English articles

Abdominal Sacral Colpopexy with Prolene Mesh

Abstract: The objective was to evaluate abdominal colposacropexy using Prolene mesh to correct total vaginal vault prolapse or total procidentia. Between 1994 and 1997 we performed colposacropexy on 15 patients for simple vaginal vault prolapse (in 7 cases after hysterectomy) and for total uterine prolapse in 8 cases. In these cases a simple abdominal hysterectomy was performed. We simultaneously performed colposacropexy with colposuspension according to the Burch ‘technique for urinary stress incontinence in 6 cases. The colposacropexy technique consisted of isolating the vaginal apex and creating a retroperitoneal tunnel from the vagina to the sacral promontory. Between the vaginal cui de sac and the sacrum, a mesh of Prolene is inserted and fixed with non-absorbable sutures. The Foley catheter was removed after 4-12 days (average 5). Average folIow-up was 15 months. No intraoperative complications occurred, and alI patients who were sexualIy activehave resumed normal sexual activity; no infections or rejections of the prostheses have been verified. We believe that it is very important to restore the normal anatomie support of the vaginal vault after prolapse. This strong support is assured by fixing the vaginal apex to the periosteum of the sacrum using Prolene mesh. Colposacropexy witl) Prolene mesh’ is a safe and effective technique for the surgical therapy of vaginal vault prolapse.
 

Introduction

The vaginal vault constitutes the cephalic end of the vagina. The vaginal vault may prolapse through the vagina in a patient after hysterectomy [1]; however, it may also occur together with a total prolapse of the uterus, especialIy in multiparous patients, in menopausal women, or in patients with previous gynecological operations that alter the vaginal axis (Burch, MarshalI¬Marchetti, Raz, etc.) [2].

   Treatment of this prolapse may be non-surgical, especialIy in women who are high risk because of serious comorbidities, or those who are totalIy bed¬ridden. Non-surgical treatment may include behavioral techniques with biofeedback, vaginal cones, and pessaries of several types and sizes [1]. Corrective surgery of the vaginal prolapse must aim at realizing the objectives emphasized by Hendee: ‘relief of symptoms; restoration of normal vaginal anatomy; rest-oration of potential vaginal coital function’ [2].

   Surgical methods for the correction of prolapse are via the vaginal route, with suspension of the vaginal vault to the sacrospinous ligament, or via the abdominal approach, using several colpopexy techniques. We report our e{Cperience with abdominal sacral colpopexy using Prolene mesh in women with vaginal vault prolapse.


Materials and Methods

From 1994 to 1997 we operated on 15 patients. The ages ranged frolf 52 to 65 years, with an average of 57 years. AlI the patients had severe prolapse of the vaginal vault; 8 of them had concomitant . uterine prolapse. Seven patients had had a hysterectomy, 5 of which were vaginal and 2 were abdominal.. Four had had previous operations for urinary incontinence, 3 with needle suspensions according to the Raz technique, and 1 with the colposuspension according to Burch. The patients complained of severe sensations of hypogastric heavi¬nesso Of those who were sexually active, all complained about the impossibility of having sexual intercourse. One patient had an abdominal incisional hemia in a xiphopubic incision used for cholecystectomy and uterine suspension. Seven patients had bleeding ulcers of the prolapsed vaginal apex. All patients were evaluated by history and clinical pelvic examination with Q-tip test and Bonney’s test, a retrograde and voiding cystourethrography (VCUG), and a complete urodynamic test consisting of cystometry and urethral pressure profilometry to determine bladder sensory per-ception of first desire to void and the capacity, bladder compliance and the detrusor contractility, and urethro-vesical junction supporto In 6 cases urinary incontinence coexisted secondary to urethral hypermobility. The operation consisted of a suprapubic abdominal approach, entering the peritoneal cavity to access the pouch of Douglas. A simple hysterectomy was performed when uterine prolapse coexisted; otherwise, in patients who had had a hysterectomy, the vaginal apex was isolated. Identification of the vaginal apex was made easier by insertion of a glass plunger into the previously prepared vagina. A retroperitoneal tunnel was then created along the right side of the true pelvis to isolate the anterior surface of the sacrum (Figs 1, 2).

