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Prolapse - What can we do |
Part 2
Part 1 - New Approaches to Prolapse
There is an 11% lifetime risk of at least one operation for utero-vaginal prolapse and re-operation is required in nearly one-third of cases (Olsen et al 1997).
Childbirth predisposes to prolapse by disruption of tissue and denervation of the pelvic floor muscles. Connective tissue factors possibly evidenced by joint hypermotility and excessive skin elasticity are also markers and deterioration of connective tissue with the menopause may be the �final straw�.
It is important to understand that recurrence following surgery may represent a �trade-in� prolapse whereby there is a progression of a previously inherent weakness following surgical reinforcement of another site. This is frequently seen with the development of cystocele or a posterior zone defect following bladderneck suspension. This is not surprising considering that the damage is usually global involving the entire vagina and its ligamentous supports so that the effects of intra-abdominal pressure will now be brought to bear on these areas away from the site of surgical reinforcement. This would be akin to a general surgeon being confronted with the need to repair a contra-lateral inguinal hernia after dealing with the opposite side.
There are of course genuine recurrences related to further prolapse in an area already surgically repaired but critical assessment of results can only be achieved if this appropriate distinction is made.
As mentioned in Part 1, the scope of surgical procedures has dramatically increased in the last few years allowing us to offer surgery to older or medically compromised women who might previously have been considered unfit. Many women are disaffected with the traditional and most commonly offered vaginal hysterectomy and repair and it is valid that the problem lies with the uterine supports and vagina rather than the uterus itself with prolapse.
Traditional hysterectomy, either abdominal or vaginal, particularly in the absence of restoration of continuity between the uterosacral cardinal ligament complex and the peri-cervical ring of fascia, may be followed by vault prolapse in somewhere between 5% and 30% of cases, a situation causing considerable distress to women who cannot understand how they could have developed a prolapse following hysterectomy, believing that there was nothing else to �fall out�. Other examples of what might be considered iatrogenic prolapse are the enterocele post colposuspension that we have already mentioned, a high rectocele following inadequate repair involving only the lower posterior vagina and cystocele post sacrospinous colpopexy.
New operations
ANTERIOR IVS, TVT, SPARC: These are minimally invasive procedures that involve the placement of a nontension tape around the mid urethra. The tape is passed either from a small 1cm to 2cm midline vaginal incision with IVS and TVT or from above with the SPARC to lie under the mid urethra passing retropubically in front of the bladder to anchorage sites suprapubically in the abdominal wall. Polypropolene has properties of excellent biocompatibility and the patient�s own tissues grow through the pores of the tape providing long lasting support. The procedures can be completed in less than 30 minutes with immediate noticeable results to the patient, minimal discomfort and pain with a short hospital stay and rapid return to most normal activities. The most serious complication has been vascular damage due to wayward progression of the TVT introducer, which has a sharp pyramidal leading edge as distinct from the IVS, which is conical and blunt. All the techniques have been involved with damage to the urethra and bladder which should be recognised and managed intra-operatively by cystoscopy and removal of the instrument or tape.
While the end result of the three procedures is essentially the same, there are some important differences in the method of introduction of the tape and the instrumentation and clinical studies are in progress to give us the answers to a number of important questions about the risk benefit value of the three approaches.
POSTERIOR IVS: This is a new minimally invasive approach to the common problem of post-hysterectomy vault prolapse, enterocele and apical defects. A prolene tape is attached to the cervix or vaginal vault below the mucosa along the course of the uterosacral ligaments beside the rectum with the ends of the tapes penetrating the pelvic floor on either side of the rectum. This is done with a tunneller introduced through 1cm buttock incisions, 3cms to the side of the anus midway between anus and coccyx. This allows a simple approach to major posterior and apical defects, alternative procedures being sacrospinous colpopexy and promonto-fixation of the vaginal vault, procedures that are much more invasive and in the case of the former, far less successful.
UTERINE CONSERVATION: Women who have no uterine pathology or symptoms are good candidates for management by a variety of new procedures offering uterine conservation. The evidence suggests that the damage to the uterosacral ligaments allowing of descensus occurs in the 4cm to 5cm adjacent to the cervix. Thomas Lyons described his laparoscopic vault suspension procedure wherein the vault or cervix was attached on each side by delayed absorbable or non-absorbable sutures to the viable uterosacral on each side. The posterior IVS procedure described above can also be used offering a successful vaginal approach by anchoring the tape to the posterior cervix medial to the uterosacral ligaments. Co-existent vaginal defects may also be repaired.
VAGINAL WALL PROLAPSE: Reliance on repair of the patient�s own deficient endo-pelvic fascia to achieve a midline repair has not infrequently resulted in poor results. This could be anticipated where we have simply repaired the patient�s own deficient attenuated tissues in the hope that they will not give way again. In addition, because invariably in the past the repairs were undertaken in the mid line when the defect was often lateral or transverse, it was not surprising that many patients were unhappy with the results of surgery. Again often the redundant vagina was excised to remove redundancy and reduce vaginal capacity with resultant painful scar tissue and dyspareunia (the so-called �resident�s ring�) and yes! occasionally of course � the �consultant�s constriction�.
These situations may be avoided by using the redundant vaginal wall for reinforcement to provide a double layered strong repair and increasingly mesh is being used. Our concerns about mesh erosion and severe infections necessitating removal have in fact not been realised, problems being averted by placing the mesh, as with the tapes, without tension. Avoidance of painful perineal incisions � the traditional site of entry for posterior repair has made an enormous difference to post-operative pain relief requirements and the Kelly procedure with excision of anterior vaginal wall and plication of para-cervical tissue at the bladderneck is now rarely performed having been replaced by newer and better techniques.
TETHERED VAGINA: Some women who remain incontinent, sometimes more so following aggressive suprapubic bladderneck suspension, have a tethered vagina wherein the urethra is pulled open by contractions of the pelvic floor providing a strong posterior force that opens the urethra by its attachment to a tethered drum-like anterior wall. Some of these patients require a full thickness skin graft in the region of the bladderneck and we have had some modest success with this procedure although success can not be guaranteed.
This is an interesting time for those of us involved in reconstructive vaginal surgery and our patients are experiencing the benefits of these new developments. It has been said that �nothing stands in the way of progress as much as thirty years experience� and I recall that I started practice here in Lismore in 1970. Hopefully this old dog can still learn a few new tricks before I take that ride into the sunset!
Brendan O�Sullivan is an obstetrician and gynaecologist with rooms in Lismore.
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