Karanvir Virk M.D.

Minimally Invasive & Pelvic Reconstructive Surgery

01/28/2015

I have none

Disclosures

Identify the basic Anatomy and causes of Pelvic

Organ Prolapse

Examine office diagnosis of Pelvic Organ prolapse

Discuss treatment options available for Pelvic Organ Prolapse

Objectives

History

History

Pts Definition: My insides are falling/bulging out

Physicians definition: Your uterus is falling

In reality it’s a weakness in the support structures of the pelvis

POP is actually a hernia

Vagina is the most dependent part of the abdominal cavity

What is Prolapse?

Newest data suggests 1in 2 women will have POP

1 in 5 will need surgery in their lifetime for POP

Is the incidence increasing???

POP

NO

The reporting is increasing

More and more women talk to their physicians about this problem

POP

29.2% Recurrences

Scarring and fibrosis produced by conventional surgery restores only 50% of tissue strength

58% recurrence rate after 1 year of surgery

Will any other surgery be acceptable in medical community with such high rates and the surgery is for quality of life!!!!

POP Facts

Why?

Why?

We were doing wrong repairs

We didn’t know the real anatomic reason for prolapse

Traditional repairs were making prolapse worse

Why such high failure?

John DeLancey

Level 1: The uterosacral-cardinal ligament complex

provides apical attachment to the uterus and vaginal vault to the bony sacrum

Level 2: The arcus tendineous fascia pelvis and fascia overlying the levator ani muscles

Level 3: The urogenital diaphregm and perineal body

Delancey’s levels of support

Muscular: Levator ani/pelvic floor muscles

Ligaments: Uterosacral-Cardinal complex

Fascial: Endopelvic( Pubocervical & Rectovaginal)

Anatomic supports

Predispose

Incite

Promote

Decompensate

Risk Factors for POP

Genetic: Collagen defects

Race: Latina and white women 4-5 times higher than AA

Gender: Female> Male

Being human: Erect posture

Predispose

Pregnancy & Delievery

1st birth: 4 fold

2nd birth: 8 fold

3rd birth: 9 fold

4th birth: 10 fold

Hysterectomy: Vaginal> abdominal

Myopathy

Neuropathy

Incite

Obesity 40-75%

Smoking

Chronic cough

Constipation

Heavy ligting

Promote

Aging

Menopause

Neuropathy

Myopathy

Debilitation

Medication??

Decompensate

Not specific to compartment

Bulge in the vagina

Pelvic pressure/pain

Dyspareunia

Incomplete bladder emptying

Recurrent UTI’s in severe cases

Incomplete rectal empting

Putting fingers in vagina to empty bladder/bowels

Acute urinary retention in severe cases

Symptoms

Most widely used

Using hymen as a fixed point of reference

Stage 1: Descends halfway to hymen

Stage 2: Descends to the hymen

Stage 3: Descends halfway past hymen

Stage 4: Maximum descent

Baden-Walker Halfway system

Every patient is different

The best choice is first choice

The first choice is the best choice

NEVER treat an asymptomatic patient. You can only make it worse

40% patients with prolapse have dyspareunia. Document it.

Treatment

Patients age

Sexual function

Symptoms

Vaginal/abdominal/laparoscopic/Robotic

Again…. NEVER treat an asymptomatic patient

Treatment

Pessarries

Fewer wound complications

Less post operative pain

Less cost

Categorized into 3 groups

1) Restorative: Use of patients endogenous support structures

2) Compensatory: Replace deficient support with some form of graft

3) close the vagina

Vaginal Surgeries

Old frail patients

Quick and easy procedure

90-95% success rate

Can be combined with sling/incontinence procedure

LeForte’s Colpoclesis and complete colpoclesis

Colpoclesis

Colpoclesis

Anterior repair

Posterior repair

Paravaginal repair

A must in prolapse surgery

Isolated anterior & posterior defects very rare

40% increase in success rates for all prolapse surgery if apical support surgery is done with anterior or posterior repair

Uterosacral ligaments

Sacrospinous ligaments

Apical support

Uterosacral

Sacrospinous

Can be done open, laparoscopic/Robotic

Graft attached to the anterior and posterior vaginal apex and suspended to anterior longitudinal ligament of sacrum

Excellent support for apex and anterior wall

Cure rates 87-100%

Technically difficult

Risk of injury to major organs

Abdominal

Biological

1) Human cadaver

2) Fascia lata

Porcine

1) Dermis

2) Bladder

Degraded/absorbed over time

Help native tissue to regenerate

Less success that synthetic grafts

Less complications compared to synthetic grafts

Grafts

Synthetic

Polypropylene

Inert

High objective success

More complications

Grafts

Vaginal mesh erosion

Pain/dyspareunia

Infection

Urinary problems

Bleeding

Organ perforation

Recurrent prolapse

Vaginal scarring/shrinkage

Emotional problems

FDA 2011

Reported 7 deaths from 2008-2010

3 deaths with mesh placement procedures( 2 bowel perforation, 1 hemorrhage)

4 deaths postop medical complications

FDA

Surgeon

1) Lack of training with mesh kits

2) Lack of informed consent

Patient

1)Why only few women develop symptomatic POP

2) Weak native tissue

Mesh

1) No ideal material available

2) Foreign body

3) Contraction

The problem is??

NEVER repair asymptomatic prolapse

Document dyspareunia

If in doubt do urodynamics and fix incontinence at the same time

High recurrence risk/recurrent cases, short vagina, younger patient; sacrocolpopexy

Low recurrence risk, unable to tolerate abdominal procedure, vaginal surgery

Use grafts only and only if you are familiar with dissection and use them on regular basis

Synthetic graft used for Sacrocolpopexy and sling procedure have shown their safety over time. NO FDA WARNING.

Pearls to success

Thank You Questions?