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PELVIC ORGAN PR0LAPSE PowerPoint Presentation

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Description : The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy) through an opening or hiatus.

Tags : aginal wall, posterior vaginal wall, the uterus, cervix

Published on : Sep 19, 2020 | Views : 2127 | Downloads : 11

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PELVIC ORGAN PR0LAPSE ALMIRA J. AMIN-ONG, MD, FPOGS, FPSURPS Clinical Associate Professor University of the Philippines – Philippine General Hospital
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Definition The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy) through an opening or hiatus.
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Anterior vaginal wall Posterior vaginal wall Uterus and upper vagina
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Incidence More than 200 patients per year Age-related surgical incidence: 10-30 per 10,000 year
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Symptoms Vaginal bulge Most are asymptomatic even with documented POP on physical examination
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Symptoms Difficulty in walking, sitting or squatting Vaginal bleeding Recurrent urinary tract infection Dermatitis of the perineum Sensation of “falling out” from the perineum Walker GJA, Gunasekera P. Pelvic organ prolapse and incontinence in developing countries: Review of prevalence and risk factors. IntUrogynecol J 2011
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Risk factors Pregnancy Parity Age Connective tissue disorders Menopausal status Chronic constipation Obesity
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Risk Factors No increased risk of POP in women who underwent TH for non-POP indications However, if the primary surgery is POP-related, there is a 30-50% chance of a second prolapse surgery Risk is lower 6-30% if POP surgery includes suspension of the vaginal apex (level II-3) Eilber KS, Alperim M, Khan A, et al, Obstet Gynecol 2013
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Clinical Considerations and Recommendations Abrams P, Andersson KE, Birder L, Brubaker L, Cardoza L, Chapple C. Fourth International Consultation on Incontinence recommendations of the International Scientific Committee: evaluation and treatment of urinary incontinence, pelvic organ prolapse, and fecal incontinence. Neurourol Urodyn 2010
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Clinical Considerations and Recommendations Haylen BT, de Ridder D, Freeman RM, Swift SE, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. International Urogynecological Association, International Continence Society. Neurourol Urodyn 2010 NICE Recommendations for Pelvic Organ Prolapse 25 April 2019
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Clinical Considerations and Recommendations NICE Recommendations for Pelvic Organ Prolapse 25 April 2019
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Clinical Considerations and Recommendations Is pelvic organ prolapse (POP) life threatening? NO However, It contributes to discomfort and significant distress to the patient It may pose a lot of complications: incarceration vaginal ulcerations vaginal bleeding acute or chronic urinary retention decreased kidney function (hydronephrosis, pelvocaliectasia, etc) ACOG Practice Bulletin No. 185. Pelvic Organ Prolapse. November 2017
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Complications of POP ACOG Practice Bulletin No. 185. Pelvic Organ Prolapse. November 2017
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Clinical Considerations and Recommendations Are additional testings needed in evaluation of POP before treatment? NONE However, If advanced POP and (+) voiding symptoms  check postvoid residual volume If with lower urinary tract symptoms  urinalysis and urine culture If with incontinence  urodynamic studies ACOG Practice Bulletin No. 185. Pelvic Organ Prolapse. November 2017
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Clinical Considerations and Recommendations Is the Pelvic Organ Prolapse Quantification (POP Q) necessary before treatment of POP? YES Objectively evaluates and documents extent of prolapse Preoperative comparator by which to measure postoperative anatomic success The ONLY validated tool for objective measurement of the different compartments of the vagina, recommended by the AUGS, SGS, ICS. Used in most scientific publications on POP More precise and reproducible Pham T, Burgart A, et al. Current use of pelvic organ prolapse quantification by AUGS and ICS members. Female Pelvic Med Reconstr Surg 2011 Treszezamsky AD, Rascoff L, et al. Use of pelvic organ prolapse staging systems in published articles of selected specialized journals. Int Urogynecol J 2010
