Reisenauer_subbed.qxp 22/4/09 09:29 Page 72
Urogynaecology
Pelvic Floor Reconstruction and Prolapse
Christl Reisenauer
Associate Professor, and Head, Urogynaecological Division, Department of Obstetrics and Gynaecology, University Hospital Tübingen
Abstract
Women with a symptomatic prolapse can be treated non-surgically or surgically. The surgical procedure varies depending on the type of
prolapse and associated symptoms. The aim of pelvic reconstructive surgery is to correct prolapse, maintain urinary and faecal continence
and preserve coital and reproductive function, if desired. The vaginal vault can be suspended in variety of ways. Abdominal sacral
colpopexy may lead to better results than vaginal sacrospinous colpopexy. Sacrohysteropexy was designed to treat uterine prolapse. After
literature research it can be concluded that native tissue repair remains appropriate in anterior and posterior vaginal wall repair compared
with biologic and absorbable synthetic grafts. It is possible that non-absorbable synthetic mesh may improve anatomical outcome of
anterior vaginal wall repair, but there are significant trade-offs with regard to the risk of adverse events. After a discussion of the risks and
benefits of the possible treatments, the patient should make a decision about therapy together with her urogynaecologist.
Keywords
Pelvic organ prolapse (POP), pelvic floor reconstruction, pelvic floor surgery, cystocele, enterocele, rectocele, vaginal vault prolapse, graft, mesh
Disclosure: Christl Reisnenauer has received speaker’s fees from Johnson & Johnson Company.
Received: 17 January 2009 Accepted: 23 February 2009
Correspondence: Christl Reisenauer, Department of Obstetrics and Gynaecology, University Hospital Tübingen, Calwerstrasse 7, 72076 Tübingen, Germany.
E: christl.reisenauer@med.uni-tuebingen.de
Pelvic organ prolapse occurs when pelvic organs descend into or symptoms such as leakage of urine or problems with intercourse. The
through the vagina. It is a common problem, affecting 50% of parous surgical procedure varies depending on the type of prolapse and the
women.
1
The degree of observed prolapse does not correlate well with associated symptoms. The operative management of pelvic organ
patient symptomatology. The symptoms of prolapse can vary from being prolapse can be accomplished transabdominally, transvaginally,
asymptomatic to complaints of vaginal discomfort, coital difficulties and laparoscopically or by using a combination of these methods. The aim
urinary and bowel symptoms associated with significant impairment of of pelvic reconstructive surgery is to correct prolapse, maintain
the quality of life of patients. Pelvic organ prolapse rarely causes severe urinary and faecal continence and preserve coital and reproductive
morbidity or mortality. However, a hydroureternephrosis has been function, if desired. Between the 1960s and the 1980s, operations for
reported to occur in 30–40% of stage IV prolapses.
2
Due to an extended prolapse were primarily colporrhaphies performed vaginally. Greater
life expectancy, the incidence of primary and recurrent pelvic organ awareness of multiple defects and increased attention to prolapse
prolapse has increased. A North American study showed that 11% of recurrence in unrepaired compartments of the pelvic floor have led to
women run a lifetime risk of surgery for prolapse or stress urinary more comprehensive operations. Over 90% of patients have defects
incontinence. One in three patients required more than one surgical involving more than one compartment.
5
repair.
3
The 29% risk of requiring a repeat procedure may be due to the
age-dependent progressive deterioration in support tissues, but also Anterior Vaginal Wall Prolapse
reflects inadequacies in the surgical repair technique.
4
Anterior vaginal prolapse results from either a central fascial
defect or detachment of the endopelvic fascia from the pelvic
Asymptomatic women do not require treatment. Women with a sidewall, which leads to a pulsion/distension cystocele or a
symptomatic prolapse can be treated non-surgically (pessaries and/or traction/displacement cystocele. The paravaginal repair has been
behavioural therapy) or surgically. After a discussion of the risks and described via open, laparoscopic and vaginal approaches. The route
benefits of the possible treatments, the patient should make a decision of repair is dictated by other concomitant procedures, patient factors
about therapy together with her urogynaecologist. Despite the fact that (body habitus, previous surgeries and overall health) and the
surgical procedures are planned following an assessment of the surgeon’s experience. After extensive literature research it can be
patient’s bowel, bladder and sexual functions and pelvic support concluded that native tissue repair remains appropriate in anterior
defects, a good anatomical restoration does not necessarily correlate central vaginal wall repair compared with biologic and absorbable
with a restoration of normal function. The impact of pelvic organ synthetic grafts. It is possible that non-absorbable synthetic mesh
prolapse surgery on bowel, bladder and sexual function can sometimes may improve anatomical outcome of anterior vaginal wall repair, but
be unpredictable and may make symptoms worse or result in new there are significant trade-offs with regard to the risk of adverse
72 © TOUCH BRIEFINGS 2009
Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84