Pelvic Floor Reconstruction

Transcription

1 3.9 Curriculum in Urology Trauma and Reconstruction Pelvic Floor Reconstruction W. Artibani a, Stuart L. Stanton b, D. Kumar c, R. Villet d a University of Verona, Italy; b Saint George Hospital Medical School, London, UK; c Saint George s Health Hospital, London, UK; d Hôpital des Diaconesses, Paris, France At present, surgery on the anterior, middle and posterior compartments of the pelvic floor is largely performed by urologists, gynaecologists and colorectal surgeons, respectively. However, it is more appropriate to regard the pelvic floor as a single anatomical and functional unit. An integrated multidisciplinary approach to the evaluation and treatment of pelvic floor disorders is therefore required. This approach would draw upon the expertise of the various existing specialities. The management of pelvic floor disorders is discussed with reference to the published outcome data for the various surgical procedures. A Multidimensional, Transdisciplinary Approach to Pelvic Floor Disorders Currently surgery on the anterior, middle and posterior regions of the pelvic floor is largely performed by urologists, gynaecologists and colorectal surgeons, respectively, with urologists mainly treating stress urinary incontinence and focusing on bladder and urethral function, gynaecologists performing vaginal surgery, and colorectal surgeons concentrating upon anorectal disease. It is, however, more logical and appropriate to consider the pelvic floor as a single anatomofunctional unit, both from a physiological and a pathophysiological perspective. It is common for patients to present with problems affecting more than one Prof. W. Artibani University of Verona, Department of Urology, I Verona (Italy) Tel , Fax , Walterartibani@libero.it Published in cooperation with European Urology and Karger

2 Table 1. Vaginal, suprapubic and laparoscopic procedures for pelvic floor reconstruction Vaginal operations Suprapubic operations Laparoscopic operations Anterior compartment Anterior compartment Anterior compartment W Anterior colporrhaphy W Abdominal paravaginal W Colposuspension W Anterior colporrhaphy with mesh W Colposuspension W Paravaginal W Vaginal paravaginal repair W Mesh Middle compartment Middle compartment Middle compartment W Conventional vault repair W Sacrocolpopexy W Sacrocolpopexy W Manchester operation W Sacrohysteropexy W Sacrospinous ligament fixation W Uterosacral sacrospinous ligament fixation W Iliococcygeal hitch Posterior compartment Posterior compartment Posterior compartment W Posterior colporrhaphy W Sacrocolpopexy with W Sacrocolpopexy with W Posterior colporrhaphy with mesh W mesh interposition W mesh interposition W Transanal repair W Rectocele repair W Levator plication compartment of the pelvic floor. Furthermore, it is important to remember that intervention in one compartment can often cause changes in others. For example, colposuspension may lead to secondary uterine prolapse or enterocele. An integrated multidisciplinary approach to the evaluation and treatment of pelvic floor disorders is therefore required, drawing upon the expertise and techniques of the various specialities to achieve the best possible standards of treatment. This multidisciplinary approach is perhaps best summarised in the words of Turner-Warwick, who stated: The best person to treat incontinence and prolapse is not the urologist, the gynaecologist nor the colorectal surgeon it is the person who has been trained to do this. According to this approach, urologists need to consider not only urological and quality-oflife evaluation, but should also consider the gynaecological, sexual, psychiatric and colorectal perspectives. Thus, outcome measurement should comprise an overall evaluation including quality of life, continence, pain, sexual and bowel function. A better-integrated approach to patient care should also be of value in the determination of the optimal treatment strategies for individual patients from the wide range of surgical techniques currently performed. Vaginal versus Suprapubic versus Laparoscopic Pelvic Floor Reconstruction The aim of pelvic floor reconstruction is to correct prolapse and urinary and faecal incontinence while preserving vaginal function. There remain a number of unresolved issues in pelvic floor surgery. These include the clinical value of performing fascial repair, for which more data are needed, the use of laparoscopic techniques, the role of mesh and the optimal surgical treatments for cystocele (anterior repair or paravaginal repair), vault prolapse (sacrospinous ligament fixation, iliococcygeal hitch or sacrocolpopexy) and rectocele (posterior colporrhaphy, fascial repair or transanal). Of the three approaches to surgery, the vaginal route has the advantages of causing less pain than the suprapubic or laparoscopic approaches and no visible scarring. However, this approach provides limited abdominal access. The suprapubic approach is usually quick, safe and provides good access and results. However, there may be a painful scar and there is usually a longer period of hospitalisation than following vaginal or laparoscopic surgery. Whether a quick return to work following prolapse repair is beneficial or harmful remains a matter for debate. Laparoscopic repair offers Artibani/Stanton/Kumar/Villet

