Recent advances in POP Dr. Bernhard Uhl Department for Obstetrics and Gynecology St. Vinzenz-Hospital Dinslaken Germany
Level of pelvic floor support Level I apical Level II transverse/ horizontal Level III Perineum
Central DamageD Pulsion Cystocele Lateral Sulci conserved Cross folds (Rugae) flat
Paravaginal defect Cross folds (Rugae) conserved Lateral Sulci flattened
Operation methods Anterior or posterior colporrhaphy Sacrospinal Fixation Hystero-/Colpo-Sacrofixation (open or laparoscopic) Vagina Cervix Lateral Colpofixation Pectinopexie Bilateral sacrospinal Cervicofixation (BSC) Meshrepair
Coloprhaphia anterior Indication: Pulsion cystozele Tightening of the anterior vaginal wall Readaptation of the pelvic fascia Success rate of primary surgery 64% in combination with apical fixation 56% without apical fixation
Colporrhaphy posterior Tightening of the posterior vaginal wall Readaptation of the posterior pelvic fascia Combining the connective tissue of both sides next to the rectum Combining the levator muscle increases the risk of dyspareunia don t do this!! Success rate 86%
Notice: Often there is no isolated recto- or cystocel Combination with level I (apical) defect No treatment of level I defect Recurrence rate after colporhaphia increases
Sacrospinal Fixation Indications: Apical descent Subtotalprolapse Totalprolapse Success rate: 79 97% Os sacrum Lig. sacrotuberale Using non-resorbable suture Risk of dyspareunia increases
Sacrospinal Fixation
Hystero- /Vagina- Sacrofixation = Lifting and reattachment of the prolapsed vagina or uterus Vaginopexy/Hysteropexy on the sacrum with and (without) mesh interposition (by abdominal or laparoscopic surgery) Success rate 90 100% Vaginal mesh erosion in 3.5-8%
Paravaginal defect Enddarm= Rectum Gebärmutterhals = Cervix Blase= bladder
Lateral repair
Lateral repair Defect Level II Paravaginal Colpopexy Abdominal Vaginal Success rate: 78 100% Success rate: 76 100%
Notice: Look for symptoms of paravaginal defect Only colporhaphia anterior Paravaginal defect is enlarged Recurrence rate of cystocele is increased
Bilateral sacrospinal Cervicopexie Treatment of level I (apical) Defect Vaginal approach Combination with colporhaphia possible
Pectopexie Laparoscopic treatment of apical prolapse (no standard)
Transvaginal Meshrepair In case of recurrence In case of severe prolaps and old patient Risk of (FDA Alert) Arrosion Pelvic pain Dyspareunia Second surgery necessary Only for experienced surgeons Not in case of not completed family planning Before and after surgery local treatment with estriol (for lifetime)
Attachmentpoints for meshrepair Posterior point posterior transobt. point Foramen Obturatum anterior transobt. point
Anterior Mesh Possible Attachementpoints
Posterior Mesh Possible Attachmentpoints Alternatives
Some examples for external fixated meshes
Transobturatic external fixated Mesh Bladderneck Tuber ischiadicum Vagina
Internal Fixation Single inscision technic by vaginal approach By suture By anchor
Notice: Transobturatory Fixation Shortened functionaly the vagina Risk of dyspareunia More risk of recurrence than in apical fixation Better results with apical fixation
Mesh-complications Complication Arrosion Pain De novo Dyspareunia Recurrence Re-OP-rate De novo-sui Prevalence (%) 1 19 3 18 2 44 7 33 1 22 12 17 Datas of FDA and American College of Obstreticans and Gynecologists (ACOG)
Problems of the literature basing the FDA Alert Many studies refer to anatomical results and less on functionality and quality of life Primary and recurrent surgeries are not separated Mix with various additional procedures complicate comparability Different definitions and reports on adverse events Very few studies have follow up> 2 years underrepresented second-generation meshes with apical fixation (less risk of dyspareunia) Results highly dependent on surgeon Treatment with local estriol is not reported
Last but not least: Pessary-treatment Should be offered as a first step Alternative, of surgery is not possible
Thank you for your attention www.st-vinzenz-hospital.de Email: bernhard.uhl@st-vinzenz-hospital.de