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Colposacrosuspension for severe genital prolapse
International Journal of Gynecology and Obstetrics 85 (2004) 30–35
Article
Colposacrosuspension for severe genital prolapse ´ H.S. Cronje* Department of Obstetrics and Gynecology, University of the Free State, Bloemfontein, South Africa Received 24 March 2003; received in revised form 1 September 2003; accepted 3 September 2003
Abstract Objective: A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension. Methods: A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro䉸 (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter. Results: The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1–29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%). Conclusion: Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures. 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Prolapse; Genital; Cystocele; Vault prolapse; Uterine prolapse; Enterocele; Rectocele; Colposacrosuspension; Burch colposuspension; Mesh
1. Introduction Genital prolapse is a disease of aging women affecting mostly white patients w1x. The lifetime risk for surgery due to prolapse or urinary incon*Tel.: q27-51-405-3444; fax: q27-51-444-2660. ´ E-mail address: [email protected] (H.S. Cronje).
tinence was estimated at 11.1% w2x. Of all patients subjected to surgery for prolapse or urinary incontinence, 29% had a second operation within 2 years w2x. These figures reflect the enormous magnitude of prolapse as a health problem. In the short term, it is not possible to decrease the incidence of prolapse. Therefore, the focus of attention
0020-7292/04/$30.00 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2003.09.007
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
should be on the effective treatment thereof with as few recurrences as possible. Surgical procedures for prolapse are numerous, which include vaginal, abdominal or vaginal– abdominal approaches w3x. Over the years, we have used different approaches with varying results. The approaches included anterior and posterior colporrhaphy w4,5x with or without vaginal hysterectomy w1x, Ward culdoplasty popularized by McCall w6,7x, Moschcowitz repair with or without sacrocolpopexy w8,9x, sacrospinous ligament fixation w10x, and the modified Burch colposuspension w11x. None of these were entirely satisfactory except the Burch colposuspension for cystocele and urinary stress incontinence. In 1996 Sullivan w12x published an article with a comprehensive approach. A mesh was inserted from the perineum to the sacrum between the rectum and vagina. A second mesh was inserted anteriorly from the symphysis pubis, between the bladder and vagina, extending to the sacrum. We adopted Sullivan’s approach, but with modifications. Initially, the mesh was placed over the upper third of the vagina anteriorly and fixated halfway down the posterior wall posteriorly. As our expertise improved, we extended the mesh to the perineum. The objective of this study was to report on 140 consecutive patients with severe prolapse treated by colposacrosuspension. 2. Patients and methods The 140 patients included in the study attended either the urogynecology unit at Universitas Hospital, a tertiary teaching hospital of the University of the Free State, Bloemfontein (ns75), or the author’s private practice (ns65). All patients gave informed consent and the Ethics Review Board of the Faculty of Health Sciences, University of the Free State approved the study. Each patient’s data were collected by completing a structured form at discharge from hospital. The forms were verified at weekly departmental meetings and the data were entered into a computer database (EPI-INFO 6.0, CDC, Atlanta, GA). The author or urogynecology unit residents examined the patients at follow-up. A structured questionnaire was used at each follow-up and the data
31
Table 1 Grading of prolapse Grade
Description
1
Descent extending within vagina maximally to the level of the hymen Descent to the level of the vaginal introitus Descent extending beyond the vaginal introitus
2 3
Based on Parsons and Sommers 1978 w15x.
entered into the same database. Patients who did not return for follow-up were phoned and the structured questionnaire was completed by telephone. The patients were seen during 19 November 1990 and 10 September 2002 and were included if they presented with grade 2 or 3 prolapse of any type (Table 1) and a semisynthetic mesh (Vypro䉸, Johnson & Johnson, Brussels, Belgium) was used in the procedure. During the developmental phase of our current surgical technique, other forms of mesh were used but were less satisfactory. The technique was stabilized once the Vypro䉸 mesh came into use. No patient eligible for this study was excluded. The author performed the private patients’ and half the urogynecology unit patients’ surgery. The residents performed the rest of the urogynecology unit patients’ surgery, with the author’s assistance and guidance. Patients underwent a surgical procedure based on a technique described by Sullivan w12x (Fig. 1). A laparotomy was performed, usually by a subumbilical midline incision. The peritoneum medially to the rectum was opened, from the sacral promontory down to the bottom of the pouch of Douglas. At the same time the rectum was separated from the vagina. Care was taken not to divide the pararectal tissue on the right side, which contained much of the nerve supply to the rectum. The surface over S1–2 was exposed and with blunt dissection between the sacrum and rectum, the rectum was mobilized anteriorly for attachment to the mesh at a later stage. Vaginally, a small midline incision was made over the perineum. Higher up, an ellipse of posterior vaginal wall was excised for approximately two-thirds of the vaginal length. The width of the ellipse was adjusted according to the amount of
32
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
Fig. 1. Surgical procedure based on the Sullivan technique w12x. A perineal repair is done with a mesh positioned from the perineum to the sacrum to which the vagina and rectum are attached (arrows). A second mesh is fixated anteriorly to the vagina (arrows) and a modified Burch colposuspension is done.