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Grading Systems for Pelvic Organ Prolapse
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Levels of Pelvic Support
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_ *DeLancey Am J Obstet Gynecol 1991 Levels of Pelvic Support
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Pelvic Organ Prolapse Quantification (POP Q)
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Pelvic Organ Prolapse Quantification (POP Q) HYMEN is the fixed point of reference. Unit measurement is in centimeters. Above the level of the hymen (-) Below the level of the hymen (+)
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Pelvic Organ Prolapse Quantification (POP Q) SIX points in the vagina Points A (Aa, Ap) Points B (Ba, Bp) Apex C, D
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Staging of POP
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Question: What is the stage of prolapse? A. Stage I B. Stage II C. Stage III D. Stage IV
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Question: What is the stage of prolapse? A. Stage I B. Stage II C. Stage III D. Stage IV
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Question: What is the stage of prolapse? A. Stage I B. Stage II C. Stage III D. Stage IV
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Question: What is the stage of prolapse? A. Stage I B. Stage II C. Stage III D. Stage IV
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Clinical Considerations and Recommendations Are effective nonsurgical treatments available? YES Most will have no change or only a small increase in the size of the POP over the next year.
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Clinical Considerations and Recommendations
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Clinical Considerations and Recommendations When is surgery indicated for the management of POP? Bothersome symptoms Failure of conservative treatment Refusal of nonsurgical treatments Factors to consider in deciding the type and route of surgery Location and severity of prolapse Nature of symptoms Patient’s general health Patient preference Surgeon’s expertise Maher C, Feiner B, Baessler K, et al. Cochrane Database of Systematic Reviews 2016
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Clinical Considerations and Recommendations Are vaginal surgical approaches effective? YES However, vaginal hysterectomy alone is NOT an adequate treatment. Vaginal apical suspension procedures should be performed to reduce the risk of recurrence (Level 1) Barber MD, Brubaker L, et al. Comparison of TV surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014. Cruikshank SH, Kovak SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999.
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Types of Pelvic Organ Prolapse Surgery Adapted from Maher C, Feiner B, Baessler K, et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse. Cochrane Database of Systematic Reviews 2016
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Sacrocolpopexy Placement of a synthetic mesh or biologic graft from the apex of the vagina to the anterior longitudinal ligament of the sacrum Candidates for ASC: Shortened vaginal length Intra-abdominal pathology Risk factors for recurrent POP (e.g. <60 years old, BMI >26 kg/m2) Lower risk of recurrent POP, greater anatomic success rate than vaginal apex repair with native tissue (pooled OR, 2.04; 95% CI, 1.12-3.72) Siddiqui NY, Grimes CL, et.al. Mesh sacrocolpopexy compared with native vaginal tissue repair: a systematic review and meta-analysis. Society of Gynecologic Surgeons Systematic Review Group. Obstet Gynecol 2015
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Sacrocolpopexy More complications than vaginal apex repair with native tissue Ileus or small bowel obstruction (2.7% vs 0.2%, P<0.01) Thromboembolic phenomena (0.6% vs 0.1%, P=0.03) Mesh or suture complications (4.2% vs 0.04%, P<0.01) Colpopexy And Urinary REduction Trial (CARE) trial Mesh complications (erosion into the vagina, visceral erosions, sacral osteitis) were 10.5% (95% CI, 6.8-16.1) with significant number of reoperations. Nygaard I, Brubaker L, et al. Long term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA 2013
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Vaginal suspension procedures Uterosacral (USL) and sacrospinous ligament suspension (SSLF) are equally effective, with comparable anatomic, functional and adverse outcomes. OPTIMAL trial involving 285 patients (mean age: 57.2 years), 244 completed the extended trial Surgical failure: a. apical descent >1/3 of the total vaginal length b. anterior or posterior vaginal wall beyond the hymen c. retreatment for prolapse d. bothersome bulge symptoms Surgical success rate in 2 years: 64.5% vs 63.1% (adjusted OR, 1.1 [95% CI, 0.7-1.7]) Failure rate 5 years: 61.5% vs 70.3% (adjusted diff, -8.8% [95%CI, -24.2 to 6.6])
