Maryam Ashrafi

* ratio surgery for prolapse vs incontinence: 2:1 * prevalence of 31% in women aged yrs * 20% of women on gynecology waiting lists * 11% lifetime risk of at least one operation * re-operation in 30% of cases

* Restoration of pelvic structures to normal anatomical relationship * Restore and maintain urinary &/or fecal continence * Maintain coital function * Correct co-existing pelvic pathology * Obtain a durable result Principles of Pelvic Reconstructive Surgery

Approach Approach to prolapse surgery include vaginal, abdominal, and laparoscopic routes or combination of approaches. Vaginal approach results in: * fewer wound complications, * less postoperative pain, * shorter hospital stay

Vaginal procedures for prolapse * Restorative → use the patient’s endogenous support structures Sacrosinous Suspension Uterosacral suspension Iliococcygeus Fascia Suspension * Compensatory → replace deficient support with some type of graft * Obliterative → close the vagina Le fort colpoclisis Total colpoclisis

Preoperative Evaluation And Preparation * A thorough pelvic floor history, * Assessment of bothersome urinary symptoms and/or defecatory problems. * A thorough speculum and bimanual pelvic examination The findings of the examination should be recorded using a quantitative and reproducible method for recording POP.

Evaluation Of Urinary Dysfunction * Urinary incontinence Reduced stress testing. Urodynamics? * Urinary retention Measure PVR 13 to 65 percent of continent women develop symptoms of SUI after surgical correction of the prolapse.

Obliterative Procedure Obliterative surgery corrects prolapse by removing and/or closing off all or a portion of the vaginal canal (colpocleisis) * Total colpocleisis * Partial colpocleisis (Le Fort colpocleisis) Concomitant hysterectomy? Concomitant stress urinary incontinence surgery ? Kelly suburethral plication midurethral sling

Effects of colpocleisis on bowel symptoms At baseline Bothersome bowel symptom(s) were present in 77% : * Obstructive (17-26%), * Incontinence (12-35%) and * Pain/irritation (3-34%) Procedu res performed: partial colpocleisis (61%), total colpocleisis (39%), levator myorrhaphy (71%), and perineorrhaphy (97%).

RESULTS: Of 121 (80%) subjects with complete data, Mean age was /- 5.4 years and all had stage 3-4 prolapse The majority of bothersome symptoms resolved (50-100%) with low rates of de novo symptoms (0-14%). CONCLUSIONS: Most bothersome bowel symptoms resolve after colpocleisis, especially obstructive and incontinence symptoms, with low rates of de novo symptoms.

Sacrospinous Ligament Fixation * The surgeon should be familiar with the anatomy of the sacrospinous ligament complex and of the pararectal space. * Obtaining adequate exposure can be difficult. * The sacrospinous ligament is a cordlike structure that exists within the body of the coccygeus muscle. * The sacrospinous ligament attaches medially to the sacrum and coccyx and attaches laterally to the ischial spine.

Sacrospinous Ligament Fixation * The pudendal nerve and vessels pass directly posterior to the ischial spine. * The sciatic nerve lies superior and lateral to the sacrospinous ligament. * Superior to the ligament lies the inferior gluteal vessels and the hypogastric venous plexus. * To avoid trauma to these structures, it is important to place the fixation sutures two fingers medial to the ischial spine.

Complications * Hemorrhage can result from injury to the hypogastric venous plexus inferior gluteal vessels, and internal pudendal vessels. * Postoperative gluteal pain due to pudendal nerves and the sciatic nerve injury. * Approximately 10% to 15% of patients have transient moderate to severe buttock pain * Inadvertent proctotomy. * Potential stress incontinence.

88%6-4850Jenkins % Barber % Karram %6-4333Amundsen et al % Viviane Diet z 2006 Results of sacrospineous Ligament Suspension for Vaginal Vault Prolapse AuthorNo. of patients Follow-up in months (range) Success

Total transvaginal mesh (TVM) technique Prolift Pelvic Floor Repair System™

Complications * Febrile morbidity * Urinary tract infection * Deep hematoma * Granuloma (without exposure) * Mesh exposure * Shrinkage of mesh

Ojectives: The objective of the study was to assess the effectiveness and complication rates for the transvaginal (TVM) technique in the treatment of pelvic organ prolapse (POP). Methods: All enrolled patients underwent prolapse repair surgery with GYNEMESH PS Prolene Nonabsorbable Soft Mesh using the TVM technique

Conclusions: Five-year results indicated that TVM provided a stable anatomic repair. Improvements in quality of life and associated improvements in specific prolapse symptoms were sustained over the 5-year period. Mesh exposure was the most common complication

Of 85 patients: 16 Mesh exposure 16 comlicated with Mesh exposure 9 mesh excision 9 required partial mesh excision. 3dyspareunia 3 patients with some degree of dyspareunia, (in 8, preexisting dyspareunia resolved). 1rectovaginal fistula 1 rectovaginal fistula reported and 2 ureteral injuries 2 reported ureteral injuries, one of which resulted in a ureteral-vaginal fistula; all resolved after repair 5reoperation 5 required reoperation for prolapse by 5 years

To elucidate the outcome of transvaginal pelvic reconstructive surgery using polypropylene mesh (Gynemesh; Ethicon, Somerville, NJ, USA) for patients with pelvic organ prolapse (POP) stage III or IV. RESULTS: The average age of the patients was 64.1 years and average parity was 3.9 The success rate was 97.4%. Only one patient (2.6%) had recurrent genital prolapse (stage II) postoperatively.). The complication rate was 10.3 %, including onevaginal mesh erosion (2.6%), one dyspareunia (2.6%) (and two prolonged bladder drainage (longer than 14 days Neither long-term nor major complication was identified CONCLUSION: Transvaginal pelvic reconstructive surgery with polypropylene mesh reinforcement is a safe and effective procedure for POP on 1.5 years' follow- up. It also has positive influence on quality of life.

Sacrocolpopexy and paravaginal repair for total pelvic floor prolapse