posterior compartment prolapse; the more prolapse, the wider the ellipse. With this procedure, the recto-vaginal space was opened widely and connected with the abdominal cavity. Before the mesh was introduced, a perineal repair was done (unless the perineum was adequate). The deep portion of the external sphincter on both sides were tied together with absorbable material anteriorly to the rectum. Thereafter, the mesh was introduced in the form of a strip measuring 15=4 cm. The lower part was sutured to the perineum and the section above that to the postero-lateral vaginal wall as laterally as possible. Following the fixation of the mesh, the posterior vaginal wall and perineum were closed. Abdominally, the bladder was separated from the vagina for a distance of approximately 4–5 cm. A second strip of mesh, approximately 3 cm in width, was attached to the upper vagina. Together, the two strips of mesh were measured to reach S1 without tension and sutured to the anterior longitudinal ligament of the sacrum at S1. The
rectum was pulled upwards and on the medial side fixated to the mesh. Finally, the peritoneum, which was opened during the initial phase of the surgery, was closed over the mesh and sutured to the rectum. Thereby the mesh remained extraperitoneally. Initially, the mesh did not extend to the perineum, but only halfway down the posterior vaginal wall. This variation was called a colposacrosuspension. If the mesh extended to the perineum, it was called a perineo-colposacrosuspension. Patients with an intact uterus underwent the same procedure together with a subtotal hysterectomy or, when deemed necessary, a total hysterectomy. Before attachment of the mesh to the sacrum, the uterosacral ligaments were tied together across the posterior mesh. A modified Burch colposuspension according to the technique of Tanagho w11x was subsequently done on almost all patients, even if a cystocele was absent. The objective was either the reduction of a cystocele (or the control of urinary stress incontinence), or prevention of future cystocele formation. Patients left the operating room with a transurethral bladder catheter, which was usually removed on day 2. Discharge from hospital usually occurred on the fourth or fifth postoperative day. Postoperative follow-up occurred at 6 weeks, 6 months, and annually. 3. Results The median age was 61 years (26–86 years) and the median parity 3 (1–10). White patients contributed 90.7% of the 140 patients while 5% were black and 4.3% from other racial groups. Seventy-one patients (50.7%) reported previous prolapse surgery and 29 (20.7%) gave a history of thyroid problems (mostly hypothyroidism, but on treatment). Bladder symptoms and signs included urinary stress incontinence (ns17; 12.1%), detrusor instability (ns24; 17.1%) and mixed incontinence excluding the aforementioned (ns16; 11.4%). Nine patients (6.4%) reported difficulty in voiding. Constipation was present in 54 patients (38.6%), while 46 (32.9%) reported difficulty in defecation
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35 Table 2 Findings at gynecological examination Prolapsea (ns140)
Cysctocele Uterine prolapse Vault prolapse Enterocele Rectocele a
Grade (see Table 1) 1 n (%) 33 11 23 28 16
(23.6) (7.9) (16.4) (20.0) (11.4)
2 n (%) 42 4 17 60 22
(30.0) (2.9) (12.1) (42.9) (15.7)
3 n (%) 15 3 25 27 7
(10.7) (2.1) (17.9) (19.3) (5.0)
More than one type of prolapse may occur in one patient.
