Urogynecology and Reconstructive Pelvic Surgery Edition 3

Urogynecology and Reconstructive Pelvic Surgery Third edition

1600 John F. Kennedy Blvd. Suite 1800 Philadelphia, PA 19103-2899 UROGYNECOLOGY AND RECONSTRUCTIVE PELVIC SURGERY Copyright © 2007, 1999, 1993 by Mosby Inc., an affiliate of Elsevier Inc.

ISBN-13: 978-0-323-02902-5 ISBN-10: 0-323-02902-7

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Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors assumes any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book. The Publisher

Library of Congress Cataloging-in-Publication Data Urogynecology and reconstructive pelvic surgery/[edited by] Mark D. Walters, Mickey M. Karram. – 3rd ed. p.; cm. Includes bibliographical references and index. ISBN 0-323-02902-7 1. Urogynecology. 2. Pelvis–Surgery. 3. Generative organs, Female–Surgery. I. Walters, Mark D. II. Karram, Mickey M. [DNLM: 1. Genital Diseases, Female. 2. Fecal Incontinence. 3. Urinary Incontinence. 4. Urodynamics. 5. Urogenital Surgical Procedures. 6. Uterine Prolapse. WJ 190 U775 2007] RG484.W35 2007 616.6–dc22 2006044898 Acquisitions Editor: Rebecca S. Gaertner Developmental Editor: Martha Limbach Project Manager: Bryan Hayward

Printed in The United States of America. Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Ginny, for over 20 years of love and friendship, and to my children, Samantha, Max, and Zoe, who continue to make me proud. Mark D. Walters In memory of my mother, Mary Karram, for her love, kindness and unselfish support. To my father, Mike Karram, Sr., for instilling in me the values of education, discipline, and hard work. Mickey M. Karram

Acknowledgments We would like to acknowledge the indispensable and exemplary work of Beth Dobish and Rose Sirks for the huge volume of administrative support and transcribing work involved in this book, and Joe Chovin from Cincinnati and

Ross Papalardo from Cleveland Clinic for their creation of particularly clear surgical, anatomic, and urodynamic drawings. We also wish to again thank Dr. Anne M. Weber for her invaluable medical editing of our manuscripts.

List of Authors Matthew D. Barber, MD

Kathryn L. Burgio, PhD

Director of Clinical Research Section of Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology Cleveland Clinic Cleveland, Ohio Neurophysiologic Testing for Pelvic Floor Disorders; Outcome and Quality-of-Life Measures in Pelvic Floor Research

Associate Director for Research Birmingham VA Medical Center Birmingham, Alabama Stress Urinary Incontinence and Pelvic Organ Prolapse: Nonsurgical Management

J. Thomas Benson, MD Clinical Professor, Department of Obstetrics and Gynecology Indiana University Medical Center Director of Obstetrics and Gynecology Education Methodist Hospital of Indiana Indianapolis, Indiana Neurophysiology and Pharmacology of the Lower Urinary Tract

Alfred E. Bent, MD, FRCSC Professor and Head, Division of Gynaecology Dalhousie University Department of Obstetrics and Gynaecology Halifax, Nova Scotia, Canada Endoscopic Evaluation of the Lower Urinary Tract; Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency

Jerry Blaivas, MD Clinical Professor of Urology Weill Medical College of Cornell University New York Presbyterian Hospital and Lenox Hill Hospital New York, New York Urodynamics: Cystometry and Urethral Function Tests

Raymond A. Bologna, MD Assistant Professor of Urology Northeastern Ohio University College of Medicine Akron, Ohio Painful Bladder Syndromes

Geoffrey W. Cundiff, MD Professor Department of Obstetrics and Gynecology University of British Columbia Vancouver, B.C., Canada Endoscopic Evaluation of the Lower Urinary Tract

Nicole Fleischmann, MD Assistant Professor Department of Urology Mount Sinai School of Medicine New York, New York Voiding Dysfunction and Urinary Retention

Tara L. Frenkl, MD, MPH Fellow, Female Pelvic Medicine and Reconstructive Surgery Glickman Urologic Institute Cleveland Clinic Cleveland, Ohio Sacral Neuromodulation Therapy

W. Thomas Gregory, MD Assistant Professor Division of Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology Oregon Health and Science University Portland, Oregon Obstetrics and Pelvic Floor Disorders vii

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List of Authors

Alexander G. Heriot, MD, MA, FRCS

Steven D. Kleeman, MD

Advanced Colorectal Fellow The Department of Colorectal Surgery Cleveland Clinic Cleveland, Ohio Rectal Prolapse

Assistant Professor Department of Obstetrics and Gynecology University of Cincinnati Cincinnati, Ohio Overactive Bladder Syndrome and Nocturia; Urinary Tract Infection

Wen-Chen Huang, MD Division of Urogynecology Department of Obstetrics and Gynecology Cathay General Hospital Taipei, Taiwan, Republic of China Radiologic Studies of the Lower Urinary Tract and Pelvic Floor

Tracy L. Hull, MD Head, Section of Anal Physiology Department of Colorectal Surgery Cleveland Clinic Cleveland, Ohio Fecal Incontinence

W. Glenn Hurt, MD Professor Department of Obstetrics and Gynecology Medical College of Virginia Richmond, Virginia Gynecologic Injury to the Ureters, Bladder and Urethra: Prevention, Recognition and Management

J. Eric Jelovsek, MD Section of Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology Cleveland Clinic Cleveland, Ohio Constipation

Mickey M. Karram, MD Director, Division of Urogynecology and Reconstructive Pelvic Surgery Good Samaritan Hospital Professor of Obstetrics and Gynecology University of Cincinnati School of Medicine Cincinnati, Ohio Urodynamics: Cystometry and Urethral Function Tests; Urodynamics: Voiding Studies; Sling Procedures for Stress Urinary Incontinence; Surgical Treatment of Vaginal Vault Prolapse and Enterocele; Obliterative Procedures for Vaginal Prolapse; Rectovaginal Fistula and Perineal Breakdown; Overactive Bladder Syndrome and Nocturia; Urinary Tract Infection; Lower Urinary Tract Fistulas

Tristi W. Muir, MD Assistant Professor Section of Female Pelvic Medicine and Reconstructive Surgery Department of Obstetrics and Gynecology Scott & White Clinic Temple, Texas Surgical Treatment of Rectocele and Perineal Defects

Edward R. Newton, MD Professor and Chairman Department of Obstetrics and Gynecology East Carolina University Greenville, North Carolina The Urinary Tract in Pregnancy

Victor W. Nitti, MD Associate Professor and Vice Chairman Director of Residency Training Department of Urology New York University School of Medicine New York, New York Voiding Dysfunction and Urinary Retention

Ingrid Nygaard, MD, MS Professor Department of Obstetrics and Gynecology University of Utah Salt Lake City, Utah Obstetrics and Pelvic Floor Disorders

Marie Fidela R. Paraiso, MD Section of Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology Cleveland Clinic Cleveland, Ohio Laparoscopic Surgery for Stress Urinary Incontinence and Pelvic Organ Prolapse; The Use of Biologic Tissue and Synthetic Mesh in Urogynecology and Reconstructive Pelvic Surgery

List of Authors

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Raymond R. Rackley, MD

Anthony P. Tizzano, MD

Co-Head, Section of Female Urology and Voiding Dysfunction Glickman Urological Institute Cleveland Clinic Cleveland, Ohio Sacral Neuromodulation Therapy

Wooster Clinic Wooster, Ohio Historical Milestones in Female Pelvic Surgery, Gynecology, and Female Urology

Feza H. Remzi, MD

Co-Head, Section of Female Urology and Voiding Dysfunction Glickman Urological Institute Cleveland Clinic Cleveland, Ohio Urethral Diverticula

Colorectal Surgeon Department of Colorectal Surgery Cleveland Clinic Cleveland, Ohio Rectal Prolapse

Holly E. Richter, PhD, MD Associate Professor Department of Medical and Surgical Gynecology University of Alabama–Birmingham Medical Center Birmingham, Alabama Stress Urinary Incontinence and Pelvic Organ Prolapse: Nonsurgical Management

Baha M. Sibai, MD Professor Department of Obstetrics and Gynecology University of Cincinnati Cincinnati, Ohio The Urinary Tract in Pregnancy

William Andre Silva, MD Pacific Northwest Gynecology Federal Way, Washington Obliterative Procedures for Vaginal Prolapse

Andrew M. Steele, MD Department of Obstetrics, Gynecology and Women's Health Saint Louis University School of Medicine St. Louis, Missouri Case Presentations with Expert Discussions

Kevin J. Stepp, MD Urogynecology and Reconstructive Pelvic Surgery MetroHealth Medical Center Cleveland, Ohio Anatomy of the Lower Urinary Tract, Rectum, and Pelvic Floor

Carmen J. Sultana, MD Assistant Professor Thomas Jefferson Medical College Philadelphia, Pennsylvania Bladder Drainage and Urinary Protective Methods

Sandip P. Vasavada, MD

Mark D. Walters, MD Head, Section of General Gynecology, Urogynecology and Reconstructive Pelvic Surgery Department of Obstetrics and Gynecology Cleveland Clinic Cleveland, Ohio Anatomy of the Lower Urinary Tract, Rectum, and Pelvic Floor; Neurophysiology and Pharmacology of the Lower Urinary Tract; Description and Classification of Lower Urinary Tract Dysfunction and Pelvic Organ Prolapse; Evaluation of Urinary Incontinence and Prolapse: History, Physical Examination, and Office Tests; Radiologic Studies of the Lower Urinary Tract and Pelvic Floor; Pathophysiology of Urinary Incontinence; Retropubic Operations for Stress Urinary Incontinence; Sling Procedures for Stress Urinary Incontinence; Surgical Correction of Anterior Vaginal Wall Prolapse; Surgical Treatment of Vaginal Vault Prolapse and Enterocele; Case Presentations with Expert Discussions

Anne M. Weber, MD Pelvic Floor Disorders Program National Institutes of Health Bethesda, Maryland Epidemiology and Psychosocial Impact of Pelvic Floor Disorders

James L. Whiteside, MD Assistant Professor Dartmouth-Hitchcock Medical Center Dartmouth Medical School Lebanon, New Hampshire Pathophysiology of Urinary Incontinence; The Effects of Gynecologic Cancer on Lower Urinary Tract Function

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List of Authors

Kristene E. Whitmore, MD Clinical Associate Professor Department of Urology Drexel University Director, Pelvic and Sexual Health Institute Graduate Hospital Philadelphia, Pennsylvania Painful Bladder Syndromes

Massarat Zutshi, MD Clinical Associate Department of Colorectal Surgery Cleveland Clinic Cleveland, Ohio Fecal Incontinence We wish to specially acknowledge the following physicians who we believe represent some of the true experts in the fields of urogynecology/reconstructive pelvic surgery, urology, and colorectal surgery, and who reviewed the case presentations in Chapter 40 and provided their opinions.

Michael P. Aronson, MD, Worcester, Massachusetts

John B. Gebhart, MD, Rochester, Minnesota Howard B. Goldman, MD, Cleveland, Ohio Cheryl B. Iglesia, MD, Washington, DC Lisa C. Labin, MD, Worcester, Massachusetts Fah Che Leong, MD, St. Louis, Missouri Christopher F. Maher, MD, Brisbane, Australia Mary T. McLennan, St. Louis, Missouri G. Rodney Meeks, MD, Jackson, Mississippi John R. Miklos, MD, Atlanta, Georgia Ingrid Nygaard, MD, Salt Lake City, Utah Rachel Pauls, MD, Cincinnati, Ohio Rebecca G. Rogers, MD, Albuquerque, New Mexico

Matthew D. Barber, MD, Cleveland, Ohio

Carlos J. Sarsotti, MD, Buenos Aires, Argentina

Alfred E. Bent, MD, Halifax, Canada

Bobby Shull, MD, Temple, Texas

Linda Brubaker, MD, Chicago, Illinois

Andrew C. Steele, MD, St. Louis, Missouri

Richard C. Bump, MD, Indianapolis, Indiana

James P. Theofrastous, MD, Asheville, North Carolina

Susan M. Congilosi, MD, Minneapolis, Minnesota Jeffrey L. Cornella, MD, Scottsdale, Arizona Patrick J. Culligan, MD, Morristown, New Jersey Geoffrey W. Cundiff, MD, Vancouver, B.C., Canada Peter L. Dwyer, MD, Melbourne, Australia Stephen P. Emery, MD, Pittsburgh, Pennsylvania

Paul K. Tulikangas, MD, Hartford, Connecticut Sandip P. Vasavada, MD, Cleveland, Ohio Brett J. Vassallo, MD, Park Ridge, Illinois Anthony G. Visco, MD, Chapel Hill, North Carolina

Andrew J. Walter, MD, Sacramento, California

Foreword During the past 30 years the management of disorders of the pelvic floor has assumed an increasingly important role for gynecologists, urologists, and colon and rectal surgeons. Organizations such as the American Urogynecologic Society and the Society of Gynecologic Surgeons were formed to provide a more structured environment for physicians, nurses, and other medical providers to share their experiences in the care of women with disorders of the pelvic floor. Internationally, organizations such as the International Continence Society and the International Urogynecologic Association have provided a similar forum for physicians worldwide. Drs. Mark Walters and Mickey Karram are leaders who have been recognized nationally and internationally for their contributions to patient care, education, and research. Their book, Urogynecology and Reconstructive Pelvic Surgery, has been an invaluable reference for doctors around the world. In their Third Edition, Drs. Walters and Karram have assembled a multidisciplinary group of authors who represent the perspective of all surgical specialists involved in the care of women with disorders of the pelvic floor. All of the authors are individually committed to excellence in patient care, education, and research. Many of the current and future leaders in our discipline have been educated under the tutelage of these men and women. The current edition has been updated to include discussions on the use

of materials and mesh in reconstructive surgery, the place of neuromodulation in disorders of the pelvic floor, and a chapter on outcomes analysis and the evaluation of qualityof-life measures and research. I personally have found their text to be valuable not only in the care of my own patients, but in the education of residents, fellows, and practitioners. The section on case presentations with expert discussion in particularly valuable because of its clinical relevance. Drs. Walters and Steele have assembled a group of well-respected experts to give their opinions on the management of problems that many of us face on a regular basis. I find the format of the text to be very satisfying, beginning with an overview of the history of the subject matter followed by a discussion of the pathophysiology, the clinical evaluation, and the clinical treatment options available to our patients. The inclusion of discussion of research methods is timely and appropriate. My hope is that, in the future, investigators will have learned enough about the pathophysiology of disorders of the pelvic floor that we can have a chapter on prevention strategies. As Drs. Walters and Karram and their contributing authors continue to educate future clinicians and scientists, prevention is a realistic goal. Bob L. Shull, M.D. Professor of Obstetrics and Gynecology Scott & White Clinic and Hospital

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Preface As the population lives longer and has improved health, the prevalence of various pelvic floor disorders is increasing. The term pelvic floor disorders incorporates a broad array of inter-related clinical conditions that includes urinary incontinence, pelvic organ prolapse, fecal incontinence, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, and sexual dysfunction. More than half of women experience one or more of these disorders for some period in their lives, and one in nine will undergo surgery for pelvic floor abnormalities by age 80. Economic analyses estimate that the total annual cost of urinary incontinence in the United States alone is up to $19.5 billion. Beyond the economic costs and general health care burden, pelvic floor disorders result in significant psychosocial costs and can have a profound impact on an individual's quality of life. Women desire and are able to remain active longer and are less interested in tolerating the lower quality of life that accompanies these conditions. This leads to a greater number of otherwise healthy women presenting to their physicians with various pelvic floor disorders. It is estimated that the growth and demand for services to care for women with pelvic floor disorders will increase at twice the rate of growth of the population over the next 30 years. International interest in diseases of women and older persons in general has helped to increase awareness of the high prevalence of urinary and fecal incontinence in women. Clinical care guidelines were developed by the National Institute on Aging and the Office of Medical Application of Research within the National Institutes of Health in conjunction with other agencies. This was followed by expanded national research funding; the resulting research data and manuscripts are now gradually being reported. The demographics of incontinence also have stimulated corporate interest, and many new drugs, products, and surgical devices for the evaluation and treatment of pelvic floor disorders have been or are being developed. Recent popularity and increased circulation of journals such as International Urogynecology Journal (Springer Publishing) and Neurourology and Urodynamics (Wiley Publishing) underscore the heightened level of interest among clinicians and researchers. Furthermore, the expanding membership and attendance at annual meetings of the American Urogynecology Society (AUGS), the International Continence Society (ICS), and

the International Urogynecology Association (IUGA) are evidence to this specialty's popularity. The First International Consultation on Incontinence held in 1998 in Monaco further highlighted the plight of some 200 million sufferers from urinary incontinence worldwide. The Third Consultation on Incontinence was held in June 2004 and was represented by an international faculty of almost 200 individuals from a wide range of professions and specialties. The spectrum of subcommittees spanned all of the basic and clinical problems of pelvic floor disorders and led to a recent comprehensive publication from this group. There continues to be a widespread need for education and training in urogynecology and reconstructive pelvic surgery for practicing generalists and residents in obstetrics and gynecology. More physicians with special expertise in urogynecology and vaginal and laparoscopic surgery are needed to meet the increasing patient volume and the additional training needs within this specialty. Over the last 10 years, the specialty of Urogynecology—since renamed Female Pelvic Medicine and Reconstructive Surgery—has expanded to a fourth subspecialty approved by the American Board of Obstetrics and Gynecology. Formal 3-year fellowships conform with the other subspecialties and allow for advanced training and research. This updated textbook is an effort to address the educational needs of physicians and advanced care practitioners interested in female pelvic floor disorders and to serve as a core reference text in urogynecology and reconstructive pelvic surgery. The third edition of Urogynecology and Reconstructive Pelvic Surgery is a clinically oriented yet comprehensive textbook addressing our subspecialty. We believe that this subject fundamentally encompasses three main topics: female urinary incontinence and voiding dysfunction, pelvic organ prolapse, and disorders of defecation. This book is separated into nine sections. Chapter 1 is a new chapter reviewing historical milestones in pelvic surgery and female urology. Chapters 2 through 5 describe in detail basic principles and subjects needed to understand and treat disorders of the lower urinary tract and pelvic floor. Chapters 6 through 11 outline basic and advanced concepts in the evaluation of lower urinary tract and pelvic floor disorders in woman. Chapters 12 through 23 present management guidelines for women with stress urinary incontinence and pelvic organ prolapse. Chapters xiii

xiv

Preface

24 through 27 address disorders of defecation. Chapters 28 through 31 address the subjects of overactive bladder and painful and irritative voiding disorders, as well as their expanding list of innovative treatments. Chapters 32 through 38 discuss specific conditions and special subjects that are occasionally encountered by physicians treating patients with pelvic floor disorders. In a new section, Chapter 39 reviews important research methods regarding outcome analysis and quality-of-life measures in pelvic floor research. Finally, using an innovative and popular format, Chapter 40 presents a series of 19 interesting and difficult cases, with opinions from international experts in urogynecology, urology, colorectal surgery, and obstetrics. The Third Edition has been expanded to include historical highlights, neurophysiologic testing and more complete information on neuromodulation therapy, the latest information on the use of biologic and synthetic prosthesis

in urogynecologic and reconstructive pelvic surgery, and important concepts on research methods in pelvic floor research. Because female incontinence is best managed in a multidisciplinary fashion, recognized authorities in urology, maternal fetal medicine, and colorectal surgery have contributed chapters related to their particular areas of expertise. Some of the original drawings from the First and Second Editions are retained, but a large number of new anatomic and surgical drawings were added. We hope that this book will meet the training needs of residents in obstetrics and gynecology, urology, and other specialties and can be used by fellows in Female Pelvic Medicine and Reconstructive Surgery and Female Urology as an important reference text. We also hope that generalists and urogynecologists alike will find it interesting and useful as they strive to take better care of their patients.

Historical Milestones in Female Pelvic Surgery, Gynecology, and Female Urology

1

Anthony P. Tizzano

ON THE SHOULDERS OF GIANTS: AN INTRODUCTION 1 GYNECOLOGY IN ANTIQUITY: THE EBERS PAPYRUS TO THE 5TH CENTURY 1 MEDIEVAL MEDICINE: THE AGE OF FAITH (AD 476 TO 1453) 1 THE RENAISSANCE: 1453 TO 1600 4 THE SEVENTEENTH CENTURY: THE CLARIFICATION OF ANATOMY, EMBRYOLOGY, AND PHYSIOLOGY 4 THE EIGHTEENTH CENTURY: THE OLD VERSUS THE NEW 4 THE NINETEENTH CENTURY BEFORE THE ASEPTIC AGE: THE RISE OF GYNECOLOGY 7 THE MID-NINETEENTH CENTURY: THE DAWN OF ASEPTIC SURGERY 8 THE TWENTIETH CENTURY: A SUBSPECIALTY EVOLVES 11

GYNECOLOGY IN ANTIQUITY Gynecology in antiquity finds its roots in the Ebers papyrus (1500 bc) that portrayed the uterus as a wandering animal— usually a tortoise, newt, or crocodile—capable of movement within its host. Hippocrates perpetuated this animalistic concept, stating that the uterus often went wild when deprived of male semen. He provided the earliest description of a pessary, using a pomegranate to reduce uterine prolapse and using catheters fashioned from tin and lead to irrigate and drain the uterus. The seven cells doctrine of the Common Era replaced the animalistic concept, depicting the uterine cavity as being divided into seven compartments whereby male

ON THE SHOULDERS OF GIANTS From the earliest days of recorded medical history, physicians struggled with the problems of pelvic organ prolapse (Fig. 1-1), urinary incontinence, and vesicovaginal fistula. An inadequate understanding of pelvic anatomy plagued practitioners before the nineteenth century. Ignorance of asepsis, the absence of anesthesia, faulty suture materials, inadequate instrumentation, and suboptimal exposure delayed any consistent success until the mid-nineteenth century. The evolution of pelvic surgery from the Hippocratic age to the antiseptic period is a fascinating one, where original theories occasionally fell from favor only to be resurrected and popularized by subsequent generations. Equally intriguing is the development of a wide array of innovative instrumentation and materials that often paralleled many surgical advances. This chapter is an attempt to touch upon the milestones that occurred along the way and to pay homage to the pioneers who helped shape a specialty and upon whose shoulders we stand. The author's selection of important milestones in our specialty up to 1961 is shown in Table 1-1. Note that this chapter emphasizes American contributions and milestones that influenced contemporary thought, patient care, and surgical practices. I am grateful for the works of Dr. Thomas Baskett, Dr. James V. Ricci, and, particularly, Dr. Harold Speert, whose extensive research on the subject made this chapter possible.

Figure 1-1 ■ Sixteenth-century woodcut showing examination of women with uterine prolapse. (From Stromayr C. Die Handschrift des Schnitt-und Augenarzles Caspar Stromayr, Lindau Munscript, 1559.)

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Part 1

Table 1–1

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History

Timeline of Milestones Related to Pelvic Surgery and Female Urology

Second half of first century AD Soranus’s (De Morbis Mulierum) first good description of the human uterus. 1561 First accurate description of the human oviduct. Observationes Anatomicae by Gabriele Falloppio. 1672 First accurate account of the female reproductive organs and ovarian follicles (“Graafian Follicles”) De Mulierum Organis Generationi Inservientibus by Regnier de Graaf. 1677 Description of the vulvovaginal glands,”Bartholin Glands.” De Ovariis Mulierum by Caspar Bartholin. 1691 Description of the female inguinal canal. Adenographia by Anton Nuck. 1705 François Poupart describes the inguinal ligament and its function. 1727 Jacques Garengeot modifies a trivalve speculum to better differentiate ”vaginal hernias” during pelvic examination. 1737 Description of the peritoneum and posterior cul-de-sac. A Description of the Peritoneum by James Douglas. 1759 Description of the embryonic mesonephros or ”Wolffian Body and Duct.” Theoria Generationis by Caspar Fredrich Wolff. 1774 William Hunter completes his monumental work, Anatomy of the Gravid Uterus, which remains the finest work on uterine anatomy to date. 1801 Joseph Claude Récamier popularizes the use of a tubular vaginal speculum to treat ulcers and infections of the vagina and cervix. 1803 Pieter Camper describes the superficial layer of abdominal fascia. 1804 Astley Paston Cooper describes the ligamentous covering of the pubis and its condensation above the linea ileo-pectinea as it extends from the pubis outward. 1805 Philipp Bozzini introduces his lichtleiter (light conductor), the earliest endoscope. 1809 Ovariotomy is performed by Ephraim McDowell. 1813 Conrad Johann Martin Langenbeck carries out the first planned and successful vaginal hysterectomy. 1825 Marie Anne Victorie Boivin devises the bivalve vaginal speculum. 1836 Charles Pierre Denonvilliers describes the rectovesical fascia. 1838 John Peter Mettauer uses lead sutures to perform the first surgical correction of vesicovaginal fistula in the United States. 1849 Anders Adolf Retzius describes prevesical space. 1852 James Marion Sims describes his knee-chest positioning of patients for vesicovaginal fistula repair. 1860 Hugh Lenox Hodge details the use of his pessary to correct for uterine displacement. 1877 Léon Le Fort describes his method of partial colpocleisis as a simple and safe means for treatment of uterine prolapse. 1877 Max Nitze introduces an electrically illuminated cystoscope. 1878 T.W. Graves designs a speculum that combines features of both bivalve and Sims’s specula. 1879 Alfred Hegar introduces his metal cervical dilator to replace laminaria. 1890 Friedrich Trendelenburg describes his technique for positioning patients to facilitate a transvesical approach in the repair of vesicovaginal fistula. 1893 Howard Atwood Kelly devises the air cystoscope for inspection of the bladder and identification and catheterization of the ureters. 1895 Alwin Mackenrodt provides a comprehensive and accurate description of the pelvic connective tissue and correlation with pelvic prolapse. 1898 Ernst Wertheim performs radical hysterectomy for cervical cancer. 1899 Thomas James Watkins performs an ”interposition” operation for treatment of uterine prolapse associated with cystocele. Thus, the uterus is brought forth through an anterior colpotomy incision and sutured under the anterior vaginal wall, with the cervix secured posteriorly. The markedly anteverted uterus essentially pivots on twisted broad ligaments, thus producing antagonistic forces, because any dropping of the bladder increases the anterior displacement of the uterus, and any prolapse of the uterus elevates the cystocele. 1900 David Todd Gilliam describes his method of uterine ventrosuspension, whereby he ligated the proximal round ligament and attached it to the anterior rectus sheath lateral to the rectus muscle. 1900 Hermann Johannes Pfannenstiel introduces a transverse incision for laparotomy. 1901 Alfred Ernest Maylard advocates the oblique transection of the rectus muscles to improve exposure. 1901 John Clarence Webster and John Baldy introduce their suspension technique for correction of uterine retroversion, whereby the proximal round ligament is brought under an opening made under the utero-ovarian ligament and, ultimately, secured at just above the uterosacral ligament. 1909 George Reeves White noted that certain cases of cystocele were due to lateral paravaginal defects and thus could be repaired by reconnecting the vagina to the ”white line” of the pelvic fascia. 1910 Max Montgomery Madlener introduces a popular female sterilization technique using ligation of the tube alone. 1911 Max Brödel becomes head of the world’s first Department of Medical Illustration at Johns Hopkins University. 1912 Alexis Victor Moschcowitz describes the passage of silk sutures around the cul-de-sac of Douglas to prevent prolapse of the rectum. 1913 Howard Atwood Kelly describes the Kelly plication stitch, a horizontal mattress stitch placed at the urethrovesical junction to plicate the pubocervical fascia and ”reunite the sphincter muscle.” 1914 Wilhelm Latzko describes a technique for vaginal closure of vesicovaginal fistula following hysterectomy. 1915 Arnold Sturmdorf introduces his tracheloplasty technique. 1917 W. Stoeckel is the first to successfully combine a fascial sling and sphincter plication for treatment of stress urinary incontinence. 1929 Ralph Hayward Pomeroy devises a method of female sterilization involving ligation and resection of the tube. 1940 Noble Sproat Heaney describes his technique for vaginal hysterectomy using a clamp, needle holder, and retractor of his own design. His method for closing the vaginal cuff that incorporates peritoneum, vessels, and ligaments is known as the ”Heaney stitch.” 1941 Leonid Sergius Cherney suggests a modified low transverse abdominal incision, whereby the rectus muscle is cut at its very insertion into the pubis to provide better access to the space of Retzius. 1941 Raoul Palmer popularizes the use of the laparoscope in gynecology. 1942 Albert H. Aldridge reports on rectus fascia transplantation as a sling for relief of stress urinary incontinence. 1946 Richard W. TeLinde continues the Johns Hopkins legacy in gynecology with the introduction of his text, Operative Gynecology. 1948 Arnold Henry Kegel describes his progressive resistance exercise to promote functional restoration of the pelvic floor and perineal muscles. 1949 Victor Marshall, with Marchetti and Krantz, describe retropubic vesicourethral suspension for stress urinary incontinence. 1957 Milton L. McCall describes his posterior culdoplasty to prevent or treat enterocele formation at vaginal hysterectomy. 1961 John Christopher Burch introduces his method of urethrovaginal fixation for treatment of stress urinary incontinence.

