Presentation on theme: "Pelvic Organ Prolapse(POP) Treatment: A Urogynecology Perspective"— Presentation transcript:
1 Pelvic Organ Prolapse(POP) Treatment: A Urogynecology Perspective Case StudyM .Zargham MDIsfahan university MC2013
2 A 38-yr-old pregnant women presented with urinary incontinence and perineal mass
3 Uterine Prolapse Apical Prolapse S4 38 years old pregnant womenPI: Gestational age 24 week.She wears pads all time and change them 5 times a day Perineal mass.
4 Halfway Classification System. Perspective: schematic 3D sagittal view.
5 Clinical and paraclinical evaluation PI: Gestational age 24 week. She wears pads all time and change them 5 times a day Perineal massPMH: Gravid 2/para 1/ab 0Sono: Renal and bladder showed bilateral hydroureteronephrosis(LT-G 1,Rt-G2)U/A :microscopic hematuria and pyuria.U/C :Neg.CBC: normalCr: 1.2 mg/dl
6 Apical Prolapse Enterocele S4 The enterocele bulge is outside theintroitus.
8 What is the best method of delivery? A total of 1.4 million women were investigated!
9 pelvic organ prolapse and method of delivery, The benefits andpotential risks of a cesarean sectionwith resultant uterine scar have to beweighed against the risk of developing pelvic organ prolapse.Liu S, et al:Severe morbidity associated with low-risk planned cesarean delivery versus planned vaginaldelivery at term. CMAJ 2007Villar J,et al. Maternaland neonatal individual risks and benefits associated with cesarean delivery: multicentre prospectivestudy. BMJ 2007
10 2 years after delivery she presented with Urinary Incontinence and vaginal mass
11 Case study:2 years after vaginal delivery 40-years old female, presented with perineal mass ,sever sexual dysfunction, and mild SUI?PMH: 4 month ago she had underwent A-P repair that was failed one month after surgery.6 month ago her inguinal hernia was repaired.PE :She suffered from advanced prolapse and vaginal apex reaches significantly above the ischial spines on vaginal exam.lab.: bilateral HUN, Cr=2.1
12 She refused hysterectomy! Uterine prolapsevaginal apex reaches significantly above the ischial spines on vaginal exam .She refused hysterectomy!
13 Why is hysterectomy unnecessary in the treatment of uterine prolapse? She refuse hysterectomy!
14 Why is hysterectomy unnecessary in the treatment of uterine prolapse? Level 1 is represented by the parametrial ligaments, which continue down the sides of the upper vagina as the paracolpium. Damage to this level of support will lead to apical (i.e. uterine and upper vaginal) prolapse.The uterus itself plays a passive role in this process and its removal does not address the underlying pelvic organ support weakness or improve the outcome of the repair procedure.Marana H, Andrade J, Marana R et al. Vaginal hsyterectomy for correcting genital prolapse. J Reprod Med 1999; 44: 529–534.Diwan A, Rardin CR & Kohli N. Uterine preservation during surgery for uterovaginal prolapse.
16 At least 20% of hysterectomies were performed for the primary indication of POP. 57.4%, 45.0%, and 40.1% of all admissions for POP surgery included a hysterectomy.
17 What is the best surgical treatment for “uterine-sparing” techniques? Vaginal approach?Abdominal approach?Laparoscopic approach?Should prostheses be considered for primary repairs,or secondary repairs?
18 Abdominal Sacrocolpopexy with mesh elevation of the vaginal apex to the sacral promontory with a mesh bridge.
19 Sacrospinous colpopexy and POP Sacrospinous vaginal vault suspension has also been associated with recurrent anterior segment prolapse theoretically because of the exposure of the anterior segment to increased pressure caused by the fixed retroversion of the vaginaHolley RL, Varner RE, Gleason BP, Apffel LA, Scott S. Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse. J Am Coll Surg 1995; 180:444–448.
20 Tissue Fixation System(TFS): Vaginal sacral colpopexy The synthetic prostheses for sacrocolpopexyare well establishedyet remain controversial forrepairing isolated anterior and posterior compartmentdefects.
21 Sling and POPConversely, concomitant suburethral slings at the time of reconstructive vaginal surgery have been shown to significantly reduce the recurrence of anterior vaginal wall prolapse.Goldberg RP, Koduri S, Lobel RW, Culligan PJ, Tomezsko JE, Winkler HA, Sand PK. Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation. Am J Obstet Gynecol 2001; 185:1307–1313.
22 The AUA strongly reinforced the need to differentiate between the use of mesh to treat POP versus SUI
38 How to manage prolapse once the decision has been made for surgery? Plication and interposition procedures are both reasonable options, and interposition can be accomplished with biologic or synthetic materials, based upon surgeon experience, patient preference and presenting anatomic and functional disorder
39 Roger R. Dmochowski, MD Department of A1302 Medical Center North Nashville, TN , USA Mickey Karram, MD The Christ Hospital 2123 Auburn Avenue, Suite 307 Cincinnati, OH 45219, USA Urologic Surgery Vanderbilt University Medical Center