(where manual assistance for defecation was necessary). Five patients (2.9%) reported fecal incontinence. Vaginal symptoms and signs included dyspareunia (ns10; 7.1%) and something protruding through the vaginal introitus (ns111; 79.3%). Furthermore, 19 patients (13.6%) complained of lower abdominal pain and 16 (11.4%) of low backache. The findings at gynecological examination are summarized in Table 2. Posterior compartment prolapse was more prominent than anterior prolapse. In addition, 70 patients (50.0%) had an obvious defective perineum. Two patients presented with transverse vaginal fibrotic ridges due to previous colporrhaphy. The surgical procedures are listed in Table 3. All patients had suspension procedures with Vypro䉸 mesh. In 94 (67.1%) patients the mesh extended from the perineum to the sacrum and in the remaining patients (ns46, 32.9%) from half way along the posterior vaginal wall to the promontory. The latter included 21 patients who had previously undergone a hysterectomy. Three of the 19 patients who did not have anterior mobilization of the rectum had previously undergone a hysterectomy. The median blood loss during surgery was 400 ml (100–10 000 ml), excluding 26 patients with ‘minimal blood loss’. A transurethral bladder catheter was inserted in 132 patients (94.3%), a suprapubic catheter in six (4.3%), no catheter in one (0.7%) and unknown in one (0.7%). Patients were catheterized for a median of 2 days (range 1–21 days). Nine patients (6.5%) were discharged from
33
hospital with a catheter. A drain was left in the surgery area of nine patients (6.4%). Intraoperative complications included bladder injury (ns5; 3.6%), ureter injury (ns1; 0.7%) and bowel injury (ns5; 3.6%). Postoperatively, there were four patients with hematoma formation (2.9%), one with temporaly ileus (0.7%) and two with pneumonia (1.4%). Postoperative follow-up was achieved in 136 patients (97%) with a median duration of 8.5 months (mean 10.2 months, range 1–29). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%). Of these, nine involved the posterior compartment (recto-enterocele) and two the anterior aspect (cystocele). Seventeen patients (12.1%) developed significant urinary incontinence requiring surgery. Follow-up surgery was required in 23 patients (16.3%). These included one perineo-colposacrosuspension (0.7%), three posterior repairs (colporrhaphy) (2.1%), one mesh removal (0.7%), one repair of an incisional hernia (0.7%) and 17 (12.1%) transurethral vaginal tape (TVT) procedures. All the patients responded well to these procedures. 4. Discussion Several grading systems for prolapse are in use and include those of the International Continence Society, American Urogynecologic Society and the Society of Gynecologic Surgeons w13x. Recently, the Revised New York Classification System was proposed w14x. Since these classifications are fairly Table 3 Surgical procedures (ns140) Procedurea
n (%)
Hysterectomy Subtotal Total Perineo-colposacrosuspension Colposacrosuspension Rectum mobilized (abdominally) Posterior colporrhaphy Perineal repair Burch colposuspension
16 5 94 46 121 51 90 110
a
(11.4) (3.6) (67.1) (32. 9) (86.4) (36.4) (64.3) (78.6)
More than one procedure was possible in each patient.
34
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
complicated and difficult to implement at a teaching institution (under- to postgraduate level), a more simplified system was used in this study (Table 1) w15x. The terminology for different surgical procedures for prolapse is confusing. For example, the term ‘sacrocolpopexy’ is used for different degrees of suspension, ranging from the sacrum to the vaginal vault w16x, midway down the posterior vaginal wall w17x or extending to the perineal body w18,19x. A need exists for a more uniform nomenclature system. We called our procedure a perineocolposacrosuspension when the mesh extended from the perineal body, via the vault of the vagina (the colpos) to the sacrum, where it was suspended. When the mesh did not reach the perineum, we called it a colposacrosuspension. However, when the mesh extended from the mid-vagina via the colpos to the sacrum, a more descriptive term would be vaginal-colposacrosuspension. A suspension from the top of the vagina to the sacrum would then be a colposacrosuspension. Our perineo-colposacrosuspension is based on Sullivan’s total pelvic mesh repair w12x. In our perineo-colposacrosuspension (Fig. 1) and colposacrosuspension procedures, we routinely performed a concomitant perineal and posterior repair based on Nichols’ description w5x. In addition, we inserted the anterior mesh maximally one-third of the length of the anterior vaginal wall. The reason being the risk of hemorrhage and postoperative detrusor instability when the mesh is inserted behind the trigonal area of the bladder. Instead of extending the anterior mesh to the anterior pelvic wall, we performed a modified Burch procedure for suspension of the anterior mid-vaginal area w11x. Recently, Sullivan published their 10-year follow-up results w20x. Although their patient population was fairly similar to ours, the amount of additional surgery after the primary procedure was significantly more compared with our experience (36% involving the anterior compartment and 28% posteriorly) Our follow-up was, however, significantly shorter. Much of Sullivan’s additional surgery could be ascribed to not acknowledging the importance of a good quality perineum and the placement of excessive mesh behind the bladder.