Chapter 1

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Historical Milestones in Female Pelvic Surgery, Gynecology, and Female Urology

embryos developed on the right, females on the left, and hermaphrodites in the center. Similar notions remained popular until the Middle Ages. Soranus of Ephesus (ad 98 to 138) is commonly considered the foremost gynecologic authority of antiquity. He described the uterus based on human dissection and performed a hysterectomy for uterine prolapse. His writings provided the foundation for gynecologic texts up to the seventeenth century. The ancients used instruments fashioned from tin, iron, steel, lead, copper, bronze, wood, and horn. Those made of iron and steel were likely quite popular, but very few survived the oxidation of more than two millennia. Gynecologic instruments from the first century bc were unearthed at Pompeii, including forceps, catheters, scalpels, as well as massive bivalve, trivalve, and quadrivalve vaginal specula.

MEDIEVAL MEDICINE The medieval period (Middle Ages) (ad 476 to 1453), from the Fall of Rome to the Goths to the Fall of Constantinople to the Turks, are often referred to as the Age of Faith or Era of Monastatic Medicine, when confidence in any one individual was replaced by divine trust. As such, St. Benedict, founder of the Benedictine Order, encouraged his monks to tend to the sick but forbade any formal study of medicine. The struggle against leprosy, plagues, and prostitution was the focus of the day, and little was added to the fund of medical knowledge. Surgery rarely took place during the period, and the majority of physicians were itinerant practitioners, many of whom were quacks and charlatans.

THE RENAISSANCE The Renaissance period was marked by the rebirth of individualism and the release from the ban of authority. The rise of universities, the printing press, and the subsequent emergence of self-education elevated medicine to the next level and provided for a clearer understanding of female anatomy. Leonardo da Vinci (1452–1519), founder of iconographic and physiologic anatomy, provided the basis for modern anatomic illustration. His illustrations of female pelvic anatomy provide the earliest accurate descriptions of the fetus in utero. Unfortunately, his sketches were seen by only a few of his contemporaries and were not published until the end of the nineteenth century. The first authenticated report of vaginal hysterectomy was given by Giacomo Berengario Da Capri (1470–1550) in 1521. He described two cases: one performed by him in 1507 and the other by his father. Ambrose Paré (1510–1590), a renowned military surgeon of the period, was the first to introduce vascular ligatures for hemostasis in place of cautery. However, the use of ligatures was not popularized until Baron Joseph Lister (1827–1912), a British surgeon, introduced a longer lasting aseptic suture in the mid-nineteenth century. Andreas Vesalius (1514–1564) commissioned Jan Stefan van Kalkar to produce the most famous anatomic illustrations of all time, revolutionizing the science of anatomy and

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the manner in which it was taught. He was among the first to successfully challenge the teachings of Galen (ancient Greek physician) and asserted that the physician must perform cadaver dissection firsthand to learn the art. Hence, Vesalius made human dissection a viable and respectable profession. His illustrations provided an accurate description of the entire female urogenital tract and its vasculature, depicting the left ovarian vein entering the left renal vein for the first time. Distinguished pupils of Vesalius include Gabriele Falloppio (1523–1562), who provided the earliest accurate description of the human oviduct and who described the clitoris as a vasomuscular structure. Another pupil was Matthaeus Columbus (1484–1559), who is credited with the earliest use of the term labia, which he considered essential in protecting the uterus from dust, cold, and air. Last, his student Bartolomeo Eustachio (1520–1574) furnished the earliest accurate delineation of the uterine cavity and cervical canal. Among the more comprehensive accounts of sixteenth century gynecologic surgery is Caspar Stromayr's Practica Copiosa, which contains beautifully executed watercolors depicting diseases of women. Included are illustrations of the examination of uterine prolapse and placement of a pessary comprised of sponge bound by twine, sealed with wax, and dipped in butter (Figs. 1-2 and 1-3). Despite the many advances regarding pelvic anatomy during the Renaissance, the approach to most gynecologic problems changed very little from that which was popular during the classical period.

THE SEVENTEENTH CENTURY Throughout the seventeenth century, theories regarding physiology, generation, and anatomy were clarified. Regnier de Graaf (1641–1673) described ovarian follicles and uterine fibroids and provided the first accurate account of the ovary's gross morphology, anatomic relations, and function. Pelvic surgery and instruments of the period are nicely portrayed by the engravings of Johannes Scultetus (1595–1645) in his Armamentarium Chirurgicum. He was the first to use a series of illustrations to provide a stepwise account of surgical procedures (Fig. 1-4). Included are examples of treatment of imperforate hymen, hematocolpos, clitoral hypertrophy, and the use of a T-binder following vaginal surgery.

THE EIGHTEENTH CENTURY The eighteenth century might be best characterized by the constant conflict that occurred between old and new ideas. As such, relatively few advances occurred in medicine while numerous notable contributions were made in the fields of natural philosophy, including microscopy, physics, and biology. Surgery during the century began to rise above the skills of an individual surgeon with the founding of surgical societies and the publishing of various medical journals. Physicians, however, remained under close public scrutiny at the hands of popular medical caricaturists, such as Thomas Rowlandson. Many outstanding contributions were made toward the

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Figure 1-4 ■ Seventeenth-century woodcut illustrating incision and drainage of a hematocolpos. (From Schultes J. Armamentarium Chirurgicum. Ulmae Suevorum, Balthasari, 1655.)

Figure 1-2 ■ Sixteenth-century woodcut depicting placement of a pessary to treat uterine prolapse. (From Stromayr C. Die Handschrift des Schnitt-und Augenarzles Caspar Stromayr, Lindau Munscript, 1559.)

Figure 1-3 ■ Sixteenth-century woodcut showing a pessary fashioned from a sponge, bound by twine, covered in wax, and dipped in butter before placement. (From Stromayr C. Die Handschrift des Schnitt-und Augenarzles Caspar Stromayr, Lindau Munscript, 1559.)

understanding of pelvic anatomy. In 1730, James Douglas gave the first adequate description of the peritoneum that helped to pave the way for retroperitoneal surgery and the concomitant decrease in peritonitis that typically plagued abdominal procedures during that time. Later, in 1774, William Hunter (1718–1783) completed his monumental work, Anatomy of the Gravid Uterus. Thanks to the artistic talent of Jan van Rymsdyk, many regard this work as the finest anatomical atlas ever produced, including Choulant (1791–1861), who described it as “anatomically exact and artistically perfect.” Vaginal specula continued to evolve with a modification in 1727 by RenéJacques-Croissant de Garengeot (1688–1759), who devised blades with a distinctly concave surface. Garengeot used the speculum for vaginal examinations and to differentiate the various “vaginal hernias” (presumably cystocele and rectocele) (Fig. 1-5) (Ricci, 1948–1949).

Figure 1-5 ■ Eighteenth-century vaginal speculum used to differentiate the various “vaginal hernias.”

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THE NINETEENTH CENTURY BEFORE THE ASEPTIC AGE Before the nineteenth century, surgical attempts at managing uterine prolapse and cervical disease were, for the most part, limited to amputation of the cervix. In 1813, Conrad Langenbeck (1776–1851) performed the first planned and successful vaginal hysterectomy. Moreover, he did so alone and without the benefit of anesthesia. “At one point Langenbeck was left clutching the bleeding area in one hand and holding one end of the ligature in his teeth while tying the other end with his right hand” (Baskett, 1996). The following occurred in America during the first half of the nineteenth century, before the aseptic age: Ephraim McDowell performed an ovariotomy in 1809; William Dewees published the first American textbook on gynecology in 1826; and James Marion Sims (Fig. 1-6) described the treatment of vesicovaginal fistula in 1838. The first successful operation for vesicovaginal fistula used lead suture and is believed to have been performed in August 1838 by John Peter Mettauer (1787–1875), a Virginia gynecologist. However, the first published report of an acceptable result did not appear until a year later when George Hayward, unaware of Mettauer's success and using silk for his repair, performed eight operations that resulted in only two cures, at the Massachusetts General Hospital. Mettauer is also credited with the introduction of metallic suture and a retention catheter.

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Surgical instruments manufactured during the preseptic era, which finally came to a close around 1890, were nothing short of extraordinary in terms of variety and beauty. “Surgical instruments made before 1890 exhibited standards of workmanship, fit, finish and overall artistry that were later sacrificed in the production of aseptic instruments. Moreover, instruments of the earlier period frequently incorporated rare and beautiful materials in their design, including ebony, tortoise shell, ivory, agate, gold and silver” (Edmonson, 1997). Among the most notable examples was the vaginal speculum that, as described by Ricci (1948–1949), continued to evolve with literally hundreds of modifications by inventors in an attempt to enhance exposure. Charriere introduced a novel form designed for use as a bivalve, threeblade, or four-blade speculum (Fig. 1-7) in 1838. The more familiar “duckbill” design used by clinicians today was initially put forth by Edward Gabriel Cusco in 1870. However, the most popular speculum currently in use was designed by T.W. Graves, a general practitioner from Massachusetts, and introduced more than a century ago in 1878. In 1845, Sims began a series of surgical experiments on his now legendary slaves, Anarcha, Betsy, and Lucy, who suffered from vesicovaginal fistulas. After nearly 40 fruitless attempts at fistula repair, over the course of 6 years, Sims finally succeeded. His triumph was due, in part, to his use of silver sutures and the exposure afforded him by a speculum of his own design and used with the patient in knee-chest position. Sims originally reported on his technique in January 1852 and then more formally in Silver Sutures in Surgery, his 1857 discourse before the New York Academy of Medicine. An immodest man, Sims declared, “Silver as a suture is the greatest surgical achievement of the century.” In a subsequent narrative Sims described the events surrounding his conception of the “Sims knee-chest position” (Fig. 1-8): “Full of thought I hurried home and the patient (with the vesicovaginal fistula) was placed in the position described, with an assistant on each side to elevate and retract the nates. I cannot, nor is it needful to describe my emotions, when the air rushed in and dilated the vagina to its greatest capacity, whereby its whole surface was seen at one view, for the first time by any mortal man. With this sudden flash of light, with the fistulous opening seen in its proper relations, all the principles of the operation were presented to my mind. And thus, in a moment, in the twinkling of an eye, new hopes and aspirations filled my soul, for a flood of dazzling light had suddenly burst upon my enraptured vision, and I saw in the distance the great and

Figure 1-6 ■ James Marion Sims (1813–1883). (From Clinical Notes on Uterine Surgery. London, 1866.)

Figure 1-7 ■ Four-valve vaginal speculum with detachable blades by Charriere, circa 1850, private collection.

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Figure 1-8 ■ Sims knee-chest position. (From Bourgery JM. Traitem Complet de L'Anatomie de L' Homme Comprenant la Medicine Operatorie. Guerin, Paris, 1866–1868.)

glories triumph that awaited determined and persevering effort. I thought only of relieving the loveliest of all God's creations of one of the most loathsome maladies that can possibly befall poor human nature…. Full of sympathy and enthusiasm, I found myself running headlong after the very class of sufferers that I had all of my professional life most studiously avoided.”

sized lithographs, nearly all of which are in the very realistic style of Nicolas Jacob” (Roberts and Tomlinson). Figure 1-9, A–C shows an example of Bourgery's work illustrating Sims's operation for vesicovaginal fistula. (Also see Color Plate 1.) The latter half of the century is marked by many noteworthy contributions to pelvic surgery and an improved understanding of pelvic anatomy. Anders Adolf Retzius defined the boundaries of the prevesical space in 1849. In 1877, Léon Clément Le Fort (1829–1893) described his procedure for partial colpocleisis, which continues to provide a simple and safe way to manage uterine prolapse in the highrisk patient. Alwin Mackenrodt (1859–1925) (Fig. 1-10) elegantly described the cause and cure of uterine prolapse in 1895 and put forth an accurate description of the pelvic connective tissue, including the transverse cervical or cardinal ligaments (Mackenrodt's ligaments) (Fig. 1-11). Soon thereafter, Archibald Donald (1908) and William Fothergill (1915) developed the Manchester operation, uniting parametrial and paravaginal tissues to one another anterior to the cervix to effectively counter uterine prolapse. Thomas Watkins proposed a novel approach to uterine prolapse and cystocele reduction by using the uterus as a prosthesis. He introduced his interposition operation in 1898, contending that it was ill-advised to remove the uterus in any case of

Although one may argue that Sims was not the first to use silver sutures in surgical repairs, most will concede that he was the first to combine the essentials for cure and thus popularize one of the first major innovations in pelvic surgery. Within the same decade, Washington Atlee performed a myomectomy in 1844, and Walter Burnham conducted the first successful abdominal hysterectomy in 1853.

THE MID-NINETEENTH CENTURY During the later half of the nineteenth century, the requisites for advancement of surgery began to fall into place. These included adequate anesthesia, antisepsis, and acceptable suture materials. Throughout the latter half of the century, the evolution of pelvic surgery gained momentum because advances in gynecologic therapy were unparalleled in the entire realm of medicine. For more than two millennia, therapy was primarily medical and, in less than half a century, it became surgical and spectacular. The rapidly increasing frequency of successful surgery was made possible by the advent of adequate anesthesia in 1846, Joseph Lister's treatise on asepsis in 1867, and his introduction of aseptic suture (silk soaked in carbolic) in 1869. The extraordinary range of pelvic surgical techniques performed before the last quarter of the nineteenth century is beautifully illustrated in Jean-Baptiste Marc Bourgery's and Nicolas Henri Jacob's magnificent Traite complet de l' anatomie comprenant la medicine operatorie (1831–1854). “In the entire literature of medicine during the nineteenth century there is nothing that compares with the 749 hand-colored folio-

Figure 1-9 ■ A series of watercolor lithographs depicting Sims's operation for vesicovaginal fistula. (From Bourgery JM. Traitem Complet de L'Anatomie de L' Homme Comprenant la Medicine Operatorie. Guerin, Paris, 1866–1868.) A. Trimming the edge of vesicovaginal fistula. (Note silver catheter in place.)

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cont’d B. Placement of silver sutures. C. Completed closure of fistula. (See Color Plate 1.)

prolapse unless it was diseased. Thus, through an anterior colpotomy incision, Watkins brought the uterus forward such that the bladder rests on the posterior wall of uterus, thereby elevating the lower uterine segment and creating antagonistic forces between the prolapsing bladder and uterus. During the same year, Ernst Wertheim (1864–1920) introduced and, ultimately, popularized radical hysterectomy to the extent that the procedure became known as the Wertheim operation (1900). The popularity of pessaries flourished throughout the latter half of the century because practitioners were apparently concerned with uterine malposition (Fig. 1-12; Color Plate 2). In 1860 Hugh Lenox Hodge (1796–1873) spoke for many gynecologists of the era, when he stated: “The mechanical treatment of uterine displacements by intravaginal supports is essential, a ‘sine qua non,’ for their perfect relief; that by pessaries, of suitable material, size and form, the uterus may very generally be replaced and be maintained in situ; that the local symptoms of weight, pain, etc., the leukorrhea, the menorrhagia, the dysmenorrhea, and all the innumerable direct and indirect symptoms of spinal and cerebral irritation, including neuralgia, nervous headache, nervous affections of the larynx, lungs, heart, stomach, bowels, etc., and also spasms, cramps, and convulsions, may often thus be dissipated; that the intellectual and spiritual being may be elevated from the lowest states of depression, bordering on melancholy,

or delivered from the highest degree of maniacal excitement. Patients often are amazed at their own altered sensations; they can hardly realize their identity—feeling as if they were either renovated, or that they had been transported to a ‘new world.’” Among the most important diagnostic and operative innovations of the century occurred in 1877, when Max Nitze (1848– 1906) introduced an electrically illuminated cystoscope. This made possible great improvements in surgery, including excision of bladder tumors in situ and endoscopic photography. Shortly afterward, in 1893, Howard Atwood Kelly (1858–1943) (Fig. 1-13) introduced his air cystoscope and published a bulletin on aeroscopic examination of the female bladder and the catheterization of the ureters under direct inspection (Figs. 1-14 and 1-15). His innovation occurred, in part, by accident while using a water cystoscope in the kneechest position. The instrument apparently fell to the floor, breaking the glass diaphragm. Kelly reintroduced the cystoscope into the bladder without its glass diaphragm, and the bladder immediately distended with air permitting visualization of its interior and ureteric orifices. Kelly's two-volume Operative Gynecology (1898), Medical Gynecology (1908), and Diseases of the Kidneys, Ureters, and Bladder (with Burnam, 1914)—the latter distinguished by the great illustrations by the German artist Max Brödel (1870–1941)—defined the specialty and laid the foundation for progress well into the

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F.2.

Fig.3.

F.6.

F.7.

F.5.

F.10.

F.8.

F.15.

Figure 1-12 ■ Various nineteenth-century pessaries. (From Bourgery JM. Traitem Complet de L'Anatomie de L' Homme Comprenant la Medicine Operatorie. Guerin, Paris, 1866–1868.) (See Color Plate 2.)

Figure 1-10 ■ Alwin Karl Mackenrodt (1859–1925). (From Baskett TF. Eponyms and Names in Obstetrics and Gynaecology. RCOG Press, London, UK, 1996, with permission.)

Figure 1-11 ■ An illustration of the cardinal ligaments in a fetus of 8 months. (From Mackenrodt A. Uber die Ursachen der normalen und pathologischen Lagen des Uterus. Arch Gynakol 1895;48:394, with permission.) U.Rd.d lig. truasp.coll

lig.sa.-ut

Fasr pelv ni. lig.transadert coll.

Hafd.d.lig. lat.corp.

Corp.ut.

Symph.

Uebg.d.sept.-i Fasc.pl. Sept.rerl.

Sept.ves.vag. Vag.wd.

Vag.wd.

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Figure 1-15 ■ Beginning catheterization of the left ureter in knee-chest posture through an open-air cystoscope. (From Kelly HA, Burnam CS. Diseases of the Kidneys, Ureters, and Bladder, vol. 1. D. Appleton & Co., New York, 1914, p. 269, fig. 141, with permission.)

Figure 1-13

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Howard Atwood Kelly (1858–1943).

sibly higher standard of ethics—there is no measure which can compare with the decrease in physical suffering in man, woman, and child when stricken by disease or accident…. This is the Promethean gift of the century to man.”

Retro pubic (5) Vertex (4) Right cornu (3) Sacral area (2)

Base (1)

Figure 1-14 ■ Various positions that air cystoscope may take to illuminate all parts of the bladder. (From Kelly HA, Burnam CS. Diseases of the Kidneys, Ureters, and Bladder, vol. 1. D. Appleton & Co., New York, 1914, p. 262, fig. 135, with permission.)

next century. With a thorough study of anatomy, gynecology, and surgery, Brödel revolutionized the appearance of medical literature and went on to become head of the world’s first “Department of Art as Applied to Medicine” at Johns Hopkins University in 1911. William Osler, addressing the Johns Hopkins Historical Club in January 1901, reflected on the accomplishments of medicine in the nineteenth century, stating: “In the fullness of time, long expected, long delayed, at last Science emptied upon him from the horn of Amalthea blessings which cannot be enumerated, blessings which have made the century forever memorable; and which have followed each other with a rapidity so bewildering that we know not what to expect next…. Measure as we may the progress of the world—materially, in the advantages of steam, electricity, and other mechanical appliances; sociologically, in the great improvements in the conditions of life; intellectually, in the diffusion of education; morally, in a pos-

THE TWENTIETH CENTURY The rapid evolution of technology and procedures related to gynecology and female urology continued into the twentieth century. In 1900, David Gillman introduced round-ligament ventrosuspension of the uterus for treatment of uterine prolapse, whereby he carried the proximal round ligament through the peritoneum just lateral to the rectus muscle and sutured it to the posterior rectus sheath. Shortly thereafter, in 1902, John Montgomery Baldy (1860–1934) and John Clarence Webster (1863–1950) independently devised a virtually identical operation for uterine retrodisplacement. The Baldy-Webster uterine ventrosuspension involved plication of redundant uterosacral ligaments to the posterior aspect of the uterus at a point just above the insertion of the uterosacral ligaments. In 1900 Herman Pfannenstiel (1862–1909) proposed his low transverse incision to help reduce postoperative hernias. Frederick Foley introduced a new plastic operation for stricture at the ureteropelvic junction for treatment of hydronephrosis. The pathogenesis of rectal prolapse as a form of sliding hernia was put forth by Alexis Moschcowitz (1865– 1933) in 1912. He devised an operation whereby silk sutures were passed circumferentially about the cul-de-sac of Douglas. Subsequently, gynecologists appropriated the operation to prevent and treat enterocele at the time of hysterectomy. Throughout the twentieth century, the evolution of urinary incontinence procedures took place. In 1913 Kelly first described his anterior plication stitch, a horizontal mattress stitch placed at the urethrovesical junction and thereby effectively plicating the pubocervical fascia. The Kelly plication stitch, as shown in Fig. 1-16, resulted in the narrowing of a patulous urethra and elevation of the urethrovesical junction and was the essential component of anterior colporrhaphy for stress urinary incontinence.

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Figure 1-16 ■ The Kelly plication stitch for stress urinary incontinence. (From Kelly HA. Incontinence of urine in women. Urol Cutaneous Rev 1913;17:291, with permission.)

Although the Kelly plication was somewhat effective and popular, stress incontinence frequently recurred. Various muscular and fascial suburethral sling operations were thus devised to treat this distressing and persistent problem. The slings used adjacent anatomic structures with the purpose of providing proper support for the urethra and developing a substitute muscular sphincter-like action to replace the one that had been damaged or lost. Muscle transposition procedures to create a sling under the urethra using rectus muscle, pyramidalis muscle, and levator ani were used in the early twentieth century. In 1917, Stoeckel, building on previous work by Goebell (1910) and Frangenheim, was the first to combine sphincter plication and the use of a fascial sling with complete success. In 1942 Aldridge described a technique of making a transverse suprapubic incision and developing bilateral strips of fascia attached at the midline: “In such circumstances or when the sphincter muscles have undergone too much destruction, complete restoration of function by the usual vaginal procedures can hardly be expected.” The fascial strips were brought down through the rectus muscle, behind the symphysis, and united as a sling beneath the urethra. Aldridge was one of the first to emphasize that much of stress incontinence might be due to disruption from birth trauma. The Aldridge rectus fascia sling became the model for similar fascial sling procedures used for recurrent stress incontinence and sphincter deficiency for the next 50 years. In 1949 a New York urologist, Victor Marshall (b. 1913), began to develop an operation for urinary incontinence in men during the mid-1940s. He used a suprapubic approach to suspend the bladder and bladder neck by placement of interrupted chromic catgut sutures to the periosteum of the symphysis and posterior rectus sheath. Thereafter, he collaborated with two gynecologists, Andrew Anthony Marchetti (1901–1970) and Kermit Edward Krantz (b. 1923), to refine and modify the procedure to treat incontinence in women.

During the half century since its introduction, the MarshallMarchetti-Krantz procedure remained a standard approach to female incontinence. Necessity being the mother of invention gave rise to a modification of the procedure in 1961, when John Christopher Burch (1900–1970) was unable to secure sutures into the retropubic periosteum and, ultimately, found the support he required in Cooper's ligaments. His publication on the procedure remains one of the simplest, most widely accepted, and most studied methods of elevating the urethrovesical junction in cases of stress urinary incontinence (Fig. 1-17A, B). In 1934 Nobel Sproat Heaney (1880–1955) reported on 565 vaginal hysterectomies performed for benign disease. Henceforth, he became one of the most influential proponents of the procedure praising its lower morbidity and mortality compared to an abdominal approach. While developing the technique, he designed a needle holder, retractor, and pedicle clamp to facilitate the procedure, and incorporated peritoneum, vessels, and ligaments in a maneuver known as the Heaney stitch. The development of an enterocele subsequent to vaginal hysterectomy was addressed in 1957 by Milton McCall's posterior culdoplasty. The operation was performed from below with obliteration of redundant posterior cul-de-sac by a series of continuous sutures along the length of the uterosacral ligaments. Operative laparoscopy was first used in gynecologic procedures by Raoul Palmer (1905-1985) in 1943. At a time when laparoscopy was largely the domain of surgeons, he established its role for evaluating infertility and visualizing pelvic organs by placing the patient in the Trendelenburg position and elevating the uterus by means of a transcervical manipulator. However, credit for devising the earliest endoscope goes to Philipp Bozzini (1773–1809) who described his “lichtleiter” in 1806. He advocated the inspection of all “interior cavities …by looking through natural openings or at least small wounds.” Expounding on the use of his device, Bozzini wrote: “To give an idea how distinctly the light transmitter reflects the rays, I would like to site just one example: if, observing proper cleanliness, one places a piece of writing in the fundus of the uterus of a woman who died during delivery, it can be read through the vagina with the help of the light transmitter containing an ordinary wax candle as clearly as by light of a candle standing at the same distance on a table.” Furthermore, he correctly predicted the development of operative endoscopy, writing: “Surgery will not only develop new and previously impossible procedures, but all uncertain operations which rely on luck and approximation will become safe under the influence of direct vision, since the surgeon's hand will now be guided by his eyes.” Amazingly, Bozzini was formally reprimanded for his “undue curiosity” after visualizing the interior of the urethra of a living patient, a reaction that repeats itself on many occasions throughout history as innovations or new ideas are initially put forth. In 1914 Wilhelm Latzko (1863–1945) introduced a partial colpocleisis technique for closure of vesicovaginal

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Urethra and neck of bladder

Cooper's lig.

