This
article will discuss the different surgical procedures which are used when
treating apical prolapse, a descent of the uterus, cervix or vaginal vault
which currently affects millions of women across the globe. A recent article
published in Current Urology Reports titled Surgery
for Pelvic Organ Prolapse: A
Historical Perspective by Barbalat and Tunuguntla (2012 13: 256-261)
described the three current transvaginal techniques to repair apical prolapse:
“Transvaginal techniques to correct
apical prolapse include sacrospinous vault suspension, iliococcygeus suspension
and uterosacral vault suspension.” The article also noted that a technique
known as the McCall culdoplasty reattaches the uterosacral ligaments to the
back wall of the vagina following a hysterectomy. The original McCall repair
used three uninterrupted permanent sutures across the midline which prevents or
corrects enteroceles.
According
to the September, 2012 issue of Women’s Health, “Pelvic organ prolapse is a common medical condition that affects the
quality of life of many women. Approximately 50% of parous women have pelvic
organ prolapse and the lifetime risk for surgical intervention is 6.7% at the
age of 80 years.” The article goes on to say that in the United States the
number of women at risk is increasing due to the overall aging of the
population. The Obstetrics and
Gynecology Board Review Manual believes that by the age of 80-85 nearly 20% of
all women will have undergone a surgical procedure in an attempt to correct
prolapse or incontinence.
Pelvic Organ Prolapse Facts and Consequences
Pelvic
organ prolapse is hardly a cause of mortality however it can have a serious
impact on quality of life. For women who are still sexually active, pelvic
organ prolapse can significantly impact their future. There are different types
of herniations: herniations of the bladder are known as cystoceles, while
herniations of the rectum are called rectoceles. An article titled Pelvic organ prolapse in the Women’s Health
Initiative gave the results of a study of 16,616 women: Overall the risk of
uterine prolapse was 14.2%, the risk of cystoceles was 34.3% and the risk of
rectoceles was 18.6%. Parity (how many children the women had born) as well as
obesity was strongly correlated with an increased risk of uterine prolapse,
cystocele and rectocele.
Samuel Choppin’s First Vaginal
Hysterectomy for Uterine Prolapse
The
very first vaginal hysterectomy which was considered a treatment for uterine
prolapse was performed in 1861 in New Orleans by American Civil War surgeon
Samuel Choppin. According to a book titled Continence:
Current Concepts and Treatment Strategies Choppin’s patient was said to
have survived the operation and “later
presented before a medical class with her uterus held in her hand as proof of
her survival after the procedure.” While today’s medical practices and
surgical techniques have certainly come a long way since Choppin’s day, his
results were reported in a Mayo clinic publication and still hold an honored
position in medical history.
The
Barbalat and Tunuguntla article details two doctors who also made contributions
in the treatment of pelvic organ prolapse. “Arthure
and Savage from the Charing Cross Hospital in London significantly contributed
to the repair of apical defects and recognized that vault prolapse could occur
after abdominal or vaginal hysterectomy and that hysterectomy alone would not
cure prolapse.” These results were published in 1957 with the assumption they
would be the best technique when repairing a sacral hysteropexy.
Repairing the Sacrospinous Ligament
Barbalat
and Tunuguntla’s article further describes how two physicians—Sederl and
Richter—attempted a vaginal prolapse repair. The technique used by these
doctors has changed little through the years, is still used in Europe today and
is currently known as the Amreich-Richter procedure. The instruments used to
perform the surgery have changed, however, including “The introduction of the Miya Hook in 1987, the Shutt needle driver in
1993 and the Laurus needle driver in 1997” (Barbalat and Tunuguntla, 2012,
p. 259). These more advanced tools have made the surgical procedure to repair
the sacrospinous ligament both easier for the surgical team as well as giving
it a more predictable outcome.
Sacral Colpopexy as a Treatment for
Apical Prolapse
A
surgical procedure which treats prolapse of the vagina through attaching one
end of a synthetic mesh product to the top of the vagina and the other end to
the lower spine or upper tail bone is called a sacral colpopexy. This procedure
is considered to be the gold standard for treatment of apical prolapse as
reported by Barbalat and Tunuguntla. Bridging the gap between the vaginal cuff
to the sacrum is completed by using a synthetic graft, primarily polyethylene
and Gore-Tex meshes. Reviews of sacral colpopexy surgeries found that the
polypropylene mesh generally performed better overall than biologic grafts. The
Current Urology Reports states that “The
first large series of sacral colpopexy using a polypropylene graft was
published in 1990. Subsequent review of sacral colpopexy has reported the
vaginal erosion rate of polypropylene to be lower than that with other
synthetic grafts.”
New Robotic Techniques Used in Abdominal
Sacral Colpopexy
The
Current Urology Reports states that “Great strides in the recent endoscopic
technology led to the introduction of laparoscopic and, subsequently, the
robot-assisted laparoscopic approach to the abdominnal sacrocolpopexy.” By improving
technologies it is hoped that pelvic visualization will be enhanced, leading to
more positive outcomes form women undergoing the surgery. Because laparoscopic
surgery is considered very technically challenging, and operating times are
considerably longer (particularly for those surgeons with no formal
laparoscopic training) using robotic assistance will shorten the learning
curve, minimizing post-operative complications often seen with this procedure.
Procedures Used in the Repair of
Enteroceles
Enteroceles
are caused when the small intestine loops dip down into the pelvic region,
ultimately bulging into the vagina and causing chronic – and often serious –
pain. The surgeon must first identify the enterocele then excise it from the
rectum and vagina. The resulting wounds are properly closed with sutures then
the uterosacral ligaments are shortened and reattached. Barbalat and Tunuguntla
detail the four basic surgical procedures used in the treatment of enteroceles:
“McCall culdoplasty closes the cul-de-sac
by bringing the uterosacral ligaments
together in the midline. The Torpin technique excises a trainagular part
of the peritoneum, fascia and excessive vaginal vault wall through a posterior
incision…In the Moschowitz procedure, purse-string sutures are placed…The
Halban enterocele repair closes the cul-de-sac by suturing the peritoneum of
the sigmoid to the posterior vaginal wall by several rows of sutures.”
Colpocleisis as a Treatment for Apical
Prolapse
Colpocleisis
is a procedure which treats apical prolapse by essentially obliterating the
vagina meaning it is not a viable procedure for those women who want to engage
in sexual intercourse. While there is virtually no risk of death and the
procedure can provide good results for those who are older and have had
multiple failed prolapse repairs. Stress urinary incontinence can also be
addressed using a surgical sling at the same time the colpocleisis is
performed. As detailed by Barbalat and Tunuguntla, “In 1877 Le Fort developed his partial colpocleisis, but it was not
until the 20th century that further understanding of prolapse led to
Edebohl’s first published report of a post-hysterectomy total colpocleisis.”
Modifications to the procedure were made over the years with advances being
made to improve pelvic floor symptoms and overall patient satisfaction. This article detailed the various repairs in
the treatment of apical prolapse.
| Stress urinary incontinence | Abdominal hernia repairs |
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