3 Table 2. Cure rates for vaginal, suprapubic and laparoscopic techniques for pelvic floor reconstruction Cure Stress UI Cystourethrocele Vault/enterocele Rectocele % % % % Vaginal W Anterior colporrhaphy W Paravaginal W Posterior colporrhaphy W Mesh 89 W Iliococcygeous Suprapubic W Paravaginal W Sacrocolpopexy W Colposuspension Laparoscopic W Colposuspension W Sacrocolpopexy 100 W Rectocele repair 80 the advantages of minimal scarring and pain and allows day case or 24-hour surgery; however, bladder and bowel injuries are common and there are at present few long-term data from randomised, controlled clinical trials. The variety of vaginal, suprapubic and laparoscopic procedures for pelvic floor reconstruction are listed in table 1, while table 2 summarises the data for cure rates of different surgical techniques from published clinical trials. Vaginal Surgery Although vaginal operations represent the oldest approach to prolapse surgery, there is still little objective evidence of their effectiveness. Anterior Compartment. A wide variety of techniques for anterior colporrhaphy are practised. A fundamental anatomical question is the position of the paravaginal fascia depending on the dissection, some clinicians believe the fascia lies at the back of the skin flap, while others choose the surface of the bladder. The success rate for correction of cystourethrocele is in the range 66 80%. The success rate if mesh is used (in some cases of secondary surgery) may rise to 100%; however, mesh erosion was recorded in 25% of the small series of 12 patients reported in the literature [1]. The success rate for cure of stress urinary incontinence is poor (37 84%) [2; WHO Consensus Meeting, Monaco]. Anterior colporrhaphy is not associated with voiding difficulties and rarely results in detrusor instability. The vaginal paravaginal operation has been shown to achieve correction of cystourethrocele in 86-97% of patients [3]. Middle Compartment. It is difficult to find reliable data for success rates following conventional vaginal correction of vault prolapse. Success rates of up to 96% have been reported for the McCall culdoplasty. However, this does not take into account the role of fascial tissues which is becoming more controversial, particularly with gynaecologists in the USA, many of whom believe that as prolapse is associated with fascial defects, repair of paravaginal and rectal fascia must be performed to correct them. Success rates are believed to be in excess of 90% with fascial repair although ureteric and colorectal complications are associated with these techniques, partly because of the difficulty of obtaining good exposure. The Manchester operation is now less frequently performed as it may not adequately corrrect the enterocele and there may be problems with future uterine bleeding as it leaves the uterus in situ. Fixation of the vault to the sacrospinous Pelvic Floor Reconstruction