Although our follow-up was short (mean 10.2 months, range 1–29 months), a large proportion of our patients were followed-up (97%). Our failure rate, defined as grade 2 prolapse or more, was low (8%). However, if we include the surgery for mesh reaction (one patient, 0.7%) and urinary incontinence (17 patients, 12%), the figure rises to 16% which is still less than the 29% reoperation rate quoted by Holley w3x but higher compared with other series w19–21x. Our results are, however, satisfactory if our inclusion of patients with severe prolapse only (50% of which were secondary to previous prolapse surgery) is taken into account. The problem of urinary incontinence after prolapse surgery, is well recognized w22x. Although the mechanism is not quite clear, we concentrate on avoiding overelevation of the anterior vaginal wall and excessive suspension of the vagina. In view of the excellent results of the TVT procedure w23x, the distal sutures on the anterior vaginal wall during the Burch colposuspension were placed as distally as possible. This modification was applied during the latter half of the study period. Mobilization of the rectum with fixation to the mesh was introduced by Sullivan w12x. The reason being the wide and deep cul-de-sac present in most of these patients. Subsequently, the rectum abruptly folds backwards just above the perineum, which may be responsible for inadequate bowel function. By mobilizing the rectum, it is not only straightened but the bottom of the cul-de-sac is dramatically elevated. Mesh erosion is an unavoidable problem and the incidence of mesh related complications with sacrocolpopexy is 5–35% w24x. During the initial phase of our experience with sacrocolpopexy, we used non-absorbable mesh with 10% of the patients developing erosion. When using the semi-absorbable mesh, patients developing erosion decreased to only 1%. The main advantage of our colposacrosuspension (with Burch colposuspension) is the completeness of prolapse repair involving all the compartments, including repositioning of the rectum. Noticeable on follow-up were the normal length and angle of the vagina. It is a well-tolerated procedure with a low complication rate. However,
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
it involves major surgery and in compromised or elderly patients, less invasive procedures such as the vaginally performed paravaginal repair w25x. w14x
References w1x Marana HR, Andrade JM, Marana RR, de Sala MM, Philbert PMP, Rodriques R. Vaginal hysterectomy for correcting genital prolapse. Long term evaluation. J Reprod Med 1999;44:529 –534. w2x Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501 –506. w3x Holley RL. Enterocele: a review. Obstet Gynecol Surv 1994;49:284 –293. w4x Kelly HA, Dumm WM. Urinary incontinence in women without manifest injury to the bladder. Surg Gynecol Obstet 1914;18:444 –450. w5x Nichols DH. Posterior colporrhaphy and perineorrhaphy: separate and distinct operations. Am J Obstet Gynecol 1991;164:714 –721. w6x Ward GG. Technique of repair of enterocele (posterior vaginal hernia) and rectocele. J Am Med Assoc 1922;79:709 –715. w7x McCall M. Posterior culdoplasty: surgical correction of enterocele during vaginal hysterectomy: a preliminary report. Obstet Gynecol 1957;10:595 –602. w8x Moschcowitz AV. The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 1912;15:7 –11. w9x Addison WA, Livengood CH 3rd, Sutton GP, Parker RT. Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele. Am J Obstet Gynecol 1985;153:140 –146. w10x Morley GW, DeLancey JO. Sacrospinous ligament fixation for eversion of the vagina. Am J Obstet Gynecol 1988;158:872 –881. w11x Tanagho EA. Colpocystourethropexy: the way we do it. J Urol 1976;116:751 –753. w12x Sullivan ES, Stranburg CO, Sandoz IL, Tarnasky JW, Longaker CJ. Repair of total pelvic prolapse: an overview. In: Schrock T, editor. Perspectives in Colon and Rectal Surgery. St. Louis: Quality Medical Publishing, 1990. p. 119 –131. w13x Bland DR, Earle BB, Vitolins MZ, Burke G. Use of the Pelvic Organ Prolapse staging system of the Internation-
w15x w16x
w17x
w18x
w19x
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w21x
w22x
w23x
w24x
w25x
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al Continence Society, American Urogynecologic Society, and Society of Gynecologic Surgeons in perimenopausal women. Am J Obstet Gynecol 1999;181:1324 –1328. Scotti RJ, Flora R, Greston WM, Budnick L, Hutchinson-Colas J. Characterizing and reporting pelvic floor defects: the revised New York classification system. Int Urogynecol J Pelvic Floor Dysfunct 2000;11:48 –60. Parsons L, Sommers SC. Gynecology. 2nd ed. Philadelphia, PA: WB Saunders, 1978. (p. 1442) Menefee SA, Miller KF, Wall LL. Results of abdominal sacral colpopexy using polyester mesh in the treatment of post hysterectomy vaginal vault prolapse and enterocele. J Pelv Surg 1999;5:136 –142. Surgico N, Ruspa G, Longo D, Salini A, Arnulfo A, Baj G. Abdominal sacrocolpopexy with collagen biosynthetic mesh: analysis of 21 cases. J Gynecol Surg 2002;18:45 –48. Cundiff GW, Harris RL, Coates K, Low VH, Bump RC, Addison WA. Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse. Am J Obstet Gynecol 1997;177:1345 – 1355. Fox SD, Stanton SL. Vault prolapse and rectocele: assessment of repair using sacrocolpopexy with mesh interposition. Br J Obstet Gynecol 2000;107:1371 – 1375. Sullivan ES, Longaker CJ, Lee PY. Total pelvic mesh repair: a ten-year experience. Dis Colon Rectum 2001;44:857 –863. Webb MJ, Aronson MP, Ferguson LK, Lee RA. Posthysterectomy vaginal vault prolapse: primary repair in 693 patients. Obstet Gynecol 1998;92:281 –285. Bombieri L, Freeman RM, Perkins EP, Williams MP, Shaw SR. Why do women have voiding dysfunction and de novo detrusor instability after colposuspension? Br J Obstet Gynecol 2002;109:402 –412. Nilsson CG, Kuuva N, Falconer C, Rezapour M, Ulmsten U. Long-term results of the tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2001;12(Suppl 2):S5 –S8. Iglesia CB, Fenner DE, Brubaker L. The use of mesh in gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct 1997;8:105 –115. Meeks GR, Washburne JF, McGehee RP, Wiser WL. Repair of vaginal vault prolapse by suspension of the vagina to iliococcygens (prespinous) fascia. Am J Obstet Gynecol 1994;171:1444 –1454.
Article
Colposacrosuspension for severe genital prolapse ´ H.S. Cronje* Department of Obstetrics and Gynecology, University of the Free State, Bloemfontein, South Africa Received 24 March 2003; received in revised form 1 September 2003; accepted 3 September 2003
Abstract Objective: A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension. Methods: A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro䉸 (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter. Results: The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1–29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%). Conclusion: Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures. 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. Keywords: Prolapse; Genital; Cystocele; Vault prolapse; Uterine prolapse; Enterocele; Rectocele; Colposacrosuspension; Burch colposuspension; Mesh
1. Introduction Genital prolapse is a disease of aging women affecting mostly white patients w1x. The lifetime risk for surgery due to prolapse or urinary incon*Tel.: q27-51-405-3444; fax: q27-51-444-2660. ´ E-mail address: [email protected] (H.S. Cronje).
tinence was estimated at 11.1% w2x. Of all patients subjected to surgery for prolapse or urinary incontinence, 29% had a second operation within 2 years w2x. These figures reflect the enormous magnitude of prolapse as a health problem. In the short term, it is not possible to decrease the incidence of prolapse. Therefore, the focus of attention
0020-7292/04/$30.00 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2003.09.007
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
should be on the effective treatment thereof with as few recurrences as possible. Surgical procedures for prolapse are numerous, which include vaginal, abdominal or vaginal– abdominal approaches w3x. Over the years, we have used different approaches with varying results. The approaches included anterior and posterior colporrhaphy w4,5x with or without vaginal hysterectomy w1x, Ward culdoplasty popularized by McCall w6,7x, Moschcowitz repair with or without sacrocolpopexy w8,9x, sacrospinous ligament fixation w10x, and the modified Burch colposuspension w11x. None of these were entirely satisfactory except the Burch colposuspension for cystocele and urinary stress incontinence. In 1996 Sullivan w12x published an article with a comprehensive approach. A mesh was inserted from the perineum to the sacrum between the rectum and vagina. A second mesh was inserted anteriorly from the symphysis pubis, between the bladder and vagina, extending to the sacrum. We adopted Sullivan’s approach, but with modifications. Initially, the mesh was placed over the upper third of the vagina anteriorly and fixated halfway down the posterior wall posteriorly. As our expertise improved, we extended the mesh to the perineum. The objective of this study was to report on 140 consecutive patients with severe prolapse treated by colposacrosuspension. 2. Patients and methods The 140 patients included in the study attended either the urogynecology unit at Universitas Hospital, a tertiary teaching hospital of the University of the Free State, Bloemfontein (ns75), or the author’s private practice (ns65). All patients gave informed consent and the Ethics Review Board of the Faculty of Health Sciences, University of the Free State approved the study. Each patient’s data were collected by completing a structured form at discharge from hospital. The forms were verified at weekly departmental meetings and the data were entered into a computer database (EPI-INFO 6.0, CDC, Atlanta, GA). The author or urogynecology unit residents examined the patients at follow-up. A structured questionnaire was used at each follow-up and the data
31
Table 1 Grading of prolapse Grade
Description
1
Descent extending within vagina maximally to the level of the hymen Descent to the level of the vaginal introitus Descent extending beyond the vaginal introitus
2 3
Based on Parsons and Sommers 1978 w15x.