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Symphysis Cooper’s lig.

Symph

Arcus tendineus

Perivaginal fascia Foley catheter

Perivaginal fascia elevated by finger in vagina

Bladder Peritoneum

A B Figure 1-17 ■ Burch urethrovaginal fixation procedure. A. The suture has been passed through the perivaginal fascia and the wall of the vagina but not through the mucous membrane. The sutured point is now matched to that point on Cooper's ligament to which it is most easily approximated, and the suture is passed through this point and tied. B. The lateral edges of the vagina have been approximated to Cooper's ligament by three interrupted sutures. (From Burch JC. Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol 1961;81:281, with permission.)

fistula following hysterectomy. By dissecting and removing the vaginal mucosa surrounding the fistula and inverting the denuded area with multiple layers, he effectively obliterated the fistulous opening. From the end of the nineteenth century and well into the twentieth century, the faculty from the Departments of Obstetrics and Gynecology at Johns Hopkins Hospital became a guiding force for the specialty. Among the leaders was Howard Atwood Kelly, often regarded as the father of American gynecology due to his important role in establishing gynecology as a surgical specialty in America (see Fig. 1-13). For three decades he was the chairman of gynecology at the Johns Hopkins Hospital, where he established the first residency program in gynecology, an innovation in surgical training and an important contribution to the development of the specialty. He was, by all measures, a prolific author with a bibliography of 485 book titles, journal articles, and pamphlets by 1919. In 1899 Kelly consented to the department's division and delegated responsibility for obstetrics to John Whitridge Williams (1866–1931). Williams and Kelly introduced a new standard of scholarship into America's obstetric and gynecologic literature and teaching. For three decades Williams exercised a near monopoly in filling the “chairs” of the Departments of Obstetrics and Gynecology at the country's major universities. His widely popular textbook continues to bear his name under new editorship. Later, Richard Wesley TeLinde was appointed chairman in 1939, a post that he held for 21 years. During his tenure, he played a role in the development of fascial slings for stress incontinence and performed much of the preliminary work in delineating the diagnosis of and appropriate treatment for cervical

carcinoma-in-situ. Perhaps TeLinde is best known for his text Operative Gynecology, which was published in 1946 and was destined to be and remains the standard American work on the subject under successive authors. Thus, we owe a great debt of gratitude to these and many others who established the foundation for successful pelvic surgery and, ultimately, for our specialty. Perhaps Kelly, an avid historian and bibliophile, summarized it best by stating, “No group should ever neglect to honor the forebears upon whom their contributions are based. Great is the loss to anyone who neglects to study the lives of those he follows.”

Bibliography Aldridge AH. Transplantation of fascia for relief of urinary stress incontinence. Am J Obstet Gynecol 1942;44:398. American Armamentarium Chirurgicum (intro by Edmonson JM, Hambrecht FT), Centennial ed. George Tiemann & Company, San Francisco/ Boston, 1989. Baldy JM. A new operation for retrodisplacement. Am J Obstet 1902;45:650. Baskett TF. Eponyms and Names in Obstetrics and Gynaecology. RCOG Press, London, UK, 1996. Bourgery JM. Traitem Complet de L'Anatomie de L' Homme Comprenant la Medicine Operatorie. Guerin, Paris, 1866–1868. Bush RB, Leonhardt H, Bush IM, Landes RR. Dr. Bozzini's lichtleiter: a translation of his original article (1806). Urology 1974;3:119. Burch JC. Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol 1961;81:281. Choulant L. History and bibliography of anatomic illustration (reprint; originally published in 1852). Hafner Publishing, New York, 1962. De Graaf R. De Mulierum Organis Generationi Inservientbus. Hackiana, Leyden, 1672. Donald, A. Operation in cases of complete prolapse. J Obstet Gynaecol Br Emp 1908;13:195.

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Douglas J. A Description of the Peritoneum and of that Part of the Membrana Cellularis Which Lies on Its Outside. J. Roberts, London, 1730. Edmonson JM. American Surgical Instruments: An Illustrated History of Their Manufacture and a Directory of Instrument Makers to 1900. Norman Publishing, San Francisco, 1997. Fallopius G. Observationes Anatomicae. Marco Antonio Ulmun, Venice, 1561, p. 221. Fothergill WE. Anterior colporrhaphy and its combination with amputation of the cervix as a single operation. J Obstet Gynaecol Br Emp 1915;27:146. Goebell R. Zur operativen beesitigung der angelborenen incontinez vesicae. Z Gynaek Urol 1910;2:187. Graves TW. A new vaginal speculum. NY Med J 1878;28:506. Heaney NS. A report of 565 vaginal hysterectomies performed for benign pelvic disease. Am J Obstet Gynecol 1934;28:751. Hodge HL. On Diseases Peculiar to Women, Including Displacements of the Uterus. Blanchard and Lea, Philadelphia, 1860. Hunter W. The Anatomy of the Human Gravid Uterus. John Baskerville, Birmingham, England, 1774. Kelly HA. The examination of the female bladder and the catheterization of the ureters under direct inspection. Bull Johns Hopkins Hosp 1893;4:101. Kelly HA. Medical Gynecology. D. Appleton and Co., New York, 1908. Kelly HA. Operative Gynecology, 2 vols. D. Appleton and Co., New York, 1898. Kelly HA. Incontinence of urine in women. Urol Cutaneous Rev 1913;17:291. Kelly HA, Burnam CS. Diseases of the Kidneys, Ureters and Bladder, 2 vols. D. Appleton & Co., New York, 1914. Langenbeck CJ. Geschichte einer von mir glucklich verichteten extirpation der ganger gebarmutter. Bibliotheck Chir Ophthalmol Hanover 1817;1:557. Latzko W. Behandlung hochsitzender blasen und mastdarmscheidenfisteln nach uterusextipation mit hohem schedienverschluss. Zentralbl Gynakol 1914;38:906. Latzko W. Postoperative vesicovaginal fistulas: genesis and therapy. Am J Surg 1942;58:211. Le Fort L. Nouveau procede pour la guersison du prolapsus uterin. Bull Gen Therapie 1877;92:337. Mackenrodt A. Uber die Ursachen der normalen und pathologischen Lagen des Uterus. Arch Gynakol 1895;48:394. Marshall VF, Marchetti AA, Krantz KE. The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet 1949;88:509. McCall ML. Posterior culdeplasty: surgical correction of enterocele during vaginal hysterectomy: a preliminary report. Obstet Gynecol 1957;10:595. McDowell E. Three cases of extirpation of diseased ovaria. Elect Repertory Analyst Re Phila 1817;7:242. Mettauer JP. Vesico-vaginal fistula. Boston Med Surg J 1840;22:154.

Moschcowitz AV. The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 1912;15:7. Osler W. Medicine in the Nineteenth Century. In Aeguanimitas with Other Addresses. McGraw-Hill, New York, 1932. Palmer R. La coelioscopie gynecocgique. Acad Chir 1946;72:363. Pare A. The Works of Ambroise Parey, Johnson TH, transl. Clark Publishing, London, 1678. Pfannenstiel J. Uber die vortheile des wuprasymphysaren Fascienquerschnitts fur die Gynakologischen Koliotomein zugleich ein Beitrag zu der Indikationsstellung der Operationswerge. Samml Klin Vortr Leipzig 1900;268:1753. Retzius AA. Uber das ligamentum Pelvoprostaticum oder den apparat, durch welchen die Harnblasee, die Prostata und die Harnrohre an den untern Beckenoffnung befestigt sind. Muller's Arch Anat Physiol Wiss Med 1849;11:182. Ricci JV. The Genealogy of Gynecology: History of the Development of Gynecology Throughout the Ages, 2000 bc–ad 1800. The Blakiston Company, Philadelphia, 1972. Ricci JV. The Vaginal Speculum and Its Modifications Throughout the Ages. New York Medical College, New York, 1948–1949. Scultetus J. L'Arsenal de Chirurgie. Antoine Celleier, Lyon, 1653. Schultheiss D, Udo J. Max Brödel (1870–1941) and Howard A. Kelly (1858– 1943)—Urogynecology and the birth of modern medical illustration. Eur J Obstet Gynecol 1999;86:113. Sims JM. Silver Sutures in Surgery. The Anniversary Discourse before the New York Academy of Medicine. Samuel S. and William Wood, New York, 1858. Sims JM. Clinical Notes on Uterine Surgery. Robert Hardwicke, London, 1866. Speert H. Obstetric and Gynecologic Milestones: Essays in Eponymy. Macmillan, New York, 1958. Speert H. Obstetrics and Gynecology in America: A History. ACOG, Chicago, 1980. Stoeckel W. The use of the pyramidal muscle in the surgical treatment of urinary incontinence. Zentralbl Gynakol 1917;41:11. Stromayr C. Die Handschrift des Schnitt-und Augenarzles Caspar Stromayr, Lindau Munscript. 1559. TeLinde RW. Operative Gynecology, 1st ed. Lippincott, Philadelphia, 1946. TeLinde RW. The modified Goebell-Stoeckel operation for urinary incontinence. South Med J 1934;27:193. Temkin O, transl. Soranus' Gynecology. Johns Hopkins University Press, Baltimore, 1956. Watkins TJ. The treatment of cystocele and uterine prolapse after the menopause. Am J Obstet Dis Wom 1899;15:420. Webster JC. A satisfactory operation for certain cases of retroversion of the uterus. JAMA 1901;37:913. Wertheim E. Zur frage der radical operation beim uteruskrebs. Arch Gynakol 1900;61:627.

Anatomy of the Lower Urinary Tract, Rectum, and Pelvic Floor

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Kevin J. Stepp and Mark D. Walters

EMBRYOLOGY 17 Lower Urinary Tract 17 Rectum and Anal Sphincters 20 ANATOMY 20 Bones of the Pelvis 20 Bladder 20 Trigone 21 Pelvic Ureter 21 Urethra 21 Vagina 22 Pelvic Floor and Sidewalls 23 Perineum 25 Transobturator Anatomy 25 PELVIC ORGAN SUPPORT 26 Support of Uterus and Vagina 26 Urethral Support 28 RECTUM AND ANAL SPHINCTERS 28

EMBRYOLOGY Lower Urinary Tract FORMATION OF INTRAEMBRYONIC MESODERM At approximately 15 days after fertilization, invagination and lateral migration of mesodermal cells occur between the ectodermal and endodermal layers of the presomite embryo. These migrating cells form the intraembryonic mesoderm or mesodermal germ layer. By the seventeenth day of development, the endoderm and ectoderm layers are separated entirely by the mesoderm layer, with the exception of the prochordal plate cephalically and the cloacal plate caudally. The cloacal plate consists of tightly adherent endodermal and ectodermal layers. FORMATION OF ALLANTOIS AND CLOACA Concomitantly, at about the 16th day of development, the posterior wall of the yolk sac forms a small diverticulum, the allantois, which extends into the connecting stalk. With ventral bending of the embryo cranially and caudally dur-

ing somite development, the connecting stalk and contained allantois, as well as the cloacal membrane, are displaced onto the ventral aspect of the embryo. The hindgut undergoes slight dilation to form the cloaca; it receives the allantois ventrally and the two mesonephric ducts laterally. Ventral mesodermal elevations occur, forming the urethral folds (primordia of the labia minora) and genital tubercle (primordium of the clitoris). PARTITIONING OF CLOACA INTO UROGENITAL SINUS AND RECTUM A spur of mesodermal tissue migrates from the base of the allantois toward the cloacal membrane around 28 days after fertilization, forming the urorectal septum (Fig. 2-1). This structure partitions the cloaca into a ventral urogenital sinus and a dorsal rectum. The urogenital opening (future vestibule) is formed by the independent involution of the urogenital membrane. The point at which the urorectal septum intersects with the cloacal membrane will become the perineal body. FORMATION OF URETERIC BUD AND INDUCTION OF FUTURE KIDNEY By 28 days of development, the mesonephric ducts have reached and fused with the urogenital sinus. At this time, the ureteric bud appears as a diverticulum from the posteromedial aspect of the mesonephric duct, at the point where the terminus of the duct bends to enter the cloaca. The free cranial end of the ureter grows dorsally, then cranially, and induces the formation of the metanephrogenic blastema (future kidney; see Fig. 2-1). The presence of the developing ureter is essential for this differentiation; absence of the ureteric bud is invariably associated with renal agenesis. The ureteric bud branches and dilates to create the renal pelvis, major and minor calyces, and collecting ducts. The remaining parts of each are derived from the mesoderm of the metanephrogenic blastema. At this time in the woman, the mesonephric system is undergoing degeneration. The renal blastema originates at the level of the upper sacral segments. The final position of the kidney at the level of the upper lumbar vertebrae is attributed to ascent of the renal blastema. According to Maizels (1986), the four mechanisms that lead to normal renal ascent are caudal growth of

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Figure 2-1 ■ Embryo approximately 32 days (8-mm crown-rump length) after fertilization. The urorectal septum is shown dividing the cloaca into a ventral urogenital sinus and dorsal rectum. Definitive ureter and mesonephric duct share a common opening into partially divided cloaca. Note that the ureter has induced formation of a kidney from metanephrogenic blastema. (From Gosling JA, Dixon J, Humpherson JR. Functional Anatomy of the Urinary Tract. Gower Publishing, London, 1982, with permission.)

Figure 2-2 ■ By day 37 (14-mm crown-rump length), kidney has continued to ascend and undergo medial rotation, and the mesonephric duct and future ureter have separated. Also, cloaca has been divided into ventral urogenital and dorsal alimentary parts. (From Gosling JA, Dixon J, Humpherson JR. Functional Anatomy of the Urinary Tract. Gower Publishing, London, 1982, with permission.)

the spine, active elongation of the ureter into the metanephrogenic blastema, intrinsic growth and molding of the renal parenchyma, and axial growth of the spine after fixing of the kidney to the retroperitoneum. FORMATION OF BLADDER, TRIGONE, AND URETHRA At the point of its connection with the mesonephric ducts, the urogenital sinus is divided into the vesicourethral canal cranially and the definitive urogenital sinus caudally. Dilation of the cranial portion of the vesicourethral canal forms the definitive bladder, which is of endodermal origin. The vesicourethral canal communicates at its cranial end with the allantois, which becomes obliterated at about 12 weeks of fetal life, forming the urachus. This structure runs from the bladder dome to the umbilicus and is called the median umbilical ligament in the adult. The ureteric bud begins as an outgrowth of the mesonephric duct, but with positional changes of the embryo during growth, the mesonephric duct and the ureteric bud shift positions so that the ureter comes to lay posterolaterally to the duct (Fig. 2-2). The segment of the mesonephric duct distal to the site of origin of the ureteric bud dilates and is absorbed into the urogenital sinus, forming the bladder trigone. The bladder trigone effectively gives the endodermal wall of the vesicourethral canal a mesodermal contribution. At about 42 days after fertilization, the trigone may be defined as the region of the vesicourethral canal lying between the ureteric orifices and the termination of the mesonephric ducts (Fig. 2-3). The caudal portion of the vesicourethral canal remains narrow and forms the entire urethra. A small

Figure 2-3 ■ Urogenital sinus and associated ducts approximately 40 days (17-mm crown-rump length) after fertilization. Trigone lies between separated ureteric and mesonephric ducts. (From Gosling JA, Dixon J, Humpherson JR. Functional Anatomy of the Urinary Tract. Gower Publishing, London, 1982, with permission.)

portion of the posterior proximal urethra may be derived, like the trigone, from the mesoderm of the mesonephric duct, although this theory is controversial. A timetable and schematic representation of the embryologic contributions of the various structures of the urogenital system are shown in Table 2-1 and Figure 2-4, respectively.

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Table 2-1

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Timetable of Events in the Development of the Lower Urinary Tract

Time After Fertilization

Event

15 days 16–17 days 17 days 28–38 days 28 days 30–37 days 41 days 42–44 days

Ingrowth of intraembryonic mesoderm Allantois appears Cloacal plate forms Partitioning of cloaca by urorectal septum Mesonephric duct reaches cloaca; ureteric bud appears Ureteric bud initiates formation of metanephros (permanent kidney) Lumen of urethra is discrete; genital tubercles prominent Urogenital sinus separates from rectum; mesonephric ducts and ureters drain separately into urogenital sinus, defining boundaries of trigone Kidneys in lumbar region; glomeruli appear in kidney First likelihood of renal function External genitalia become distinctive for sex Bladder becomes muscularized Further growth and development complete the urogenital organs

51–52 days 9 weeks 12 weeks 13 weeks 20–40 weeks

Trigone

Mesonephric ducts

Ureters, renal pelvis, calyces, and collecting tubules

Urethra (posterior proximal part only)

Bladder Urogenital sinus

Urethra (main part)

Urethra

Rectum

Distal 1/5 - 1/3 of vagina Hymen Vestibule of vagina

Vagina

Cloaca

Proximal 2/3 - 4/5 of vagina Paramesonephric ducts Uterus and tubes Figure 2-4

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Schematic representation of the embryologic contributions of various structures of the female urogenital system.

The separate development of the trigone and bladder may explain why the muscle laminas of the trigone are contiguous with the muscle of the ureter and not with the detrusor muscle of the bladder. This separate development may also account for pharmacologic responses of the musculature of the bladder neck and trigone, which differ partially from those of the detrusor.

CONGENITAL ANOMALIES OF THE URINARY TRACT Knowledge of the embryology of the genitourinary system is necessary for understanding the causes of the multiple congenital anomalies of the upper and lower urinary tracts. Selected congenital anomalies of the urinary tract and their embryologic causes are shown in Table 2-2.

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Table 2-2

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Selected Congenital Anomalies of the Urinary Tract and Their Embryologic Causes

Condition

Embryologic Cause

Renal agenesis Pelvic kidney Horseshoe kidney

Early degeneration of the ureteric bud Failure of kidney to ascend to the lumbar region Fusion of lower poles of both kidneys; ascent to lumbar region prevented by root of inferior mesenteric artery Variable persistence of the intraembryonic portion of allantois, from bladder to umbilicus Early splitting of the ureteric bud Two ureteric buds develop from one mesonephric duct. One bud is in normal position; the abnormal bud moves downward with the mesonephric duct to enter into the urethra, vagina, vestibule, or uterus Failure of the ventral wall of the urogenital sinus to increase to accommodate positional changes, followed by breakdown of the urogenital membrane

Urachal fistula, cyst, sinus Double ureter Ectopic ureter Bladder exstrophy

Rectum and Anal Sphincters NORMAL DEVELOPMENT OF THE HINDGUT The hindgut, which in the embryo extends from the posterior intestinal portal to the cloacal membrane, gives rise to the distal third of the transverse colon, the descending colon, the sigmoid, the rectum, and the upper part of the anal canal. The terminal portion of the hindgut enters into the cloaca, an endoderm-lined cavity that is in direct contact with the surface ectoderm. In the contact area between the endoderm and ectoderm, the cloacal membrane is formed. During further development, a transverse ridge, the urorectal septum, arises in the angle between the allantois and the hindgut. This septum gradually grows caudad, thereby dividing the cloaca into an anterior portion, the primitive urogenital sinus, and a posterior portion, the anorectal canal. The primitive perineum is formed when the urorectal septum reaches the cloacal membrane when the embryo is 7 weeks old. The cloacal membrane is thus divided into the posterior anal membrane and the anterior urogenital membrane. The anal membrane is then surrounded by mesenchymal swellings, and in the ninth week it is found at the bottom of an ectodermal depression, known as the anal pit. The surrounding swellings are the anal folds. Soon thereafter, the anal membrane ruptures and an open pathway is formed between the rectum and the outside, which is the amniotic cavity. The upper part of the anal canal is thus endodermal in origin; the lower third of the anal canal is ectodermal. The external anal sphincter appears in human embryos at approximately 8 weeks or perhaps 7 weeks. The sphincter, together with the levator ani, is believed to originate from hypaxial myotomes. Although the anal sphincter and levator ani may arise from distinct primordia, their relationship is very close. CONGENITAL MALFORMATIONS OF THE HINDGUT Imperforate anus is one of the more common abnormalities of the hindgut. In simple cases, the anal canal ends blindly at the anal membrane, which then forms a diaphragm between the endodermal and ectodermal portions of the anal canal. In more severe cases, a thick layer of connective tissue may be found between the terminal end of the rectum and the surface because of either a failure of the anal pit to develop or atresia of the ampullar part of the rectum (rectal atresia).

A slight deviation of the urorectal septum in the dorsal direction probably causes many rectal and anal abnormalities. Rectal fistulas are often observed in association with an imperforate anus and may be found between the rectum and vagina, urinary bladder, or urethra. Fistulas may also open to the surface of the perineal region.

ANATOMY Bones of the Pelvis The bones of the pelvis provide the foundation to which all of the pelvic structures are ultimately anchored. In the standing position, forces are dispersed to minimize the pressures on the pelvic viscera and musculature and to distribute forces to the bones that are better suited to the long-term, cumulative stress of daily life. In the upright position, the iliopubic rami are oriented in an almost vertical plane. Similar to the supports of an archway or bridge, the weight of the woman is transmitted along these bony supports to her femurs. This directs the pressure of the intra-abdominal and pelvic contents toward the bones of the pelvis instead of the muscles and endopelvic fascia attachments of the pelvic floor. The pubic rami are nearly horizontal where they articulate in the midline. The weights of the abdominal viscera and some of the pelvic viscera are supported inferiorly by the bony articulation.

Bladder The bladder is a hollow, muscular organ that is the reservoir for the urinary system. The bladder is flat when empty and globular when distended. The superior surface and upper 1 or 2 cm of the posterior aspect of the bladder are covered by peritoneum, which sweeps off the bladder into the vesicouterine pouch. The anterior bladder is extraperitoneal and adjacent to the retropubic space (space of Retzius). Between the bladder and pubic bones lie adipose tissue, pubovesical ligaments and muscle, and a prominent venous plexus. The bladder rests inferiorly on the anterior vagina and lower uterine segment, separated by an envelope of adventitia (endopelvic fascia). The epithelium lining the bladder lumen is loosely attached to the underlying musculature, except at the trigone, where it is firmly adherent. The bladder lining consists of transitional epithelium (urothelium) supported by a layer

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of loose connective tissue, the lamina propria. The internal surface of the bladder has a rugose appearance formed by mucosal folds in the contracted state. In the distended state, a variably prominent mesh-like appearance is formed by mucosa-covered detrusor musculature. The bladder wall musculature is often described as having three layers: inner longitudinal, middle circular, and outer longitudinal. However, this layering occurs only at the bladder neck; the remainder of the bladder musculature is composed of fibers that run in many directions, both within and between layers. This plexiform arrangement of detrusor muscle bundles is ideally suited to reduce all dimensions of the bladder lumen on contraction. The inner longitudinal layer has widely separated muscle fibers that course multidirectionally. Near the bladder neck, the muscle fibers assume a longitudinal pattern that is contiguous through the trigone and, according to Tanagho (1986), into the inner longitudinal muscular layer of the urethra. The middle circular layer is prominent at the bladder neck, where it fuses with the deep trigonal muscle, forming a muscular ring. This layer does not continue into the urethra. The outer longitudinal layer forms a sheet of muscle bundles around the bladder wall, above the level of the bladder neck. These fibers continue anteriorly past the vesical neck as the pubovesical muscles and insert into tissues on the posterior surface of the pubic symphysis. The pubovesical muscles may facilitate bladder neck opening during voiding. The longitudinal fibers fuse posteriorly with the deep surface of the trigonal apex and communicate with several detrusor muscle loops at the bladder base; the loops probably aid in bladder neck closure.

Trigone In the bladder base is a triangular area: the trigone. The trigone has a flattened appearance with a smooth epithelial covering. The corners of the trigone are formed by three orifices: the paired ureteral orifices and the internal urethral orifice. The superior boundary of the trigone is a slightly raised area between the two ureteric orifices, called the interureteric ridge. The two ureteral openings are slit-like and, in an undistended organ, lie about 3 cm apart. The trigone has two muscular layers: superficial and deep. The superficial layer is directly continuous with longitudinal fibers of the distal ureter and is also continuous posteriorly with smooth muscle of the proximal urethra. The deep muscular layer of the trigone forms a dense, compact layer that fuses somewhat with detrusor muscle fibers. The deep layer is in direct communication with a fibromuscular sheath, Waldeyer’s sheath, in the intravesical portion of the ureter (Fig. 2-5). The deep trigonal muscle has autonomic innervation identical to that of the detrusor, being rich in cholinergic (parasympathetic) nerves and sparse in noradrenergic (sympathetic) nerves. In contrast, the superficial trigonal muscle has few cholinergic nerves and a greater number of noradrenergic nerves.

Pelvic Ureter As the ureter courses retroperitoneally from the renal pelvis to the bladder, it is divided anatomically into abdominal and pelvic segments, which are approximately equal in

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length of 12 to 15 cm each. The ureter enters the pelvis by crossing over the iliac vessels where the common iliac artery divides into the external iliac and hypogastric vessels. The ureter travels lateral to the hypogastric artery and, eventually, crosses to lie medial to the branches of the anterior division of the hypogastric artery and lateral to the peritoneum of the cul-de-sac. The ureter is attached to the peritoneum of the lateral pelvic wall. As the ureter proceeds more distally, it courses along the lateral side of the uterosacral ligament and enters the endopelvic fascia of the parametrium (cardinal ligament). The ureter courses medially as the uterosacral ligament is traced from the sacrum toward the vagina. At the level of the ischial spine, the ureter is approximately 2.3 cm lateral to the uterosacral ligament (Buller et al., 2001). The ureter is closest to the uterosacral ligament at its distal end, approximately 1 cm. The ureter passes beneath the uterine artery approximately 1.5 cm lateral to the cervix. The distal ureter then moves medially over the lateral vaginal fornix and travels through the wall of the bladder until reaching the trigone. The ureter has only one muscular coat that forms an irregular, helical pattern of muscle bundles, with fibers oriented in almost every direction. As the ureter approaches and enters the bladder wall, its helical fibers elongate and become parallel to its lumen. The intravesical ureter is about 1.5 cm long and is divided into an intramural segment (totally surrounded by the bladder wall) and a submucosal segment directly under the urothelium. The longitudinal muscle fibers of the distal ureter proceed uninterrupted into the superficial trigonal muscle. The distal and intramural segments of the ureter are surrounded by Waldeyer’s sheath, which fuses proximally with the intrinsic musculature of the ureter and distally acts as an added fixation, linking the ureter proper to the detrusor muscle (see Fig. 2-5). Waldeyer’s sheath has been described thoroughly by Tanagho (1986) and Woodburne (1968).

