic Floor Disorders

Sexual Function

Pelvic OrganProlapse

UrinaryIncontinence

AnalIncontinence

Pelvic Floor Disorders

SexualFunction

Which procedure(s) did Which procedure(s) did she have?she have?

a.a. HysterectomyHysterectomy

b.b. LeFort colpocleisis and LeFort colpocleisis and Stamey procedureStamey procedure

c.c. Sacro-colpopexy and MMKSacro-colpopexy and MMK

d.d. Enterocele rectocele Enterocele rectocele repairrepair

e.e. Sacrospinous ligament Sacrospinous ligament suspension and anterior-suspension and anterior-posterior repairposterior repair

f.f. Only (a)Only (a)

g.g. All of the aboveAll of the above

Underlying ConceptsUnderlying Concepts

The prevalence and the natural The prevalence and the natural

history of pelvic defects have not history of pelvic defects have not

been well documented.been well documented.

The Natural History of Pelvic The Natural History of Pelvic Organ ProlapseOrgan Prolapse

Objective: Pelvic organ prolapse (POP) affects 30-93% of Objective: Pelvic organ prolapse (POP) affects 30-93% of adult women. However, the natural history of this adult women. However, the natural history of this common condition remains unknown. We undertook common condition remains unknown. We undertook this study to describe POP in a longitudinal study of this study to describe POP in a longitudinal study of postmenopausal women.postmenopausal women.

Conclusions: Our data suggest that POP is not chronic and Conclusions: Our data suggest that POP is not chronic and progressive, as traditionally thought. Spontaneous progressive, as traditionally thought. Spontaneous regression of POP was surprisingly common in this regression of POP was surprisingly common in this study, especially for grade 1 prolapse. While our study, especially for grade 1 prolapse. While our findings may not be generalizable to the nationwide findings may not be generalizable to the nationwide WHI cohort or to all postmenopausal women, these WHI cohort or to all postmenopausal women, these findings raise important questions about the clinical findings raise important questions about the clinical significance of grade 1 POP. Further studies are needed significance of grade 1 POP. Further studies are needed to clarify the prognosis for mild prolapse and to explain to clarify the prognosis for mild prolapse and to explain the biologic mechanisms of progression and regression.the biologic mechanisms of progression and regression.

Handa VL, Garrett E, Hendrix S, Gold E, Robbins JA. AUGS Abstracts from the 24th Annual Scientific Meeting, Sept. 2003.

Pelvic support defects are similar to Pelvic support defects are similar to

a hernia, i.e., the connective tissue a hernia, i.e., the connective tissue

responsible for maintaining support responsible for maintaining support

has a visibly identifiable defect.has a visibly identifiable defect.

Pelvic support defects may or Pelvic support defects may or

may not be associated with may not be associated with

abnormal function of the urethra, abnormal function of the urethra,

bladder, rectum, or vagina.bladder, rectum, or vagina.

AnalAnalIncontinenceIncontinence

Pelvic OrganPelvic OrganProlapseProlapse

UrinaryUrinaryIncontinenceIncontinence

Pelvic Floor DisordersPelvic Floor DisordersPelvic Floor DisordersPelvic Floor Disorders

Sexual Function

The operative repair of pelvic The operative repair of pelvic

support defects must address support defects must address

each individual defect.each individual defect.

Superior Segment Superior Segment (Supra vaginal defects) (Supra vaginal defects) Cardinal-Uterosacral Cardinal-Uterosacral Ligament ComplexLigament Complex

Defect: Repair:

Uterosacral Ligament U-S ligament plication/suspension Sacral fixation

U-S Cardinal Ligament Shortening U/S-cardinal ligaments Complex Sacrospinous fixation Sacrocolpopexy Cul-de-sac Excision sac and cerclage

Uterosacral ligament plication Puborectalis plication/ interposition

Defect: Repair:

Uterosacral Ligament U-S ligament plication/suspension Sacral fixation

U-S Cardinal Ligament Shortening U/S-cardinal ligaments Complex Sacrospinous fixation Sacrocolpopexy Cul-de-sac Excision sac and cerclage

Uterosacral ligament plication Puborectalis plication/ interposition

Anterior Segment - Anterior Segment - Urethra, Bladder Urethra, Bladder DefectsDefectsDefect: Repair:

Midline Anterior colporrhaphy Excision urethral diverticulum Para urethral Retropubic suspensions (Lateral detachment) • Marshall-Marchetti-Krantz • Burch • Paravaginal (Lateral Vaginal Wall) Combined • Needle suspensions (Pereyra, Stamey, Raz) • Sling procedures Para vesicle Paravaginal repair (Lateral detachment) (Retropubic or vaginal reattachment) Superior Reattachment to cervix or cuff

Defect: Repair:

Midline Anterior colporrhaphy Excision urethral diverticulum Para urethral Retropubic suspensions (Lateral detachment) • Marshall-Marchetti-Krantz • Burch • Paravaginal (Lateral Vaginal Wall) Combined • Needle suspensions (Pereyra, Stamey, Raz) • Sling procedures Para vesicle Paravaginal repair (Lateral detachment) (Retropubic or vaginal reattachment) Superior Reattachment to cervix or cuff

Posterior SegmentPosterior Segment

Defect: Repair:

Midline Posterior colporrhaphy

Lateral detachment Pararectal reattachment

Superior Reattachment to cuff

PERINEAL DEFECTS: Perineorrhaphy Anal sphincter laceration Sphincteroplasty

Defect: Repair:

Midline Posterior colporrhaphy

Lateral detachment Pararectal reattachment

Superior Reattachment to cuff

PERINEAL DEFECTS: Perineorrhaphy Anal sphincter laceration Sphincteroplasty

Correction of pelvic support Correction of pelvic support

defects may or may not result defects may or may not result

in improvement, deterioration, in improvement, deterioration,

or maintenance of function of the or maintenance of function of the

urethra, bladder, rectum, or vagina.urethra, bladder, rectum, or vagina.

Surgical Techniques for Surgical Techniques for Pelvic Support Defects Pelvic Support Defects Must be Individualized Must be Individualized Depending on the Depending on the Patient’s”Patient’s” ExpectationsExpectations

Support defectsSupport defects

Functional status of urethra, Functional status of urethra, bladder, bowel, and vaginabladder, bowel, and vagina

Surgical techniques for pelvic Surgical techniques for pelvic

support defects must be support defects must be

individualized depending on the individualized depending on the

surgeon’s skillssurgeon’s skills

The Assessment of The Assessment of Surgical Intervention Surgical Intervention Includes:Includes:

Cure of the support defectsCure of the support defects

Maintenance or improvement of Maintenance or improvement of visceral or sexual functionvisceral or sexual function

Acquisition of new support Acquisition of new support defects or visceral or sexual defects or visceral or sexual complaintscomplaints

Cured Improved No change

Worse


Worse

de novo detrusor instability

Voiding dysfunction Chronic infection



Urethra Bladder

Cervix / Cuff Cul-de-sac

Rectum Perineum

Urethra Bladder


Rectum Perineum

Urethra Bladder


Rectum Perineum

Urethra Bladder


Rectum Perineum

Relief of SymptomsRelief of

Symptoms

Acquisition of new

Symptoms

Acquisition of new

SymptomsCorrection of Defect

Correction of Defect

Acquisition of Defect


Maintenance Enhancement Deterioration

Loss


Loss

Visceral FunctionVisceral Function

Sexual FunctionSexual

Function AnatomicAnatomic

Adverse Effects of Adverse Effects of Burch ColposuspensionBurch Colposuspension

284 Women with G. S. I.284 Women with G. S. I.

Mean follow-up 3-4 yearsMean follow-up 3-4 years

54% cured without complication54% cured without complication

32% cured but with one or more 32% cured but with one or more complications... usually genital complications... usually genital prolapseprolapse

8%8% failed without complicationsfailed without complications

6%6% failed with one or more complicationsfailed with one or more complications

Colombo, Maggioni, Caruso, et alColombo, Maggioni, Caruso, et alProceedings I.C.S., 1993, RomeProceedings I.C.S., 1993, Rome


Loss


Loss


Worse


Worse





Urethra Bladder


Rectum Perineum

Urethra Bladder


Rectum Perineum

Urethra Bladder


Rectum Perineum

Urethra Bladder


Rectum Perineum

Visceral FunctionVisceral Function

Sexual FunctionSexual

Function AnatomicAnatomic

Relief of SymptomsRelief of

Symptoms

Acquisition of new

Symptoms

Acquisition of new

Symptoms





Generally, there are 6 Generally, there are 6 reasons for failure! reasons for failure!


1.1. Wrong diagnosisWrong diagnosis– UnderstagedUnderstaged

ClinicalClinical IntraoperativeIntraoperative ImagingImaging

– Misdiagnosed – for example, Misdiagnosed – for example, transverse cystoceletransverse cystocele

Clinical Examination and Dynamic Clinical Examination and Dynamic Magnetic Resonance Imaging in Vaginal Magnetic Resonance Imaging in Vaginal Vault ProlapseVault ProlapseObjective: To estimate the role of dynamic magnetic resonance Objective: To estimate the role of dynamic magnetic resonance

imaging (MRI) as a diagnostic tool in the evaluation of vaginal imaging (MRI) as a diagnostic tool in the evaluation of vaginal

apex prolapse in women with previous hysterecomy.apex prolapse in women with previous hysterecomy.

Methods: Clinical examinations were performed on 51 women Methods: Clinical examinations were performed on 51 women

presenting with symptoms of prolapse. A preoperative presenting with symptoms of prolapse. A preoperative

dynamic MRI assessment was performed.dynamic MRI assessment was performed.