entered into the same database. Patients who did not return for follow-up were phoned and the structured questionnaire was completed by telephone. The patients were seen during 19 November 1990 and 10 September 2002 and were included if they presented with grade 2 or 3 prolapse of any type (Table 1) and a semisynthetic mesh (Vypro䉸, Johnson & Johnson, Brussels, Belgium) was used in the procedure. During the developmental phase of our current surgical technique, other forms of mesh were used but were less satisfactory. The technique was stabilized once the Vypro䉸 mesh came into use. No patient eligible for this study was excluded. The author performed the private patients’ and half the urogynecology unit patients’ surgery. The residents performed the rest of the urogynecology unit patients’ surgery, with the author’s assistance and guidance. Patients underwent a surgical procedure based on a technique described by Sullivan w12x (Fig. 1). A laparotomy was performed, usually by a subumbilical midline incision. The peritoneum medially to the rectum was opened, from the sacral promontory down to the bottom of the pouch of Douglas. At the same time the rectum was separated from the vagina. Care was taken not to divide the pararectal tissue on the right side, which contained much of the nerve supply to the rectum. The surface over S1–2 was exposed and with blunt dissection between the sacrum and rectum, the rectum was mobilized anteriorly for attachment to the mesh at a later stage. Vaginally, a small midline incision was made over the perineum. Higher up, an ellipse of posterior vaginal wall was excised for approximately two-thirds of the vaginal length. The width of the ellipse was adjusted according to the amount of
32
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
Fig. 1. Surgical procedure based on the Sullivan technique w12x. A perineal repair is done with a mesh positioned from the perineum to the sacrum to which the vagina and rectum are attached (arrows). A second mesh is fixated anteriorly to the vagina (arrows) and a modified Burch colposuspension is done.
posterior compartment prolapse; the more prolapse, the wider the ellipse. With this procedure, the recto-vaginal space was opened widely and connected with the abdominal cavity. Before the mesh was introduced, a perineal repair was done (unless the perineum was adequate). The deep portion of the external sphincter on both sides were tied together with absorbable material anteriorly to the rectum. Thereafter, the mesh was introduced in the form of a strip measuring 15=4 cm. The lower part was sutured to the perineum and the section above that to the postero-lateral vaginal wall as laterally as possible. Following the fixation of the mesh, the posterior vaginal wall and perineum were closed. Abdominally, the bladder was separated from the vagina for a distance of approximately 4–5 cm. A second strip of mesh, approximately 3 cm in width, was attached to the upper vagina. Together, the two strips of mesh were measured to reach S1 without tension and sutured to the anterior longitudinal ligament of the sacrum at S1. The
rectum was pulled upwards and on the medial side fixated to the mesh. Finally, the peritoneum, which was opened during the initial phase of the surgery, was closed over the mesh and sutured to the rectum. Thereby the mesh remained extraperitoneally. Initially, the mesh did not extend to the perineum, but only halfway down the posterior vaginal wall. This variation was called a colposacrosuspension. If the mesh extended to the perineum, it was called a perineo-colposacrosuspension. Patients with an intact uterus underwent the same procedure together with a subtotal hysterectomy or, when deemed necessary, a total hysterectomy. Before attachment of the mesh to the sacrum, the uterosacral ligaments were tied together across the posterior mesh. A modified Burch colposuspension according to the technique of Tanagho w11x was subsequently done on almost all patients, even if a cystocele was absent. The objective was either the reduction of a cystocele (or the control of urinary stress incontinence), or prevention of future cystocele formation. Patients left the operating room with a transurethral bladder catheter, which was usually removed on day 2. Discharge from hospital usually occurred on the fourth or fifth postoperative day. Postoperative follow-up occurred at 6 weeks, 6 months, and annually. 