Urethra The female urethra is about 4 cm long and averages 6 mm in diameter. Its lumen is slightly curved as it passes from the retropubic space, perforates the perineal membrane, and ends with its external orifice in the vestibule directly above the vaginal opening. Throughout its length, the urethra is embedded in the adventitia of the anterior vagina. The urethral epithelium has longitudinal folds and many small glands that open into the urethra throughout its entire length. The epithelium is continuous externally with that of the vulva and internally with that of the bladder. It is primarily stratified squamous epithelium that becomes transitional near the bladder. The epithelium is supported by a layer of loose fibroelastic connective tissue, called lamina propria. The lamina propria contains many bundles of collagen fibrils and fibrocytes, as well as an abundance of elastic fibers oriented both longitudinally and circularly around the urethra. Numerous thin-walled veins are another characteristic feature. This rich vascular supply contributes to urethral resistance. The urethral smooth muscle is composed primarily of oblique and longitudinal muscle fibers, with a few circularly

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Figure 2-5 ■ Normal ureterovesico-trigonal complex. A. Side view with Waldeyer’s muscular sheath surrounding vestige of the intravesical ureter and continuing downward as the deep trigone, which extends to the bladder neck. The ureteral musculature becomes the superficial trigone, which extends to just short of the external meatus in the woman. B. Waldeyer’s sheath connected by a few fibers to the detrusor muscle in the ureteral hiatus. This muscular sheath, inferior to the ureteral orifice, becomes the deep trigone. The musculature of the ureters continues downward as the superficial trigone. (From Tanagho EA. Anatomy of the lower urinary tract. In Walsh PC, Gittes RF, Perlmutter AD, Stamey TA, eds. Campbell’s Urology, 5th ed. WB Saunders, Philadelphia, 1986, with permission.)

oriented outer fibers. This muscle and the detrusor muscle in the bladder base form what is called the intrinsic urethral sphincter mechanism. This smooth muscle is usually noted to be under both α-adrenergic and cholinergic control, although Gosling et al. (1981) found an extensive cholinergic nerve supply with few noradrenergic nerves. The longitudinally directed muscles probably shorten and widen the urethral lumen during micturition, whereas the circular smooth muscle (along with the striated urogenital sphincter muscle) contributes to urethral resistance to outflow at rest. The striated urethral and periurethral muscles form the extrinsic urethral sphincter mechanism, which has two components: an inner portion, which lies within and adjacent to the urethral wall, and an outer portion, composed of skeletal muscle fibers of the pelvic diaphragm. The inner portion is made up of the sphincter urethrae (a striated band of muscle that surrounds the proximal two thirds of the urethra) and the compressor urethrae and urethrovaginal sphincter (formerly known together as the deep transverse perineus muscle), which consist of two strap-like bands of striated muscle that arch over the ventral surface of the distal one third of the urethra (Fig. 2-6, inset). These three muscles, which function as a single unit, have been called the striated urogenital sphincter (Oelrich, 1983). It is composed primarily of small-diameter, slow-twitch muscle, making it

ideally suited to exert tone on the urethral lumen over prolonged time periods. The muscles may also contribute (along with the levator ani) to voluntary interruption of the urine stream and to urethral closure with stress, via reflex muscle contraction.

Vagina The vagina is a hollow, fibromuscular tube with rugal folds that extends from the vestibule to the uterine cervix. In the standing woman, the upper two thirds of the vagina is almost horizontal, whereas the lower one third is nearly vertical. Histologically, the vaginal wall is composed of three layers. It is lined by nonkeratinizing stratified squamous epithelium that lies over a thin, loose layer of connective tissue, called the lamina propria. The lamina propria contains no glands. Coursing through the lamina propria are small blood vessels. Vaginal lubrication is via a transudate from the vessels, cervix, and from the Bartholin’s and Skene’s glands. Beneath this is the vaginal muscularis, a well-developed fibromuscular layer consisting primarily of smooth muscle with smaller amounts of collagen and elastin. The muscularis is surrounded by an adventitial layer, which is a variably discrete layer of collagen, elastin, and adipose tissue containing blood vessels, lymphatics,

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Figure 2-6 ■ Diagrammatic representation showing the component parts of the urethral support and sphincteric mechanisms. Note that the proximal urethra and bladder neck are supported by the anterior vaginal wall and its musculofascial attachments to the pelvic diaphragm. (Inset) Contraction of the levator ani muscles elevates the anterior vagina and overlying bladder neck and proximal urethra, contributing to bladder neck closure. The sphincter urethrae, urethrovaginal sphincter, and compressor urethrae are all parts of the striated urogenital sphincter.

and nerves. The adventitia represents an extension of the visceral endopelvic fascia that surrounds the vagina and adjacent pelvic organs and allows for their independent expansion and contraction. The walls of the vagina are in contact except where its lumen is held open by the cervix. The vagina has an H-shaped lumen, with the principal dimension being transverse. In addition, the upper vagina is supported by connective tissue attachments to the sacrum, coccyx, and lateral pelvic sidewalls; these are identified at surgery as the cardinal and uterosacral ligament complex. The presence of a true fascia between the vagina and adjacent organs has been debated. Surgical terms, such as pubocervical and rectovaginal fascia, refer to layers that are developed as a result of separating the vaginal epithelium from the muscularis, or by splitting the vaginal muscularis layer. The vagina lies anteriorly adjacent to and supports the bladder base, from which it is separated by the vesicovaginal adventitia (endopelvic fascia). The urethra is fused with the anterior vagina, with no distinct adventitial layer separating them. The terminal portions of the ureters cross the lateral fornices of the vagina on their way to the bladder base. The vagina is related posteriorly to the cul-de-sac and rectal ampulla and related inferiorly to the perineal body. Embryologically an extension and fusion of peritoneum from the cul-de-sac, and attached to the posterior surface of the vaginal muscularis, forms the rectovaginal septum. A layer of adventitia separates the muscular layer of the rectum from the rectovaginal septum, except at the level of the perineal body, where there is fusion of the vaginal muscularis and connective tissue of the perineal body. The connective tissue of the perineal body extends 2 to 3 cm cephalad from the hymenal ring along the posterior vaginal wall and forms what is sometimes called the rectovaginal fascia. Although, at the time of surgery, an identifiable fascial plane is apparent, Weber and Walters (1997) and DeLancey (1999) have concluded that between the adjacent organs is primarily vaginal muscularis, and no fascia is present histologically.

Pelvic Floor and Sidewalls With the change from plantigrade to erect posture, the pelvis and vertebral column of humans underwent various evolutionary changes that restored balance between intra-abdominal pressure and visceral support. The lumbosacral curve, a specific human characteristic, directs abdominal pressure forward onto the abdominal wall and nearly horizontal, flattened pubic bones. Downward pressure is directed backward onto the sacrum and the rearranged pelvic muscles, which now fill in the pelvic cavity to form the pelvic floor and sidewalls. The pelvic floor and sidewalls are made up of muscular and fascial structures that enclose the abdominal-pelvic cavity, the external vaginal opening (for intercourse and parturition), and the urethra and rectum (for elimination). The fascial components consist of two types of fascia: parietal and visceral (endopelvic). Parietal fascia covers the pelvic skeletal muscles and provides attachment of muscles to the bony pelvis; it is characterized histologically by regular arrangements of collagen. Visceral endopelvic fascia is less discrete and exists throughout the pelvis as a meshwork of loosely arranged collagen, elastin, and adipose tissue through which the blood vessels, lymphatics, and nerves travel to reach the pelvic organs. By surgical convention, condensations of visceral endopelvic fascia of the pelvis have been described as discrete “ligaments,” such as the cardinal or uterosacral ligaments. The role of the endopelvic fascia in pelvic organ support will be discussed in detail later in the chapter. The obturator internus and piriformis are the muscles of the pelvic sidewalls. The obturator membrane is a fibrous membrane that covers the obturator foramen. Lying on the superior (intrapelvic) side of the obturator membrane, the obturator internus originates on the inferior margin of the superior pubic ramus and passes through the lesser sciatic foramen to insert onto the greater trochanter of the femur to laterally rotate the thigh. The piriformis is dorsal and lateral to the coccygeus. It extends from the anterolateral

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Basic Science

sacrum to pass through the greater sciatic foramen and to insert on the greater trochanter. The skeletal muscles of the pelvic floor include the levator ani muscles, the coccygeus muscle, the external anal sphincter, the striated urethral sphincter, and the superficial perineal muscles (bulbocavernosus, ischiocavernosus, and superficial transverse perinei). The pelvic diaphragm consists of the levator ani muscles and the coccygeus muscle. The levator ani muscles are the puborectalis, pubococcygeus, and iliococcygeus muscles. The pelvic diaphragm is stretched hammock-like between the pubis in front and the coccyx behind, and is attached along the lateral pelvic walls to a thickened linear band in the obturator fascia, called the arcus tendineus levator ani (Fig. 2-7). This thickened fascia forms an identifiable line from the ischial spine to the posterior surface of the ipsilateral superior pubic ramus. The levator ani muscles originate from this musculofascial attachment. The puborectalis muscle originates on the posterior inferior pubic rami and arcus tendineus levator ani. Its fibers pass posteriorly, forming a sling around the vagina, rectum, and perineal body to form the anorectal angle and to contribute to fecal continence. Some muscle fibers may blend with the muscularis of the vagina and rectum. The pubococcygeus has a similar origin but inserts in the midline onto the anococcygeal raphe and the anterolateral borders of the coccyx. The levator crura are formed by the pubococcygeus and puborectalis muscles. The iliococcygeus originates along the arcus tendineus levator ani from the pubis to the ischial spine and inserts on the anococcygeal raphe to form the leva-

Obturator internus muscle and fascia

Cooper's ligament

Pubococcygeus muscle

tor plate. The space between the levator crura through which the rectum, vagina, and urethra pass is called the genital hiatus. The coccygeus muscle, although not part of the levator ani, does make up the posterior part of the pelvic floor and plays a role in support. It originates on the ischial spine and sacrospinous ligament, overlies the sacrospinous ligament, and inserts on the lateral lower sacrum and coccyx. The coccygeus becomes thin and fibrous with age and often blends with the sacrospinous ligament, which can be difficult to distinguish from the coccygeus because both have the same origin and insertion. The levator ani muscles exhibit constant baseline tone and can also be voluntarily contracted. The muscles contain both type I (slow-twitch) fibers to maintain constant tone, and type II (fast-twitch) fibers to provide reflex and voluntary contractions. Constant tone of the pelvic floor, except during voiding, defecation, and during a Valsalva maneuver, provides constant support for the pelvic viscera. The levator ani muscles and the skeletal components of the urethral and anal sphincters all have the ability to contract quickly at the time of an acute stress, such as a cough or sneeze, to maintain continence. Although the muscles of the pelvic floor were initially thought to have innervation from direct branches of the sacral nerves on the pelvic surface and via the pudendal nerve on the perineal surface, recent anatomic, neurophysiologic, and experimental evidence indicates that these standard descriptions are inaccurate and that the levator ani muscles are innervated predominantly by a nerve traveling on the superior (intrapelvic) surface of the muscles without

Urethra

Vagina

Arcus tendineus fasciae pelvis

Obturator canal and neurovascular bundle

Arcus tendineus levator ani

IIiococcygeus muscle

Rectum Coccygeus muscle Ischial spine

Piriformis muscle

Levator plate

Figure 2-7 ■ The relationships of the muscles of the pelvic floor and sidewalls and their attachments from an abdominal view. The arcus tendineus fasciae pelvis has been removed on the left, showing the origins of the levator ani muscles. On the right, the arcus tendineus fasciae pelvis remains intact showing the attachment of the lateral vagina via the endopelvic fascia (cut away). (Reprinted with the permission of The Cleveland Clinic Foundation.)

Chapter 2

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Anatomy of the Lower Urinary Tract, Rectum, and Pelvic Floor

contribution of the pudendal nerve. Small branches penetrate the body of each muscle as the nerve traverses them.

25

then travels along the medial surface of the obturator internus, through the ischiorectal fossa in a thickening of fascia called Alcock’s canal. It emerges posteriorly and medially to the ischial tuberosity and divides into three branches to supply the perineum: clitoral, perineal, and inferior rectal (also called inferior hemorrhoidal). The blood supply to the perineum is from the pudendal artery, which travels with the pudendal nerve to exit the pelvis.

Perineum The perineum is divided into two compartments: superficial and deep. These are separated by a fibrous connective tissue layer called the perineal membrane. The perineal membrane is a triangular sheet of dense fibromuscular tissue that spans the anterior half of the pelvic outlet. It had been called the urogenital diaphragm previously; this change in name reflects the appreciation that it is not a two-layered structure with muscle in between, as had been thought in the past. The perineal membrane provides support to the vagina and urethra as they pass through it. Cephalad to the perineal membrane lies the striated urogenital sphincter muscle, which, as already mentioned, compresses the mid- and distal urethra. The borders of the perineum are the ischiopubic rami, ischial tuberosities, sacrotuberous ligaments, and coccyx. The perineal body marks the point of convergence of the bulbospongiosus muscles, superficial and deep transverse perinei, perineal membrane, external anal sphincter, posterior vaginal muscularis, and the insertion of the puborectalis and pubococcygeus muscles. The deep perineal compartment is composed of the deep transverse perineus muscle, portions of the external urethral sphincter muscles (compressor urethrae and urethrovaginal sphincter), portions of the anal sphincter, and the vaginal musculofascial attachments. The neurovascular anatomy of the perineum is illustrated in Figure 2-8. The motor and sensory innervation of the perineum is via the pudendal nerve. The pudendal nerve originates from S2–S4 and exits the pelvis through the greater sciatic foramen, hooks around the ischial spine,

Transobturator Anatomy The obturator membrane is a fibrous sheath that spans the obturator foramen, through which the obturator neurovascular bundle penetrates via the obturator canal. The obturator artery and vein originate as branches of the internal iliac vessels. As they emerge from the inferior side of the obturator membrane and enter the obturator space, they divide into many small branches supplying the muscles of the adductor compartment of the thigh. Recent cadaver work by Whiteside and Walters (2004) has contradicted previous reports of the obturator vessels bifurcating into medial and lateral branches. Rather, the vessels are predominately small (1 cm above the level of the hymen (i.e., its quantitation value is 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters (i.e., its quantitation value is >+1 cm but 40 cm/H2O) is associated with the propensity for upper tract deterioration. Abdominal and detrusor leak point pressures actually reflect outlet resistance at the time that these forces individually induce leakage. Neither leak point pressure reflects the strength or character of the detrusor contraction.

Methodology Ideally, the technique of performing an abdominal leak point pressure should be standardized and performed exactly the same way each time to allow comparison between patients and to make posttreatment studies meaningful. Many controversies exist regarding the technique of this test. These include catheter size, bladder volume, type of provocation, patient positioning, how the actual rise in pressure is determined, and how to best perform the test in the presence of genital prolapse. In abdominal leak point pressure measurements it is essential that the cystometrogram is stable (i.e., there is no significant increase in detrusor pressure during filling). If abnormal bladder compliance does exist, leak point pressure testing will underestimate urethral sphincter resistance. The technique we use for measuring abdominal leak point pressures is as follows. With a 6-French dual-sensor microtip transducer in the bladder, subtracted filling cystometry is performed to a bladder volume of 150 to 200 mL. Assuming no abnormalities in bladder compliance

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Evaluation

Figure 7-15 ■ Multichannel urodynamic tracing of a patient with urethral instability (uninhibited urethral relaxation). Note that bladder pressure remains stable and visual loss of urine occurs, simultaneous with drop in urethral pressure.

are present, leak point pressure measurements are performed at this volume. In the sitting position, the patient performs a gradually more vigorous Valsalva maneuver until leakage occurs. The lowest bladder pressure at which leaking occurs is considered the abdominal leak point pressure (Fig. 7-17, A). If a Valsalva maneuver cannot produce enough abdominal pressure to produce leakage or the patient is unable to strain on command, coughing is used as the provocative maneuver. Because coughing is a more “rapid” process than straining, attainment of accurate and reproducible values is more difficult. The patient is asked to cough repetitively, and the external urethral meatus is visualized for leakage. Once leakage has occurred, the strength of the cough is reduced until the cough that generates the minimal amount of abdominal pressure required to produce leakage is isolated (Fig. 7-17, B). These maneuvers are then performed several times in the

hope of documenting reproducible values. If patients do not leak with either a Valsalva maneuver or repetitive coughing, the catheter is removed from the bladder and the provocative maneuvers are repeated with the abdominal pressure being measured via an intravaginal or intrarectal catheter. Filling cystometry is then continued to maximum cystometric capacity, and the leak point pressure measurements are repeated. Although these numbers are usually significantly lower than those noted at 150 to 200 mL, they can be useful in objectively documenting and following the severity of the disease after various modes of nonsurgical or surgical therapy. To perform a bladder leak point pressure, the filling cystometrogram is performed at a slower filling rate, usually 25 mL/min. The patient is typically supine for this study. Filling continues to the point at which leakage occurs and is

Chapter 7

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Urodynamics: Cystometry and Urethral Function Tests

Figure 7-16 ■ Graphic representation to show difference between urethral instability (uninhibited urethral relaxation) and unstable urethral pressure. (From Karram MM. Urodynamics. In Benson JT, ed. Female Pelvic Floor Disorders: Investigation and Management. Norton Medical Books, New York, 1992, with permission.)

identified by either direct observation or fluoroscopy. The total bladder pressure (i.e., detrusor and abdominal pressures) is measured and recorded as the bladder leak point pressure. In some patients the pressure may occur at very large volumes and high pressures. Once a bladder pressure of 40 cm H2O is reached, the study should be terminated because ongoing filling above this pressure can be dangerous.

Interpretation Variables Variables in performing this study revolve around the lack of standardization. Multiple parameters have been shown to affect the abdominal leak point pressure measurements. These include catheter caliber, catheter location (vaginal versus intravesical), bladder volume, the use of coughing versus Valsalva maneuver as the provocation, patient position, and the use of an absolute or change in measured pressure. More subjects demonstrate urine loss during Valsalva maneuvers with a 3-French rather than 8-French transurethral catheter, and the abdominal leak point pressures obtained with the 3-French catheter are consistently lower. At least two investigators have shown that removal of the transurethral catheter and measurement of the intra-abdominal pressure rise with an intravaginal or intrarectal catheter consistently lowered abdominal leak point pressure by up to 20 cm H2O, suggesting that the transurethral catheters are obstructive. An inverse relationship exists between bladder volume and abdominal leak point pressures. Miklos et al. (1995) per-

97

formed Valsalva leak point determination at various bladder volumes and found a 19-cm H2O fall in the leak point pressure as the volume increased from 150 mL to more than 400 mL. Although the effect of patient positioning on leak point pressure measurements has not yet been studied, one could postulate that if the patient moves from a supine to an upright position, the value of the leak point pressure diminishes, provided that a mechanical obstruction such as a large prolapse is not accentuated in the erect position. Another area of controversy concerns the use of coughing versus a Valsalva maneuver as the technique for provoking urine loss. Cough-induced leak point pressures are consistently higher than Valsalva-induced leak point pressures. A major concern with coughing is that it is technically more difficult to control the intensity of a cough and to pinpoint the absolute lowest value associated with urine loss. Unfortunately, some patients demonstrate incontinence only with coughing because Valsalva-induced incontinence has only a 70% to 80% sensitivity in detecting stress incontinence. Valsalva leak point pressures have been shown to have excellent reproducibility, with test-retest correlation coefficients of more than 0.9. The test-retest reliability of a cough-induced leak point pressure has not been studied. Finally, how should the actual number be determined? Some investigators have used a subtracted value or an increase in intravesical pressure over the baseline resting intravesical pressure, whereas others used the absolute increase in intravesical pressure, which reflects the increase plus the resting baseline pressure.

Clinical Applications The abdominal leak point pressure is being used as a severity measure for dysfunction of the urethral sphincteric mechanism, with implications regarding surgical management. Many urologists and urogynecologists use abdominal leak point pressures below 60 cm H2O to define ISD or type III stress incontinence. These concepts are not universally accepted and to date no surgical outcome data are available. These recommendations are based mostly on data published by McGuire et al. (1993), who performed leak point pressures on 125 women with urodynamic stress incontinence. They noted that 76% of patients who had a leak point pressure less than 60 cm H2O were noted to have type III incontinence on video-urodynamic testing. They defined type III incontinence as proximal urethral pressures less than 10 cm H2O or a nonfunctioning open internal sphincter. If leak point pressure measurements truly correspond to urethral function, then as urethral function worsens (manifested by worsening symptoms), leak point pressure should decrease. Two studies have correlated leak point pressures with subjective degrees of stress incontinence in women. Both studies defined severe incontinence due to ISD as loss of urine with minimal activity or gravitational incontinence. McGuire et al. (1993) noted that 81% of patients with leak point pressures less than 60 cm H2O had ISD, whereas Nitti and Combs (1996) noted that 75% and 50% of patients with ISD had leak point pressures less than 90 cm H2O and 60 cm H2O, respectively.

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Figure 7-17 ■ A. Graphic representation of Valsalva leak point pressure measurement at bladder volumes of 150 and 300 mL. Leak point pressures tend to decrease with increased bladder volume. B. Graphic representation of cough leak point pressure at bladder volumes of 150 and 300 mL. Note the difficulty involved in isolating the cough that generates the minimal amount of abdominal pressure required to produce leakage.

Theofrastous et al. (1996) reported women who leaked with Valsalva at lower bladder volumes had significantly worse measures of incontinence severity (incontinence episodes per week and quantitative pad test) compared with women who leaked at higher volumes and those who did not leak at all with Valsalva. Actual leak point pressure values were not analyzed relative to measures of incontinence severity. Cummings et al. (1997) analyzed the cumulative association of severity of symptoms and previous surgery with low leak point pressure (2.4 >2.1 not specified not specified >2.3 not specified >2.5 >2.2 not specified >2.4 >2.2 >2.2 >2.2

Definition Prolonged (msec) 19 16 55 94 10 18 42 48 31 15 12 77 89

N 9–36 3–16 50 12–98 6 3–39 12–36 3–61 1–36 4–32 20–73 2–96 6–120

Follow-up (mo) 80 92 — 55 100 — 73* 73 67 100 100 63 61†

Normal PNTML

Prolonged PNTML and Outcomes from anal Sphincter Surgery for Fecal Incontinence

11 50 — 30 67 — 60* 38 63 14 64 16 56†

Prolonged PNTML

Success Rate (%)

.05 ns ns 12 12

10/10/10 10/8/23

90 78 †

90

10

10/10/10

12 12 >12 24

30/32 35/34 46/46 36/36

94 91 80 † 68

12.9/16.3 60 12

70/87 30/30 83/78

91 57 83

92 93

12

28/34

93

88

6

104/96

89

94

32

38/49

18

34/40

88

85

72

38/35

77

48

18/23

23/22

77 †

12

30/30

89

11/14

23/23

83

12

120/120

12

82/75

89

21

36/26

81

100

Lsc Modification Cure (%)

Lsc MMK Cure (%)

Raz Cure (%)

75

82

TVT Cure (%)

90 90 ‡

100

93 94 § 96 64

58 †

79

62 ‡

83 73 § 83 92

74 §

84 97

Lsc, Laparoscopic; MMK, Marshall-Marchetti-Krantz; Raz, needle suspension; TVT, tension-free vaginal tape. *Published in abstract form. † Lsc 1 stitch, Burch. ‡ In this modification, bone anchors were used with one stitch on each side. § The staple/tack-mesh modification was used.

with open colposuspension (relative risk [RR] 0.89; 95% confidence interval [CI] 0.82–0.98), with an additional 9% risk of failure for laparoscopic versus open colposuspension. When one poor quality trial was excluded from the analysis for objective cure, the cure rate for stress urinary incontinence was lower but not significantly so for the laparoscopic compared with the open colposuspension (RR 0.91; 95% CI 0.82–1.01), with 8% more failures for laparoscopy compared with open procedures. Based on a single trial by Persson and Wollner-Hanssen (2000), two stitches placed on each side of the bladder neck are better than one. When further analyzing the methods of the RCTs, Carey et al. (2000), Fatthy et al. (2001), and Summitt et al. (2000) performed identical procedures by both routes and showed similar cure rates; however, Fatthy

et al. (2001) used only one polypropylene suture on each side. The main criticisms of Burton’s (1999) trial are that he had not gained sufficient experience with laparoscopic colposuspension before initiating the study and that the suture used was absorbable with a smaller needle, which may have included insufficient thickness of tissue. Similarly, Su et al. (1997) used three absorbable sutures in the open Burch compared with a single nonabsorbable suture in the laparoscopic procedure. Unfortunately, three of the five RCTs,—those of Burton, Carey et al., and Summitt et al.—have been published as abstracts only. Several cohort studies (Miannay et al., 1998; Ross, 1995; Saidi et al., 1998) have shown similar cure rates between laparoscopic and open colposuspension (see Table 17-2). Huang and Yang (2004) used ultrasound cystourethrography to compare laparoscopic and open Burch

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Management of Stress Urinary Incontinence and Pelvic Organ Prolapse

and found that resting and straining positions at 12 months were similar. Three studies, thus far, compare tension-free vaginal tape (TVT) procedure with laparoscopic retropubic procedures (see Table 17-2). In a prospective randomized trial comparing TVT and laparoscopic Burch urethropexy, Üstun et al. (2003) showed 83% cure in both groups. Longer operative times, hospital stay, and duration of catheterization were reported in the laparoscopic Burch group. In a two-center randomized trial comparing TVT and laparoscopic Burch colposuspension, Paraiso et al. (2004) found a higher cure rate of 97% for TVT versus 81% for laparoscopic Burch, based on urodynamic studies at 1 year (p = .056). Postoperative subjective symptoms of incontinence (stress, urge, and any) were reported significantly more often in the laparoscopic Burch group than in the TVT group (p < .04 for each category). Operative times were significantly longer for the laparoscopic Burch group. Hospital stay, total cost, and duration of catheterization did not differ between groups. In a prospective nonrandomized study comparing TVT with single-stitch laparoscopic bladder neck suspension, Liang and Soong (2002) showed no difference in subjective and objective cure. Operative time and time to resumption of spontaneous urination was significantly lower in the TVT group. Moehrer et al. (2003) reported that trends (no statistical difference) were shown toward a higher complication rate (bladder injury, obturator vein laceration, retropubic hematoma, wound infection, voiding difficulties, cystitis), less postoperative pain, less analgesic requirement, shorter hospital stay, and shorter time to return to normal function for laparoscopic compared with open colposuspension. Operating time is longer for laparoscopic than for open colposuspension in most studies. Estimated blood loss was higher, and duration of catheterization was longer in the open colposuspension group when compared to the laparoscopic group. In general, major intraoperative and short-term complications (urinary tract injury, bowel injury, inferior epigastric and other major vessel injury, blood loss requiring transfusion, and abscess formation in the space of Retzius) are noted in 0% to 25% of cases (see Table 17-1). Bladder injury is the most common major complication but occurs less frequently with increased experience. Laparoscopic bladder injury is detected by direct observation of urine or fluid in the operating field or by gaseous distention of the urinary bag. Most studies do not differentiate between major and minor complications. Major operative and early postoperative complications include urinary tract and bowel injury, inferior epigastric and other major vessel injury, blood loss requiring transfusion, and abscess formation of the space of Retzius. Long-term problems include failure of the procedure requiring resuspension, new-onset urethral intrinsic sphincter deficiency, de novo detrusor overactivity requiring long-term medical management, urinary retention requiring permanent catheterization, voiding pain with or without suture material in the bladder, vesicovaginal fistula, ureteral obstruction requiring reoperation, posterior and apical compartment compensatory defects requiring surgery, small bowel obstruction in a postoperative peritoneal defect, and incisional hernias. No deaths have been reported.