4 ligament is associated with an anatomical cure rate in the range of 63 97% but complications include haemorrhage, buttock pain, sciatic nerve injury, stress incontinence and an incidence of cystourethrocele of up to 20%. In a study which compared outcomes in patients following sacrospinous ligament fixation or iliococcygeal hitch, symptomatic success rates of 94 and 91% were recorded for the two procedures, respectively. However, the patient satisfaction rating was higher in the group who underwent sacrospinous ligament fixation and the incidences of cystocele and dyspareunia were higher in the patients who were treated by the iliococcygeal hitch method [4]. These data indicate that the sacrospinous procedure may be superior; however, it is more difficult to perform and there is a greater risk of nerve entrapment. Posterior Compartment. Posterior colporrhaphy has been shown to achieve anatomical cure of rectocele in 76 82% of cases. The incidence of postoperative complications, including dyspareunia, incomplete bowel emptying and constipation, shows a similar degree of variability [5]. The use of an inorganic mesh (Prolene) for secondary surgery may achieve anatomical and functional cure in up to 89% of patients [6]. Suprapubic Surgery Suprapubic techniques allow for better access and vision than vaginal or laparoscopic techniques and appear to have a lower incidence of postoperative complications. However, they are often more painful and require longer periods of hospitalisation. Anterior Compartment. Abdominal paravaginal repair has been shown to achieve correction of cystourethrocele in 61 95% of cases and shows a similar variability in success rate for the correction of stress urinary incontinence [7, 8]. Open colposuspension achieves cure of incontinence in 82 90% of cases and cure of cystourethrocele in 89 96% of cases. This study also showed a recurrence rate for cystocele of about 4% and a failure rate of about 10% at 1 year and 20% at years following open colposuspension [9]. Voiding difficulties have been reported in 2 27% of patients, detrusor instability in 8 27% and prolapse in the middle and posterior compartments has been reported in approximately 26% of patients following this procedure [10]. Middle Compartment. Sacrocolpopexy has a reported success rate for the correction of vault prolapse in the range of % [11]. This procedure carries a lower risk of stress incontinence in comparison with sacrospinous ligament fixation. Posterior Compartment. Correction of a rectocele from an abdominal approach has been described by Villet et al. [12]. In this technique, the rectum is dissected away from the posterior vaginal wall and inorganic mesh is attached to the perineal body. It is then sutured to the posterior vaginal wall to the apex of the vault then to the sacrum and the mesh is then peritonealised. Villet et al. obtained a success rate of 99% for correction of prolapse using this technique. A combination of perineorrhaphy and sacrocolpopexy with mesh extension down the posterior vaginal wall has been used by Cundiff et al. [13], with anatomical improvement in 84% of patients and improvement in bowel symptoms in 66%. Sacrocolpopexy with mesh interposition along the posterior vaginal wall only has been shown to entirely correct grade II and III vault prolapse, with an increase in grade I prolapse from 20 to 27% [14]. Laparoscopic Surgery These new techniques are often performed by laparoscopic enthusiasts with minimal training in urodynamics or urogynaecology. The published studies are characterised by small series of patients, subjective outcome measures and short periods of follow-up, so that the true value of these procedures is unclear. Anterior Compartment. There are only two randomised trials of laparoscopic colposuspension. These studies indicate a cure rate in the range of 57 80% [15, 16]. Artibani/Stanton/Kumar/Villet

5 Middle Compartment. Two studies have reported a success rate of the order of 100% for the use of laparoscopic sacrocolpopexy to correct vault prolapse; however, there were significant post-operative complications [17, 18]. Posterior Compartment. Successful laparoscopic repair of primary rectocele has been reported in 80% of patients at 1-year followup using polyglactin mesh, without any apparent complications [19]. In summary, while preliminary results using laparoscopic procedures appear to be good, further data from large, randomised, controlled trials with adequate long-term follow-up are required and open procedures at present remain the gold standard. Comparative trials of vaginal, suprapubic and laparoscopic routes of access are now imperative. Ideally, surgeons should have experience of all routes of access so that the best procedure can be chosen for individual patients. A future pelvic floor surgical team might comprise a urogynaecologist and a colorectal surgeon, with help from pediatric surgeons and other specialities as required ot optimally manage each patient. The Colorectal Surgeon s Perspective Colorectal surgeons currently see patients with a wide range of problems involving the pelvic floor, including faecal leakage and incontinence, rectal prolapse, rectocele, perineal descent and urogenital prolapse. The most common problems encountered are prolapse and incontinence. Problems can often involve several compartments of the pelvic floor. There are cases presenting with faecal incontinence, where the anterior anal canal is missing so that both the posterior and middle compartments are involved. Following corrective surgery these patients can have a complete sphincter and the middle compartment can be restored to being anatomically normal. Clinical examination must be very careful in the presence of a large rectocele; when the patient s symptoms do not fit this diagnosis, barium proctography must be performed. This can show intersusception. An appropriate rectopexy can be indicated instead of inappropriate transanal or posterior colporrhaphy. Close collaboration between the colorectal surgeon and the urologist is sometimes useful in the treatment of damage involving more than one compartment to the pelvic floor. In acknowledgement of the fact that patients often present with problems involving more than one compartment of the pelvic floor and in recognition of the value of an integrated multidisciplinary approach to treatment, a pelvic floor clinic was established at the St George Hospital Medical School in Approximately 47% of the pathologies encountered at the clinic have been colorectal, while urinary problems and prolapse have accounted for approximately 32 and 22% of cases, respectively. The formation of a multidisciplinary team, including a urogynaecologist and colorectal surgeon, has proven to be beneficial and allows improved selection of the optimal treatment for individual patients. In addition to the sharing of expertise in the evaluation of patients and in determining treatment strategies, the team members have collaborated in the development of new treatment approaches to a number of conditions. For example, the team has extended the use of bulking agents into the treatment of passive incontinence due to internal anal sphincter dysfunction, with a success rate of approximately 70% at 5-year follow-up. The team has also used bulking agents following haemorrhoidectomy and internal sphincterotomy. The pelvic floor team members have also collaborated in the development of a new surgical approach for the treatment of enteroceles. Experience at the St George Hospital indicates that the formation of a multidisciplinary pelvic floor team can improve patient care through the selection and implementation of the optimal treatment approach for each individual patient. Furthermore, the close interaction and collaboration of the different specialities within the team may facilitate the development of new treatment approaches and the improvement of existing techniques. Pelvic Floor Reconstruction

