Anterior vaginal repair

Transcription

1 DOI: /j x The Obstetrician & Gynaecologist ;14: Tips and techniques Anterior vaginal repair Fiona Reid MD MRCOG a Tony Smith MD FRCOG b, a Consultant Urogynaecologist, The Warrell Unit, St Mary s Hospital, Oxford Road, Manchester M13 9WL, UK b Consultant Urogynaecologist, The Warrell Unit, St Mary s Hospital, Manchester, UK Correspondence: Anthony Smith. Anthony.Smith@cmft.nhs.uk Articles in the Tips and Techniques section are personal views from experts in their field on how to carry out procedures in obstetrics and gynaecology. Pleasecitethis paper as:reid F, Smith T. Anterior vaginal repair. The Obstetrician & Gynaecologist 2012;14: Introduction Anterior vaginal repair is the prolapse repair procedure most often performed in the UK: in in England and Wales 8560 were performed, either alone or in combination with other repair procedures. History and terminology Throughout the last century the anterior repair described by Kelly in has been the most popular technique: the epithelium of the anterior vaginal wall is opened in the midline, and the fascia under the bladder and urethra is brought together in the midline. In 1909 White 2 described the paravaginal repair, in which the lateral anterior vaginal wall fascia is sutured to the lateral pelvic side wall through bilateral anterior vaginal wall incisions. This can be performed vaginally or abdominally. Kelly s technique was probably more widely adopted because of its technical simplicity and because of Kelly s particularly high standing in the surgical community. There has been increased interest in these and other techniques for anterior repair over the last 30 years, but no robust study has shown any technique to be superior in terms of anatomical or functional outcome. Study of the literature reveals that surgeons were arguing about the relative merits of the abdominal and vaginal approaches to prolapse surgery 100 years ago in the same way they do today. Historically, the term anterior repair has been used interchangeably with the term urethral buttress, particularly in the context of surgical treatment of stress urinary incontinence. Strictly speaking, the term urethral buttress should be used for the procedure in which sutures are placed solely beneath the urethra. Anterior repair should be used to describe the procedure that provides support along the whole length of the anterior vaginal wall, thereby supporting both the urethra and the bladder base. Case selection Anterior repair is performed for symptomatic anterior vaginal wall prolapse. A woman who is found to have a prolapse on routine examination for cervical screening is not well served by being encouraged to have surgery. While troublesome urinary symptoms may be improved by anterior repair, a significant proportion of women develop new urinary symptoms following surgery, which will be particularly unwelcome if they were symptom free before. Assessment of apical support In women with anterior vaginal wall prolapse it is particularly important to assess the support of the cervix or vaginal vault in addition to the anterior and posterior vaginal wall support. It is our view that poor vault support is one of the most common reasons for failure or recurrence following anterior vaginal repair. It is difficult to be certain, from clinic assessment, whether apical support is satisfactory and, since there is no clear definition, it is wise to warn women preoperatively that surgery to support the apex may need to be included. It is worth asking the woman if she has seen or felt the cervix. Patient counselling In addition to a full discussion about the non-surgical options for management of anterior vaginal wall prolapse, women must be advised about the potential development of new symptoms postoperatively. Although vaginal narrowing and dyspareunia may follow anterior repair it is the development of stress incontinence that causes most distress. Overactive bladder symptoms are often improved by anterior repair but they may develop de novo and they are also distressing. If women are not warned about the possibility of these symptoms developing they will assume that the surgery has been performed incorrectly. Preoperative treatment of atrophy Although no studies have been performed to determine the effect of preoperative estrogenisation of the vaginal epithelium, most surgeons advise treatment of the atrophic vagina for a couple of months before surgery. There is evidence that topical estrogens are beneficial in the treatment of overactive bladder symptoms and recurrent urinary infection; this may be useful, C 2012 Royal College of Obstetricians and Gynaecologists 137

