Click here to view next page of this article

New Treatments for Pelvic Organ Prolapse

With a cystocele, on physical exam you see the bulge in the anterior wall of the vagina. In the sagittal plane, you can see this bulge, which is what we are trying to fix back up in place. If the bladder is sitting on a hammock, which is the endopelvic connective tissue that sits between the vagina and the bladder, this hammock can be damaged either with a sagging, where the bladder can come right down - this would be a midline defect - and if this patient has a midline defect, you would want to fix that person with an anterior colporrhaphy. If you have paravaginal defects, the strings of the hammock actually break and the bladder falls down, because the hammock has broken.

Unfortunately, the anterior colporrhaphy has about an eighty percent success rate; it fails about twenty percent of the time, even up to thirty percent in some series. We have worked with different materials to see if we can increase the success rate of the anterior colporrhaphy. We did a prospective randomized trial of Vicryl mesh in our institution where we just folded over a piece of mesh and imbricated it in just underneath the endopelvic connective tissue closure.

Paravaginal defects.

In paravaginal defects, you have a break in the endopelvic connective tissue on the sides. This is what you would find on examination. You can try to replace the paravaginal supports when doing an examination by having the patient strain. If things are actually held up when you are holding this up while doing a pelvic exam, you have a paravaginal defect.

Rectocele

This is weakness (bulge) in the posterior vaginal wall and rectovaginal septum or endopelvic connective tissue, causing a relaxation and allowing the rectum to bulge through. There is direct contact of the rectal serosa with the posterior vaginal wall. Looking at this on exam in the operating room, you have opened up the vaginal epithelium posteriorly. We start off with a diamond-shaped incision right at the perineum and make an incision up on the midline, dissecting off laterally. You see the right underneath. Again, we can do a midline plication of the connective tissue on either side and more distally, we can plicate the levator muscles.

Enterocele.

As you can see, the enterocele is a problem of the peritoneum that comes down in between the rectum and vagina and herniates through. Bowel can frequently come down into this area also. Most of the enteroceles that you see are posterior and therefore you see them while you are doing the posterior colporrhaphy. As you go up higher into the apex of the incision and are dissecting the endopelvic connective tissue off there, often you will come across this tissue that just looks like peritoneum; there is no fascia there and no thick tissue.

Uterine prolapse.

You see the cervix down at the level of the introitus and when you are done with the hysterectomy, what can be used well to close off the enterocele is the McCall culdoplasty. You take sutures from one uterosacral all the way to the other. We usually do a cystoscopy after we finish with the culdoplasty to make sure the ureters are okay. We actually do take the anterior peritoneum in the modified McCall culdoplasty and close this area off before we close the cuff.

For uterine prolapse, you want to support the cuff back in place and before you are done, you need to reattach the cuff to the uterosacral-cardinal ligament complex so that the vault does not prolapse afterwards. Your culdoplasty is going to get your enterocele and then you reattach that cuff to the connective tissue supporting system that is there so that you do not have prolapse again. Hysterectomy is a common cause for recurrent vaginal prolapse. The external McCall culdoplasty is described to try to attach the cuff to the uterosacral ligaments proximally.

Sacral colpopexy.

The sacral colpopexy is done abdominally; it is a suspension of the vaginal vault where you are attaching the cuff back to the sacrum via a transit, because the vagina will not stretch that far. You are using a bridge; this is usually a synthetic bridge, although cadaveric fascia has also been used. Again, when using synthetic materials, there are problems with some erosion of mesh and materials through this area. This is one of the disadvantages of the sacral colpopexy. The nice thing about the colpopexy is that we are not using the patient's native structures; we are not using her uterosacral ligaments, which we know have failed in the past and we bypass that system altogether.

Sacral colpopexy and sacrospinous suspension are the two most commonly used procedures for replacing the vaginal vault. They work well and have a good success rate. The problem with the sacral colpopexy is that there can be problems with mesh erosion and it is abdominal surgery. Again, vaginal surgery can certainly be done a lot more commonly for patients with multiple medical problems. Recovery is lower with abdominal surgery and hospital stay is longer.