SIMPLIFIED SURGICAL CORRECTION OF
MASSIVE UTEROVAGINAL PROLAPSE

Objective:
Create a relatively bloodless, nerve-sparing support of the pelvis without hysterectomy. However, massive uterovaginal prolapse is unacceptable to most who experience it.

Method:
Thirty (30) patients with Grade 4 uterovaginal prolapse underwent a simple procedure herein the endopelvic fascia cardinal uterosacral complex were raised up and anchored toward the ileopectineal line “ligament and tendinous sheet”. The uterus was preserved in each case.

Results:
Postoperative pain was minimal and hospital stay was significantly shortened. Long-term follow up of this method did not require re-operation due to failure.

Conclusion:
Quality of life was improved while sparing local nerve supply and preserving vaginal and uterine function.
A device, invented by the author, facilitated the performance of the procedure and ensured correct placement of sutures. This technique can be mastered by any competent Surgeon and should become “State of the Art.”

A major cause of gynecologic complaints, particularly in older women, relates to various types of pelvic organ prolapse.

Massive uterovaginal prolapse refers to protrusion of the uterurs and vagina out of the vaginal canal. Most patients are multiparous and there may also be co-existing cystocele, retrocele, and perineal defect. In some cases, enterocele will be found.

This entity is essentially a hernia secondary to weakness and attenuation of the endopelvic fascia. This fascia can be considered the jell into which pelvic organs are placed and supported.

Fibrous condensations of this fascia become the uterosacral ligaments, prevesical fascia, and cardinal ligaments to name only a few. Up to 50% of all parous women have some degree of vaginal wall laxity, with 10-20% being symptomatic. [13] When the supports weaken and stretch, the uterus may descend alone or be accompanied by the bladder and/or rectum.

The most extreme case is procidentia where the uterus is completely past the introitus and has carried along the adnexae and frequently the bladder and rectum.

Weakness may be due to congenital causes or aging problems, but the most common etiologies are obstetrical trauma and occupation involving heavy lifting and sometimes from a lifestyle that may include a history of heavy smoking or other types of respiratory embarrassment.

Injuries to the levator ani muscle during childbirth plays a role in the development of urinary incontinence and pelvic organ prolapse. [21} We have developed a system of correction which employs minimal surgery and provides maximal benefit. It employs a device which allows safe placement of permanent sutures resulting in elevation of the vaginal wall to its normal position. A coexisting cystocele, rectrocele or enterocele can be corrected at the same surgery. The advantage of this technique is that it allows the vagina to keep its normal axis. Problems of fixation to sacospinous ligament are avoided. Additionally, the uterus can be preserved in young women or in others who prefer to keep all of their organs.

Because the pathologic uterovaginal procidentia is the result of genital prolaspe, hysterectomy is not as important as the repair nor should it be the prime objective surgery for pelvic organ prolapse. [1-6]

MATERIALS AND METHODS
REPORT OF 20 CONSECUTIVE PATIENTS TREATED
FOR GRADE 4 GENERAL PROLAPSES FROM 2002 TO 2005.
TREATED AT THE U.S. WOMEN INSTITUTE.

Twenty patients were treated consecutively. Their chief complaintw as the presence of a “mass” in the region of the introitus, which compromised their personal hygiene, bladder and bowel function and sexual activity. A feeling of pelvic pressure and back pain were frequent complaints.

All patients prior to physical assessment completed a routine Gyn questionnaire. Appropriate investigation of coexistent morbidities followed by pre-operative treatment was done.

All patients were examined by the surgeon in the standing and lithotomy position with and without a full bladder to confirm the diagnosis. Bladder function was evaluated to exclude hypotonic and neurogenic bladder and note was made of residual urine levels. Patients ranged in age between 55 and 89 years (mean 72 years). Mean weight 75Kg.

Anatomical Principles considered in the Nerve-Sparing simplified repair:

1. The supporting endopelvic fascia must be restored to its original position to allow
normal bladder, rectal and sexual function.

2. If stress incontinence is present support of the urethrovesical junction is essential.

3. Repair of large cystocele and rectocele should be done concurrently with suspension
of the cardinal and uterosacral ligament structures

4. Correction of any separate enterocele is done concurrently also.

Operative Technique

Routinely, patients with estrogen deficiency are treated either with oral or vaginal estrogen. This results in a better-vascularized, thicker vaginal wall.