2 Anterior vaginal repair but the prime reason for treatment prior to surgery is that the well-estrogenised vaginal epithelium is thought to heal better. Choice of anaesthesia Regional and general anaesthesia are the most popular techniques employed in the UK. Use of local anaesthesia for simple anterior repair has been shown to be effective and acceptable to women. It does place additional demands on both the surgeon and the theatre staff; having a staff member to distract the woman with conversation is critical. Background music can be helpful, particularly if chosen by the woman. (Avoid Rod Stewart s The First Cut is the Deepest or The Drugs Don t Work by The Verve!) The surgeon and assistants need to employ additional sensitivity with regard to tissue handling, particularly of the areas not anaesthetised, which is good discipline. Local anaesthesia does limit the option of performing more advanced techniques, such as apical support surgery. Since cardio- and neurotoxicity are known hazards of local anaesthetic agents, women must be appropriately monitored. The main advantage of regional anaesthesia is that the woman avoids the potential respiratory complications of general anaesthesia and the sedation, nausea and vomiting that can follow. The strain on a pelvic floor repair when a woman retches after waking from general anaesthesia is unlikely to enhance the strength of the repair. Repeated coughing by a woman who develops a postoperative respiratory infection can also weaken a repair. The only significant disadvantage of regional anaesthesia is the delayed return of sensory and motor function to the legs, which can be accompanied by delayed return of normal bladder function. This can make discharge home on the day of surgery more difficult. Position on the operating table If the woman s hip mobility allows, the extended lithotomy position will enable better access to the anterior vaginal wall. It is sensible to ask the woman when she is lying on the clinic couch to demonstrate her range of hip mobility, with particular reference to whether she is able to bring her knees up to her chest. On the operating table, adjustable stirrups enable the surgeon to move the legs and ensure that the optimal position is achieved without the need to involve other members of theatre staff. Vaginal and perineal cleaning Only aqueous solutions should be used in the vagina, as spiritbased solutions can result in pooling of the inflammable fluid, with a subsequent fire risk when diathermy is used. The clear brown colour of aqueous iodine solution has the advantage that it clearly delineates the skin. After cleansing, the anus should ideally be covered with sterile drapes to reduce the risk of bacterial contamination. Care must be taken to avoid iodine-based solutions in women who are iodine sensitive. Figure 1. Infiltration. The infiltrate should be inserted between the fascia deep into the vaginal epithelium and the bladder Catheterisation Most surgeons prefer to catheterise before commencing surgery.womenwithacystocoeleoftenhaveadegreeofurinary voiding difficulty and there is sometimes a considerable volume of urine in the bladder when they arrive in the operating theatre. Catheterisation ensures that the bladder is empty and not distended to any degree at the beginning of the procedure. The urethra should be lubricated before insertion and care should be taken to minimise repeated catheterisation and urethral trauma. Infiltration (See Figure 1 and Figure 2 online.) This can be done for the purposes of dissection, vascular constriction and/or analgesia. If infiltration is to be done mainly for hydrodissection it is safest to use normal saline. If vascular constriction is required, 1 in adrenaline can be used. A solution combining adrenaline with an analgesic agent such as bupivacaine will cover all three options. The advantage of a combined solution is that no additional mixing of solutions is required. This greatly reduces the risk of error in producing the appropriate concentration. Adrenaline is produced in ampoules of different concentrations and working out the amount of saline needed introduces a risk of error. One disadvantage of adding an analgesic agent is that the total dose needs to be calculated to reduce the risk of overdosage; the dosage of bupivacaine, for example, must not exceed 2 mg/kg. We prefer to use a 1 in adrenaline solution and we are always fastidious at checking the ampoules used. Types of repair It is generally agreed that the aim of anterior repair is to increase the fascial support under the bladder, which lies immediately underneath the vaginal epithelium. There are two fundamentally different methods of gaining access to this facial layer: 138 C 2012 Royal College of Obstetricians and Gynaecologists