6 The establishment of pelvic floor clinics may yield benefits in training, patient care, audit and research. Does the Pelvic Floor Surgeon Exist? The acknowledgement of the pelvic floor as a single anatomofunctional unit and the realisation that problems commonly involve more than one compartment of the pelvic floor is by no means a recent phenomenon. In 1740 the French surgeon Pierre Dionis stated that weakness or paralysis of the levator ani musculature was the cause of both uterine and rectal prolapse. This view has, however, become increasingly widespread over the last decade with, for example, a 1994 paper entitled Treating the whole pelvis, declared, As we learn more about the natural function and causes of dysfunction of the female pelvis, we are beginning to see that the parts can no longer be regarded in isolation [20]. The first congress on pelvic floor disorders was held in Montreal in 1998 and it was at this meeting that the term pelviperineology was suggested to describe the study and treatment of disorders affecting any of the compartments of the pelvic floor. The developmental and anatomical evidence to support the view that the pelvic floor should be regarded as a single unit is clear. The different parts of the pelvic floor are all derived from the same embryological structures and the muscle fibres are woven into the connective tissue around both the urogenital hiatus and the rectum. Furthermore, the pelvic floor and the urethral and anal sphincters are all innervated by nerve fibres radiating from the same spinal roots. Pelvic floor disorders can be said to derive from an imbalance between the various opposing forces to which the pelvic floor is subjected in the maintenance of urinary, genital and anal continence while allowing for micturition, parturition, coitus and defecation. Disorders may result when there is a change in the strength or direction of the abdominal forces exerted or when there are abnormalities in the size or position of the pelvic organs. Most commonly, however, pelvic floor disorders stem from connective tissue defects and damage to the musculature, fascia or sacral or pudendal nerves. The principal factors associated with the development of pelvic floor disorders are: (1) aging; (2) pregnancy and parturition; (3) bowel dysfunction; (4) sporting activites, and (5) pelvic and perineal surgery. Aging A wide range of changes associated with aging can contribute towards the development of pelvic floor disorders. These include osteoporotic vertebral modification and abdominal wall slackening, recession of the coccyx, loss of resilience by the fascial tissue and ligaments, atrophy of the pelvic floor musculature (especially the puborectal section of the elevator ani) and shortening of the vagina. In addition, hormonal deficiency reduces urethral vascularisation and urethral and/or vaginal trophicity. Pregnancy and Parturition While pregnancy plays a role in the development of pelvic floor disorders, the most important muscular damage occurs with the first vaginal delivery. In the case of pregnancy, the abdominal wall is distended and pressure is exerted towards the vaginal opening, while the tissues are impregnated with oestrogen and become swollen. During birth the coccyx is pushed back and the perineum and the fibrous perineal centre are distended (the puborectal portion can be torn and the anal sphincter lacerated). Later, the anterior vaginal wall and the bladder can lose their inferior and posterior hold, opening the way to the development of genital prolapse. In addition to direct damage to the perineal body, nerve latency studies suggest that urinary and faecal incontinence also result from damage to the nerve fibres innervating the pelvic floor sphincter muscles [21, 22]. Occult damage to the anal sphincter can also occur during vaginal delivery. In a study by Sultan et al. [23], 28/79 (35%) primiparous women had a sphincter defect on endosonography 6 weeks after delivery and the defect persisted 6 months later in 22 of the women studied. Among 48 multiparous women, 19 (40%) Artibani/Stanton/Kumar/Villet

