Transvaginal Apical Repair (non-mesh) Bob L. Shull, M.D. Professor of Obstetrics and Gynecology Scott & White Clinic and Hospital Texas A&M University Health Sciences Center Temple, Texas

Learning Objectives At the end of the discussion the participant will be able to: To describe the key steps of uterosacral ligament suspension To describe how to minimize the risk of ureteral injury

Choice of Operative Procedure Vaginal repair Abdominal suspension Combined abdomino-vaginal repair

Sacrospinous Ligament Suspension 1898 - Zweifel - Sacrotuberous ligament 1914 - White - Tendinous arch 1951 - Amreich - Sacrotuberous ligament 1958 - Sederl - Sacrospinous ligament 1971 - Randall & Nichols - Sacrospinous ligament

% of Recurrences Vagina Author No. Pts Apex Other sites too small S.U.I. Richter 69 0% 22% 12% 4% Nichols 163 3% ? 2% 6% Morley 71 4% 20% 6% 6% Kettel 31 19% ? ? ? ? - Information not reported

Pre- and Post-Operative Analysis of Site-Specific Pelvic Support Defects in 81 Women Treated by Sacrospinous Ligament Suspension and Pelvic Reconstruction Conclusion: The principal support loss during the follow-up period was the bladder. Shull BL, Capen CV, Riggs MW, Kuehl TJ Amer J Obstet Gynecol, 1992: 166(6-1):1764-68

“RETROVERSION of the vagina… a step towards prolapse of the anterior vaginal wall” Victor Bonney, 1934

Bilateral Attachment of the Vaginal Cuff to Iliococcygeus Fascia: An Effective Method of Cuff Suspension Shull BL, Capen CV, Riggs MW, Kuehl TJ American J Obstets Gynecol, 1993, 168:1669-77.

Conclusion Ninety-five percent of women experienced no persistence or recurrence of cuff prolapse in follow-up from six weeks to five years.

Repair of Vaginal Vault Prolapse by Suspension of the Vagina to Iliococcygeus (Prespinous) Fascia 110 patients Minimum follow-up 3 years 4 patients with recurrent defects - all anterior segment Meeks GR, Washburne JF, McGehee RP, Wiser WL. Am J Obstet Gynecol 1994; 171:444-54

Fixation of the Vaginal Apex to the Coccygeus Fascia during Repair of Vaginal Vault Eversion with Enterocele 121 patients with posthysterectomy vault eversion 81 coccygeus fascia, 30 sacrospinous ligament fixation Projected cure at 2 years Coccygeus 96% Sacrospinous 80% Peters III WA. Christenson NL. Am J Obstet Gynecol 1995; 172:1894-202

Posthysterectomy Vaginal Vault Prolapse: Primary Repair in 693 Patients Study Period 1976-1987 693 underwent primary repair of posthysterectomy vaginal vault prolapse. 95% of procedures were performed with Mayo culdoplasty. Webb MJ, Aronson MP, Ferguson LK, Lee RA. Obstet Gynecol 1998;92:281-5.

Posthysterectomy Vaginal Vault Prolapse: Primary Repair in 693 Patients Complications Visceral injury 2.3% Vault hematoma 1.3% Cuff infection 0.6% Ureteral complication 0.6% Webb MJ, Aronson MP, Ferguson LK, Lee RA. Obstet Gynecol 1998;92:281-5.

Posthysterectomy Vaginal Vault Prolapse: Primary Repair in 693 Patients Outcomes 504 patients available for follow-up examination or survey Satisfied 85% Bulge or Protrusion 16% Reoperated 7% Webb MJ, Aronson MP, Ferguson LK, Lee RA. Obstet Gynecol 1998;92:281-5.

A Transvaginal Approach to Repair of Apical and Other Associated Sites of Pelvic Organ Prolapse Using Uterosacral Ligaments Shull BL, Bachofen C, Coates KW, Kuehl TJ Am J Obstet Gynecol, 2000: 183;1365-1374.

Study Design Jan 1, 1994 - Dec 31, 1998 302 consecutive patients 289 returned for follow-up Morbidity: transfusion, visceral injury, death Durability: life table analysis

Objective To describe a group of women with pelvic organ prolapse associated with apical loss of support using the Baden-Walker halfway system preoperatively, intraoperatively, and postoperatively To describe the operative repair of the support defects To report the morbidity associated with the operative repair To access the durability of the repair at each site

Uterosacral Ligament: Description of Anatomic Relationships to Optimize Surgical Safety Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the urterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament. Buller JL, Thompson JR, Cundiff GW, et. al. Obstet Gynecol 2001; 97:873-9.

Results The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean ± standard deviation distance from ureter to uterosacral ligament was 0.9±0.4, 2.3±0.9, and 4.1±0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9±2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. Buller JL, Thompson JR, Cundiff GW, et. al. Obstet Gynecol 2001; 97:873-9.

Conclusion Our findings suggest that optimal site for fixation is the intermediate portion of the uterosacral ligament 1 cm posterior to its most anterior palpable margin, with the ligament on tension Buller JL, Thompson JR, Cundiff GW, et. al. Obstet Gynecol 2001; 97:873-9.

Bilateral Uterosacral Ligament Vaginal Vault Suspension With Site-specific Endopelvic Fascia Defect Repair for Treatment of Pelvic Organ Prolapse Objective: The anatomic and functional success of suspension of the vaginal cuff to the proximal uterosacral ligaments is described. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC.Am J Obstet Gynecol 2000; 183: 1402-11

Conclusion: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential. Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Am J Obstet Gynecol 2000; 183: 1402-11

The underlying concepts for this repair are based on the anatomy of the support defects. The repair can be performed vaginally, abdominally, or laparoscopically