Two cases of foreign body erosions (tacks) into the bladder have been reported after modification of laparoscopic colposuspension using mesh and tacks (Kenton et al., 2002). Modifications of laparoscopic colposuspension using mesh and tacks or staples and diminishing the number of sutures to decrease operating time are not recommended because of compromise to the procedure. Generalizability of the data regarding laparoscopic Burch colposuspension is a concern because the majority of investigations were carried out by expert laparoscopists. Despite the steep learning curve associated with laparoscopic colposuspension, implementation of modifications should be avoided. Three investigations evaluated cost of open and laparoscopic Burch colposuspension. Kung et al. (1996) found total charges for the open Burch urethropexy ($5692) to be significantly higher than for the laparoscopic route ($2398). Average hospitalization was significantly higher for the open group (11.2 days) than for the laparoscopic group (3.6 days). However, the prolonged hospital stay in the open group of this Canadian study is not standard care in the United States. Loveridge et al. (1997) reviewed 49 consecutive patients who underwent laparoscopic (26) and open (23) colposuspension and found that overall in-hospital costs were similar because the increase in operating time in the laparoscopic group offset the longer hospital stay in the open group. Kohli et al. (1997) compared open (21 patients) and laparoscopic (17 patients) colposuspension and found that although mean length of stay was significantly different (2.1 days versus 1.3 days), the total hospital charges were significantly higher for the laparoscopic group ($4960) than for the open group ($4079). This difference was attributed to longer operating time. Ostrzenski (1998) has reported a prospective series of 28 patients who underwent laparoscopic paravaginal defect repair for urodynamic stress incontinence. Mean operative time was 2 hours and 45 minutes, and all patients were discharged on the same day. The cure rate was 93% based on subjective and objective data for minimum follow-up of 24 months. The efficacy of laparoscopic paravaginal defect repair requires additional investigation.

Technical Skill Development for Laparoscopic Colposuspension Before performing laparoscopic retropubic procedures, the surgeon should have adequate experience in performing these procedures by laparotomy and experience in performing operative laparoscopic procedures (adnexectomy, hysterectomy). The technique of laparoscopic suturing may be learned in a stepwise fashion. A surgeon can begin to develop suturing skills on inanimate models in pelvic trainers. Using laparoscopes, cameras, and video monitors to simulate operative conditions and improve depth perception is optimal. The next step involves performing laparoscopic retropubic procedures on pigs or goats in animal labs. Cadaver laboratories are ideal but less accessible. A surgeon should perform initial cases of laparoscopic bladder neck suspensions with an experienced and advanced laparoscopist who is proctoring and assisting. In our experience, a surgeon gains the most proficiency during the first 20 cases.

Chapter 17

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Laparoscopic Surgery for Stress Urinary Incontinence and Pelvic Organ Prolapse

LAPAROSCOPIC SURGERY FOR ENTEROCELE, VAGINAL APEX PROLAPSE, AND RECTOCELE Indications The indications for laparoscopic enterocele, vaginal apex prolapse, and rectocele repairs are identical to those for vaginal and abdominal routes. The choice of laparoscopic route is determined by surgeon and patient preference and the laparoscopic skill of the surgeon. Additional factors that should be considered include a history of pelvic or anti-incontinence surgery, previous failed transvaginal colpopexy, a short vagina, severe abdominopelvic adhesions, patient age and weight, need for concomitant pelvic surgery, and the patient’s ability to undergo general anesthesia.

Anatomy When considering the anatomy of the repair of pelvic organ support, a surgeon must keep in mind the three levels of support of the vagina. The upper fourth of the vagina (level I) is suspended by the cardinal/uterosacral complex, the middle half (level II) is attached laterally to the arcus tendineus fasciae pelvis and the medial aspect of the levator ani muscles, and the lower fourth (level III) is fused to the perineal body. The endopelvic fascia (also referred to as the anterior pubocervical fascia and posterior rectovaginal fascia) contributes to the integrity of the wall of the vagina. All pelvic support defects—whether anterior, apical, or posterior—represent a break in the continuity of the endopelvic fascia and/or a loss of its suspension, attachment, or fusion to adjacent structures. The goals of pelvic reconstructive surgery are to correct all defects, thus reestablishing vaginal support at all three levels, and to maintain or restore normal visceral and sexual function. The anatomic landmarks during laparoscopic enterocele repair are the pubocervical fascia, the rectovaginal fascia, the uterosacral ligaments, and the ureter, which courses along the pelvic sidewall and is approximately 1 to 1.5 cm lateral to the uterosacral ligament as it passes underneath the uterine artery. If a uterosacral ligament vaginal vault suspension is performed, the portion of the uterosacral ligaments proximal to their break from previous attachment to the vagina is delineated. Richardson (1995) describes breaks in the endopelvic fascia and uterosacral/cardinal ligaments rather than attenuation and stretching of tissue as the cause of vaginal apex prolapse. The key anatomic landmarks of sacral colpopexy are the middle sacral artery and vein; the sacral promontory with anterior longitudinal ligament; the aortic bifurcation and the vena cava, which are at the L4–L5 level; the right common iliac vessels and right ureter, which are at the right margin of the presacral space; and sigmoid colon, which is at the left margin. The left common iliac vein is medial to the left common iliac artery and can be damaged during dissection or retraction. The anatomic landmarks of laparoscopic rectocele repair are the rectovaginal septum, made up of Denonvilliers’ fascia, and its lateral attachment to the medial aspect of the levator ani muscles. Denonvilliers’ fascia is the endopelvic

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fascia attached superiorly to the uterosacral cardinal ligament complex, laterally to the superior fascia of the levator ani muscle, and inferiorly to the perineal body. The rectovaginal septum is the posterior point of attachment of the sacral colpopexy mesh. Rectovaginal fascia, rectovaginal septum, and Denonvilliers’ fascia are synonymous. The pubocervical fascia is the anterior point of mesh attachment during sacral colpopexy.

Operative Technique LAPAROSCOPIC MOSCHCOWITZ AND HALBAN PROCEDURES The Moschcowitz procedure is performed laparoscopically exactly as during laparotomy. A No. 0 nonabsorbable 36-inch suture is stitched in the peritoneum around the cul-de-sac in a purse-string fashion and subsequently tied extracorporeally. Additional sutures are placed as needed. The ureters should be examined carefully during and after the Moschcowitz procedure. The peritoneum medial to the ureters may be incised to prevent ureteral kinking. The Halban procedure is performed by suturing No. 0 nonabsorbable suture starting at the posterior vagina and proceeding longitudinally over the cul-de-sac peritoneum and then over the inferior sigmoid serosa. These sutures are tied as they are placed. Sutures should be approximately 1 cm apart. Little risk of ureteral compromise is present with this procedure; however, it is important to visualize the ureters after all sutures are tied. LAPAROSCOPIC ENTEROCELE REPAIR The enterocele sac is dissected laparoscopically or vaginally so that the endopelvic fascial defects are identified and the pubocervical fascia and rectovaginal fascia are delineated. If the enterocele is large, the surgeon excises redundant peritoneum and vagina by the vaginal route, taking care not to foreshorten or narrow the vaginal apex. A vaginal obturator, sponge stick, or equivalent vaginal manipulator (EEA sizer by U.S. Surgical Corp., Norwalk, CT; the CDH by Ethicon Endo-Surgery, Inc., Cincinnati, OH) may be used for delineation of the vaginal apex or rectum when performing the dissection laparoscopically. The pubocervical and rectovaginal fascial edges are reapproximated with a No. 0 nonabsorbable suture in interrupted stitches until the fascial defect is closed. Extracorporeal knot-tying is performed after each stitch is placed, which is often performed concomitantly with a uterosacral ligament vaginal vault suspension so that level I suspension is reestablished. LAPAROSCOPIC UTEROSACRAL LIGAMENT AND VAGINAL VAULT SUSPENSION To suspend the vaginal apex to the uterosacral ligament, the surgeon must dissect and delineate the pubocervical and rectovaginal fascias. The surgeon sutures the full thickness of the uterosacral ligament at the proximal portion of its break with a No. 0 nonabsorbable suture and reattaches it to the vaginal apex with a full thickness stitch incorporating the uterosacral/cardinal ligament complex and rectovaginal fascia, excluding the vaginal epithelium. This stitch is tied extracorporeally, and the opposite uterosacral ligament is reattached in the same fashion. Two or three additional

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stitches are taken more proximally in the uterosacral ligaments on each side to reattach it to the rectovaginal fascia (Color Plate 5). Plication of the uterosacral ligaments is not necessary. If concomitant enterocele repair is performed, the uterosacral ligaments may be tagged before dissection of the posterior vagina and rectovaginal septum so that they are easily identified for subsequent suspension. To protect the ureters, peritoneal incisions may be made laterally to the uterosacral ligaments. The apical vault repair described by Ross (International Urogynecology Journal, 1997) reestablished the lateral and posterior paracervical rings of endopelvic fascia by bringing the rectovaginal septum and cardinal/uterosacral ligaments together. After the peritoneum is dissected off the vaginal apex and the pubocervical fascia and rectovaginal septum are identified, a No. 0 nonabsorbable suture is used to incorporate the left and right uterosacral and cardinal ligaments, the rectovaginal septum, and posterior vaginal wall in purse-string stitches, thus plicating the uterosacral ligaments. The first stitch is placed in the uterosacral ligament approximately 3 to 4 cm proximal to the vaginal apex. Three or more successive stitches are placed until the vaginal apex is reached. The final suture incorporates the pubocervical fascia into the repair. This repair differs from the uterosacral ligament vaginal vault suspension by placement of purse-string sutures resulting in uterosacral ligament plication. LAPAROSCOPIC SACRAL COLPOPEXY In addition to the intraumbilical port, a 5/12-mm trocar should be placed in both lower quadrants for suture introduction. One or two additional 5-mm ports are placed at the level of the umbilicus, lateral to the rectus muscle for simultaneous suturing and/or retraction (see Fig. 17-1). After the ancillary ports are placed, dissection of the peritoneum between the vaginal apex and rectum is performed to delineate the rectovaginal fascia (Color Plate 6). Anterior dissection is performed (taking care to avoid damage to the bladder) if a mesh is stitched to the pubocervical fascia or if enterocele repair is needed. A vaginal obturator, sponge stick, or equivalent vaginal manipulator is used for delineation of the vaginal apex or rectum. If exposure of the sacral promontory and presacral space is not adequate, the patient should be tilted to her left and a reusable snake retractor (Snowden Pencer, Tucker, GA) or fan retractor (Origin Medsystems, Menlo Park, CA) placed through an ancillary port. The peritoneum overlying the sacral promontory is incised longitudinally with laparoscopic scissors or harmonic scalpel (Gynecare, Inc., Somerville, NJ) and extended to the cul-de-sac. A laparoscopic dissector or hydrodissection is used to expose the periosteum of the sacral promontory. If blood vessels are encountered during the dissection, coagulation or clip placement is used to achieve hemostasis. Some surgeons prefer to first dissect the presacral space, thus eliminating the most technically difficult portion of the procedure. A Halban procedure or Moschcowitz culdoplasty may be performed based on surgeon preference or when a deep cul-de-sac is noted. When a concomitant culdoplasty is performed, it is completed after posterior mesh placement.

A 12- × 3.5-cm polypropylene mesh or biologic tissue is introduced through a 5/12-mm port. When a T-shaped mesh is used, a 4- × 3.5-cm mesh is sutured to the larger piece of mesh with a No. 0 nonabsorbable suture before intraperitoneal placement. The mesh is sutured anteriorly to the vaginal apex, with two to three pairs of No. 0 nonabsorbable sutures, and into the posterior vaginal apex and rectovaginal septum, with three to four similar rows of suture. When a T-shaped mesh is used, it is easier to first suture the anterior portion so that the cephalad portion of the mesh may be retracted anteriorly while the posterior rows of sutures are being placed. A second technique used to incorporate a Tshaped mesh is suturing separately two pieces of mesh. The larger piece of mesh is sutured into the posterior wall of the vagina, and the smaller piece of mesh is sutured to the anterior wall. We then sew both pieces together into the vaginal apex and trim the excess anterior mesh. A third technique incorporates two pieces of 12- × 3.5-cm polypropylene mesh or biologic tissue. We first sew on the posterior mesh. The most caudal stitch is placed on the posterior vaginal wall and rectovaginal fascia. After placement of the first stitch, the mesh is threaded through the stitches before introducing the mesh into the peritoneal cavity. The corresponding contralateral stitch is taken and threaded through the mesh to anchor the inferior border of the mesh to the rectovaginal septum or perineum. (Note that a 15- to 18-cm mesh length may be required for laparoscopic sacral colpoperineopexy.) The sutures are tied extracorporeally as they are placed. Care is taken to place the stitches through the entire thickness of the vaginal wall, excluding the epithelium. The surgeon sutures the mesh to the longitudinal ligament of the sacrum in two rows of two No. 0 nonabsorbable sutures (Color Plate 7). No undue tension is placed on the mesh. Titanium tacks or hernia staples may also be used to attach the mesh to the anterior longitudinal ligament of the sacrum. The redundant portion of the mesh is excised, and the peritoneum is reapproximated over the mesh with a No. 2–0 polyglactin suture. If the mesh remains exposed, sigmoid epiploic fat may be sutured over it. A concomitant laparoscopic Burch colposuspension is performed, if the patient has urethral hypermobility with urodynamic stress incontinence. A paravaginal defect repair is performed, if needed, to treat anterior vaginal wall defects. If rectal prolapse is present, a rectopexy with or without sigmoid resection can be performed laparoscopically. We perform these combined cases with our colorectal surgery colleagues. Our technique for sacrohysteropexy (sacrocervicopexy) involves dissection of the rectovaginal space approximately one third to one half of the length of the posterior vaginal wall. A 3.5- × 12-cm polypropylene mesh or biologic tissue graft is stitched to the posterior vaginal wall with a No. 0 nonabsorbable suture in several rows along the rectovaginal fascia and posterior cervix to the level of the internal os of the cervix. Peritoneal closure of the mesh is then performed. LAPAROSCOPIC RECTOCELE REPAIR The rectovaginal septum is opened using electrocautery, harmonic scalpel, or laser. Blunt dissection with blunt-tipped dissectors or dolphin-tipped dissectors, hydrodissection, or sharp dissection may be used to open the rectovaginal space

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down to the perineal body. This dissection should follow surgical planes and be bloodless. The perineal body is sutured to the rectovaginal septum. The rectovaginal fascial defects are closed with a No. 0 nonabsorbable suture. If the rectovaginal fascia is detached from the iliococcygeus fascia, it is reattached with a No. 0 nonabsorbable suture. The medial aspects of the levator ani muscles may also be plicated, but care should be taken to avoid a posterior vaginal ridge. Lyons and Winer (1997) have reported the use of polyglactin mesh in extensive rectocele repairs. Most surgeons prefer rectocele repair by vaginal route.

Clinical Results and Complications The current gynecologic literature for laparoscopic pelvic reconstruction is sparse and consists of descriptive studies with short-term follow-up. Several reports of laparoscopic rectopexy in the colorectal surgery literature are beyond the scope of this chapter. No reports evaluate clinical results and complications of uterosacral shortening and culdoplasty, although these techniques have been described by a few authors. Lyons and Winer (1995) reported 276 enterocele repairs or prophylaxis with Halban or Moschcowitz procedures and noted no complications other than trocar site infections. Cadeddu et al. (1996) described a modified Moschcowitz procedure, approximating the posterior vaginal fascia with the anterior wall of the rectum. Koninckx et al. (1995) used the carbon dioxide laser for vaporization of the enterocele sac, followed by uterosacral shortening and suspension of the posterior vaginal wall. Lyons and Winer (1997) evaluated prospectively, at 3-month intervals for 1 year, 20 patients who underwent laparoscopic rectocele repair with polyglactin mesh and concomitant reparative procedures. An objective telephone interviewer asked a series of questions with regard to bowel and sexual function. The mean operative time for rectocele repair was 35 minutes (range, 20 to 48 minutes). Estimated blood loss was minimal and hospital stay was less than 24 hours. Eighty percent of patients had symptomatic relief of digital defecation and prolapse at 1 year. A small number of reports is documented of laparoscopic repair of vaginal apex prolapse. Nezhat et al. (1994) reported a series of 15 patients who underwent laparoscopic sacral colpopexy in whom the mean operative time was 170 minutes (range, 105 to 320 minutes) and mean blood loss was 226 mL (range, 50 to 800 mL). The mean hospital stay was 2.3 days, excluding a case converted to laparotomy for presacral hemorrhage. The cure rate for apical prolapse was 100% at 3 to 40 months. Lyons (1995) reported 4 laparoscopic sacrospinous fixations and 10 laparoscopic sacral colpopexies, with operative times comparable to vaginal and abdominal approaches. He reported less intraoperative and postoperative morbidity with the laparoscopic route; this was attributed to a superior anatomic approach and visualization of anatomic structures. Nezhat et al. (1994) and Lyons (1995) used mesh and suture, and, at times, they stapled the mesh into the longitudinal ligament of the anterior sacrum. Ross (Journal of the American Association of Gynecologic Laparoscopists, 1997) evaluated 19 patients with prospective posthysterectomy vaginal apex prolapse with extensive preoperative and postoperative testing, including multichan-

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nel urodynamics and transperineal ultrasound. All patients underwent sacral colpopexy, Burch colposuspension, and modified culdoplasty. Paravaginal defect repair and posterior colporrhaphy were added as indicated. The author reported seven complications: three cystotomies, two urinary tract infections, one seroma, and one inferior epigastric vessel laceration. Five patients had recurrent defects that were all less than grade 2 (two paravaginal defects and three rectoceles). Vaginal length ranged from 10.8 to 12.1 cm and all sexually active patients reported no sexual dysfunction. All patients but four voided spontaneously and none required more than 4 days of catheterization. All were discharged within 24 hours. The cure rate at 1 year was 100% for vaginal apex prolapse and 93% for stress incontinence, although two patients were lost to follow-up. In another study, Ross (2004) prospectively analyzed 51 cases of laparoscopic sacral colpopexy for grade III or IV apical vaginal prolapse. Forty-three patients demonstrated an objective cure rate of 93% at the vaginal apex during their 5-year follow-up visit. Complications included one partial small bowel obstruction secondary to bowel adherence to the mesh and two locally treated mesh erosions. The author concluded that patient recovery was greatly enhanced with the majority of patients requiring only an overnight hospitalization. Gadonneix et al. (2004) reported the use of two separate meshes for laparoscopic sacral colpopexy with or without Burch colposuspension in 46 consecutive patients with primary vaginal apex prolapse, with or without primary stress incontinence. Mean operating time was 171 minutes and mean hospital stay was 4 days. Median follow-up was 24 months (range, 12 to 60). Eleven percent of patients required conversion to laparotomy. Complications included de novo urge incontinence in 5% of patients, laparoscopically treated bladder injury in 7% of patients, and 12% recurrence of rectoceles (occurring only in women who had undergone laparoscopic Burch colposuspension compared with no colposuspension; P = .036). One patient developed obstructed defecation, which the authors attributed to excessive mesh tension. At the Cleveland Clinic we compared our first 56 consecutive laparoscopic sacral colpopexies to 61 consecutive open sacral colpopexies performed during the same period (Paraiso et al., 2005). Mean follow-up was 14 and 16 months in the laparoscopic and open groups, respectively. Laparoscopic sacral colpopexy and concomitant procedures required a significantly longer operating time when compared with open sacral colpopexy, with mean operating times of 269 versus 218 minutes. However, mean hospital stay was significantly longer in the open group than the laparoscopic group: 4 versus 1.8 days. We found similar clinical outcomes and reoperation rates. Our sample size was too small to determine differences in complications. Long-term outcomes of laparoscopic sacral colpopexy were reported by Higgs et al. in 2005. One hundred and three women with a median follow-up of 66 months were contacted and asked to complete questionnaires. Sixty-six patients underwent physical examination with the POPQ system. Overall, 79% reported subjective cure or improvement of prolapse symptoms, whereas 38% still complained of prolapse. Among those examined, 92% were cured at the vaginal apex, whereas 42% had a recurrence of prolapse in at least one vaginal segment.

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The literature regarding laparoscopic uterosacral ligament suspension is equally as sparse with no comparative studies. Miklos et al. (1998) reported a series of 17 women who underwent laparoscopic uterosacral ligament identification with site-specific vaginal repair of enterocele and rectocele. They reported mild asymptomatic apical prolapse in 12% of patients at a mean of 6 months (range, 1 to 17). More recently, Seman et al. (2003) reported their 2-year experience with laparoscopic pelvic reconstruction. They retrospectively assessed 73 consecutive women who underwent various laparoscopic procedures for genital prolapse with a mean follow-up of 8 months (range, 0 to 26). Fortyseven patients underwent uterosacral vaginal vault suspension with an objective success rate of 100%.

DISCUSSION Laparoscopy is a means of less-invasive surgical access, not a unique procedure, and its use is expanding rapidly in all surgical specialties. We believe that the laparoscopic and open Burch procedures should be identical in operative techniques. Bladder injury is probably more common with laparoscopy, but the risk of cystotomy decreases with surgical experience. Complications associated with open Burch bladder neck suspension, such as wound infection and hernias, are rare with the laparoscopic route. The benefits of improved visualization of anatomic structures and the small incisions associated with the laparoscopic approach are desirable, particularly in obese patients. The advantages of less postoperative pain, shorter hospitalization, shortened recovery period, and earlier return to work are very popular with patients, but these advantages are partially offset by increased operating time and, possibly, increased cost. The operating time and cost will probably decrease as surgeons gain experience with the advanced laparoscopic techniques of suturing and knot-tying. However, the technical ease and clinical success associated with midurethral sling procedures and the steep learning curve in development of laparoscopic suturing skills may deter many gynecologic surgeons from performing retropubic procedures by this approach. Although over 50 articles are published on laparoscopic colposuspension, the data are influenced by many confounding variables. A meta-analysis by Moehrer et al. (2003) of the randomized clinical trials comparing laparoscopic and open colposuspensions shows similar subjective cure rates with an additional 8% risk of objective failure for laparoscopic compared with open colposuspension. Although it is possible that no difference exists between laparoscopic and open colposuspension, a trend appears to be moving toward lower cure rates with the laparoscopic Burch procedure. One- to two-year follow-up data from one randomized clinical trial and one nonrandomized prospective trial show similar cure rates of TVT to laparoscopic colposuspension. One recently published randomized trial (Paraiso et al., 2004) demonstrated similar subjective improvement and patient satisfaction after both laparoscopic Burch colposuspension and TVT. However, TVT resulted in significantly greater subjective cure rates for stress incontinence

than the laparoscopic Burch colposuspension. Also, substantially more subjects demonstrated urodynamic stress incontinence during urodynamic testing 1 year after surgery in the laparoscopic Burch colposuspension group than in the TVT group (Absolute risk increase 15.6%; P = .056). Multiple outcome measures were analyzed, which confirmed the superior efficacy of the TVT procedure. The evidence for laparoscopic Burch colposuspension is limited by short-term follow-up, small numbers, and poor methodology in some studies; therefore, the value of this procedure cannot be determined. Further well-designed and adequately powered randomized trials are required. We do not recommend the staple/tack-mesh modification because of multiple comparative trials showing significantly lower cure rates compared with standard laparoscopic and open Burch colposuspension and because of the increased potential of staple- and mesh-related complications. The principles of laparoscopic reparative procedures for enterocele, rectocele, and vaginal apex prolapse are not new; the difference is the route by which they are performed. Adequate laparoscopic suturing skills are essential in performing these procedures. The increase in operating time may increase the cost of the procedure, especially early in a surgeon’s experience. A review regarding innovations in prolapse surgery by Deval and Haab (2003) stated that laparoscopic approaches for pelvic organ prolapse are the least used because of the great degree of technical difficulty associated with laparoscopic suturing. However, the greatest potential for laparoscopic advances and innovations may be for surgeries for prolapse. We believe that laparoscopic sacral colpopexy will gain popularity because the abdominal sacral colpopexy remains the most proven and effective surgery for cure of severe apical prolapse. Pelvic floor surgeons in specialized centers will strive to offer their patients pelvic reconstruction by laparoscopic route. Many centers are applying robotic assistance to laparoscopic sacral colpopexies with some success. More comparative studies and prospective clinical trials with long-term follow-up are warranted.

Bibliography LAPAROSCOPIC RETROPUBIC SURGICAL PROCEDURES Albala DM, Schuessler WE, Vancaillie TG. Laparoscopic bladder suspension for the treatment of stress incontinence. Semin Urol 1992;10:222. Ankardal M, Ekerydh A, Crafoord K, et al. A randomized trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence. BJOG 2004; 111:974 Aslan P, Woo HH. Ureteric injury following laparoscopic colposuspension. Br J Obstet Gynaecol 1997;104:266. Birken RA, Leggett PL. Laparoscopic colposuspension using mesh reinforcement. Surg Endosc 1997;11:1111. Burton G. A randomised comparison of laparoscopic and open colposuspension (abstract). Neurourol Urodyn 1993;13:497. Burton G. A three-year prospective randomised urodynamic study comparing open and laparoscopic colposuspension (abstract). Neurourol Urodyn 1997;16:353. Burton G. A five-year prospective randomized urodynamics study comparing open and laparoscopic colposuspension (abstract). Neurourol Urodyn 1999;18:295–296. Carey M, Rosamilia A, Maher C, et al. Laparoscopic versus open colposuspension: a prospective multicentre randomized single-blind study (abstract 8). Neurourol Urodyn 2000;19:389. Carter JE. Laparoscopic bladder neck suspension. Endosc Surg 1995;3:81.

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Zullo F, Palomba S, Piccione F, et al. Laparoscopic Burch colposuspension: a randomized controlled trial comparing two transperitoneal surgical techniques. Obstet Gynecol 2001;98:738.

LAPAROSCOPIC SURGERY FOR ENTEROCELE, VAGINAL APEX PROLAPSE, AND RECTOCELE Cadeddu JA, Micali S, Moore RG, et al. Laparoscopic repair of enterocele. J Endourol 1996;4:367. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166:1717. Deval B, Haab F. What’s new in prolapse surgery? Curr Opin in Urol 2003;13:315. Dorsey JH, Sharp HT. Laparoscopic sacral colpopexy and other procedures for prolapse. Baillieres Clin Obstet Gynaecol 1995;9:749. Gadonneix P, Ercoli A, Salet-Lizee D, et al. Laparoscopic sacrocolpopexy with two separate meshes along the anterior and posterior vaginal walls for multicompartment pelvic organ prolapse. J Am Assoc Gynecol Laparosc 2004;11:29. Higgs PJ, Chua HL, Smith AR. Long-term review of laparoscopic sacrocolpopexy. BJOG 2005;112:1134. Koninckx PR, Poppe W, Deprest J. Carbon dioxide laser for laparoscopic enterocele repair. J Am Assoc Gynecol Laparosc 1995;2:181. Lyons TL. Minimally invasive treatment of urinary stress incontinence and laparoscopically directed repair of pelvic floor defects. Clin Obstet Gynecol 1995;38:380. Lyons TL, Winer WK. Vaginal vault suspension. Endosc Surg 1995;3:88.