   Between the vaginal apex and the front wall of the sacrum a Prolene mesh was anchored using non¬absorbable O Prolene sutures (Fig. 3). The length of the mesh was such as to allow comfortable anchorage to the sacrum without tension. Following attachment of the vaginal vault to the sacrum the Prolene mesh was retroperitonealized (Fig. 4). In 6 cases with associated urethral hypermobility colposuspension was performed according to Burch. In 1 case an abdominoplasty with Prolene mesh was performed.

Results

The total operative times varied from 150 minutes in the case with hysterectomy to 20 minutes in the case of simple sacrocolpopexy (average 105 min). In no case was blood transfusion needed. The average follow-up was 15 months, with a range of 6–45 months. At 3 months all patients had a pelvic examination. The Q-tip test and urodynamic tests were performed in patients who had had the Burch colposuspension: all vaginal vault prolapse was cured, with a good high position of the vaginal apex, and urethrovesical junction support showed excellent fixation of the bladder neck. All patients had had an indwelling urethral Foley catheter for 4-12 days (average 5 days). In 1 patient, who had had a previous Raz bladder neck suspension and who underwent sacrocolpopexy only, a high residual urine volume persisted after the catheter was removed on the 5th day. This patient was treated by self-intermittent catheterization, and the residual volume disappeared after 20 days. All the Il patients who were sexually active were able to have normal sexual intercourse again.

 

No current prolapse or infection or rejections of the prostheses were observed. In 1 patient pollakiuria unresponsive to anticholinergics had persisted, and she was started on a course of perineal electrostimulation. Four patients have felt a hypogastric ‘sense of weight’ with no evidence of pathology.

 

Discussion

DeLancey [3,4] has studied in detail the severallevels of vaginal support to explain the different types of cystocele, rectocele and prolapse of the vaginal vault after hysterectomy. The bladder, the uterus, the vagina and the rectum are supported from the pelvic walls by means of a complex connective net called the endopelvic fascia. In particular the vagina is supported from the pelvi c structures through three different levels: the proximal part of the vagina, adjacent to the cervix, is supported by long connective fibers of the paracolpium, in the middle part of the vagina, the fibers of the paracolpium are shorter and support the vagina sideways from the pelvic walls. The third level of support is the distaI one at the vaginal outlet, in which the side fibers of the vagina merge directly with the levator ani muscle [5]. The first level of suspension of the vaginal apex prevents longer prolapse of the vaginal vault when pressure is applied from the top; this is no longer possible when these ligaments are damaged [3]. The collapse of the first level of support after hysterectomy is responsible for the prolapse of the vaginal vault, but if this structure is intact and the second level of support collapses, then cystocele and rectocele can occur without prolapse of the vault. In this regard it is essential that an accurate clinical examination of the prolapse be carried out to ascertain which level of support has given way and must be corrected. If the first level is undamaged, a simple cystocele or rectocele will require a different surgical approach from a complete collapse of the first level, or when the first and second levels collapse at the same time.

   We believe that abdominal sacrocolpopexy is a valid technique for the treatment of prolapse of the vaginal vault [5]. According to the experience of Timmons and Addison, the Prolene mesh technique is the only one that ensures the best prognosis in the treatment of complete vaginal prolapse [6,7]. Addison and Timmons suggest culdoplasty according to Halban, combined with partial obliteration of the pouch of Douglas at the time of sacrocolpopexy. Likewise, it is sometimes necessary to stabilize the bladder neck to correct hypermobility. In this situation, as we have easy access to the space of Retzius, it is natural for this operation to consist of either a Burch or Marshall-Marchetti procedure. We favor the Burch technique. The synthetic mesh must be firmly fixed to the periosteum of the sacrum and to the vaginal apex. With time, the prosthesis will be invaded by fibroblastic cellular elements, producing a fibrotic tissue that fixes the organs in pIace. It is not advisable to try to remove the prosthesis in cases of recurrent prolapse. Rather, Addison and Timmons recommend the im¬plantation of another prosthesis parallel to the first one [2,7,8]. As one of the complications of this technique is infection of the prosthesis [8], we recommend irrigating the operating area with a solution of vancomycin and we use the same antibiotic parenterally for 4 days after the operation. We have never had problems with infection, although in several surveys the protrusion of the prosthesis from the vaginal apex has been reported. Addison and Timmons recommend transvaginal resec¬tion of the exposed mesh, followed by c10sing the eroded vaginal vault.

