International Federation of Gynecology and Obstetrics

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International Federation of Gynecology and Obstetrics

COMMITTEE FOR UROGYNAECOLOGY AND PELVIC FLOOR MEMBER: TSUNG-HSIEN (CHARLES) SU, CHAIR (TAIWAN) DAVID RICHMOND, CO-CHAIR (UK) CHITTARANJAN PURANDARE, EX OFFICIO (INDIA) OSCAR CONTERAS ORTIS (ARGENTINA) BOBFREEMAN (IUGA, UK) PETER DE JONG (SOUTH AFRICA) PAUL RISS (AUSTRIA) STEVEN SWIFT (USA)

NATIVE TISSUE REPAIR FOR PELVIC ORGAN PROLAPSE

Pelvic organ prolapse (POP) Herniation of the pelvic organs Uterus, vaginal cuff, bladder, small or large bowel Associated vaginal segments

Prevalence for POP Prevalence of pelvic floor dysfunction: 30-50% of population. 50% of parous women lose pelvic floor support. The lifetime risk of surgery for POP or UI: 11% Reoperation risks after previous surgery: 13-56%

Classification (NIH) NIH Terminology Workshop for Researchers in Female Pelvic Floor Disorders, 2001 POP was described: Anterior vaginal prolapse Apical or uterine prolapse Posterior vaginal prolapse

Types of prolapse Anterior cystocele, urethrocystocele Apical uterine prolapse, vaginal vault prolapse Posterior enterocele, rectocele From IUGA website: http://www.iugastore.com/en/pfd-anatomical-andsurgical-chart/98-pfd-anatomical-and-surgical-chart.html

Pelvic floor support by DeLancey Level I: cervix /upper third vagina, suspension by paracolpium, cardinal-uterosacral ligament DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166:1717.

Pelvic floor support by DeLancey Level II: middle third vagina, supported by attachment of fascial sheet to pelvic sidewall DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166:1717.

Pelvic floor support by DeLancey Level III: lower third vagina, fusion to urogenital diaphragm and perineal body, ant and post. DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992;166:1717.

Management of POP Observation Conservative tx: PFMT, Pessary Surgery

Surgery for POP Obliterative Reconstructive

Obliterative procedures for POP Less invasive Better tolerated by frail, older women Not candidates for more extensive surgery Shorter operative duration Decreased perioperative morbidity Low risk of recurrence

Obliterative procedures for POP Partial colpocleisis (LeFort colpocleisis) Total colpocleisis Highly effective for treating POP Success rate: 90~100%

Partial colpocleisis (LeFort colpocleisis) Uterus is left in situ Removal of strips of ant and post vaginal epithelium Leaving a small strip of lateral epithelium on each side ~outlet for cx or u t bleeding or drainage

Adapted from Uptodate : https://www.uptodate.com/contents/image?imagekey=obgyn%2f51734&topickey=obgyn%2f15268&source=outline_ link&search=partial%20colpocleisis%20&selectedtitle=1~150

Goals of pelvic reconstructive surgery Repair all the defects Restoration of normal anatomy Maintain normal vaginal function Improve symptoms related to POP Improve QoL Prevent of recurrence

Route of pelvic reconstructive surgery Transvaginal Transabdominal Laparoscopy => Choice based on type and severity of POP, surgeon s training /experience, patient s preference

Anterior compartment Anterior colporrhaphy Paravaginal repair Concomitant anti-incontinence surgery: Burch, sling

Anterior colporrhaphy Ant vaginal wall defects : thinning/stretching of weakened vaginal tissue. Excision and/or plication of redundant ant vag wall mucosa to reduce of ant vag defect. Central plication of fibromuscular layer of ant vag wall

Adapted from Upto date: https://www.uptodate.com/contents/image?imagekey=obgyn%2f69730&topickey=obgyn%2f8084&source= outline_link&search=transvaginal%20anterior%20repair&selectedtitle=1~150

Anterior colporrhaphy Success rates: 80~100% at 1 year f/u 37~57% at long-term f/u (Sand 2001, Weber 2001) High recurrence rate

Lateral defect Paravaginal repair Adapted from website: http://www.oxfordgynaecology.com/tabpages/surgery/vaginalprolapse/paravaginal- Repair.htm

Apical compartment Sacral colpopexy Sacrospinous ligament suspension Uterosacral ligament suspension Ilioccygeus suspension

Sacral colpopexy Abdominal and laparoscopic Suturing ant and post vaginal wall via mesh to the ant sacral ligament Complex Least impact on sexual dysfunction

Adapted from Upto date: https://www.uptodate.com/contents/image?imagekey=obgyn%2f69730&topickey=obgyn%2f8084&source= outline_link&search=transvaginal%20anterior%20repair&selectedtitle=1~150

Sacrospinous ligament suspension Most commonly used transvaginal procedure for apical prolpase repair Unilateral or bilateral Right-side preferred

From IUGA website: http://www.iugastore.com/en/pfd-anatomical-and-surgical-chart/98-pfd-anatomical-andsurgical-chart.html

Sacrospinous ligament suspension Objective cure rate: 67~97% Neurovascular complications (inf gluteal or pudendal vessels, branches of sciatic nerve ) Buttock pain as high as 30%

Uterosacral ligament suspension Adapted from Upto date: https://www.uptodate.com/contents/image?imagekey=obgyn%2f69730&topickey=obgyn%2f8084&source=outline _link&search=transvaginal%20anterior%20repair&selectedtitle=1~150

Posterior colporrhaphy Plication the post vaginal muscularis, rectovaginal septum or medical aspect of levator ani muscle in the midline Anatomic cure rate: 76~96%

Adapted from Upto date: https://www.uptodate.com/contents/image?imagekey=obgyn%2f69730&topickey=obgyn%2 F8084&source=outline_link&search=transvaginal%20anterior%20repair&selectedTitle=1~150

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