Conclusion: There is a poor correlation between clinical and MRI Conclusion: There is a poor correlation between clinical and MRI

findings when assessing vaginal apex prolapse. Magnetic findings when assessing vaginal apex prolapse. Magnetic

resonance imaging allows the identification of other resonance imaging allows the identification of other

prolapsing compartments and may be a complementary prolapsing compartments and may be a complementary

diagnostic tool for the diagnosis of complex vaginal apex diagnostic tool for the diagnosis of complex vaginal apex

prolapse.prolapse.Cortes E, Reid WMN, Singh K, Berger L. Obstet Gynecol 2004;103:41-46

2. Surgical Skills2. Surgical Skills– Learning curveLearning curve– Repetition – Repetition –

experienceexperience GolfGolf TennisTennis Marathon runningMarathon running


3. Iatrogenic defects3. Iatrogenic defects– Retropubic repairs and Retropubic repairs and

subsequent enterocele and subsequent enterocele and vault prolapsevault prolapse

– Sacrospinous ligament Sacrospinous ligament suspension and subsequent suspension and subsequent cystocelecystocele


4. Wound healing4. Wound healing– 100 days for maturity100 days for maturity

Use sutures to Use sutures to compliment wound compliment wound healinghealing


5. Patient compliance5. Patient compliance

- - Postoperative Postoperative activitiesactivities


Prevalence of Severe Pelvic Organ Prevalence of Severe Pelvic Organ Prolapse in Relation to Job Description Prolapse in Relation to Job Description and Socioeconomic Status: A Multi-and Socioeconomic Status: A Multi-Center Cross-Sectional StudyCenter Cross-Sectional Study

Objective:Objective: To determine if certain job descriptions or socioeconomic To determine if certain job descriptions or socioeconomic

statuses are associated with pelvic organ prolapse. statuses are associated with pelvic organ prolapse.

Results: The overall prevalence of severe pelvic organ prolapse in our Results: The overall prevalence of severe pelvic organ prolapse in our

group was 4.1% (37/912). Women reported their job description in group was 4.1% (37/912). Women reported their job description in

the following categories and proportions: laborers/ factory workers the following categories and proportions: laborers/ factory workers

(6.9%), housewives (31.7%), professional/ managerial (18.1%), (6.9%), housewives (31.7%), professional/ managerial (18.1%),

service (10.2%), technical/sales/clerical (16.2%) and other (16.2%).service (10.2%), technical/sales/clerical (16.2%) and other (16.2%).

Conclusions: Laborers/factory worker jobs are associated with more Conclusions: Laborers/factory worker jobs are associated with more

severe pelvic organ prolapse using the POP-Q exam. Severe severe pelvic organ prolapse using the POP-Q exam. Severe

prolapse is also associated with an annual household income of prolapse is also associated with an annual household income of

$10,000 or less.$10,000 or less.

Woodman P, McCullough D, O’Boyle A, Valley M, Bland D, Kahn M, et al. AUGS Abstracts from the 24th Annual Scientific Meeting, Sept. 2003.

6.6. OtherOther– GeneticsGenetics– UnknownUnknown– Protein Protein

synthesis?synthesis?


Differences in Pelvimetry Differences in Pelvimetry between Women with and between Women with and without Pelvic Floor without Pelvic Floor DisordersDisordersObjective: To investigate the hypothesis that the dimensions of the Objective: To investigate the hypothesis that the dimensions of the

bony pelvic differ between women with and without pelvic floor bony pelvic differ between women with and without pelvic floor disorders.disorders.

Results: Subjects included 59 women with pelvic floor disorders and Results: Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with a 39 women without pelvic floor disorders. Women with a transverse inlet greater than 139 mm were more than 7 times transverse inlet greater than 139 mm were more than 7 times more likely to have a pelvic floor disorder (odds ratio 7.2, more likely to have a pelvic floor disorder (odds ratio 7.2, P<0.01), controlling for the effects of age, parity, and other pelvic P<0.01), controlling for the effects of age, parity, and other pelvic dimensions.dimensions.

Conclusions: A wide transverse inlet and narrow obstetrical Conclusions: A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may speculate that these features of bony pelvic architecture may predispose to neuromuscular and connective tissue injuries, predispose to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.leading to the development of pelvic floor disorders.

Handa VL, Pannu H, Siddique S, Gutman R, Cundiff GW. AUGS Abstracts from the 24th Annual Scientific Meeting, Sept. 2003.

Reasons for FailureReasons for Failure

05

10152025303540

1 2 3 4 5 6

Reasons for Failure

Perc

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1. Wrong diagnosis 4. Wound healing2. Surgical skills 5. Patient compliance3. Iatrogenic 6. Other

general principles of prolapse repair bob l. shull, m.d. professor of gynecology department of...

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