7 has a sphincter defect before delivery (comparable to the 35% of primiparous women after delivery) and 21 (44%) has a sphincter defect after delivery, suggesting that the risk of sphincter damage is greatest during the first vaginal delivery. Bowel Dysfunction During defecation the puborectal muscle and the anal sphincter must relax. In some subjects, paradoxical contraction is responsible for chronic straining which in the long term can induce first denervation neuropathy with a urethral and/or anal sphincter contraction decrease and second stretching of supporting and suspensory systems which may result in prolapse. A study has shown that straining at stool as a young adult prior to the development of urogynaecological problems was significantly more common in women with stress urinary incontinence or prolapse (30 and 61%, respectively, vs. 4% for controls). At the time of consultation, 95% of the women with uterovaginal prolapse were constipated compared with only 11% of controls [24]. Sporting Activities Abdominal pressure can increase dramatically (up to 200 cm H 2 O) during some sports activities. A study by Nygaard et al. [25] showed that the incidence of genuine stress urinary incontinence varied from 10% for swimming and body building to 40% for running and intensive aerobics. Pelvic and Perineal Surgery In addition to the obvious local trauma resulting from procedures such as urethral diverticula and episiotomy, pelvic surgery may also induce prolapse by modifying the topography of the pelvic organs with resultant changes in abdominal pressures. The best example of imbalance between the anterior and posterior tensions is the development of enterocele following anterior hysteropexy. Similarly, prolapse has been reported in 5 25% of patients following Burch colposuspension [26, 27] and this incidence increases markedly if the Burch procedure is associated with hysterectomy. Conclusion Is There a Role for a Pelvic Floor Surgeon? As noted previously, at present, surgical procedures involving the anterior, middle and posterior compartments of the pelvic floor are largely the preserve of different surgical specialties. The treatment of rectoceles offers a striking example of how this specialisation works in France. One type of rectocele, resulting from overstretching and subsequent damage to the connective tissue between the rectum and vagina, is treated by the colpoproctologist. Another type of rectocele, which results from rupture of the levator ani attachments to the perineal body, is treated by the gynaecologist. It is remarkable that the surgical approach depends more upon the experience and training of the surgeon rather than the rectocele type: the transanal approach by a colpoproctologist, or the perineal approach with colporrhaphy by a gynaecologist. In summary, the developmental and anatomical evidence that supports the view of the pelvic floor as a single anatomofunctional unit, the fact that disorders commonly affect more than one compartment of the pelvic floor, and the incidence of iatrogenic injuries to other compartments during procedures such as colposuspension highlight the importance of a more holistic approach to the evaluation and treatment of pelvic floor disorders. With sufficient training it should be possible for the same surgeon the pelvic floor surgeon to be competent in dealing appropriately with any pelvic floor disorder. Ultimately, however, what is important is not to establish whether or not the same surgeon must treat all problems related to the pelvis but to realise that surgeons dealing with pelvic floor disorders can no longer afford to focus on one particular aspect of pelvic floor dysfunction to the exclusion of others. Thus, it is important that surgeons work closely with other colleagues in integrated pelvic floor teams. Pelvic Floor Reconstruction

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