Pelvic Organ Prolapse(POP) Treatment: A Urogynecology Perspective Case Study M .Zargham MD Isfahan university MC 2013

A 38-yr-old pregnant women presented with urinary incontinence and perineal mass

Uterine Prolapse Apical Prolapse S4 38 years old pregnant women PI: Gestational age 24 week. She wears pads all time and change them 5 times a day Perineal mass .

Halfway Classification System. Perspective: schematic 3D sagittal view.

Clinical and paraclinical evaluation PI: Gestational age 24 week. She wears pads all time and change them 5 times a day Perineal mass PMH: Gravid 2/para 1/ab 0 Sono: Renal and bladder showed bilateral hydroureteronephrosis(LT-G 1,Rt-G2) U/A :microscopic hematuria and pyuria. U/C :Neg. CBC: normal Cr: 1.2 mg/dl

Apical Prolapse Enterocele S4 The enterocele bulge is outside the introitus.

Various types of pessaries.

What is the best method of delivery? A total of 1.4 million women were investigated!

pelvic organ prolapse and method of delivery, The benefits and potential risks of a cesarean section with resultant uterine scar have to be weighed 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 2007 Villar J,et al. Maternaland neonatal individual risks and benefits associated with cesarean delivery: multicentre prospective study. BMJ 2007

2 years after delivery she presented with Urinary Incontinence and vaginal mass

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

She refused hysterectomy! Uterine prolapse vaginal apex reaches significantly above the ischial spines on vaginal exam . She refused hysterectomy!

Why is hysterectomy unnecessary in the treatment of uterine prolapse? She refuse hysterectomy!

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.

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.

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?

Abdominal Sacrocolpopexy with mesh elevation of the vaginal apex to the sacral promontory with a mesh bridge.

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 vagina Holley 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.

Tissue Fixation System(TFS): Vaginal sacral colpopexy The synthetic prostheses for sacrocolpopexy are well established yet remain controversial for repairing isolated anterior and posterior compartment defects.

Sling and POP Conversely, 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.

The AUA strongly reinforced the need to differentiate between the use of mesh to treat POP versus SUI

Mesh extrusion Described methods: observation alone? use of topical estrogen or antiseptics? systemic or topical antibiotics? Office based trimming of the extruded material? operative excision?

6 month latter she complain of constipation, fecal incontinence and vaginal discomfort

Rectocele and Enterocele Apical and posterior vaginal wall prolase S4 She complain of fecal incontinence ,incomplete emptying of rectom and vaginal discomfort.

POP Q classification

POP Q classification

What are the risk factors for surgical failure?

Advance utrine prolapse! Surgeon experience!

Defecography Proctography Constipation, Melanosis Coli, Stercoral Ulcer, Obstructed Defecation (Anismus), Short-Segment Hirschsprung's Disease, Intestinal Pseudo-obstruction (Ogilvie's Syndrome), Proctalgia Fugax(Levator Spasm), Coccygodynia

Sagittal view of typical rectocele deformity

Defecography Proctography

Defecography Proctography

Rom the posterior IVS procedure lies from pelvic side wall,to pelvic sidewall allowing the vaginal cuff to be supported by neo cardinal ligaments.

Enterocele &Rectocele repair with mesh

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

Roger R. Dmochowski, MD Department of A1302 Medical Center North Nashville, TN 37232-2765, USA Mickey Karram, MD The Christ Hospital 2123 Auburn Avenue, Suite 307 Cincinnati, OH 45219, USA Urologic Surgery Vanderbilt University Medical Center

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