After positioning the anaesthetized patient in the Allen stirrups utilizing a modified lithotomy position, the bladder is emptied after tagging most prominent bulging area on the anterior vaginal wall

A vertical incision is then made in the center and joined by a transverse incision perpendicular to the first. The vaginal epithelium is carefully dissected off the fascia covering the bladder bulge. This is then reduced by using a series of concentric sutures which results in plication of the endopelvic fascia. A delayed absorption or in some cases non-absorbable suture is essential to maintain support during the healing phase. The rectocoele should be treated in a similar manner using similar suture materials. The cerclage suture is next placed around the cervix and tied. A #2 monofilament nylon suture is used and the 2 ends are left long and placed through the vaginal epithelium on the right about 1.5 cm lateral to the urethrovesical junction. One can use a Hegar dilator to prevent shutting of the cervix while tying the ligature.

On the left side a similar suture is placed through the vaginal epithilium about 1.5 cm lateral to the urethrovesical junction using a Mayo needle.

Suspension of the cardinal ligament and uterosacral complex is now accomplished by using the Bladder Saver Device as follows:

Bilateral transverse incisions each measuring 2.5 cm are made suprapubically 3 cm from the midlne. By careful blunt dissecton the region of Cooper's ligament and the ileopectineal line is identified and the double pronged trocar and sleeve is passed through tendinous tissue, the lacunar ligament and external oblique aponeurosis through the Space of Retzius under direct finger guidance.

On each side, one end of the nylon suture is brought up through sleeve and tagged. Traction on these sutures elevates the cervix and the bladder neck. Cystourethroscopy is used to check proper placement and a suprapubic catheter is then inserted under direct guidance.

Attention is then directed posteriorly and any enterocoele eliminated by plication of endopelvic fascia and excision of sac.

Following this an adequate colpoperineorrhaphy is performed.

Finally, the nylon sutures are tied and the position of the bladder neck and its support is checked with the cystopscope.

RESULT

It has been recognized that prolapse [14-17] and stress incontinence are associated as much as 38% of the time and correction of both are done at the same time. [11] We prefer a Nerve-Sparing operation for the correction of Stress Urinary Incontinence [5,8] which is a modified Burch-Sling procedure which is described below.

Utilizing a patented Bladder Saver Device the bladder is elevated bilaterally at the urethrovesical junction. This repositions the proximal urethra within the abdominal cavity toward Cooper's ligament using permanent sutures. By doing this, the vaginal wall becomes an endogenous suburethral sling. Unique to this technique is the fat that there is no vaginal wall dissection around urethra and urethrovesical junction and most patients can be done as an outpatient if incontinence is their only problem.

With the 20 patients in the study, it was noted that the average length of stay was shortened by 2 days. Blood loss was minimal and postoperative pain appeared to be reduced as well.

DISCUSSION

NO CONDITION HAS STIMULATED THE INVENTIVE GENIUS OF GYNECOLOGIC SURGEONS
MORE THAN THE MANAGEMENT OF UTERINE PROLAPSE. [1]

We know that genital prolapse can also be treated by other techniques [2, 15] in addition to our technique women may choose the Manchester Procedure, abdominal uterine suspension [3,4] or sacrohysteropexy7, 13 where they desire to preserve the uterus. Unfortunately, the last procedure has been associated with major complications like retroperitonel hematoma, hemorrhage of sacral veins, urinary retention, urinary tract infection, wound infection, vaginal mesh erosion1 [6,17] post incision abdominal hernia, intestinal occlusion, recurrent urinary tract infection, and sciatic pain. The use of various subrethral slings for correction of stress urinary incontinence has been associated with an unacceptable risk of urethral erosion infections, [18,20] mortality and incurable obstructive urethritis.

It is our belief that a significant decrease in morbidity, combined with savings secondary to reduced length of hospital stay, will accrue by using our newer techniques in the correction of genital prolapse and stress urinary incontinence. [19,21] The potential reduction in damage to regional nerve fibers by avoiding hysterectomy [7,12] and periurethral dissection should allow for better bladder control and not interfere with sexual function. We hope to reduce the recurrence rate following surgeries for genital prolapse. [10,16] The rate currently is reported between 4% and 33%. We believe that consideration be given to performing a concurrent endogenous sling urethropexy9 on all patients undergoing repair of genital prolapse. The reduced trauma described is very consistent with the surgical principle of keeping dissection and hence injury to a minimum. [15] To perform this technique, training is required


Click to read entire publication