Lyons TL, Winer WK. Laparoscopic rectocele repair using polyglactin mesh. J Am Assoc Gynecol Laparosc 1997;4:381. Miklos JR, Kohli N, Lucente V, Saye WB. Site-specific fascial defects in the diagnosis and surgical management of enterocele. Am J Obstet Gynecol 1998;179:1418. Nezhat CH, Nezhat F, Nezhat C. Laparoscopic sacral colpopexy for vaginal vault prolapse. Obstet Gynecol 1994;84:885. Paraiso MF, Walters MD, Rackley RR, et al. Laparoscopic and abdominal sacral colpopexies: a cohort study. Am J Obstet Gynecol 2005;192:1752. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;35:976. Richardson AC. The anatomic defects in rectocele and enterocele. J Pelvic Surg 1995;1:214. Ross JW. Apical vault repair, the cornerstone of pelvic floor reconstruction. Int Urogynecol J 1997;8:146. Ross JW. Techniques of laparoscopic repair of total vault eversion after hysterectomy. J Am Assoc Gynecol Laparosc 1997;4:173. Ross JW. The role of laparoscopy in the treatment of severe vaginal vault prolapse: 6 to 10 year outcome (abstract). J Am Assoc Gynecol Laparosc 2004;11:S4. Seman EI, Cook JR, O’Shea RT. Two-year experience with laparoscopic pelvic floor repair. J Am Assoc Gynecol Laparosc 2003;10:38. Vancaillie TG. The role of laparoscopy in the management of pelvic floor relaxation. J Am Assoc Gynecol Laparosc 1997;4:147.

Urethral Injection of Bulking Agents for Intrinsic Sphincter Deficiency

18

Alfred E. Bent

INDICATIONS AND CONTRAINDICATIONS EVALUATION 228 MATERIALS 228 TECHNIQUES 229 Periurethral Method 229 Transurethral Method 229 Insertion Devices 230 Post-Injection Follow-up 230 COMPLICATIONS 230 SAFETY 231 EFFECTIVENESS 231 FUTURE CONSIDERATIONS 232

227

In 1938 Murless reported the use of morrhuate sodium for injection management of urinary incontinence. Since the use of injectable polytetrafluoroethylene (PTFE) in the 1970s for treatment of urinary incontinence, a number of materials for this purpose have gradually emerged. The ideal material is biocompatible, nonimmunologic, and hypoallergenic. It retains its bulking characteristics for a prolonged interval and therefore should not biodegrade or migrate (particle size over 80 μm). The material should be easy to prepare and easy to inject, and the ideal material is safe, readily obtainable, inexpensive, efficacious, durable, and induces minimal tissue reaction. The theory on how injectable materials treat incontinence is by mucosal coaptation with subsequent increased urethral resistance to outflow of urine. Although transmission of pressure to the urethra during increased intra-abdominal pressure may not occur in these patients, the pressure forcing the urine from the bladder through the urethra is resisted by the bulking of the mucosa in the immediate proximal urethra. This essentially prevents involuntary bladder neck opening.

INDICATIONS AND CONTRAINDICATIONS The ideal patient for urethral bulking has both limited mobility of the bladder neck and a poorly functioning sphincteric mechanism. More often she is older; because repeat injec-

tions are usually required over time to maintain effect, this could mean many injections in a young patient. Although some reports indicate equal effectiveness in patients with hypermobility of the bladder neck, others have noted that bulking is not as effective in these patients. The Medicare guidelines for reimbursement were first published in 1994 and then revised in 1996, and indicated that immobility of the bladder neck had to be present. It was not specified as to how immobility was to be determined, but most physicians use a Q-tip test with a straining value of less than 30 to 40 degrees as the cutoff value for hypermobility. In one study, hypermobility was determined radiologically by a standing stress test with 2 cm or greater descent of the bladder neck determined to be hypermobile. The other requirement was initially a leak point pressure of 65 cm H2O or less that was later changed to 100 cm H2O. The measurement of leak point pressure required at least 150 mL of bladder filling, but no requirement was present regarding position of the patient, size of urethral catheter, or kind of effort used to increase the intra-abdominal pressure. One standard method is to do the test in the sitting position, with 200 mL in the bladder, using an 8-French catheter, and asking to patient to gradually strain harder and harder until urine leakage is observed. Certain patients respond better to periurethral bulking. Should the procedure provide no relief after two injections, subsequent ones are usually futile. A suburethral sling can be performed after periurethral bulking without concern for residual material. It may be preferable to use a nonsynthetic sling in those patients who have bulking agents that do not biodegrade, although no study has shown this. If a surgery has first been performed, either an anti-incontinence procedure or other pelvic floor surgery, and stress incontinence persists or recurs, no contraindication to using a bulking agent is known, and often it is very effective. This may be done as early as 6 weeks after surgery. As stated, bulking agents are not generally indicated for patients with urethral hypermobility. In some cases in highrisk patients with prolapse and stress incontinence, a pessary has provided excellent control of pelvic organ prolapse, and some temporary stabilization of bladder neck mobility has been present. Periurethral bulking may be used in this patient to treat the potential stress incontinence that was unmasked after the prolapse was reduced.

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Contraindications to the use of periurethral bulking include active urinary tract infection, high residual urine (>100 mL), severe detrusor overactivity, and reduced bladder capacity ( 80 mL) in 92% of patients 3 months after needle suspension procedures and anterior colporrhaphy. Approximately 5% of patients developed a recurrent anterior vaginal prolapse, and 8% developed a recurrent enterocele after an average of 2 years of follow-up. Risk factors for failure of anterior vaginal prolapse repair have not been studied specifically. Vaginal prolapse recurs with increasing age, but the actual frequency is unknown. Recurrence may represent a failure to identify and repair all support defects, or may be due to weakening, stretching, or breaking of patient’s tissues, as occurs with advancing age and after menopause. Sacrospinous ligament suspension of the vaginal apex, with exaggerated retrosuspension of the vagina, may predispose patients to recurrence of anterior vaginal prolapse. Other characteristics that may increase chances of recurrence are severity of initial prolapse, genetic predisposition, subsequent pregnancy, heavy lifting, chronic pulmonary disease, smoking, and obesity.

COMPLICATIONS Intraoperative complications are uncommon with anterior vaginal prolapse repair. Excessive blood loss may occur, requiring blood transfusion, or a hematoma may develop in the anterior vagina; this is probably more common

after vaginal paravaginal repair than anterior colporrhaphy. The lumen of the bladder or urethra may be entered in the course of dissection. Accidental cystotomy should be repaired in layers at the time of the injury. After repair of cystotomy, the bladder is generally drained for 7 to 14 days to allow adequate healing. Ureteral damage or obstruction occurs rarely (0% to 2%), usually with very large cystoceles or apical prolapse. Other rare complications include intravesical or urethral suture placement (and associated urologic problems), and fistula, either urethrovaginal or vesicovaginal. If permanent sutures or mesh material are used in the repair, erosion, draining sinuses, or chronic areas of vaginal granulation tissue can result. The incidence of these complications is unknown but may be as high as 13%. Urinary tract infections occur commonly (especially with concurrent catheter usage), but other infections, such as pelvic or vaginal abscesses, are less common. Voiding difficulty can occur after anterior vaginal prolapse repair. In our hands, the average time to adequate voiding after cystocele repair with suburethral plication is 9 days. This problem may occur more often in women with subclinical preoperative voiding dysfunction. Treatment is bladder drainage or intermittent self-catheterization until spontaneous voiding resumes, usually within 6 weeks. Sexual function may be positively or negatively affected by vaginal operations for anterior vaginal prolapse. Haase and Skibsted (1988) studied 55 sexually active women who underwent various operations for stress incontinence or genital prolapse. Postoperatively, 24% of the patients experienced improvement in their sexual satisfaction, 67% experienced no change, and 9% experienced deterioration. Improvement often resulted from cessation of urinary incontinence. Deterioration was always caused by dyspareunia after posterior colporrhaphy. These authors concluded that the prognosis for an improved sexual life is good after surgery for stress incontinence, but that posterior colpoperineorrhaphy causes dyspareunia in some patients. The current popularity of synthetic or allograft mesh to augment vaginal prolapse repairs could improve sexual function if cure rates improve, or worsen function if vaginal stiffness, mesh erosions, or draining sinuses result. More data with careful anatomic and functional follow-up after surgery are needed.

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Bibliography ANATOMY AND PATHOLOGY Aronson MP, Bates SM, Jacoby AF, et al. Periurethral and paravaginal anatomy: an endovaginal magnetic resonance imaging study. Am J Obstet Gynecol 1995;173:1702. DeLancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187:93. Nichols DH, Randall CL. Vaginal Surgery, 4th ed. Williams & Wilkins, Baltimore, 1996. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568. White GR. A radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA 1909;21:1707. White GR. An anatomical operation for the cure of cystocele. Am J Obstet Dis Women Child 1912;65:286.

EVALUATION Barber MD, Cundiff GW, Weidner AC, et al. Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall prolapse. Am J Obstet Gynecol 1999;181:87. Beverly CJ, Walters MD, Weber AM, et al. Prevalence of hydronephrosis in women undergoing surgery for pelvic organ prolapse. Obstet Gynecol 1997;90:37. Bhatia NN, Bergman A. Pessary test in women with urinary incontinence. Obstet Gynecol 1985;65:220. Bump RC, Fantl JA, Hurt WG. The mechanism of urinary continence in women with severe uterovaginal prolapse: results of barrier studies. Obstet Gynecol 1988;72:291. de Gregorio G, Hillemanns HG. Urethral closure function in women with prolapse. Int Urogynecol J 1990;1:143. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on urethrovesical pressure dynamics. Am J Obstet Gynecol 1983;146:901. Tulikangas PK, Lukban JC, Walters MD. Anterior enterocele: a report of three cases. Int Urogynecol J 2004;15:350. Whiteside JL, Barber MD, Paraiso MF, et al. Clinical evaluation of anterior vaginal wall support defects: interexaminer and intraexaminer reliability. Am J Obstet Gynecol 2004;191:100.

SURGICAL REPAIR TECHNIQUES AND COMPLICATIONS Barber MD. Surgical correction of paravaginal defects. In Vasavada S, Appell R, Sand P, Raz S, eds. Female Urology, Urogynecology and Voiding Dysfunction. Marcel Dekker, New York, 2005. Beck RP, McCormick S. Treatment of urinary stress incontinence with anterior colporrhaphy. Obstet Gynecol 1982;59:269. Black NA, Downs SH. The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 1996;78:497. De Tayrac R, Gerviase A, Chauveaud A, et al. Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse. J Reprod Med 2005;50:75. Flood CG, Drutz HP, Waja L. Anterior colporrhaphy reinforced with Marlex mesh for the treatment of cystoceles. Int Urogynecol J 1998;9:200. Gandhi S, Goldberg RP, Kwon C, et al. A prospective randomized trial using solvent dehydrated fascia lata for the prevention of recurrent anterior vaginal wall prolapse. Am J Obstet Gynecol 2005;142:1649. Gardy M, Kozminski M, DeLancey J, et al. Stress incontinence and cystoceles. J Urol 1991;145:1211. Glazener CM, Cooper K. Anterior vaginal repair for urinary incontinence in women (Cochrane Review). In The Cochrane Library. Update Software, Oxford, 2002, Issue 3. Goldberg RP, Koduri S, Lobel RW, et al. Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation. Am J Obstet Gynecol 2001;185:1307.

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Gomelsky A, Rudy DC, Dmochowski RR. Porcine dermis interposition graft for repair of high grade anterior compartment defects with or without concomitant pelvic organ prolapse procedures. J Urol 2004;171:1581. Haase P, Skibsted L. Influence of operations for stress incontinence and/or genital descensus on sexual life. Acta Obstet Gynecol Scand 1988;67:659. Hardiman P, Oyawoye S, Browning J. Cystocele repair using polypropylene mesh. Br J Obstet Gynaecol 2000;107:825. (Abstract). Julian TM. The efficacy of Marlex mesh in the repair of severe, recurrent vaginal prolapse of the anterior midvaginal wall. Am J Obstet Gynecol 1996;175:1472. Karram MM. Vaginal operations for prolapse. In Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. WB Saunders Co., Philadelphia, 2001. Kobak WH, Walters MD, Piedmonte MR. Determinants of voiding after three types of incontinence surgery. Obstet Gynecol 2001;97:86. Kwon CH, Goldberg RP, Koduri S, et al. The use of intraoperative cystoscopy in major vaginal and urogynecologic surgeries. Am J Obstet Gynecol 2002;187:1466. Macer GA. Transabdominal repair of cystocele, a 20-year experience, compared with the traditional vaginal approach. Am J Obstet Gynecol 1978;131:203. Mage P. Interposition of a synthetic mesh by vaginal approach in the cure of genital prolapse. Gynecol Obstet Biol Reprod (Paris) 1999;28:825. (in French). Mallipeddi PK, Steele AC, Hohli N, Karram MM. Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior vaginal prolapse. Int Urogynecol J 2001;12:83. Meschia M, Pifarotti P, Spennacchio M, et al. A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence. Am J Obstet Gynecol 2004;190:609. Migliari R, De Angelis M, Madeddu G, Verdacchi T. Tension-free vaginal mesh repair for anterior vaginal wall prolapse. Eur Urol 2000;38:151. Migliari R, Usai E. Treatment results using a mixed fiber mesh in patients with grade IV cystocele. J Urol 1999;161:1255. Natale F, Marziali S, Cervigini M. Tension-free cystocele repair (TCR): longterm follow-up. Int Urogynecol J 2000;11:S51. (Abstract). Nicita G. A new operation for genitourinary prolapse. J Urol 1998;160:741. Palma P, Riccetto C, Dambros M, Netto NR. New trends in the transobturator management of cystoceles. BJU Int 2006;97:201. Pelusi G, Bacchi P, Demaria F, et al. The use of Kelly plication for the prevention and treatment of genuine stress urinary incontinence in patients undergoing surgery for genital prolapse. Int Urogynecol J 1990;1:196. Salvatore S, Soligo M, Meschia M, et al. Prosthetic surgery for genital prolapse: functional outcome. Neurourol Urodyn 2002;21:296. (Abstract). Sand PK, Koduri S, Lobel RW, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184:1357. Shull BL, Benn SJ, Kuehl TJ. Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome. Am J Obstet Gynecol 1994;171:1429. Stanton SL, Norton C, Cardozo L. Clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence. Br J Obstet Gynaecol 1982;89:459. Symmonds RE, Jordan LT. Iatrogenic stress incontinence of urine. Am J Obstet Gynecol 1961;82:1231. Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and techniques of surgical repair. Obstet Gynecol 1997;89:311. Weber AM, Walters MD, Piedmonte MA, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299. Young SB, Daman JJ, Bony LG. Vaginal paravaginal repair: one-year outcomes. Am J Obstet Gynecol 2001;185:1360. Zacharin RF. Free full-thickness vaginal epithelium graft in correction of recurrent genital prolapse. Aust N Z J Obstet Gynaecol 1992;32:146.

Surgical Treatment of Rectocele and Perineal Defects

20

Tristi W. Muir

ANATOMY AND PATHOPHYSIOLOGY 246 EVALUATION 247 History 247 Physical Examination 248 Diagnostic Tests 249 SURGICAL REPAIR TECHNIQUES 250 Posterior Colporrhaphy 250 Site-Specific Defect Repair 253 Graft Augmentation 253 Abdominal Sacral Colpopexy (Colpoperineopexy) Endorectal Repair 257 Perineorrhaphy 258 Postoperative Instructions 258 ANALYSIS OF OUTCOMES 258 COMPLICATIONS 259 CONCLUSION 260

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Pelvic organ prolapse is very common. Annually, approximately 200,000 women undergo prolapse surgery in the United States. Approximately three fourths of women with prolapse have a rectocele. Although rectocele repair has been commonly performed for over a century, the longterm functional and anatomic outcomes and ideal procedure have not been determined. This chapter will review the anatomy, pathophysiology, evaluation techniques, and surgical management of rectoceles and perineal body defects.

ANATOMY AND PATHOPHYSIOLOGY “The gynecologist, searching for a means of holding up and maintaining sagging structures and organs, has placed reliance on a mythical support of his own creation.” (Ricci and Thom, 1954) The terminology of the anatomic tissue that is present under the vaginal epithelium has been the subject of debate for most of the past century. The term fascia was introduced by Emmet in 1883. The histology of the apical portion of the

posterior vaginal wall consists of mucosa (which includes the epithelium of the posterior wall and the lamina propria), a superficial and deep muscularis layer, and adventitia. This fibromuscularis has been named rectovaginal fascia and perirectal fascia, perhaps giving the surgeon an illusion of sturdier tissue than is actually present. Comparisons of the histology of women with and without prolapse have shown that the smooth muscle content of the posterior vaginal wall of women with prolapse is disorganized and significantly reduced in comparison to women without prolapse. Prolapse of the posterior vaginal wall may be secondary to the presence of an enterocele, sigmoidocele, or rectocele, or a combination of these entities. A rectocele is an anterior protrusion of the rectal wall to the posterior vaginal wall. The rectovaginal space exists between the vaginal tube and the rectum. This potential space, occupied by areolar tissue, allows the vagina and rectum to function independently of each other. Support of the posterior vaginal wall is provided by a complex interaction of the integrity of the vaginal tube, the connective tissue support, and muscular support of the pelvic floor. DeLancey (1996) divided the connective tissue support of the vagina into three levels. All three levels of support should be evaluated and addressed during surgical management of the posterior vaginal wall. At level I, the apical portion of the posterior vaginal wall is suspended and supported primarily by the cardinaluterosacral ligaments. This mesentery of support originates at the sacrum and the pelvic sidewalls and inserts onto the posterior cervix and upper vagina. With normal support, the apical posterior wall of the vagina is dorsally directed to lie upon the rectum in a horizontal fashion overlying the levator ani muscles. With increases in abdominal pressure, the vaginal tube is closed top-to-bottom and supported by the pelvic floor muscles. Level II includes the support for the middle half of the vagina. This support is provided by the endopelvic fascia attaching the lateral posterior vaginal wall to the aponeurosis of the levator ani on the pelvic sidewall. Most of the fibers of the endopelvic fascia connect the lateral edge of the vaginal tube to the pelvic sidewall. Very few of the fibers actually run like a sheet from sidewall to sidewall. This lateral attachment, the arcus tendineus fasciae rectovaginalis, is dorsal to the arcus tendineus fasciae pelvis for the distal

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Figure 20-1 ■ Level II support of the posterior vaginal wall includes attachment to the pelvic sidewall from the arcus tendineus fasciae rectovaginalis in the distal half of the vagina and from the proximal arcus tendineus fasciae pelvis, which is attached to the ischial spine near the apex. ATFP, arcus tendineus fasciae pelvis; ATFR, arcus tendineus fasciae rectovaginalis; IS, ischial spine. (Reprinted with the permission of The Cleveland Clinic Foundation.)

half of the posterior wall (Fig. 20-1). The sidewall attachment of the posterior vaginal wall converges with the sidewall attachment of the anterior wall approximately midway in the vaginal canal. The proximal half of the posterior vagina is supported by bilateral endopelvic attachments to the arcus tendineus fasciae pelvis. The role of the perineal body is to resist caudally directed forces by the rectum and to provide a physical barrier between the vagina and rectum. The perineal body is thicker (approximately 3 cm long) and more defined in women. It includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter. The perineal body is anteriorly attached to the vaginal epithelium and muscularis of the posterior vaginal wall. Laterally, the perineal body is attached to the ischiopubic rami through the transverse perinei muscles and the perineal membrane. Anteriorly, the perineal membrane spans the anterior half of the pelvic outlet and is comprised of dense fibromuscularis. The perineal body extends cranially in the posterior wall of the vagina to approximately 2 to 3 cm proximal to the hymenal ring. This dense, fused level of support represents level III. Posteriorly, the perineal body includes the anterior portion of the external anal sphincter and its attachment to the longitudinal fibrous sheath of the internal anal sphincter. The perineal body is suspended by and attached to the puborectalis muscle. Interruption in the support of the perineal body will allow the posterior vaginal wall, perineal body, and the distal portion of the anterior rectal wall to descend with increased abdominal and rectal pressure. The puborectalis also provides a sling of support for the vaginal tube. This sling leads to an angulation of the midposterior wall of approximately 45 degrees from vertical. The proximal portion of the vagina lies upon (and is supported by) the pubococcygeus and iliococcygeus muscles. The puborectalis helps close the potential space of the vagina and close the levator hiatus. With a healthy pelvic floor, little

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stress and strain are placed on the connective tissue support system. The levator hiatus has been shown to be larger in women with prolapse than in those with normal support. In a woman with an intact pelvic floor, the puborectalis is in a chronic state of contraction. This contraction closes the vaginal canal, and the anterior and posterior vaginal walls are in direct apposition. With defecation, the increased pressure placed on the posterior vaginal wall is equilibrated by the opposing anterior vaginal wall, and minimal stress is placed on the endopelvic fascial attachments (Fig. 20-2, A). If there is muscular and/or neurologic damage to the puborectalis, the levator hiatus widens and the vaginal canal opens. The increased rectal pressure and distension associated with defecation places strain on the endopelvic fascial attachments and the fibromuscularis of the posterior vaginal wall and can result in rectocele and perineal descent (Fig. 20-2, B,C). Any condition or event that damages the support of the posterior vaginal wall can lead to prolapse. Vaginal delivery, particularly in the occipitoposterior position, is associated with an increased risk for posterior vaginal wall and perineal body trauma. Magnetic resonance images in the postpartum period show changes in intensity within the levator ani muscle. These changes likely reflect the recovery process following neurologic or muscular damage related to childbirth. Aging may also affect the levator ani muscles, leading to muscle atrophy and devascularization. Chronic strain and constipation have been associated with (but do not necessarily cause) rectocele, perineal descent, and fecal incontinence. With chronic straining, a stretch is placed in the pudendal nerve and the nerve to the levator ani muscle. Meschia et al. (2002) found that fecal incontinence was more prevalent in women with a rectocele that extended beyond the hymen (31%) than in women with prolapse inside the hymenal ring (19%). Increasing body mass index has been strongly associated with incident rectocele but not with prolapse of other areas of the vagina (cystocele or uterine prolapse). Pelvic surgery can predispose a woman to develop prolapse. Alterations of the connective tissue support, and injury to the innervation and vascularization to the pelvic floor muscles, occur with pelvic surgery. Alterations of the axis of the vagina may increase the forces placed on the connective tissue supports. Overelevation of the anterior vaginal wall, as with a retropubic urethropexy or needle suspension procedure, alters the distribution of force on the vaginal walls and can open the posterior wall to the development of an enterocele or rectocele.

EVALUATION History Many women with a rectocele or a perineal body defect are asymptomatic. However, women may complain of symptoms associated with prolapse, such as bulging of the vagina and pressure, which worsens by the end of the day and improves when lying down. Sexual dysfunction also occurs in some women with prolapse. A woman may reduce sexual activity due to the discomfort of the prolapse or the embarrassment

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of the urinary or anal incontinence, which may accompany her prolapse. A woman with a perineal body defect, which leads to a widened genital hiatus, may describe loss of sensation for herself and her partner during intercourse. Defecatory dysfunction and pelvic organ prolapse are both common in women. It is often difficult to determine whether there is a causal link between the posterior wall prolapse and defecatory dysfunction or whether they are separate, concurrent disorders. Many women state that they are constipated. It is important to determine what a woman means when she states that she is constipated. Constipation includes excessive straining; hard, lumpy stools; splinting; feeling of incomplete emptying; and infrequent stools. Infrequent defecation is not likely related to a rectocele and may require additional evaluation. Women with a large rectocele may trap stool within this rectal pocket, leading to feeling of incomplete emptying, which can result in soiling. Splinting, or placing manual pressure in the vagina, over the rectum, or on the perineum to reduce the prolapse and facilitate emptying of the rectum, is commonly described. Anal incontinence is commonly seen in patients with posterior wall and perineal body defects. Many women are reluctant to initiate the conversation about anal incontinence due to embarrassment, so it is important to ask about accidental loss of solid or liquid stool or gas. An important part of the history to obtain from your patient is an understanding of her management desires. If the patient requires and is willing to undergo surgical management, having her express her expectations of surgery can be illuminating.

Physical Examination

Figure 20-2 ■ Pathophysiology of rectocele. A. Normal posterior wall support provided by the levator ani muscles holds the vagina closed. When abdominal pressure is increased, pressure on the posterior vaginal wall is equilibrated by pressure on the anterior vaginal wall (upper arrows). Stress on the connective tissue supports is avoided. Distally, the pressure in the rectum is resisted by the perineal body. ARW, anterior rectal wall; PB, perineal body; PVW, posterior vaginal wall. B. When the levator ani no longer holds the vagina closed, the anterior wall pressure no longer balances the posterior wall pressure. The pressure in the rectum is not counterbalanced by atmospheric pressure in the open vagina, and stress is placed on the connective tissue support. As this gives way (or in the presence of a connective tissue defect), a rectocele may develop (arrow). C. Increased distal abdominal pressure on a damaged perineal body may result in severe rectocele and perineal descent (arrow). (Reprinted with the permission of The Cleveland Clinic Foundation.)

The patient is generally examined in the dorsal lithotomy or semirecumbent position. An excellent correlation exists in the evaluation of prolapse between the supine and standing positions in women performing maximal Valsalva maneuver. If the prolapse observed in the lithotomy position does not recreate the degree of prolapse that the patient described, a standing examination should be performed. However, it is physically more difficult to make measurements of the prolapse in this position. To stage the severity of prolapse the posterior vaginal wall is visualized with the posterior blade of a bivalve speculum or a Sims speculum. The retractor elevates the anterior wall and reduces any uterine or apical prolapse. The patient is asked to increase abdominal pressure with a Valsalva maneuver or cough. The Pelvic Organ Prolapse Quantification (POPQ) system is a standardized, validated tool for measuring and staging pelvic organ prolapse (see Chapter 5). Measurements of the posterior vaginal wall are documented at maximal strain, 3 cm proximal to the hymen (Ap), at the most dependent portion of the posterior vaginal wall proximal to this mark (Bp), and at the vaginal cuff (C) or cul-de-sac, if the uterus is present (D). The genital hiatus (GH) and perineal body (PB) are measured with the patient straining. Evaluation for and staging of concurrent anterior wall and apical prolapse should be performed. The perineal body should be evaluated for descent. It may be difficult to measure perineal descent, but documentation of its presence or absence can be helpful in planning your

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surgery. Descent of the perineal body occurs with a lack of continuity from the suspensory support at the apex (level I) to the perineal body (level III). It may also occur because of a mass effect of the rectum or small bowel herniating into the perineal body, a perineocele. Perineal descent has also been associated with fecal incontinence. Nerve stretch and subsequent neuromuscular damage is one of the proposed mechanisms of fecal incontinence. Perform a careful rectovaginal examination evaluating the posterior vaginal wall and perineal body. If the area of anterior rectal wall bulging and the posterior wall prolapse is the same, this provides clinical confirmation of the presence of a rectocele. Palpation of loops of small bowel confirms an enterocele; a sigmoidocele is diagnosed if sigmoid colon is palpated. Performing a rectovaginal examination in the standing position may increase the detection of an enterocele by allowing the bowel to enter the enterocele sac. This search for an enterocele should continue in the operating room. If an enterocele is missed, posterior wall prolapse may persist following surgical management. Elevating the rectal finger up to the posterior vaginal wall helps identify an area with less support, although the clinical examination has not been shown to be accurate in comparison to the surgical identification of site-specific defects of the posterior vaginal wall. Last, pressure on the posterior wall of the vagina, directed downward toward the rectum, may facilitate identification of rectal prolapse or intussusception. Because anal incontinence commonly occurs with rectocele, assessment of the anal sphincter should be performed. This includes evaluation of anal tone, squeeze, and symmetry. If a symptomatic woman is found (or suspected) to have a disrupted anal sphincter on examination, further testing is indicated. A focused neurologic examination includes evaluation of sensation, motor function, and reflexes of sacral nerves 2–4. The patient is asked to discriminate between sharp and dull on the perineum. Assess pelvic floor muscle strength with the patient contracting and relaxing the pelvic floor muscles around the examiner’s fingers. Reflex testing includes the bulbocavernosus reflex and anal wink (see Chapters 6 and 11).

