4 Elements comprising the Pelvis BonesIlium, ischium and pubis fusionLigamentsMusclesObturator internis muscleArcus tendineus levator ani or white lineLevator ani musclesUrethral and anal sphincter muscles
5 “Ligaments and Fascia” Cardinal/Uterosacral Complex(Delancy level I)Paracervical RingArcus Tendineus Fascia Pelvis ATFPPubocervical “fascia”Rectovaginal “fascia”
20 DeLancey’s three levels of vaginal support Apical suspensionUpper paracolpium suspends apex to pelvic walls and sacrumDamage results in prolapse of vaginal apexMidvaginal lateral attachmentVaginal attachment to arcus tendineus fascia and levator ani muscle fasciaPubocervical and rectovaginal fasciae support bladder and anterior rectumAvulsion results in cystocele or rectoceleDistal perineal fusionFusion of vagina to perineal membrane, body and levatorsDamage results in deficient perineal body or urethrocele
21 De Lancey’s Levels I. Uterosacral cardinal ligament II. ATFP III De Lancey’s Levels I. Uterosacral cardinal ligament II. ATFP III. Perineal membrane and perineal body
22 Factors associated with pelvic floor prolapse ageparitybig babiesmenopauseobesityoccupationhome deliveryfamily history
26 POP-Q (Pelvic Organ Prolapse Quantitation) International Continence SocietyAmerican Urogynecologic SocietySociety of Gynecologic SurgeonsPelvic Organ ProlapseDefinicitionQuantitationStagingObjectiveDefect specificBump RC. Am J Obstet Gynecol, 1996
28 Pelvic Relaxation Cystocele Stress urinary incontinence Rectocele EnteroceleUterine and vaginal prolapseResult of weakness or defect in supporting tissues - endopelvic fascia and neuromuscular damage
65 No data supporting their use to prevent prolapse progression. Are effective non-surgical treatments available for women with pelvic organ prolapsePessary.Pelvic Floor Muscle Rehabilitation.Symptom-Directed TherapyNo data supporting their use to prevent prolapse progression.
69 Surgical Procedures for Female Genital Prolapse Anterior vaginal wall:Anterior colporrhaphy.Paravaginal repair (vaginal, laparotomy, laparoscopic).Posterior vaginal wall:Posterior colporrhaphy.Site specific rectocele repair.Enterocele repair (vaginal, laparotomy, laparoscopic).Apical suspension:Sacrospinous suspension,Uterosacral ligament suspension (mc call),Iliococcygeal suspension.Sacrocolpopexy (vaginal, laparotomy, laparoscopic).Anterior enterocele repair by laparotomy or laparoscopically. Dysparuenia is the main concern with traditional post colporrhaphy, especially with plication of levator ani plus overzealous perineorrhaphy, or the combinations of procedures that alter normal vaginal contouirs. e.g. Burch plus post. Colporrhaphy. Concommitantly 38% of pts developed p.o dysparunia after combine Burch plus posterior colporrhaphy ( persistent one year or more after surgery.). .Using permanent sutures for site specific posterior. Repair? Sacrocolpopexy –Apex to anterior longitudinal ligament of sacrum.69
70 What to do to prevent vaginal vault prolapse during abdominal hysterectomy? Plication of the uterosacral ligaments*Ureter complication!!!
71 What to do to prevent vaginal vault prolapse during vaginal hysterectomy? McCall Culdoplasty
72 Surgical techniques in vault prolapse A.Abdominal1.Sacrocolpopexy2.Robotic assisted laparoscopic sacrocolpopexy3.Suturing the cuff to the fascia of rectus abdominis muscle (Williams Operation)B.Vaginal1.Posterior IVS(Intraginal slingplasty/Infracocygeal sacropexy)2.Sacrospinous fixation3.Gynecare Prolift4.İliococygeal fixation5.Levator miyoraphy6.Colpocleisis (Le Fort Operation)
73 Sacrocolpopexy Timmons’ procedure A polypropylene synyhetic mesh is placed between the vaginal vault and sacrum (anterior longitudinal ligaments) so that the vault is hanged to the sacral bone.Burch colposuspension is a concomitant procedure.If necessary, colporaphy posterior is performed.
74 Sacrospinous Ligament Suspension Vaginal Apical RepairSacrospinous Ligament SuspensionSacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle
75 Paravaginal defects -Loss of lateral vagina attachment at the arcus tendineus resulting in a cystocele (bladder drop)
76 Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage