General Principles of General Principles of Prolapse Repair Prolapse Repair Bob L. Shull, M.D. Bob L. Shull, M.D. Professor of Gynecology Professor of Gynecology Department of Obstetrics and Gynecology Department of Obstetrics and Gynecology Scott and White Memorial Hospital and Scott and White Memorial Hospital and Clinic Clinic Texas A&M Health Science Center Texas A&M Health Science Center Temple, Texas Temple, Texas USA USA
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General Principles of Prolapse Repair Bob L. Shull, M.D. Professor of Gynecology Department of Obstetrics and Gynecology Scott and White Memorial Hospital.
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General Principles of General Principles of Prolapse RepairProlapse Repair
Bob L. Shull, M.D.Bob L. Shull, M.D.Professor of GynecologyProfessor of Gynecology
Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyScott and White Memorial Hospital and ClinicScott and White Memorial Hospital and Clinic
Texas A&M Health Science CenterTexas A&M Health Science CenterTemple, TexasTemple, Texas
USAUSA
At the completion of the lecture the At the completion of the lecture the participant will know: participant will know:
1.1. The similarity of pelvic support defects to The similarity of pelvic support defects to a herniaa hernia
2.2. The requirements for evaluation of The requirements for evaluation of anatomic defects and functional anatomic defects and functional complaints in planning a surgical strategycomplaints in planning a surgical strategy
3.3. Each compartment of the pelvis may Each compartment of the pelvis may exhibit specific support defectsexhibit specific support defects
e.e. Sacrospinous ligament Sacrospinous ligament suspension and anterior-suspension and anterior-posterior repairposterior repair
f.f. Only (a)Only (a)
g.g. All of the aboveAll of the above
Underlying ConceptsUnderlying Concepts
The prevalence and the natural The prevalence and the natural
history of pelvic defects have not history of pelvic defects have not
been well documented.been well documented.
The Natural History of Pelvic The Natural History of Pelvic Organ ProlapseOrgan Prolapse
Objective: Pelvic organ prolapse (POP) affects 30-93% of Objective: Pelvic organ prolapse (POP) affects 30-93% of adult women. However, the natural history of this adult women. However, the natural history of this common condition remains unknown. We undertook common condition remains unknown. We undertook this study to describe POP in a longitudinal study of this study to describe POP in a longitudinal study of postmenopausal women.postmenopausal women.
Conclusions: Our data suggest that POP is not chronic and Conclusions: Our data suggest that POP is not chronic and progressive, as traditionally thought. Spontaneous progressive, as traditionally thought. Spontaneous regression of POP was surprisingly common in this regression of POP was surprisingly common in this study, especially for grade 1 prolapse. While our study, especially for grade 1 prolapse. While our findings may not be generalizable to the nationwide findings may not be generalizable to the nationwide WHI cohort or to all postmenopausal women, these WHI cohort or to all postmenopausal women, these findings raise important questions about the clinical findings raise important questions about the clinical significance of grade 1 POP. Further studies are needed significance of grade 1 POP. Further studies are needed to clarify the prognosis for mild prolapse and to explain to clarify the prognosis for mild prolapse and to explain the biologic mechanisms of progression and regression.the biologic mechanisms of progression and regression.
Handa VL, Garrett E, Hendrix S, Gold E, Robbins JA. AUGS Abstracts from the 24th Annual Scientific Meeting, Sept. 2003.
Pelvic support defects are similar to Pelvic support defects are similar to
a hernia, i.e., the connective tissue a hernia, i.e., the connective tissue
responsible for maintaining support responsible for maintaining support
has a visibly identifiable defect.has a visibly identifiable defect.
Pelvic support defects may or Pelvic support defects may or
may not be associated with may not be associated with
abnormal function of the urethra, abnormal function of the urethra,
bladder, rectum, or vagina.bladder, rectum, or vagina.
Correction of pelvic support Correction of pelvic support
defects may or may not result defects may or may not result
in improvement, deterioration, in improvement, deterioration,
or maintenance of function of the or maintenance of function of the
urethra, bladder, rectum, or vagina.urethra, bladder, rectum, or vagina.
Surgical Techniques for Surgical Techniques for Pelvic Support Defects Pelvic Support Defects Must be Individualized Must be Individualized Depending on the Depending on the Patient’s”Patient’s” ExpectationsExpectations
Support defectsSupport defects
Functional status of urethra, Functional status of urethra, bladder, bowel, and vaginabladder, bowel, and vagina
Surgical techniques for pelvic Surgical techniques for pelvic
support defects must be support defects must be
individualized depending on the individualized depending on the
surgeon’s skillssurgeon’s skills
The Assessment of The Assessment of Surgical Intervention Surgical Intervention Includes:Includes:
Cure of the support defectsCure of the support defects
Maintenance or improvement of Maintenance or improvement of visceral or sexual functionvisceral or sexual function
Acquisition of new support Acquisition of new support defects or visceral or sexual defects or visceral or sexual complaintscomplaints
Cured Improved No change
Worse
Cured Improved No change
Worse
de novo detrusor instability
Voiding dysfunction Chronic infection
de novo detrusor instability
Voiding dysfunction Chronic infection
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Relief of SymptomsRelief of
Symptoms
Acquisition of new
Symptoms
Acquisition of new
SymptomsCorrection of Defect
Correction of Defect
Acquisition of Defect
Acquisition of Defect
Maintenance Enhancement Deterioration
Loss
Maintenance Enhancement Deterioration
Loss
Visceral FunctionVisceral Function
Sexual FunctionSexual
Function AnatomicAnatomic
Adverse Effects of Adverse Effects of Burch ColposuspensionBurch Colposuspension
284 Women with G. S. I.284 Women with G. S. I.
Mean follow-up 3-4 yearsMean follow-up 3-4 years
54% cured without complication54% cured without complication
32% cured but with one or more 32% cured but with one or more complications... usually genital complications... usually genital prolapseprolapse
8%8% failed without complicationsfailed without complications
6%6% failed with one or more complicationsfailed with one or more complications
Colombo, Maggioni, Caruso, et alColombo, Maggioni, Caruso, et alProceedings I.C.S., 1993, RomeProceedings I.C.S., 1993, Rome
Maintenance Enhancement Deterioration
Loss
Maintenance Enhancement Deterioration
Loss
Cured Improved No change
Worse
Cured Improved No change
Worse
de novo detrusor instability
Voiding dysfunction Chronic infection
de novo detrusor instability
Voiding dysfunction Chronic infection
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Urethra Bladder
Cervix / Cuff Cul-de-sac
Rectum Perineum
Visceral FunctionVisceral Function
Sexual FunctionSexual
Function AnatomicAnatomic
Relief of SymptomsRelief of
Symptoms
Acquisition of new
Symptoms
Acquisition of new
Symptoms
Correction of Defect
Correction of Defect
Acquisition of Defect
Acquisition of Defect
Generally, there are 6 Generally, there are 6 reasons for failure! reasons for failure!
Generally, there are 6 Generally, there are 6 reasons for failure! reasons for failure!
– Misdiagnosed – for example, Misdiagnosed – for example, transverse cystoceletransverse cystocele
Clinical Examination and Dynamic Clinical Examination and Dynamic Magnetic Resonance Imaging in Vaginal Magnetic Resonance Imaging in Vaginal Vault ProlapseVault ProlapseObjective: To estimate the role of dynamic magnetic resonance Objective: To estimate the role of dynamic magnetic resonance
imaging (MRI) as a diagnostic tool in the evaluation of vaginal imaging (MRI) as a diagnostic tool in the evaluation of vaginal
apex prolapse in women with previous hysterecomy.apex prolapse in women with previous hysterecomy.
Methods: Clinical examinations were performed on 51 women Methods: Clinical examinations were performed on 51 women
presenting with symptoms of prolapse. A preoperative presenting with symptoms of prolapse. A preoperative
dynamic MRI assessment was performed.dynamic MRI assessment was performed.