Diagnostic Tests A number of imaging techniques have been used to evaluate rectoceles. Defecography provides a two-dimensional view of the efficiency of rectal emptying and quantification of rectal parameters. The size of the rectocele is determined by measuring the distance between the line of the anterior border of the anal canal and the maximal point of the bulge of the anterior rectal wall into the posterior vaginal wall. Rectoceles have been described in nulliparous women. Anything less than 2 cm is considered normal, whereas a rectocele is considered large if the anterior rectal wall protrudes more than 3.5 cm. Contrast in the small and large bowels may also reveal the presence of an enterocele, sigmoidocele, or perineocele. Rectal intussusception and perineal descent may also be identified, although the clinical significance of rectal intussusception has not been determined. The dynamic nature of the study allows for insight into the defecation process. Retention of more than

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10% of the barium following defecation is referred to as barium trapping. This examination is done in an artificial environment, which may make the patient more prone to incomplete emptying. A situation in which defecography may convert a surgical procedure to one managed conservatively is the identification of pelvic floor dyssynergia. Defecation is effective through the coordination of relaxation of the levator ani and external anal sphincter and contraction of the colon. If the puborectalis or external anal sphincter is paradoxically contracted during defecation, this situation might respond to more conservative measures, such as the use of enemas or biofeedback. An electrophysiologic analysis of the puborectalis may also lead to this diagnosis. Another situation in which defecography might influence treatment is the identification of a sigmoidocele; the surgical approach to prolapse management might also include a sigmoid resection. Rectoceles that retrain contrast tend to be larger than those that do not. However, fluoroscopic evidence of barium trapping does not relate to patient symptoms. In the symptomatic, elderly population, Savoye-Collet et al. (2003) found no association between the abnormalities demonstrated by defecography and symptoms. Defecography performed following surgical management of rectoceles has generally shown a reduction in the size of the rectocele and improvement in emptying. The limitations of defecography include that it requires special equipment, exposes the patient to radiation, does not show the rectum and adjacent soft tissue structures simultaneously, and is uncomfortable and poorly accepted by patients. Dynamic magnetic resonance imaging (MRI) provides high-quality images of the pelvic soft tissues and viscera. MRI is noninvasive and does not require ionizing radiation or significant patient preparation. However, poor correlation exists between MRI grading of prolapse and clinical staging. To accomplish a dynamic MRI at most facilities, the woman is placed in the dorsal supine position with her legs together. MRI defecography has also been performed in the dorsal supine position with a sonographic transmission gel placed in the rectum and vagina. Images are obtained resting and while performing a Valsalva maneuver and with evacuation. However, during a Valsalva maneuver in this position, the true extent of the prolapse may not be exhibited because this is not a normal position for defecation and may not simulate that woman’s ability to defecate. An upright evaluation has been described but requires an open configuration MRI unit that is available in only a few medical centers. The limitations of this method of imaging include a lack of standardization of grading of prolapse, high cost, and relatively limited availability. At this time, there is a lack of a standardized method of establishing a radiologic diagnosis of rectocele. Clinical examination has good sensitivity for the detection of a rectocele; therefore, radiologic confirmation of the presence or absence of a rectocele is not worthwhile. Although defecatory dysfunction is common in women with prolapse, the extent of the prolapse does not necessarily correlate with the extent of bowel symptoms. If the woman’s primary complaint is defecatory dysfunction or fecal incontinence and not a bulge, surgical correction of the rectocele or perineal body defect may not correct her symptoms. Ancillary testing

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is then pursued based on the woman’s complaints. Validated functional and quality-of-life questionnaires are now available. These may be performed preoperatively and postoperatively to provide a standardized method of evaluating the surgical outcomes. The patient’s preoperative symptoms and surgical goals will guide the provider in the selection of additional testing. A woman who describes lifelong infrequent bowel movements (less than one per week) and an absence of a daily urge to defecate is unlikely to be cured of her constipation with a rectocele repair. A colon transit study may be helpful in identifying patients with slow-transit constipation. Dietary modifications, including fiber and laxatives, should be encouraged in any woman whose main complaint is constipation (see Chapter 25). In women with symptoms of anal incontinence, an evaluation and attempt at medical management should be performed before rectocele repair. An endoanal ultrasound provides anatomic detail of the integrity of the external and internal anal sphincters; EMG study of the external anal sphincter can provide neurologic information. Urodynamic testing with prolapse reduction may be useful in women with stage III or stage IV posterior wall prolapse. With retraction of the posterior wall prolapse (simulating correction of the prolapse), women may develop stress incontinence or have an increase in leak volumes. If potential or occult stress urinary incontinence or intrinsic sphincter deficiency is uncovered, this observation should be factored into preoperative surgical recommendations and surgical planning.

SURGICAL REPAIR TECHNIQUES Current repair techniques address connective tissue defects. The dysfunctional levator ani, which widens the levator hiatus, increases the stress and strain on the connective tissue, and is a likely key contributor to the development of pelvic organ prolapse. Currently, pelvic floor muscle exercises (with or without biofeedback) are our primary method of strengthening the remaining innervated pelvic floor muscles but do not address deinnervated or damaged muscle. The goals of rectocele repair are to provide anatomic correction, relieve prolapse symptoms, and restore normal bowel and sexual function without creating new symptoms. Evaluation of prolapsed posterior vaginal wall in the operating room should include a careful inspection for an enterocele or sigmoidocele, and for associated apical support defects. To compare various techniques for repair of posterior vaginal prolapse and anterior rectal wall prolapse is difficult because the indications for surgery and the standardized definitions of bowel function symptoms are not frequently reported. The definition of anatomic or functional cure also varies from study to study. Few prospective, randomized studies compare surgical procedures to correct rectoceles. The gynecologist typically approaches repair of a rectocele through a transvaginal incision. The patient is placed in the dorsal lithotomy position with her legs in high leg holders. The colorectal surgeon often performs an endoanal

repair of the rectocele, with the patient in the prone position. Patients are given preoperative prophylactic antibiotics and mechanical bowel preparation.

Posterior Colporrhaphy The posterior colporrhaphy was introduced in the nineteenth century. The goals of this procedure were to narrow the vaginal tube and genital hiatus and to create a shelf of support. The posterior colpoperineorrhaphy was thought to be the key component of all prolapse surgery (including correction of anterior wall and uterine prolapse). When postoperative results revealed that posterior colporrhaphy with perineorrhaphy treated a rectocele but was less effective for anterior wall or uterine prolapse, it continued to be the treatment of choice. Currently, it has remained a commonly performed surgical procedure for posterior wall prolapse. The traditional posterior colporrhaphy has an anatomic cure rate of 76% to 96% (Table 20-1). The posterior colporrhaphy is a plication of the vaginal wall in the midline, decreasing the width of the posterior vaginal wall and increasing the fibromuscularis in the midline. It purposely narrows the vaginal tube. To estimate adequate caliber, Allis clamps are placed on the posterior hymen and, when brought together in the midline, allow for a three-fingerbreadth genital hiatus. Traditionally, a perineorrhaphy is included in this repair. To begin the procedure, subepithelial injection of saline or local anesthetic with dilute epinephrine may be done to aid dissection. A triangular incision is made into the perineal skin with the base of the triangle at the hymen (Fig. 20-3, A). The skin is dissected away from the perineal body. The vaginal epithelium is opened in the midline, extending the incision to the vaginal apex (Fig. 20-3, B). The posterior vaginal epithelium is dissected bilaterally, away from the underlying fibromuscularis and extended to the levators (Fig. 20-3, C). Remaining in a plane close to the epithelium is important to avoid injury to the rectum. The posterior vaginal wall, stripped of its epithelium, is plicated in the midline with interrupted vertically or transversely placed lateral sutures incorporating a generous purchase of the fibromuscularis. Plication begins proximally and progresses toward the hymenal ring (Fig. 20-4). Care should be taken during the plication to ensure that each plication suture is in continuity with the previous one. If continuity is not maintained, ridging of the posterior vaginal wall may occur and be a source of dyspareunia. The vaginal epithelium is trimmed, if necessary, and closed with a running No. 2-0 absorbable suture. Care should be taken to avoid trimming too much vaginal epithelium, particularly in women with atrophy. The caliber of the vagina at the conclusion of the vaginal reconstruction should be three fingerbreadths in sexually active women. The plication of the fibromuscularis can include plication of the levator ani muscles. Interrupted sutures are placed in the muscular sidewall of the posterior wall and brought to the midline. This provides a sturdy posterior shelf but may further constrict the vaginal caliber and be a source of postoperative pain and/or dyspareunia; however, it is effective for elderly women with a wide levator hiatus who do not expect to be sexually active.

■

42

231 171

87

12

12 >12

70 67

38 38

183 183

30 34

76 24

100 4

100 5

64 31

21 4

Vaginal Bulge (%)

100 16

33

50 0

20

Vaginal Digitation (%)

17 18

3 0

4 11

8 8

36

Fecal Incontinence (%)

Modified with permission from Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403 *Prospective study. † Definitions of “cure” and “dyspareunia” vary among studies.

82

90

12

22 33

100 88

75 54

Constipation (%)

8 17

37 5

26

16

8

23

Dyspareunia (%)†

■

53 53

76

96

12

25 25

Anatomic Cure (%)†

80

Mean FollowUp (Mo)

29 24

N

Posterior Colporrhaphy: Anatomic and Functional Results

Arnold et al. (1990) Preoperative Postoperative Mellgren et al. (1995)* Preoperative Postoperative Kahn and Stanton (1997) Preoperative Postoperative Weber et al. (2000)* Preoperative Postoperative Sand et al. (2001)* Preoperative Postoperative Maher et al. (2004)* Preoperative Postoperative Abramov et al. (2005) Preoperative Postoperative

Study (Year)

Table 20-1

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B

C Figure 20-3 ■ Surgical repair of rectocele. A. A triangular incision is made in the epithelium of the overlying posterior fourchette and perineal body. B. The vaginal epithelium is opened in the midline. C. Dissection of the posterior vaginal wall is completed bilaterally, exposing the fibromuscularis from sidewall to sidewall. (Reprinted with the permission of The Cleveland Clinic Foundation.)

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Figure 20-5 ■ Locations of site-specific defects in the posterior vaginal wall. Defects in the posterior wall fibromuscularis may be found in the lateral sidewalls (L), midline (M), or in a transverse orientation (T) at the apex or distally near the perineal body. Combinations of defects may be identified. (Reprinted with the permission of The Cleveland Clinic Foundation.)

Figure 20-4 ■ Posterior colporrhaphy includes midline plication of the vaginal fibromuscularis over the rectum. (Reprinted with the permission of The Cleveland Clinic Foundation.)

Site-Specific Defect Repair The site-specific defect repair relies upon the theory advocated by Richardson (1976), that herniation of the rectum into the vagina is the result of identifiable defects in the fibromuscularis (rectovaginal fascia). Defects of the posterior vaginal wall may occur as an isolated defect in the lateral, distal, midline, and superior portions of the wall or as a combination of defects (Fig. 20-5). The anatomic cure rate of the site-specific posterior repair is 56% to 100%, as shown in Table 20-2. Most studies report no change or a decrease in dyspareunia in the series involving defect-specific rectocele repairs. The vaginal epithelium is opened with a transverse incision at the posterior fourchette (Fig. 20-6, A). The posterior vaginal epithelium is incised in the midline to a level proximal to the bulge and dissected away from the underlying fibromuscularis (Fig. 20-6, B). The dissection is extended laterally to the endopelvic fascial attachments of the posterior vaginal wall to the arcus tendineus fasciae pelvis and arcus tendineus fasciae rectovaginalis. The fibromuscularis is carefully inspected to identify breaks. Irrigation and a rectal examination may accentuate the defects to aid identification (Fig. 20-7). Defects are individually isolated and repaired with delayed-absorbable or nonabsorbable No. 0 or 2-0 suture (Fig. 20-8). If a distal defect is present, such as a separation of the fibromuscularis from the perineal body, absorbable suture is used for repair in an attempt to reduce the incidence of postoperative dyspareunia. Repair of perineal body defects is also addressed with interrupted sutures. A levator plication is not performed. Repeating the

rectal examination should confirm repair of the rectocele. The vaginal epithelium is closed with a running No. 2-0 absorbable suture. Currently, this is the technique of choice in a sexually active woman in whom the goals are to reduce the bulge, potentially improve rectal emptying, and avoid de novo dyspareunia.

Graft Augmentation Approximately one third of women undergoing surgery for prolapse or urinary incontinence will undergo a subsequent procedure for recurrence. In an effort to improve the anatomic durability of the rectocele repair, placement of a mesh to augment support of the posterior vaginal wall can be performed. Graft materials that have been used include allografts, xenografts, and permanent synthetic materials. The graft is used as a sheet to reinforce the posterior colporrhaphy or site-specific repair or to reinforce the existing posterior vaginal wall. The graft can also be placed through a perineal incision in the rectovaginal space between the posterior vaginal wall and the anterior rectal wall. A gynecologist typically places the graft through a vaginal incision as another layer of support upon completion of the rectocele repair. The graft is placed after plication of the fibromuscularis is completed (in the posterior colporrhaphy) or after the site-specific defects are closed (Fig. 20-9). The graft is attached bilaterally to the levator fascia. If the patient is concurrently undergoing an apical suspension procedure (with or without mesh), the apical portion of the graft can be attached to the apical support sutures. The graft material is attached bilaterally to the endopelvic attachment on the levator ani muscles in a proximal to distal fashion, ensuring that no tension is placed on the graft material. Delayedabsorbable or nonabsorbable No. 0 suture is used. The graft

82 90 100 92 56

6 12 3 18

125 72

66 46

67 67

42 33

124 124 >12

82

Anatomic Cure (%)†

12

Mean FollowUp (mo)

69 61

N

33 37

41 57

60 50

46 13

Constipation (%)

100 11

78 7

86 9

38 14

100 18

Vaginal Bulge (%)

30 15

24 21

39 18

Vaginal Digitation (%)

15 19

9 5

30

24 21

13 8

Fecal Incontinence (%)

Modified with permission from Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403. *Prospective study. † Definitions of “cure” and “dyspareunia” vary among studies.

Cundiff et al. (1998) Preoperative Postoperative Porter et al. (1999) Preoperative Postoperative Kenton et al. (1999) Preoperative Postoperative Glavind and Madsen (2000)* Preoperative Postoperative Singh et al. (2003)* Preoperative Postoperative Abramov et al. (2005) Preoperative Postoperative

Study (year)

Site-Specific Defect Rectocele Repair: Anatomic and Functional Results

8 16

31 15

12 3

28 8

67 46

29 19

Dyspareunia (%)†

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Figure 20-6 ■ Opening the posterior vaginal epithelium for a site-specific defect repair. A. A transverse incision at the level of the hymen can be done if there is no perineal body defect. B. The epithelium is opened in the midline. The dissection is extended proximally to the defect. (Reprinted with the permission of The Cleveland Clinic Foundation.)

A Figure 20-7 A finger is placed in the rectum to elevate the anterior rectal wall toward the posterior vaginal wall. Areas of weakness or defects in the fibromuscularis can be identified, as shown on the left. (Reprinted with the permission of The Cleveland Clinic Foundation.) ■

Figure 20-8 ■ Site-specific rectocele defects: identification and surgical repair. A. Midline defect of the fibromuscularis.

(Continued)

B

C

D

E

F

G

Figure 20-8 ■ Cont’d B. Left lateral defect of the fibromuscularis. C. Repair of left lateral defect with interrupted sutures. D. Distal transverse defect, separating the fibromuscularis of the posterior wall from the perineal body. E. Proximal transverse defect in the fibromuscularis near the apex. Repair of the proximal transverse defect is done as with a distal defect. If a level I vaginal vault suspension procedure is done, the distal portion of the break in the fibromuscularis may be incorporated in the apical repair. F. The distal defect is repaired with interrupted sutures. These sutures should reestablish continuity of the vaginal fibromuscularis with the perineal body. G. The epithelium of the posterior vagina and perineum is closed with running absorbable suture. (Reprinted with the permission of The Cleveland Clinic Foundation.)

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Figure 20-9 ■ Graft-augmented rectocele repair. A graft is trimmed and placed over a posterior colporrhaphy or site-specific defect repair. (Reprinted with the permission of The Cleveland Clinic Foundation.)

is trimmed and the distal portion of the graft is attached to the perineal body with interrupted, absorbable No. 0 sutures. The vaginal epithelium is closed and a perineorrhaphy is performed, if needed. The variety of graft materials available and methods of placement make it difficult to summarize the efficacy of graft augmentation. Long-term efficacy and safety have not been established. Randomized trials comparing posterior colporrhaphy and site-specific defect repair, with and without graft placement, are needed.

Abdominal Sacral Colpopexy (Colpoperineopexy) An abdominal or laparoscopic approach to rectocele repair can be performed when the rectocele is accompanied by apical prolapse. Suspension of the posterior vaginal wall is accomplished through a sacral colpopexy or sacral colpoperineopexy (in the case that the posterior support defect continues to the level of the perineal body). Mesh is placed on the posterior vaginal wall, posterior to the vaginal tube and bridged to the anterior longitudinal ligament of the sacrum. Various meshes have been used in sacral colpopexy procedures, but most evidence supports the use of polypropylene. To perform the procedure, the patient is placed in low leg holders with a Foley catheter in the bladder throughout the procedure. An end-to-end anastomosis (EEA) sizer may be placed in the vagina and one in the rectum to aid in identification of tissue planes. The procedure is accomplished through a Pfannenstiel incision into the peritoneal cavity or may be performed laparoscopically (see Chapter 17). If the laparoscopic procedure is performed, a reusable 5- or 10-mm port is placed at the umbilicus for operation of the laparoscope. Two 5/12-mm disposable ports are placed in the right and left lower quadrants for suture and mesh introduction. An additional 5-mm reusable port is placed on the left side lateral to the umbilicus. To access the presacral space, the sigmoid colon may be retracted to the left with a laparoscopic snake retractor.

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The surgical steps of the procedure are the same if performed through an open incision or laparoscopically. The right ureter is identified. The peritoneum is opened from the sacral promontory to the cul-de-sac lateral to the right side of the colon and medial to the right ureter. Sharp and blunt dissection is used to expose the anterior longitudinal ligament of the sacrum over S1 to S2. Hydrodissection of the presacral space may also be performed by placing a suction-irrigator underneath the peritoneum and inserting water into the space. The rectovaginal space is identified with an EEA sizer in the vagina (elevating the vagina toward the anterior abdominal wall) and one in the rectum (deflecting the rectum posteriorly). The rectovaginal space is entered sharply between the vagina and rectum. This avascular space is dissected with sharp and blunt dissection. The dissection proceeds to the perineal body for correction of a distal rectocele or significant perineal descent. Cautery is used sparingly in this dissection to preserve vascularization of the vagina (and potentially decrease the risk of mesh erosion). Laparoscopically, the posterior mesh (approximately 3 cm wide × 15 cm long) is introduced into the abdomen through a lower quadrant port. The mesh is attached to the posterior vaginal wall with a series of three to five pairs of No. 2-0 or No. 0 nonabsorbable sutures. The posterior mesh is then laid over the sacrum to determine the length of the mesh bridge. The mesh should provide support of the posterior vaginal wall without tension. The mesh is then attached to the anterior longitudinal ligament with three No. 0 nonabsorbable sutures. The excess mesh is trimmed, and the peritoneum is closed with No. 2-0 absorbable suture.

Endorectal Repair Endorectal repair of distal rectoceles was first recommended by Sullivan et al. in 1968. A colorectal surgeon typically approaches the rectocele repair from this end. The success rate for repair of a distal rectocele is 47% to 82% (Cundiff and Fenner, 2004). An endorectal approach allows for simultaneous correction of other anorectal pathology, such as hemorrhoids and mucosal rectal prolapse. Ayabaca et al. (2002) reported that 53% of women who underwent a rectocele repair also had rectal mucosa prolapse and 41% had hemorrhoids. Repair of proximal (high) rectoceles is difficult with the endorectal approach because of inadequate exposure. This procedure is done in the prone jackknife position, with the buttocks spread and taped. An anal retractor is inserted to expose the anterior rectal wall. A transverse incision is made in the rectal mucosa at or proximal to the dentate line. Two vertical incisions are made in parallel. A flap is developed, including a portion of the muscular wall of the rectum to a level proximal to the rectocele (usually approximately 7 cm long). Vertical plication sutures are placed with No. 3-0 polyglycolic acid suture. One or two transverse sutures are placed to buttress the vertically plicated area. Levator ani plication can also be done with the endorectal approach. The rectal mucosal flap is trimmed, and the rectal mucosa is closed with a running No. 5-0 polyglycolic acid suture. The use of the circular stapler for closure of the rectocele and treatment of the redundant rectal mucosa has been described.

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Perineorrhaphy A perineorrhaphy, when indicated, completes the vaginal approach to a rectocele repair. Allis clamps are placed on the posterior hymen and brought together in the midline. Preservation of three fingerbreadths at the genital hiatus is important for comfortable future coital activity. A triangular incision is made medial to the Allis clamps, extending to the midline of the perineal skin, with the base of the triangle at the posterior hymen. The bulbospongiosus muscles are plicated in the midline of the perineal body with an interrupted Vicryl No. 0 suture. The transverse perinei muscles are plicated (Fig. 20-10). An anal sphincteroplasty may be performed, as indicated, for anal incontinence and an external/internal anal sphincter defect. The skin is closed with a running No. 2-0 Vicryl suture. Extensive dissection and repair is required for women with an absent perineal body, most commonly as a result of difficult vaginal delivery or surgical trauma. A transverse semicircular incision is made in the layer separating the posterior vaginal wall and the anterior rectal wall. Dissection is extended laterally and proximally. To facilitate proximal dissection in the rectovaginal space without injury to the rectal mucosa, the surgeon may insert a finger of the nondominant hand into the rectum. The internal anal sphincter is plicated

in the midline with No. 3-0 absorbable suture. The rectal mucosa is reapproximated, as needed, with a running absorbable No. 3-0 suture, and extended to the skin overlying the external anal sphincter. Dissection of the anus is performed to identify the retracted ends of the external anal sphincter. Care should be taken with this step to avoid extensive lateral and posterior dissection and injury to the inferior hemorrhoidal nerves and vessels. The scarred ends of the external anal sphincter are identified and reapproximated in an overlapping fashion with vertical mattress sutures of No. 0-delayed absorbable suture. The scar on the ends of the external anal sphincter is left intact and used for suture placement. The transverse perinei and bulbospongiosus muscles are plicated in the midline. With midline construction of the perineal body, the transverse portion of the initial incision becomes vertically oriented. The vaginal epithelium is closed with a No. 2-0 absorbable suture. The skin of the perineal body is closed in an inverted Y shape with interrupted absorbable No. 2-0 sutures. The patient is instructed that superficial wound breakdown on the perineum may occur. In most cases, this superficial wound breakdown will respond to conservative management rather than require aggressive debridement. The use of absorbable sutures in the perineal body and distal vagina may decrease the incidence of entrance dyspareunia, but care should be taken to avoid ridging the introitus with a tight plication of the bulbocavernosus muscles. A perineorrhaphy will increase slightly the functional length of the posterior vaginal wall.

Postoperative Instructions A vaginal pack and Foley catheter are usually placed after the surgery and removed the next morning. The patients are discharged with instructions to avoid lifting anything greater than 10 lb and to take stool softeners to avoid straining for 3 months. Pelvic rest (avoiding the use of tampons, douching, or sexual intercourse) is recommended for at least 6 weeks. Patients who undergo an anal sphincteroplasty as part of their perineal body repair are placed on broad-spectrum antibiotic coverage for 1 week.

ANALYSIS OF OUTCOMES

Figure 20-10 ■ Perineorrhaphy. Following the completion of the repair of the rectocele, the perineal body may need to be reconstructed. The bulbospongiosus and the transverse perinei muscles are plicated in the midline with absorbable sutures. (Reprinted with the permission of The Cleveland Clinic Foundation.)

The patient’s surgical goals should be elicited preoperatively. If the goal of the surgery is correction of the bulge, this may be accomplished through various techniques. To compare the various surgical repairs is difficult because the definition of cure has varied with each study. In some studies, functional resolution or improvement is defined as a cure, while others define cure as strictly anatomic but vary at which point anatomic cure lies. Cundiff and Fenner (2004) reviewed the literature and summarized the anatomic and functional outcomes after posterior colporrhaphy, site-specific defect repair, transanal repair, and rectocele repair with graft materials. Anatomic cure ranges from 76% to 96% for posterior colporrhaphy and from 56% to 100% for site-specific defect repair. The data are summarized and updated in Tables 20-1 and 20-2. The sensation of a vaginal bulge is generally relieved, as

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is vaginal digitation to assist emptying, but disorders of defecation, such as constipation and fecal incontinence, are often not significantly improved. Maher et al. (2004) reported on 38 women with symptomatic rectoceles (stage II or greater) and obstructed defecation treated with midline rectovaginal fascial plication. Seventy-nine percent of women had anatomic cure after 24 months, and 87% no longer experienced obstructed defecation. In this study, the rate of dyspareunia actually improved, possibly due to minimal trimming of vaginal epithelium, and 97% of women were very satisfied. Rates of cure after transanal repair range from 70% to 98%. A recent Cochrane Review of surgical management of pelvic organ prolapse (Maher et al., 2004, Cochrane Database Syst Rev) reported that, for posterior vaginal wall prolapse, the transvaginal approach is associated with a lower rate of recurrence for rectocele and/or enterocele than the transanal approach (RR 0.24; 95% CI, 0.09–0.64). However, a higher blood loss and more pain occur with the vaginal approach. The Cochrane Review noted that insufficient data exist on the effect of surgery on bowel symptoms and on whether one variation of vaginal repair (posterior colporrhaphy vs. sitespecific defect repair vs. graft augmentation) is superior to others. Risk factors for failure of rectocele repairs have not been systematically studied. Genetic predisposition, severe childbirth trauma with levator muscle dysfunction, chronic straining of stool, and other factors probably increase a patient’s risk of recurrence. For prolapse repairs in general, younger women with more severe disease (stage III or IV prolapse) are more likely to experience recurrence after surgery. Few studies have reported clinical results after graftaugmented rectocele repairs. In a prospective randomized surgical trial, Sand et al. (2001) showed no improvement in cure, with addition of polyglactin 910 mesh to posterior colporrhaphy. Recently, Altman et al. (2005) reported a 38% recurrence (greater than stage II) after rectocele repair with porcine dermis graft overlay. Further studies are needed to determine the role of grafts for treatment of rectoceles. Correction of anatomy is not always equivalent to symptomatic cure or patient satisfaction. In general, satisfaction seems to be high for relief of symptoms of prolapse. However, correction of function is more complicated because of multiple confounding factors, such as coexisting bowel and sexual dysfunction. Randomized, prospective trials comparing different procedures, which include anatomic and functional preoperative and postoperative data, are underway.

