Presentation on theme: "Management Of Genital Prolapse"— Presentation transcript:
1Management Of Genital Prolapse Associate Professor Semyatov S.M.Department of Obstetrics and Gynecologywith course PerinatologyPeoples’ Friendship University of Russia, Moscow
2DEFINITIONProlapse/Procidentia is downward decent of uterus &/or vagina.(Procidentia is from Latin procidere - to fall).It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia.It is not a disease but a disabling condition.
3CAUSE WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA Precipitating / Exaggerating / Unmasking Causes -INCREASED INTRA ABDOMINAL PRESSUREChronic coughChronic ConstipationHeavy Wt.Lifting / domestic WorkObesity, AscitisWEAKNESS OF THE SUPPORTS & MUSCLESChronic ill health, malnutrition dysentery, anemiaInadequate rest during pureperiumMenopause
4TYPES OF PROLAPSE Vaginal Anterior –cystocele & urethrocele Posterior - Enterocele & RectoceleVault Prolapse - a special term applied to the prolapse of upper vaginaUterine/Utero-vaginal- Acquired or Congenital.First degree.Second degree &.Third degree-(total Prolapse / complete procidentia).However Procidentia is often used only to denote third degree uterine prolapse.
5EFFECTS OF PROLAPSE NO SYMPTOM- mild & moderate prolapse. Discomfort & disability.Sexual Dysfunction.URINARY- Frequency, Dysuria, Stress incontinence, infection.Incomplete emptying of rectum.Discharge.Backache.Ulceration & Infection.
6WHEN TO TREAT ?Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse )Interferes with the normal activity of the womanThe patient seeks treatment
7HOW TO TREAT ? NON-SURGICAL Methods: -Limited Role PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium).HORMONE REPLACEMENT, both systemic and local.PESSARY TREATMENT for temporary reliefDuring Pregnancy, Puerperium & LactationWhen Operation is Unsafe due to Extreme Senility/Debility and DiseasesPreoperativelyFor therapeutic test
8HOW TO TREAT ?SURGICAL TREATMENT: -RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.
9SURGICAL TREATMENTIt is the definitive & curative treatment of Prolapse.It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first.Pre operative pessary/tampoon & or Hormone treatment should be given as indicated.Meticulous and through examination under anaesthesia should be done before deciding the surgery.
10SURGICAL TREATMENTDepending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement.Absolute haemostasis is mandatory. Diathermy should be liberally used.Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable.Catheter for more than 48 hrs should be exceptional.Strict antibiotic prophylaxis is essential
11VAGINAL OPERATIONS FOR PROLAPSE Anterior colporrhaphyPosterior colporrhapry- High / LowEnterocele repairPerineorrhaphyAmputation of cervixParavaginal repairHysterectomy with or without Colporrhaphy / Perineorrhaphy
12VAGINAL OPERATIONS FOR PROLAPSE Manchester/ Fothergill’s operation & Shirodkar’s modificationUterus/Cervix suspension/fixationVaginal vault suspension/fixationRetro-rectal levatorplasty and post. anal repair for associated rectal prolapseVaginectomy ?Colpocleisis ?
13Anterior colporrhaphy & Urethroplasty For correction of Cystocele & UrethroceleIncision- Midline / Inv.T / EllipticalExcision of vagina according to the size & site of laxityAvoid shortening &/or narrowing of vaginaClosure with interrupted sutures
14Posterior colporrhaphy & Enterocele repair For correction of Enterocele & RectoceleEnterocele repair can be done either by vaginal or abdominal route depending on the associated procedures.Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essentialExcision of vagina should be tailor madePerineorrhapy to be done only if perineal body is torn
15PerineorrhaphyNot an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tearPerformed along with posterior colporrhaphyAim-Reconstruction of the Perineal body and reduction of gaping introitus.Can cause DyspareuneaEssential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles
16Vaginal Hysterectomy with/without Vaginal repair Indicated when uterus needs removal, in old age & in total prolapse.Patient’s consent is mandatory knowing that there are alternatives to hysterectomy.Usually combined with Ant. & Posterior colporrhaphy.Perineorrhaphy is not mandatory but case specific.Vault suspension is an essential step.If sexual function is not needed narrowing of vaginal canal should be done.