3 Reid and Smith Retractors Most surgeons use a Sims speculum to hold the posterior vaginal wall away from the operating field of the anterior vaginal wall. The weighted Auvard speculum has become less popular, particularly following reports of buttock burns from heat retention in the weighted part of the speculum. The Lone Star Retractor System R is a useful device, particularly when surgical assistants are in limited supply. The hooks can be placed under varying degrees of tension at different positions throughout the operation. They are probably less traumatic to the vaginal skin than grasping instruments. Figure 4. The incision should be down to the fluid-filled space 1 it can be dissected from the vaginal epithelium, thereby leaving it still attached to the underlying bladder 2 it can be left attached to the vaginal epithelium and dissected on its inferior surface from the bladder. There are no robust studies reported in the literature to determine whether one of these techniques is superior. Over thelast30years,wehaveusedbothtechniquesbutcannotsay whether one of them produces a superior anatomical or more durable result. The first technique has the advantage that if fascial defects are identified before the surgery begins they can be identified and repaired after the fascia has been separated from the vaginal epithelium. Unfortunately, to date there are no robust studies reported concluding that clinically identified fascial defects can be reliably identified on imaging or during surgery, and if identified and repaired that this results in a superior outcome. The second technique has the advantage that it involves working in a less vascular plane and that it reduces the risk of bladder or ureteric injury when suturing the fascial repair because the fascia is separated from the bladder. Havingusedbothtechniquesovertheyears,wehavecometo the conclusion that infiltration with a 1 in adrenaline solution underneath the fascial layer, followed by a midline incision down to the infiltrated plane (Figure 3 online and Figure 4), is the simplest approach. The bladder can then simply be pushed back away from the fascia (Figure 5). In primary surgery very little sharp dissection is required and there is usually very little blood loss. In secondary surgery, sharp dissection is often required to break down adhesions. This also the plane in which mesh or graft materials are normally placed (see section below, Surgery for recurrent anterior vaginal wall prolapse ). (See Figure 6 online, Figure 6a online, Figure 7, Figure 7a, Figure 8, Figure 9 and Figure 10 online.) The fascial repair should not be under tension and there should be no gap between the components of repaired fascia, since they will not heal together if not placed in contact. (See Figure 11, Figure 12 online, Figure 13 online, Figure 14 online, Figure 15 online and Figure 15a online.) Suture materials Since the withdrawal of catgut, polyglactin (Vicryl, R Ethicon Ltd., Livingston, UK) or its equivalent has become the most popular material for both the fascial and the vaginal wall repair. To reduce the risk of repair failure, however, polydioxanone (PDS II R [Ethicon]) is increasingly being used as a stronger and more durable alternative, although there is no objective evidence to support this change in practice and there is a theoreticalriskofstitchsinusandexposureofsutures,causing dyspareunia. Removal of skin Opinion is divided on whether redundant vaginal skin should be removed or retained. There is no robust evidence to support one or the other. We generally remove excess vaginal epithelium after the fascial repair has been performed, taking care not to create a wound under tension. Particular care should be taken to ensure that there is no excessive skin visible or palpable at the distal end of the wound because women are likely to be aware of this postoperatively. Suturing techniques There is no consensus on whether interrupted or continuous sutures produce a more robust repair. In general we prefer to use continuous sutures in both planes. Although continuous locking sutures can lead to an ischaemic skin edge, they do prevent excessive bunching and shortening of the anterior vaginal wall. We believe that the problem of shortening of the anterior vaginal wall is a greater hazard. Cystoscopy Cystoscopy following anterior vaginal repair appears to be gaining popularity. 3 It is thought by some that this will pick up any inadvertent bladder or ureteric injuries. While the case for this practice is not proven, and probably never will be, we would advise any surgeon who is concerned that their technique places the bladder or ureters at risk (particularly if this involves separation of the vaginal epithelium from the underlying lamina propria), to perform cystoscopy and C 2012 Royal College of Obstetricians and Gynaecologists 139