3. Results The median age was 61 years (26–86 years) and the median parity 3 (1–10). White patients contributed 90.7% of the 140 patients while 5% were black and 4.3% from other racial groups. Seventy-one patients (50.7%) reported previous prolapse surgery and 29 (20.7%) gave a history of thyroid problems (mostly hypothyroidism, but on treatment). Bladder symptoms and signs included urinary stress incontinence (ns17; 12.1%), detrusor instability (ns24; 17.1%) and mixed incontinence excluding the aforementioned (ns16; 11.4%). Nine patients (6.4%) reported difficulty in voiding. Constipation was present in 54 patients (38.6%), while 46 (32.9%) reported difficulty in defecation
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35 Table 2 Findings at gynecological examination Prolapsea (ns140)
Cysctocele Uterine prolapse Vault prolapse Enterocele Rectocele a
Grade (see Table 1) 1 n (%) 33 11 23 28 16
(23.6) (7.9) (16.4) (20.0) (11.4)
2 n (%) 42 4 17 60 22
(30.0) (2.9) (12.1) (42.9) (15.7)
3 n (%) 15 3 25 27 7
(10.7) (2.1) (17.9) (19.3) (5.0)
More than one type of prolapse may occur in one patient.
(where manual assistance for defecation was necessary). Five patients (2.9%) reported fecal incontinence. Vaginal symptoms and signs included dyspareunia (ns10; 7.1%) and something protruding through the vaginal introitus (ns111; 79.3%). Furthermore, 19 patients (13.6%) complained of lower abdominal pain and 16 (11.4%) of low backache. The findings at gynecological examination are summarized in Table 2. Posterior compartment prolapse was more prominent than anterior prolapse. In addition, 70 patients (50.0%) had an obvious defective perineum. Two patients presented with transverse vaginal fibrotic ridges due to previous colporrhaphy. The surgical procedures are listed in Table 3. All patients had suspension procedures with Vypro䉸 mesh. In 94 (67.1%) patients the mesh extended from the perineum to the sacrum and in the remaining patients (ns46, 32.9%) from half way along the posterior vaginal wall to the promontory. The latter included 21 patients who had previously undergone a hysterectomy. Three of the 19 patients who did not have anterior mobilization of the rectum had previously undergone a hysterectomy. The median blood loss during surgery was 400 ml (100–10 000 ml), excluding 26 patients with ‘minimal blood loss’. A transurethral bladder catheter was inserted in 132 patients (94.3%), a suprapubic catheter in six (4.3%), no catheter in one (0.7%) and unknown in one (0.7%). Patients were catheterized for a median of 2 days (range 1–21 days). Nine patients (6.5%) were discharged from
33
hospital with a catheter. A drain was left in the surgery area of nine patients (6.4%). Intraoperative complications included bladder injury (ns5; 3.6%), ureter injury (ns1; 0.7%) and bowel injury (ns5; 3.6%). Postoperatively, there were four patients with hematoma formation (2.9%), one with temporaly ileus (0.7%) and two with pneumonia (1.4%). Postoperative follow-up was achieved in 136 patients (97%) with a median duration of 8.5 months (mean 10.2 months, range 1–29). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%). Of these, nine involved the posterior compartment (recto-enterocele) and two the anterior aspect (cystocele). Seventeen patients (12.1%) developed significant urinary incontinence requiring surgery. Follow-up surgery was required in 23 patients (16.3%). These included one perineo-colposacrosuspension (0.7%), three posterior repairs (colporrhaphy) (2.1%), one mesh removal (0.7%), one repair of an incisional hernia (0.7%) and 17 (12.1%) transurethral vaginal tape (TVT) procedures. All the patients responded well to these procedures. 4. Discussion Several grading systems for prolapse are in use and include those of the International Continence Society, American Urogynecologic Society and the Society of Gynecologic Surgeons w13x. Recently, the Revised New York Classification System was proposed w14x. Since these classifications are fairly Table 3 Surgical procedures (ns140) Procedurea
n (%)
Hysterectomy Subtotal Total Perineo-colposacrosuspension Colposacrosuspension Rectum mobilized (abdominally) Posterior colporrhaphy Perineal repair Burch colposuspension
16 5 94 46 121 51 90 110
a
(11.4) (3.6) (67.1) (32. 9) (86.4) (36.4) (64.3) (78.6)
More than one procedure was possible in each patient.
