1. Dr. Laleh AMINI French Board of OB&GYN Jam General Hospital Ir CS Annual Meeting June 2 nd 2011 Tehran-Iran

2. Definition ICS-IUGA Standardized Terminology in Urinary Incontinence and pelvic floor disorders in www. ir- cs.com Herniation of genital organ from vaginal mucosa (Different from herniation from rectum)

3. Classification Baden et al/ Ingelmann-Sundberg POP-Q pelvic organ prolapse quantification Anatomic Should be associated to the health care questionnaire from ICIQ, ICIQ-SF

5. POP-Q stages Stage 0 Aa Ap BaBp C D -3 cm Stage 1 -1 Stage 2 -1- +1 Stage 3 +1 Stage 4 complete vaginal procidencia

10. Physiopathology It s essential to know anatomy / physiology then to understand patho-physiology in order to think of how to repair. Great Names: De Lancey and Papa Petros

11. SUI FACTORS POP FACTORS Parity Aging, menopause Hormonotherapie Diabete Obesite hysterectomie dementia Abdominal hyperpressure (sports),COPD Obstructifs anorectal symptoms Obesity Pregnancy VD Hysterectomie Age parity

12. Genetics and constitutional * Genetics and constitutional factors incriminated because of SUI and POP in nulli parous women ( Norvegian National Registry ( n=38 000) * homozygote and heterozygote twins ( Swedish) twin Registry n=3376/n=5067) * Chromosome 9q21 predisposition gene for Pelvic floor disorders *Connective tissue disease with 30% less collagen concentrations in the POP population

13. Surgical Treatment Are considered malpractice or obsolete all surgical procedures using natural defective tissus ( Macenroth, Kapanji, ventrofixation…) Patient will come back with recurrence or will not come back at all!

14. Pelvic Organ Prolapse Surgical Treatment Abdominal Approach Sacro-Colpopexy Laparotomy Laparoscopy Vaginal approach Without prosthesis Sacro-spinous fixation Richter Unilateral Bilateral With prothesis

24. Cochrane Database Syst Revue 2006 on conservative Managament  >50 publications laparoscopic sacrocolpopexy since 15 years  Recurrence after laparoscopy <10%  NICE recommendations 2008 on vaginal surgeries based on 10 randomized clinical trials.  Recurrence 9%,18% and 30% with synthetique, biologic and without prothese  recommendations AFNOR NF S94-801 for mesh quality

25. +/- Anti-incontinence surgery? Associated to systematic prophylactic anti incontinence surgery in our practice 30% de novo SUI without anti-incontinence surgery Burch colpo suspension procedure with 2 or 4 sutures in laparotomy Mid-urethral sling procedures when done by laparoscopy When a rectocele repair is indicated it s done at the beginning of the surgery.

26. Fernandez Decisional Algorithm