   Our experience confirms the good results of this technique in the treatment of total prolapse of the vaginal apex. The technique we propose restores the vaginal axis, thanks to the solid, strong Prolene mesh, which can also provide length as a result of fixation in a tissue as solid as the sacral periosteum.

Acknowledgements. The authors wish to thank Dr Ananias Diokno for help with the revision of the paper, and Filippo Bombace Architect for the figures.

References
1. Timmons MC, Addison WA. Vaginal vault prolapse. In: Brubaker LT, Saclarides TJ, eds. The female pelvic floor. F. A. Davis Company, 1996:262-268
2. Addison W A, Timmons Me. Abdominal sacral colpopexy for the treatment of vaginal vault prolapse with enterocele. In: Rock JA, Thompson JD, eds. Te Linde’s operative gynecology, 80th edn. Philadelphia: Lippincott-Raven, 1997: 1030-1037
3. De Lancey J. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet GynecoI1992;166:1717-1724
4. De Lancey JOL. Correlative study of paraurethral anatomy. Obstet GynecoI1986;68:91-97
5. Oerlich TM. The striated urogenital sphincter muscle in the female. Anat Ree 1983;205:223-232
7. Synder T, Krantz K. Abdominal retroperitoneal sacral colpopexy for “the correction of vaginal prolapse. Obstet Gynecol 1991;77:944-949
8. Timmons M, Addison W, Addison S. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele: evolution of the operative technique. J Reprod Med 1992;37 :323-327
9. Addison W, Timmons M, Wall L. Failed abdominal sacral colpopexy: observation and recommendations. Obstet Gynecol 1989;74:480-482

Editorial Comment: These authors report their experience in a urology department in using Prolene mesh for the therapy of vaginal vault prolapse and total uterine prolapse after removal of the uterus. Excellent results were obtained. Although they had no complications, bleeding from the presacral plexus is one particular complication that every physician performing this procedure must be prepared to control, as it may be very brisk and exceed 11 per minute. Pressure is the time-honored method to deal with any bleeding, and this area is no exception. Because the venous sinuses are very hard to visualize directly, traditional definitive bleeding control measures, such as clamping, cautery and clips, do not work well. A particularly useful method is the thumb tack, owing to its ability to put pressure on a large surface area. It is now available in the United States, made of titanium for medicaI use. The only difficulty in its application is the strength required to push it into the bone. For this reason a small hammer is necessary, along with an impeller of some kind to obtain the proper direction of force to push the tack into the bone. The physician performing this procedure should be ever vigilant for bleeding from this area and be prepared to deal with it promptly.

Review of Current Literature

Biofeedback Training in Patients with Fecal Incontinence

Glia A, Gyline M, Akerlund JE, Lindfors U and Lindberg G

Karolinska Institutet, Departments of Surgery and MedicaI and Surgical Gastroenterology and Hepatology, Huddinge University Hospital, Huddinge, Sweden
Dis Colon Rectum 1998;41:359-364

This study was designed to evaluate clinical presentation, anorectal pathophysiology and the results of biofeedback training in patients with fecal incontinence. Twenty-six patients had an evaluation prior to therapy, and then were administered biofeedback. Incontinence was described as passive (leakage of fecal material without knowledge) and urge (occurrence of leakage or urge against the patient’ s will). Subjects were trained as outpatients using a manometric tracing of sphincter pressure as feedback. The goal was to improve the strength of the extemal anal sphincter. A maximum of lO sessions was given, with training once or twice per week. The types of incontinence were passive in lO, urge in 6, and mixed in lO. The response to therapy was excellent in 5 patients, good in 9, and poor in 8 of the 22 patients who completed the program. After 12-46 months, 6 more patients had returned to baseline leve!. A low maximal tolerable volume and high sphincter asymmetry may indicate poor outcome of biofeedback therapy.

Comment

Biofeedback therapy for patients with fecal incontinence may have an initial success of 54%, which deteriorates with time to 41%. Booster sessions after therapy has been completed could be useful. The program of biofeedback for urinary incontinence may be applied to fecal incontinence. A low maximum tolerable volume and high sphincter asymmetry may indicate poor outcome from biofeedback therapy.

Source: International Urogynecology Journal (1999) 10:295-299 © 1999 Springer-Verlag London Ltd

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