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H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
complicated and difficult to implement at a teaching institution (under- to postgraduate level), a more simplified system was used in this study (Table 1) w15x. The terminology for different surgical procedures for prolapse is confusing. For example, the term ‘sacrocolpopexy’ is used for different degrees of suspension, ranging from the sacrum to the vaginal vault w16x, midway down the posterior vaginal wall w17x or extending to the perineal body w18,19x. A need exists for a more uniform nomenclature system. We called our procedure a perineocolposacrosuspension when the mesh extended from the perineal body, via the vault of the vagina (the colpos) to the sacrum, where it was suspended. When the mesh did not reach the perineum, we called it a colposacrosuspension. However, when the mesh extended from the mid-vagina via the colpos to the sacrum, a more descriptive term would be vaginal-colposacrosuspension. A suspension from the top of the vagina to the sacrum would then be a colposacrosuspension. Our perineo-colposacrosuspension is based on Sullivan’s total pelvic mesh repair w12x. In our perineo-colposacrosuspension (Fig. 1) and colposacrosuspension procedures, we routinely performed a concomitant perineal and posterior repair based on Nichols’ description w5x. In addition, we inserted the anterior mesh maximally one-third of the length of the anterior vaginal wall. The reason being the risk of hemorrhage and postoperative detrusor instability when the mesh is inserted behind the trigonal area of the bladder. Instead of extending the anterior mesh to the anterior pelvic wall, we performed a modified Burch procedure for suspension of the anterior mid-vaginal area w11x. Recently, Sullivan published their 10-year follow-up results w20x. Although their patient population was fairly similar to ours, the amount of additional surgery after the primary procedure was significantly more compared with our experience (36% involving the anterior compartment and 28% posteriorly) Our follow-up was, however, significantly shorter. Much of Sullivan’s additional surgery could be ascribed to not acknowledging the importance of a good quality perineum and the placement of excessive mesh behind the bladder.
Although our follow-up was short (mean 10.2 months, range 1–29 months), a large proportion of our patients were followed-up (97%). Our failure rate, defined as grade 2 prolapse or more, was low (8%). However, if we include the surgery for mesh reaction (one patient, 0.7%) and urinary incontinence (17 patients, 12%), the figure rises to 16% which is still less than the 29% reoperation rate quoted by Holley w3x but higher compared with other series w19–21x. Our results are, however, satisfactory if our inclusion of patients with severe prolapse only (50% of which were secondary to previous prolapse surgery) is taken into account. The problem of urinary incontinence after prolapse surgery, is well recognized w22x. Although the mechanism is not quite clear, we concentrate on avoiding overelevation of the anterior vaginal wall and excessive suspension of the vagina. In view of the excellent results of the TVT procedure w23x, the distal sutures on the anterior vaginal wall during the Burch colposuspension were placed as distally as possible. This modification was applied during the latter half of the study period. Mobilization of the rectum with fixation to the mesh was introduced by Sullivan w12x. The reason being the wide and deep cul-de-sac present in most of these patients. Subsequently, the rectum abruptly folds backwards just above the perineum, which may be responsible for inadequate bowel function. By mobilizing the rectum, it is not only straightened but the bottom of the cul-de-sac is dramatically elevated. Mesh erosion is an unavoidable problem and the incidence of mesh related complications with sacrocolpopexy is 5–35% w24x. During the initial phase of our experience with sacrocolpopexy, we used non-absorbable mesh with 10% of the patients developing erosion. When using the semi-absorbable mesh, patients developing erosion decreased to only 1%. The main advantage of our colposacrosuspension (with Burch colposuspension) is the completeness of prolapse repair involving all the compartments, including repositioning of the rectum. Noticeable on follow-up were the normal length and angle of the vagina. It is a well-tolerated procedure with a low complication rate. However,
H.S. Cronje´ / International Journal of Gynecology and Obstetrics 85 (2004) 30–35
it involves major surgery and in compromised or elderly patients, less invasive procedures such as the vaginally performed paravaginal repair w25x. w14x
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