General Principles of Prolapse Repair

1. General Principles of Prolapse Repair Bob L. Shull, M.D. Professor of Gynecology Department of Obstetrics and Gynecology Scott and White Memorial Hospital and Clinic Texas A&M Health Science Center Temple, Texas USA

2. Learning Objectives At the completion of the lecture the participant will know: • The similarity of pelvic support defects to a hernia • The requirements for evaluation of anatomic defects and functional complaints in planning a surgical strategy • Each compartment of the pelvis may exhibit specific support defects

3. UrinaryIncontinence Sexual Function AnalIncontinence Pelvic OrganProlapse Pelvic Floor Disorders

4. UrinaryIncontinence Sexual Function AnalIncontinence Pelvic OrganProlapse Pelvic Floor Disorders

5. Which procedure(s) did she have? a. Hysterectomy b. LeFort colpocleisis and Stamey procedure c. Sacro-colpopexy and MMK d. Enterocele rectocele repair e. Sacrospinous ligament suspension and anterior-posterior repair f. Only (a) g. All of the above

6. Underlying Concepts The prevalence and the natural history of pelvic defects have not been well documented.

7. The Natural History of Pelvic Organ Prolapse Objective: Pelvic organ prolapse (POP) affects 30-93% of adult women. However, the natural history of this common condition remains unknown. We undertook this study to describe POP in a longitudinal study of postmenopausal women. Conclusions: Our data suggest that POP is not chronic and progressive, as traditionally thought. Spontaneous regression of POP was surprisingly common in this study, especially for grade 1 prolapse. While our findings may not be generalizable to the nationwide WHI cohort or to all postmenopausal women, these findings raise important questions about the clinical significance of grade 1 POP. Further studies are needed to clarify the prognosis for mild prolapse and to explain 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.

8. Pelvic support defects are similar to a hernia, i.e., the connective tissue responsible for maintaining support has a visibly identifiable defect.

9. Pelvic support defects may or may not be associated with abnormal function of the urethra, bladder, rectum, or vagina.

10. UrinaryIncontinence Sexual Function AnalIncontinence Pelvic OrganProlapse Pelvic Floor Disorders

11. UrinaryIncontinence Sexual Function AnalIncontinence Pelvic OrganProlapse Pelvic Floor Disorders

12. UrinaryIncontinence Sexual Function AnalIncontinence Pelvic OrganProlapse Pelvic Floor Disorders

13. UrinaryIncontinence Sexual Function AnalIncontinence Pelvic OrganProlapse Pelvic Floor Disorders

14. The operative repair of pelvic support defects must address each individual defect.

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

16. Anterior Segment - Urethra, Bladder Defects

17. Posterior Segment

18. Correction of pelvic support defects may or may not result in improvement, deterioration, or maintenance of function of the urethra, bladder, rectum, or vagina.

19. Surgical Techniques for Pelvic Support Defects Must be Individualized Depending on the Patient’s” • Expectations • Support defects • Functional status of urethra, bladder, bowel, and vagina

20. Surgical techniques for pelvic support defects must be individualized depending on the surgeon’s skills

21. The Assessment of Surgical Intervention Includes: • Cure of the support defects • Maintenance or improvement of visceral or sexual function • Acquisition of new support defects or visceral or sexual complaints

23. Adverse Effects of Burch Colposuspension 284 Women with G. S. I. Mean follow-up 3-4 years 54% cured without complication 32% cured but with one or more complications... usually genital prolapse 8% failed without complications 6% failed with one or more complications Colombo, Maggioni, Caruso, et al Proceedings I.C.S., 1993, Rome

25. Generally, there are 6 reasons for failure!

26. Generally, there are 6 reasons for failure! • Wrong diagnosis • Understaged • Clinical • Intraoperative • Imaging • Misdiagnosed – for example, transverse cystocele

27. Clinical Examination and Dynamic Magnetic Resonance Imaging in Vaginal Vault Prolapse Objective: To estimate the role of dynamic magnetic resonance imaging (MRI) as a diagnostic tool in the evaluation of vaginal apex prolapse in women with previous hysterecomy. Methods: Clinical examinations were performed on 51 women presenting with symptoms of prolapse. A preoperative dynamic MRI assessment was performed. Conclusion: There is a poor correlation between clinical and MRI findings when assessing vaginal apex prolapse. Magnetic resonance imaging allows the identification of other prolapsing compartments and may be a complementary diagnostic tool for the diagnosis of complex vaginal apex prolapse. Cortes E, Reid WMN, Singh K, Berger L. Obstet Gynecol 2004;103:41-46

28. Generally, there are 6 reasons for failure! 2. Surgical Skills • Learning curve • Repetition – experience • Golf • Tennis • Marathon running

29. Generally, there are 6 reasons for failure! 3. Iatrogenic defects • Retropubic repairs and subsequent enterocele and vault prolapse • Sacrospinous ligament suspension and subsequent cystocele

30. Generally, there are 6 reasons for failure! 4. Wound healing • 100 days for maturity • Use sutures to compliment wound healing

31. Generally, there are 6 reasons for failure! 5. Patient compliance - Postoperative activities

32. Prevalence of Severe Pelvic Organ Prolapse in Relation to Job Description and Socioeconomic Status: A Multi-Center Cross-Sectional Study Objective:To determine if certain job descriptions or socioeconomic statuses are associated with pelvic organ prolapse. Results: The overall prevalence of severe pelvic organ prolapse in our group was 4.1% (37/912). Women reported their job description in the following categories and proportions: laborers/ factory workers (6.9%), housewives (31.7%), professional/ managerial (18.1%), service (10.2%), technical/sales/clerical (16.2%) and other (16.2%). Conclusions: Laborers/factory worker jobs are associated with more severe pelvic organ prolapse using the POP-Q exam. Severe prolapse is also associated with an annual household income of $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.

33. Generally, there are 6 reasons for failure! • Other • Genetics • Unknown • Protein synthesis?

34. Differences in Pelvimetry between Women with and without Pelvic Floor Disorders Objective: To investigate the hypothesis that the dimensions of the bony pelvic differ between women with and without pelvic floor disorders. Results: Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with a transverse inlet greater than 139 mm were more than 7 times 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 dimensions. Conclusions: A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may predispose to neuromuscular and connective tissue injuries, 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.

35. Reasons for Failure • Wrong diagnosis 4. Wound healing • Surgical skills 5. Patient compliance • Iatrogenic 6. Other