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Pelvic Floor Reconstruction and Prolapse
events.
6
Overall, the rate of mesh erosion ranges from 0 to 24.5%.
7,8
colposacropexy in the absence of cervical dysplasia. The current
However, if the anterior prolapse is severe, stress incontinence may literature suggests that uterine preservation during surgery for
be masked by urethral kinking (occult stress incontinence). The uterovaginal prolapse may be an option for appropriately selected
addition of a continence procedure to a prolapse repair operation women. Prospective randomised trials are needed to corroborate
may reduce the incidence of post-operative urinary incontinence, but this.
22
Significant uterine prolapse in women in their reproductive
this benefit must be balanced against possible adverse effects.
9
years may occur in parous women, but also in young nulliparous
women. The latter may wish to remain fertile. Sacrohysteropexy was
Uterine and Vaginal Vault Prolapse designed to treat uterine prolapse. The indication for surgical
The vaginal vault can be suspended in a variety of ways. Vaginal correction of uterine prolapse, simultaneously preserving the uterus,
approaches offer the advantage of minimising post-operative pain is the failure of conservative treatment in a young woman who has
and reducing the morbidity associated with open abdominal not completed her family or if the woman refuses hysterectomy and
procedures. The advantage of an abdominal procedure is that further wishes to retain her uterus. However, there are limited data available
scarring, shortening and narrowing of the vagina are avoided. on functional outcome, and experience with subsequent pregnancy
Laparoscopic pelvic reconstructive surgery has the additional and delivery is scarce. Kovac and Cruikshank
23
described successful
potential to reduce patient morbidity and provide better visualisation pregnancies and vaginal deliveries in five of 19 patients treated by a
and access to the pelvic support structures. Limiting factors for the sacrospinous uterosacral fixation technique.
abdominal route are multiple previous abdominal surgeries, prior
inflammatory bowel or pelvic disease, obesity and mesh repair of an Hysterectomy is considered to be a risk factor for subsequent pelvic
abdominal hernia. A prospective, randomised study was conducted organ prolapse.
24,25
However, this concept is controversial. Data from
by Benson et al. to determine whether one of the two approaches Blandon et al.
26
showed that the indication for the hysterectomy (a
was superior.
10
Surprisingly, the study demonstrated that the non-prolapse indication versus a prolapse indication) correlates with
abdominal approach was more effective in treating uterovaginal the risk of a future operation for prolapse recurrence. Patients who
prolapse than the vaginal approach, with the probability of optimal have a hysterectomy because of symptomatic prolapse are more
surgical outcome being twice as high as with the vaginal approach. likely to require a subsequent surgical procedure for prolapse than
One possible contributing factor to increased failure rate in pelvic patients who have a hysterectomy without prolapse.
26
Furthermore,
floor surgery involving the vaginal approach is the development of longitudinal data in a 30-year follow-up showed that when a
neuropathy. As measured by terminal motor latency studies, such prophylactic culdoplasty is combined with hysterectomy, the risk of
neuropathy occurs with vaginal dissection.
11–14
A relationship between future reconstructive surgery is lower.
26
Obliterative surgery with or
the outcome of pelvic organ prolapse surgery and surgically induced without concurrent hysterectomy is also an effective therapy for
perineal neuropathy has been demonstrated by Welgoss et al.
15
uterovaginal prolapse. Careful consideration of the loss of vaginal
function is necessary, as perception of body for many women is just
The review of randomised controlled trials made by Maher et al.
9
as important as coital function. Vaginal obliteration may be achieved
shows that abdominal sacral colpopexy may lead to better results for by colpocleisis (removing the vaginal epithelium and applying
uterine or vault prolapse than vaginal sacrospinous colpopexy. The successive purse-string sutures) or colpectomy (removing the full-
abdominal sacral colpopexy was associated with a lower rate of thickness vagina). With either procedure, levator plication with
recurrent vault prolapse,
10,16
a reduced grade of residual prolapse,
17
a approximation of the muscles to close the genital hiatus to the
longer interval until recurrence of prolapse occurred
10
and less urethra is performed. Frail elderly women with debilitating prolapse
dyspareunia compared with the vaginal sacrospinous colpopexy.
10,16,17
problems make up the majority of patients receiving obliterative
However, the abdominal sacral colpopexy was associated with a therapy. The reported success rates after colpocleisis have been
longer operating time
10,16,17
and a longer time to recovery,
16
and between 91 and 100%.
27
was more expensive.
10,16
The data were not sufficient to evaluate
other clinical outcomes and adverse events. Culligan
18
reported Posterior Vaginal Wall Prolapse
that no recurrent vault prolapses occurred, either when abdominal Posterior vaginal wall defects include rectocele and enterocele and
sacral colpopexy with monofilament polypropylene mesh (Trelex) are frequently associated with perineal descent. For posterior vaginal
or sacral colpopexy with cadaveric fascia lata graft (Tutoplast™) was wall prolapse, the vaginal approach was associated with a lower rate
used. When mesh was used there was less recurrence of prolapse for of recurrent rectocele and/or enterocele than the transanal
any vaginal site at one-year follow-up. The number of patients in the approach, although there was higher blood loss and post-operative
trial of Meschia et al. was too small to demonstrate a difference in narcotic use.
28,29
At five-year follow up, 76% of patients were relieved
anatomical outcome between the vaginal sacrospinous colpopexy of their vaginal prolapse after posterior colporrhaphy.
30
In 1993
and posterior intravaginal slingplasty.
19
Although the posterior Cullen Richardson described the directed fascial defect repair.
31
The
intravaginal sling was quicker to perform and showed significantly operation differs from the posterior colporrhaphy in the fascial
reduced blood loss, it was associated with a 9% rate of mesh plication steps. A repair of distinct defects, identified as breaks in
complications (erosions).
19
the smooth, shiny layer of rectovaginal fascia, should be performed
rather than a midline plication. The most common defect is a low
Long-term follow-up for a maximum of 13.7 years after sacrocolpopexy transverse disruption between the fascia and the perineal body.
maintained a 74% success rate.
20
Concurrent hysterectomy may be a Attractive at first glance, this technique has been only minimally
risk factor for mesh erosion, particularly if a total hysterectomy is evaluated. It is not known whether repairing these discrete defects
performed, when erosion rates increased up to 27% compared with maintains adequate strength over time or if an additional plication of
1.3% in those who had not undergone a hysterectomy.
21
Therefore, some fascia or levator muscles improves the longevity of the repair. At six-
surgeons advocate supracervical hysterectomy at the time of month to two-year follow-up, 77–82% of patients were relieved of
EUROPEAN OBSTETRICS & GYNAECOLOGY 73
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