4 Anterior vaginal repair Figure 5. Dissection of the bladder from the inner/deep surface of the fascia record the procedure. At cystoscopy the surgeon should identify whether any sutures have perforated the bladder and whether urine is flowing from both internal ureteric orifices. The administration of intravenous indigo carmine can be used to facilitate this by staining the urine: this technique is popular in North America. Packs and catheters Historically, a vaginal pack and Foley catheter have remained in situ for 24 hours after surgery in regular practice. The purported advantage of the vaginal pack is that it creates a tamponade, preventing haematoma formation. The catheter is Figure 6 online, Figure 6a online, Figure 7, Figure 7a, Figure 8, Figure 9 and Figure 10 online. These figures illustrate dissection of the fascia from the vaginal epithelium. In this case the bladder has also been dissected from the deep surface of the fascia, although it is not necessary to perform this routinely 140 C 2012 Royal College of Obstetricians and Gynaecologists

5 Reid and Smith failure or recurrence. Penetrative intercourse is probably best avoided for 6 weeks postoperatively. Figure 11. Deep fascial repair employed to prevent urinary retention. Over the last decade, length of hospital stay has become shorter, to the extent that some surgeons, including ourselves, perform anterior repair as a day case procedure. Vaginal packing is less practical in these circumstances. Furthermore, there is evidence that removal of vaginal packing is an extremely painful and unpleasant experience for some women. 4 Whilesomesurgeonsdonot lubricate the packing, others use lubricating and bactericidal agents. There have been no robust studies to evaluate these practices and many of them are of doubtful value. Recently, tamponade with a plastic balloon for 24 hours followed by vaginal stenting with a silicone implant for 6 weeks has been recommended for one type of mesh repair. 5 It is not yet clear whether this practice confers any benefit. Length of stay in hospital In gynaecological practice today the length of hospital stay after routine anterior vaginal repair appears to vary from a few hours to a few days. In our experience, the majority of women are happier to return home on the day of surgery, providing they are able to pass urine freely and have adequate oral analgesia. Apart from the obvious reduction in hospital costs there are many advantages to the woman, not least in the lowered risk of exposure to hospital-acquired infection. Postoperative advice We advise women to mobilise as much as they are comfortably able to do so in the weeks after anterior vaginal repair. Heavy lifting (enough to bring additional colour to the face) and high impact exercise (e.g. running on a treadmill) should be avoided for 6 weeks postoperatively. Driving is probably best avoided for at least 2 weeks postoperatively. There is no evidence that a sedentary convalescence results in a lower risk of operative Surgery for recurrent anterior vaginal wall prolapse There is much debate about the optimal technique for performing anterior repair and whether fascial repair should be augmented by insertion of absorbable or non-absorbable graft material. The limited evidence available suggests that use of a non-absorbable graft reduces the risk of operative failure or recurrence but is associated with a risk of graft erosion and bladder injury. 6 A multicentre randomised controlled trial funded by the Department of Health is being carried out to evaluate the different techniques of vaginal repair with or without graft augmentation. Although this area is controversial it is probably difficult to justify graft augmentation in primary repair unless there are specific indications, such as congenital tissue hyperelasticity. The National Institute of Health and Clinical Excellence (NICE) recommends that surgeons employing graft materials counsel women fully about the procedure and audit their surgical outcomes. 7 The British Society of Urogynaecology database is a useful resource for surgical audit. There is an NIHR (National Institute for Health Research) Health Technology Assessment programme-funded multicentre trial (PROSPECT) being performed in the UK to determine the optimal techniques for primary and secondary vaginal repair. Gynaecologists are encouraged to recruit to this trial through their local research network. References 1 Kelly HA. Incontinence of urine in women. Urol Cutan Rev 1913;17: White GR. Cystocele: a radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA 1909;21: [doi: /jama b]. 3 Dwyer PL. Urinary tract injury: medical negligence or unavoidable complication? Int Urogynecol J 2010;21: [ /s ]. 4 Pack study. 33rd Annual IUGA meeting, Taipei, Taiwan, September [Abstract.] [ docs/2008abstractbook.pdf]. 5 Carey M, Slack M, Higgs P, Wynn-Williams M, Cornish A. Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device. BJOG 2008;115: [ /j x]. 6 Altman D, Väyrynen T, Engh ME, Axelsen S, Falconer C; Nordic Transvaginal Mesh Group. Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med 2011;364: [ 7 National Institute for Health and Clinical Excellence. Surgical Repair of Vaginal Wall Prolapse Using Mesh. Interventional Procedure Guidance 267. London: NICE; 2008 [ /41024/41024.pdf]. C 2012 Royal College of Obstetricians and Gynaecologists 141