17Amputation of cervixNot for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm )To be done only as a part of Fothergill’s repair/sling operations.Adequate cervical dilatation - a prerequisiteBladder displacement is a mustExcision of cervix should not exceed 2 cmLikely to affect reproductive lifeLong-term complications are real risks
18Fothergill’s operation It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required.It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must.Post. Colporrhaphy to be performed only if Ent/Rectocele is presentPerineorrhaphy is usually not required
19Fothergill’s operation Not useful if ligaments are weak & Uterus is of normal size. Purandare’s modification may help.Technically difficult operation, requiring high degree of surgical skill.Threat of short-term complications.Real possibilities of long term complications.Recurrence/Failure.Sling operations are better alternativesHAS A BLEAK FUTURE
20ABDOMINAL OPERATIONS FOR PROLAPSE Sling operationsClosure or repair of enteroceleSacrocolpopexyAnterior ColpopexyColposuspensionParavaginal repair
21Abdominal Sling operations Indicated when the ligaments are extremely weak as in nullipara & young women.Preserves reproductive function.Principle - With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis.Amp.of Cx should also be done if Utereocervical length >12.5cm.Cystocele/Rectocele repair if needed can be done vaginally before or after.Enterocele repair can also be done abdominally.
22Abdominal Sling operations It is a major abdominal operation & Synthetic material is costly & not widely available in India.Types-.Shirodkar’s posterior sling.Purandare’s anterior cervicopexy.Khanna’s sling.Virkud’s composite sling.
23Shirodkar’s slingTape is fixed to the post. Aspect of isthmus & sacral promontoryAnatomically most correct but difficult to performRisks of complication
24Purandare’s cervicopexy Tape is anchored to the ant.aspect of isthmus and ant. abd. WallEasy to performDynamic support
25Virkud’s composite sling operation Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. SideUtrosacral ligament is plicatedTechnically easy
26Khanna’s sling operation Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spineEasier to perform and saferBut tape is superficialRisk of infection
27Abdominal Colpopexy / Colposuspension Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy.Major abdominal operation & technically difficult.Sexual function is preserved.Methods-.Sacrocolpopexy.Ant.Colpopexy.Colposuspension.
28SacrocolpopexyVault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectumEnterocele repair can be done if required
29Ant.Colpopexy Corrects ant. vag laxity & stress inc. Useful at abdominal hysterectomy / for vault prolapse.Extra peritoneal supra pubic approach if done alone.Enterocele repair if required.Vagina stitched to the ileo-pectineal ligaments.
30Vault / Colposuspension Vault is fixed to the abdominal wall by a facial strip or merseline tape
31LAPAROSCOPIC SURGERY PROLAPSE Advantages of M I S-small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scarCan all types of prolapse be treated?- Yes.Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.SurgeryHowever extended period of rest is essentialExpertise is neededPresently cannot be widely practisedThis is the surgery of the future today
32LAPAROSCOPIC SURGERY PROLAPSE PROCEDURES:-Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repairVH / LAVH / LH / TLH + ColposuspensionVH / LAVH /LH/TLH+ Lap.Pelvic reconstructionRectocele repair & levatorplastyEnterocele repair with suturing of uterosacral ligamentsColpopexy- Ant / Post
33Laparoscopic Cervicopexy/sling Operations All types of sling operations can be better performed by laparoscopyAssociated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair)Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy
34Laparoscopic Vault suspension/ Culdoplasty) Can be done with VH / LAVH / LH / TLHCorrects mild laxityPrevents vault prolapse
35Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH An alternative to Ward-Mayo’s operationBefore Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspensionLap. levator plication if neededEnterocele repair and suturing of uterosacral ligaments if neededRetro pubic Colposuspension (Bruch) if required
36Laparoscopic Rectocele repair & Levatoroplasty Rectovaginal space is opened & rectum dissectedInterrupted sutures given in the levator in the midlineEnterocele repair done if indicatedVaginal vault suspension done
37Laparoscopic Enterocele repair Rectovaginal space is opened, sac excised and purse string suture givenUterosacral ligament sutured
38Laparoscopic Post Colpopexy / Sacrocolpopexy Indicated for vault prolapseEnterocele if present is first repairedProlene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the Rt.para rectal space
39Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today.THANK YOU