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

At the completion of the lecture the participant will know: 1.The similarity of pelvic support defects to a hernia 2.The requirements for evaluation of anatomic defects and functional complaints in planning a surgical strategy 3.Each compartment of the pelvis may exhibit specific support defects Learning Objectives

Anal Incontinence Pelvic Organ Prolapse Urinary Incontinence Pelvic Floor Disorders Sexual Function

Pelvic Organ Prolapse Urinary Incontinence Anal Incontinence Pelvic Floor Disorders Sexual Function

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

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

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 24 th Annual Scientific Meeting, Sept

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

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

Anal Incontinence Pelvic Organ Prolapse Urinary Incontinence Pelvic Floor Disorders Sexual Function

Anal Incontinence Pelvic Organ Prolapse Urinary Incontinence Pelvic Floor Disorders Sexual Function

Anal Incontinence Pelvic Organ Prolapse Urinary Incontinence Pelvic Floor Disorders Sexual Function

Anal Incontinence Pelvic Organ Prolapse Urinary Incontinence Pelvic Floor Disorders Sexual Function

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

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

Anterior Segment - Urethra, Bladder Defects

Posterior Segment

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

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

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

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

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

Generally, there are 6 reasons for failure!

1. Wrong diagnosis –Understaged Clinical Clinical Intraoperative Intraoperative Imaging Imaging –Misdiagnosed – for example, transverse cystocele

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

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

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

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

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

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 24 th Annual Scientific Meeting, Sept

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

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 24 th Annual Scientific Meeting, Sept

Reasons for Failure 1.Wrong diagnosis4. Wound healing 2.Surgical skills5. Patient compliance 3.Iatrogenic6. Other