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Vaginal suspension procedures Uterosacral ligament suspension Sacrospinous ligament fixation Attaches the vaginal apex bilaterally to the ipsilateral uterosacral ligament Attaches the vaginal apex to the right sacrospinous ligament
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Types of Pelvic Organ Prolapse Surgery
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Clinical Considerations and Recommendations Should culdoplasty be done as part of prolapse surgery? YES Performed during a hysterectomy to prevent enterocele formation Methods: Purse string or double purse string Halban Moschcowitz McCall Cruikshank SH. Preventing post-hysterectomy vaginal vault prolapse and enterocele during vaginal hysterectomy. Am J Obstet Gynecol 1987, updated December 2009
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Clinical Considerations and Recommendations The McCall type suture has been shown to truly prevent enterocele formation. Purse string Double purse string Vaginal Halban McCall
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Clinical Considerations and Recommendations Barber MD, Brubaker L, et al. Comparison of TV surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014. Cruikshank SH, Kovak SR. Randomized comparison of three surgical methods used at the time of vaginal hysterectomy to prevent posterior enterocele. Am J Obstet Gynecol 1999. Are there effective POP surgical treatment methods available for women who prefer to avoid hysterectomy? YES Reasons for avoiding hysterectomy: Preservation of fertility Maintenance of body image Beliefs about adverse effects on sexual function
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Uterine sparing prolapse procedure Hysteropexy Performed vaginally, abdominally or laparoscopically Laparoscopic sacrohysteropexy had similar efficacy and no significant differences in the rate of complications, blood loss or length of hospitalization compared to vaginal mesh hysteropexy. Advantages over hysterectomy: Shorter operative time, lower incidence of mesh erosion Gutman RE, Rardin CR, Sokol ER, et al. Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. Am J Obstet Gynecol 2017
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Uterine sparing prolapse procedures Le Fort Colpocleisis Indications: Women who want to avoid hysterectomy Women who no longer desire vaginal coital function Effective treatment for POP with a high success rate and high patient satisfaction. (Level II-3) Operation is irreversible. Fitzgerald MO, Richetr HE, et al. Pelvic support, pelvic symptoms, and patient satisfaction after colpocleisis. Pelvic Floor Disorders Network. Int Urogynecol J Pelvic Floor Dysfunct 2008.
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Clinical Considerations and Recommendations Barber MD, Brubaker L, et al. Comparison of TV surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014. What are the complications of POP surgery and how are they managed? Bleeding Infection Transient voiding dysfunction Rectovaginal or vesicovaginal fistula Ureteral injury Foreshortened vagina Restricted vaginal caliber Dyspareunia REFER TO SPECIALIST
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Clinical Considerations and Recommendations Barber MD, Brubaker L, et al. Comparison of TV surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014. How should recurrent POP be managed? Refer to a specialist
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Steps in Vaginal Hysterectomy Circumferential incision along the cervicovaginal plane Dissection to expose the pubocervical or rectovaginal fasciae Anterior or posterior culdotomy
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Steps in Vaginal Hysterectomy Clamping, cutting and suture ligation of the following: Uterosacral and cardinal ligaments Uterine vessels Uterotubals with the round ligaments
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Steps in Vaginal Hysterectomy Inspection of the adnexae Hemostasis Culdoplasty Colporrhaphy Vaginal suspension procedures
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SUMMARY
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CONCLUSION Pelvic organ prolapse is not life threatening but can present with a lot of complications and quality of life issues. Patient expectations should be addressed and discussed. Both conservative and surgical options are available. Prolapse surgery does not stop at vaginal hysterectomy. Suspension procedures are warranted.
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