Conclusion: There is a poor correlation between clinical and MRI Conclusion: There is a poor correlation between clinical and MRI
findings when assessing vaginal apex prolapse. Magnetic findings when assessing vaginal apex prolapse. Magnetic
resonance imaging allows the identification of other resonance imaging allows the identification of other
prolapsing compartments and may be a complementary prolapsing compartments and may be a complementary
diagnostic tool for the diagnosis of complex vaginal apex diagnostic tool for the diagnosis of complex vaginal apex
prolapse.prolapse.Cortes E, Reid WMN, Singh K, Berger L. Obstet Gynecol 2004;103:41-46
Generally, there are 6 Generally, there are 6 reasons for failure! reasons for failure!
Prevalence of Severe Pelvic Organ Prevalence of Severe Pelvic Organ Prolapse in Relation to Job Description Prolapse in Relation to Job Description and Socioeconomic Status: A Multi-and Socioeconomic Status: A Multi-Center Cross-Sectional StudyCenter Cross-Sectional Study
Objective:Objective: To determine if certain job descriptions or socioeconomic To determine if certain job descriptions or socioeconomic
statuses are associated with pelvic organ prolapse. statuses are associated with pelvic organ prolapse.
Results: The overall prevalence of severe pelvic organ prolapse in our Results: The overall prevalence of severe pelvic organ prolapse in our
group was 4.1% (37/912). Women reported their job description in group was 4.1% (37/912). Women reported their job description in
the following categories and proportions: laborers/ factory workers the following categories and proportions: laborers/ factory workers
service (10.2%), technical/sales/clerical (16.2%) and other (16.2%).service (10.2%), technical/sales/clerical (16.2%) and other (16.2%).
Conclusions: Laborers/factory worker jobs are associated with more Conclusions: Laborers/factory worker jobs are associated with more
severe pelvic organ prolapse using the POP-Q exam. Severe severe pelvic organ prolapse using the POP-Q exam. Severe
prolapse is also associated with an annual household income of prolapse is also associated with an annual household income of
$10,000 or less.$10,000 or less.
Woodman P, McCullough D, O’Boyle A, Valley M, Bland D, Kahn M, et al. AUGS Abstracts from the 24th Annual Scientific Meeting, Sept. 2003.
6.6. OtherOther– GeneticsGenetics– UnknownUnknown– Protein Protein
synthesis?synthesis?
Generally, there are 6 Generally, there are 6 reasons for failure! reasons for failure!
Differences in Pelvimetry Differences in Pelvimetry between Women with and between Women with and without Pelvic Floor without Pelvic Floor DisordersDisordersObjective: To investigate the hypothesis that the dimensions of the Objective: To investigate the hypothesis that the dimensions of the
bony pelvic differ between women with and without pelvic floor bony pelvic differ between women with and without pelvic floor disorders.disorders.
Results: Subjects included 59 women with pelvic floor disorders and Results: Subjects included 59 women with pelvic floor disorders and 39 women without pelvic floor disorders. Women with a 39 women without pelvic floor disorders. Women with a transverse inlet greater than 139 mm were more than 7 times transverse inlet greater than 139 mm were more than 7 times more likely to have a pelvic floor disorder (odds ratio 7.2, more likely to have a pelvic floor disorder (odds ratio 7.2, P<0.01), controlling for the effects of age, parity, and other pelvic P<0.01), controlling for the effects of age, parity, and other pelvic dimensions.dimensions.
Conclusions: A wide transverse inlet and narrow obstetrical Conclusions: A wide transverse inlet and narrow obstetrical conjugate are associated with pelvic floor disorders. We conjugate are associated with pelvic floor disorders. We speculate that these features of bony pelvic architecture may speculate that these features of bony pelvic architecture may predispose to neuromuscular and connective tissue injuries, predispose to neuromuscular and connective tissue injuries, leading to the development of pelvic floor disorders.leading to the development of pelvic floor disorders.
Handa VL, Pannu H, Siddique S, Gutman R, Cundiff GW. AUGS Abstracts from the 24th Annual Scientific Meeting, Sept. 2003.