COMPLICATIONS Short-term complications associated with rectocele repair include pain, temporary urinary retention, and constipation. Hematoma, infection, inclusion cyst formation, fecal impaction, injury to the rectum with the development of a rectovaginal or a rectoperineal fistula may occur but are uncommon. Anal incontinence has been reported to occur in up to 19% of women who undergo a rectocele repair. A significant association exists between fecal incontinence and more than one prior posterior colporrhaphy. A rectocele

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may be associated with altered rectal sensation and/or anal sphincter defect related to prolonged straining or trauma. Anal sphincter function may be improved if identified preoperatively and corrected at the time of rectocele repair. However, anal sphincter function may be damaged by a rectocele repair, particularly with the dilation associated with an endoanal repair. It is important to determine whether a woman with recurrent posterior wall prolapse has a history of fecal incontinence and to consider ancillary testing to anatomically evaluate the anal sphincter (endoanal ultrasonography) and neurologic function (EMG) of the external anal sphincter. Postoperative sexual dysfunction has been a significant concern for several decades with the surgical management of rectoceles and perineal body defects. Francis and Jeffcoate (1961) observed a high rate of sexual dysfunction following prolapse surgery. Seventy of 140 (50%) sexually active women reported apareunia or dyspareunia after an anterior and posterior colporrhaphy and perineorrhaphy. On postoperative examination, 43 of the 70 women were found to have a significantly narrowed vagina that would admit one finger only. Haase and Skibsted (1988) noted increased or de novo dyspareunia in 21% of woman who underwent an anterior and posterior colpoperineorrhaphy. Kahn and Stanton (1997) routinely plicated the levator muscles and attributed an increase in sexual dysfunction from 18% to 27% to pressure atrophy of the levator muscles and associated scar formation. Arnold et al. (1990) found similar rates of dyspareunia among women who underwent a transvaginal approach (23%) versus an endoanal approach (21%). In a prospective observational study of sexual function after prolapse repairs, Weber et al. (2000) found that performance of a posterior colporrhaphy, especially a posterior colporrhaphy with Burch colposuspension, were the only variables that predicted postoperative dyspareunia. Vaginal dimensions, in general, did not predict dyspareunia, and pain was often due to ridging in the posterior vaginal wall. The attractiveness of the site-specific defect rectocele repair is that sexual function was often found to improve (or not worsen) following surgical correction of a rectocele. In general, avoidance of sutures that constrict the mid- or distal vagina and care to not over-trim the vaginal epithelium before closing will help keep postoperative dyspareunia to a minimum. Venkatesh and Ramanujam (1996) reported a 50% (6/12) rate of persistent perineal pain following a perineal body reconstruction in women with a preoperative perineal pain and a cloaca. The patients with persistent postoperative perineal pain described dyspareunia and dissatisfaction with the surgical results, despite excellent anatomic reconstruction of the perineal body. Rectocele repairs that include a biologic or synthetic meshes have complications related to the specific mesh material that is used. The potential complications that have been described with the use of graft material are erosion into the surrounding tissue (in this case, the vagina and rectum); infection; scarring (which may increase the occurrence of dyspareunia); allergic reaction to the material used; and failure. A thorough understanding of the mesh material and its risks and benefits is important before its use is recommended as part of rectocele repairs.

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Risks associated with abdominal sacral colpoperineopexy include bleeding from the sacral vessels, mesh infection/erosion, bowel injury/obstruction, stress urinary incontinence, and recurrent prolapse. The risk of mesh erosion with an abdominal sacral colpopexy is approximately 3% to 8%, with the majority occurring within the first 2 postoperative years. This rate is increased if the mesh (40%) or sutures (16%) are introduced vaginally and then secured to the sacrum. The risk of mesh erosion will also differ with the type of mesh used. Polypropylene and Mersilene are commonly used synthetic mesh materials.

Olsen AL, Smith VJ, Bergstrom JO, et al. Incidence and clinical characteristics of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501. Ricci JV, Thom CH. The myth of a surgically useful fascia in vaginal plastic reconstructions. Q Rev Surg Obstet Gynecol 1954;11:253. Stern R, Bernstein P, Sherer DM. Spontaneous delivery through the rectovaginal septum and perineal body: an unusual complication of persistent occiput posterior position. J Matern Fetal Med 1998;7:194. Uhlenhuth E, Nolley GW. Vaginal fascia, a myth? Obstet Gynecol 1957;10:349. Ward GG. Technique of repair of enterocele (posterior vaginal hernia) and rectocele. JAMA 1922;79:709. Woodman PJ, Graney DO. Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair. Clin Anat 2002;15:321.

CONCLUSION

EVALUATION

Our population is aging. People over age 65 are estimated to comprise 20% of the population in 2030. The demand for the treatment of prolapse will increase as the population ages. To provide superior care for our patients, it is imperative that we perform clinical research studies in women with rectoceles to determine the most efficacious procedure associated with the fewest complications.

Bibliography Department of Health and Human Services, Administration on Aging: Older Population by Age: 1900–2050. Accessed May 9, 2004, from http://www. aoa.gov/prof/Statistics/online_stat_data/AgePop2050.asp.

ANATOMY AND PATHOPHYSIOLOGY Boreham MK, Wai CY, Miller RT, et al. Morphometric properties of the posterior vaginal wall in women with pelvic organ prolapse. Am J Obstet Gynecol 2002;187:1501. Boyles SH, Weber AM, Meyn L. Procedures for pelvic organ prolapse in the United States, 1979–1997. Am J Obstet Gynecol 2003;188:108. Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403. DeLancey JO. Standing anatomy of the pelvic floor. J Pelvic Surg 1996; 2:260. DeLancey JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol 1999;180:815. DeLancey JO, Hurd WW. Size of the urogenital hiatus in the levator ani muscles in normal women and women with pelvic organ prolapse. Obstet Gynecol 1998;91:364. Emmet TA. A study of the etiology of perineal laceration, with a new method for its proper repair. Trans Am Gyn Soc 1883;8:210. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol 2004;190:27. Hudson CN, Sohaib SA, Shulver HM, Reznek RH. The anatomy of the perineal membrane: its relationship to injury in childbirth and episiotomy. Aust N Z J Obstet Gynaecol 2002;42:193. Leffler KS, Thompson JR, Cundiff GW, et al. Attachment of the rectovaginal septum to the pelvic sidewall. Am J Obstet Gynecol 2001;185:41. Meschia M, Buonaguidi A, Pifarotti P, et al. Prevalence of anal incontinence in women with symptoms of urinary incontinence and genital prolapse. Obstet Gynecol 2002;100:719. Morren GL, Beets-Tan RG, van Engelshoven JM. Anatomy of the anal canal and perianal structures as defined by phased-array magnetic resonance imaging. Br J Surg 2001;88:1506. Oelrich TM. The striated urogenital sphincter muscle in the female. Anat Rec 1983;205:223. Oh C, Kark AE. Anatomy of the perineal body. Dis Colon Rectum 1973;16:444. Oladokun A, Babarinsa IA, Adewole IF. The deficient perineum: oblique presentation of a clinically obvious anomaly. Afr J Med Sci 2002;31:267.

Agildere AM, Tarhan NC, Ergeneli MH, et al. MR rectography evaluation of rectoceles with oral gadopentetate dimeglumine and polyethylene glycol solution. Abdom Imaging 2003;28:28. Bartram C. Dynamic evaluation of the anorectum. Radiol Clin North Am 2003;41:425. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10. Burrows LJ, Sewell C, Leffler KS, Cundiff KS. The accuracy of clinical evaluation of posterior vaginal wall defects. Int Urogynecol J 2003;14:160. Cortes E, Reid WM, Singh K, Berger L. Clinical examination and dynamic magnetic resonance imaging in vaginal vault prolapse. Obstet Gynecol 2004;103:41. Henry MM, Parks AG, Swash M. The pelvic floor musculature in the descending perineum syndrome. Br J Surg 1982;69:470. Hullfish KL, Bovbjerg VE, Gibson J, Steers WD. Patient-centered goals for pelvic floor dysfunction surgery: what is success, and is it achieved? Am J Obstet Gynecol 2002;187:88. Johansson C, Nilsson BY, Holmström B, et al. Association between rectocele and paradoxical sphincter response. Dis Colon Rectum 1992;35:503. Kenton K, Shott S, Brubaker L. The anatomic and functional variability of rectoceles in women. Int Urogynecol J 1999;10:96. Mimura T, Roy AJ, Storrie JB, Kamm MA. Treatment of impaired defecation associated with rectocele by behavioral retraining (biofeedback). Dis Colon Rectum 2000;43:1267. Myers DL, LaSala CA, Hogan JW, Rosenblatt PL. The effect of posterior wall support defects on urodynamic indices in stress urinary incontinence. Obstet Gynecol 1998;91:710. Rentsch M, Paetzel C, Lenhart M, et al. Dynamic magnetic resonance imaging defecography. Dis Colon Rectum 2001;44:999. Savoye-Collet C, Savoye G, Koning E, et al. Defecography in symptomatic older women living at home. Age Ageing 2003;32:347. Steiner RA, Healy JC. Patterns of prolapse in women with symptoms of pelvic floor weakness: magnetic resonance imaging and laparoscopic treatment. Curr Opin Obstet Gynecol 1998;10:295. Swift SE, Herring M. Comparison of pelvic organ prolapse in the dorsal lithotomy compared with the standing position. Obstet Gynecol 1998;91:961. Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol 2003;189:372. Segal JL, Karram MM. Evaluation and management of rectoceles. Curr Opin Urol 2002;12:345. Tunn R, DeLancey JO, Howard D, et al. MR imaging of levator ani muscle recovery following vaginal delivery. Int Urogynecol J 1999;10:300. Weber AM, Walters MD, Ballard LA, et al. Posterior vaginal prolapse and bowel function. Am J Obstet Gynecol 1998;179:1446.

SURGICAL TECHNIQUES AND COMPLICATIONS Abramov Y, Gandhi S, Goldberg RP, et al. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 2005;105:314. Altman D, Zetterström J, López A, et al. Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study. Dis Colon Rectum 2005;48:1.

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Altomare DF, Rinaldi M, Veglia A, et al. Combined perineal and endorectal repair of rectocele by circular stapler. Dis Colon Rectum 2002;45:1549. Arnold MW, Stewart WR, Aguilar PS. Rectocele repair: four years’ experience. Dis Colon Rectum 1990;33:684. Ayabaca SM, Zbar AP, Pescatori M. Anal continence after rectocele repair. Dis Colon Rectum 2002;45:63. Cogan JE, Harris JW. Rectal complications after perineorrhaphy and episiotomy. Arch Surg 1966;93:634. Cundiff GW, Weidner AC, Visco AG, et al. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol 1998;179:1451. Cundiff GW, Harris RL, Coates K, et al. 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. Francis WJ, Jeffcoate TN. Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw 1961;68:1. Fox SD, Stanton SL. Vault prolapse and rectocele: assessment of repair using sacrocolpopexy with mesh interposition. Br J Obstet Gynaecol 2000;107:1371. Glavind K, Madsen H. A prospective study of the discrete fascial defect rectocele repair. Acta Obstet Gynecol Scand 2000;79:145. Hakelius L. Reconstruction of the perineal body as treatment for anal incontinence. Br J Plast Surg 1979;32:245. Haase P, Skibsted L. Influence of operations for stress incontinence and/or genital descensus on sexual life. Acta Obstet Gynecol Scand 1988;67:659. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol 1959;77:490. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol 1997;104:82. Kenton K, Shott S, Brubaker L. Outcome after rectovaginal fascia reattachment for rectocele repair. Am J Obstet Gynecol 1999;181:1360. Kenton KS, Woods MP, Brubaker L. Uncomplicated erosion of polytetrafluoroethylene grafts into the rectum. Am J Obstet Gynecol 2002;187:233. Khubchandani IT, Clancy JP, Rosen L, et al. Endorectal repair of rectocele revisited. Br J Surg 1997;84:89. Kohli N, Miklos JR. Dermal graft-augmented rectocele repair. Int Urogynecol J 2003;14:146. López A, Anzén B, Bremmer S, et al. Cystodefecoperitoneography in patients with genital prolapse. Int Urogynecol J 2002;13:22. Maher C, Baessler K, Glazener CM, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2004;4: CD004014. Maher CF, Qatawneh AM, Baessler K, et al. Midline rectovaginal fascial plication for repair of rectocele and obstructed defecation. Obstet Gynecol 2004;104:685.

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Mellgren A, Anzén B, Nilsson B, et al. Results of rectocele repair: a prospective study. Dis Colon Rectum 1995;38:7. Miklos JR, Moore RD, Kohli N. Laparoscopic surgery for pelvic support defects. Curr Opin Obstet Gynecol 2002;14:387. Nichols DH. Posterior colporrhaphy and perineorrhaphy: separate and distinct operations. Am J Obstet Gynecol 1991;164:714. Olsen AL, Smith VJ, Bergstrom JU, et al. Incidence and clinical characteristics of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501. Porter WE, Steele A, Walsh P, et al. The anatomic and functional outcomes of defect-specific rectocele repairs. Am J Obstet Gynecol 1999;181:1353. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568. Rovner ES, Ginsberg DA. Posterior vaginal wall prolapse: transvaginal repair of pelvic floor relaxation, rectocele, and perineal laxity. Tech Urol 2001;7:161. Sand K, Koduri S, Lobel RW, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184:1357. Singh K, Cortes E, Reid WM. Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse. Obstet Gynecol 2003;101:320. Sullivan ES, Leaverton GH, Hardwick CE. Transrectal perineal repair: an adjunct to improved function after anorectal surgery. Dis Colon Rectum 1968;11:106. Sehapayak S. Transrectal repair of rectocele: an extended armamentarium of colorectal surgeons. A report of 355 cases. Dis Colon Rectum 1985;28:422. Van Dam JH, Hop WC, Schouten WR. Analysis of patients with poor outcome of rectocele repair. Dis Colon Rectum 2000;43:1556. Van Laarhoven CJ, Kamm MA, Bartram CI, et al. Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation. Dis Colon Rectum 1999;42:204. Venkatesh KS, Ramanujam P. Surgical treatment of traumatic cloaca. Dis Colon Rectum 1996;39:811. Visco AG, Weidner AC, Barber MD, et al. Vaginal mesh erosion after abdominal sacral colpopexy. Am J Obstet Gynecol 2001;184:297. Watson SJ, Loder PB, Halligan S, et al. Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical physiological and radiologic assessment of treatment. J Am Coll Surg 1996;183:257. Weber AM, Walters MD, Piedmonte MA. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000;182:1610. Whiteside JL, Weber AM, Meyn LA, et al. Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol 2004;191:1533.

Surgical Treatment of Vaginal Vault Prolapse and Enterocele

21

Mickey M. Karram and Mark D. Walters

PATHOLOGY OF PELVIC ORGAN PROLAPSE 262 PREVALENCE AND DEMOGRAPHICS 263 ENTEROCELE 263 Definition and Types 263 Diagnosis 264 Surgical Repair Techniques 265 VAGINAL PROCEDURES THAT SUSPEND THE APEX 267 Sacrospinous Ligament Suspension 267 Endopelvic Fascia Repair (Modified McCall Culdoplasty) 275 Iliococcygeus Fascia Suspension 276 High Uterosacral Ligament Suspension 276 Infracoccygeal Sacropexy 279 ABDOMINAL PROCEDURES THAT SUSPEND THE APEX 279 Abdominal Sacral Colpopexy 279 High Uterosacral Ligament Suspension 284 SURGICAL APPROACHES—VAGINAL VERSUS ABDOMINAL 284 UTERINE PRESERVATION DURING SURGERY FOR UTEROVAGINAL PROLAPSE 285 SUMMARY 285

In recent years, the problem of pelvic organ prolapse has been given much more attention. Many women are living longer, and more interest exists in maintaining self-image of femininity and the capacity of sexual activity beyond menopause. The management of pelvic organ prolapse can be difficult; several support defects often coexist, and simple anatomic correction of the various defects does not always result in normal function of the vagina and surrounding organs. To accomplish the goals of pelvic reconstruction, the surgeon must thoroughly understand normal anatomic support and physiologic function of the vagina, bladder, and rectum. These goals are to restore anatomy, maintain or restore normal bowel and bladder function, and maintain vaginal capacity for sexual intercourse. This chapter discusses the pathology and surgical correction of enterocele, uterovaginal prolapse, and posthysterectomy apical prolapse. Normal anatomy of the pelvic diaphragm is discussed in detail in Chapter 2. The evaluation of patients with pelvic organ prolapse, especially regarding their symptoms, physical examination, and diagnostic tests, is discussed in Chapters 5 and 6.

PATHOLOGY OF PELVIC ORGAN PROLAPSE Pelvic organ prolapse can result when normal pelvic organ supports are subjected chronically to increases in intraabdominal pressure or when defective genital support responds to normal intra-abdominal pressure. Individual organs that pass through the pelvic floor can lose support singly or in combination, resulting in various degrees and combinations of pelvic organ prolapse. This loss of support occurs as a result of damage to any of the pelvic supportive systems. These systems include the bony pelvis, to which the soft tissues ultimately attach; the subperitoneal retinaculum and smooth muscle component of the endopelvic fascia (the cardinal and uterosacral ligament complex); the pelvic diaphragm, with the levator ani muscles and their fibromuscular attachments to the pelvic organs; and the perineal membrane. The perineal body and the walls of the vagina can lose tone and weaken from pathologic stretching from childbirth and attenuating changes of aging and menopause. Loss of support or integrity of the anterior and posterior vaginal walls results in cystocele and enterorectocele, respectively. Uterovaginal prolapse occurs with damage or attenuation of endopelvic fascia that supports the uterus and upper vagina over the pelvic diaphragm. Furthermore, when the muscles within the pelvic diaphragm weaken as a result of congenital factors, childbirth injury, pelvic neuropathy, or aging, the levator ani lose resting tone and fail to contract quickly and strongly with increases in intra-abdominal pressure. Muscle atrophy and a wider levator hiatus result; weaker and less rapid muscle contractions with rises in intra-abdominal pressure contribute to related symptoms of urinary and fecal incontinence. A useful approach to understanding the pathophysiology of prolapse was described by Bump and Norton (1998). They proposed considering risk factors for the development of prolapse as predisposing, inciting, promoting, or decompensating events. Predisposing factors are genetic, race, and gender; inciting factors are pregnancy and delivery, surgery such as hysterectomy for prolapse, myopathy, and neuropathy; promoting factors are obesity, smoking, pulmonary disease, constipation, and recreational or occupational activities; and decompensating factors are aging, menopause,

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Surgical Treatment of Vaginal Vault Prolapse and Enterocele

debilitation, and medications. Depending on the combination of risk factors in an individual, prolapse may or may not develop over her lifetime. With further research on the human genome project, risk factors will continue to be identified. Eventually, we may be able to predict those at highest risk for developing prolapse. Modifiable risk factors can be altered to decrease the likelihood of subsequent prolapse. Obesity is one of the modifiable risk factors identified so far. Although increased parity is a risk factor for prolapse, nulliparity does not provide absolute protection against prolapse. Data from the Women’s Health Initiative (Hendrix et al., 2002) noted that almost one fifth of nulliparous women had some degree of prolapse. These data contradict those who enthusiastically promote cesarean delivery for all women to prevent prolapse. Normally, the vaginal axis in an erect woman is nearly horizontal in the upper half of the vagina, with the uterus and upper 3 or 4 cm of the vagina lying over the levator plate in the hollow of the sacrum (Fig. 21-1). Funt et al. (1978) found that the vagina is directed toward the S3 and S4 vertebras and extends approximately 3 cm past the ischial spines in most nulliparous women. Increases in intra-abdominal pressure compress the vagina anteriorly to posteriorly over the contracted levator muscles in the midline (levator plate). Diminished muscle tone may result in loss of stability of the levator plate, widening of the levator hiatus, and loss of an adequate base to support the upper vagina and uterus in the normal axis. Distortion of the normal vaginal axis during reconstructive pelvic surgery predisposes women to the development of pelvic organ prolapse at an anatomic site opposite to where the repair was performed. Examples of this are the development of posterior vaginal wall prolapse after colposuspension procedures for stress incontinence and the development of anterior vaginal wall prolapse after suspension of the vaginal apex to the sacrospinous ligament. Connective tissue defects have been found in women with uterine prolapse and stress incontinence. In several studies, Mädakinen et al. (1986, 1987) identified abnormal histologic changes in the pelvic connective tissue in 70% of women with uterine descent, compared with 20% of normal

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controls. Decreased cellularity (fibroblasts) and an increase in collagen fibers were observed. Ulmsten et al. (1987) reported 40% less total collagen in the skin and round ligaments of women with stress incontinence when compared with that of continent women. These studies and others suggest that abnormal connective tissue may be associated with pelvic organ prolapse and stress urinary incontinence.

PREVALENCE AND DEMOGRAPHICS Because the prevalence of pelvic organ prolapse increases with age, the changing demographics of the world’s population will result in even more affected women. Based on projections from the U.S. Census Bureau, the number of American women age 65 and over will double in the next 25 years to more than 40 million women by 2030. One study by Luber et al. (2001) noted that the demand for health care services, related to pelvic floor disorders, will increase at twice the rate of the population itself. Using data from a large U.S. Northwest health maintenance organization database, Olsen et al. (1997) reported the risks of pelvic organ prolapse or urinary incontinence surgery by age 80 as 11.1%. Surgery for pelvic organ prolapse with continence surgery (22%) or without (41%) accounted for 63% of this risk, or a lifetime risk of 7%. Boyles et al. (2003) reported that over a nearly 24-year period reviewed, the rate of procedures to correct prolapse decreased slightly, but not significantly, and that the surgical indication for approximately 7% to 14% of hysterectomies is listed as pelvic organ prolapse. Data from the U.S. National Hospital Discharge Survey (NHDS) indicate that approximately 200,000 women undergo surgery for pelvic organ prolapse annually. A study by Brown et al. (2002), using data from the NHDS for surgical rates, indicated that approximately 22.7 per 10,000 women had some form of pelvic organ prolapse surgery in a year. As expected, surgical rates vary with age peaking in the sixth decade, with an average age of surgery of 55 years. Racial differences were also reported, with Caucasian women having a threefold greater rate of pelvic organ prolapse surgery than African American women. Pelvic organ prolapse is common worldwide. Samuelsson et al. (1999) reported a prevalence of pelvic organ prolapse of 30.8% among Swedish women ages 20 to 59, with 2% having prolapse to the introitus. In the United Kingdom two hospitalizations per 1000 person-years for pelvic organ prolapse occur by age 60 (Mant et al., 1997). Sajan and Fikree (1999) reported that 19.1% of women in Pakistan who were under age 30 reported feeling symptoms of prolapse.

ENTEROCELE Definition and Types

Figure 21-1 ■ Normal vaginal axis of nulliparous woman in the standing position. Note that the upper third of the vagina is nearly horizontal and is directed toward the S3 and S4 sacral vertebras. (From Funt MI, Thompson JD, Birch H. Normal vaginal axis. South Med J 1978;71:1534, with permission.)

Enterocele is a hernia in which peritoneum and abdominal contents displace the vagina and may even be in contact with vaginal mucosa. The normal intervening endopelvic fascia is deficient or absent, and small bowel fills the hernia sac. Generally, enteroceles have been divided into four types: congenital, traction, pulsion, and iatrogenic. Congenital

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enterocele is rare. Factors that may predispose to the development of congenital enterocele include neurologic disorders, such as spina bifida and connective tissue disorders. Traction enterocele occurs secondary to uterovaginal descent, and pulsion enterocele results from prolonged increases in intraabdominal pressure. The two latter types of enterocele may coexist with apical vaginal prolapse, cystocele, or rectocele. Iatrogenic enterocele occurs after surgical procedures that elevate the normally horizontal vaginal axis toward a vertical direction; examples include colposuspension and needle urethropexy operations for stress incontinence, or hysterectomy, with or without repair, when the vaginal cuff and cul-de-sac are not managed effectively. Clinically, enteroceles are best classified based on their anatomic location. Apical enteroceles herniate through the

apex of the vagina, posterior enteroceles herniate posteriorly to the vaginal apex, and anterior enteroceles herniate anteriorly to the vaginal apex (Fig. 21-2).

Diagnosis Enteroceles may commonly occur in association with rectocele and/or cystocele. When these hernias coexist with rectoceles, the rectovaginal examination may demonstrate the rectocele as distinct from the bulging sac that arises from a higher point in the vagina. Visual inspection of the posterior vaginal wall may reveal a transverse furrow between the two hernias. However, in many posthysterectomy prolapse patients, it is difficult to preoperatively determine whether an enterocele sac coexists with a large rectocele or cystocele.

Figure 21-2 ■ Cross-section of pelvic floor showing various anatomic locations of enteroceles. A. Anterior enterocele—defect in the pubocervical fascia near its attachment to the vaginal apex. The peritoneal sac with its contents protrudes anterior to the vaginal cuff. B. Apical enterocele—defect at the vaginal apex; the peritoneal sac protrudes between the pubocervical fascia anterior and the rectovaginal fascia posterior. C. Posterior enterocele—defect posterior to the vaginal cuff. The peritoneal sac protrudes through the defect in rectovaginal fascia, posterior to the vaginal cuff.

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Surgical Treatment of Vaginal Vault Prolapse and Enterocele

For this reason, in cases of advanced anterior or posterior vaginal wall prolapse, the surgeon should attempt to determine whether a portion of the prolapse is secondary to an enterocele. This should include routine dissection of the vagina from its underlying structures all the way to the apex of the vagina. The enterocele sac can usually be visually or digitally identified as a sac of peritoneum separate and distinct from the wall of the bladder or rectum. At times, a finger in the rectum or retrograde filling of the bladder may assist the surgeon in safely isolating and entering an enterocele sac.

Surgical Repair Techniques Surgical repair of enterocele can be performed vaginally or abdominally. No data exist comparing the various types of repairs. The approach and type of procedure performed depend on the surgeon’s preference and whether there is concomitant vaginal or abdominal pathology. Vaginal surgical techniques described herein are the traditional vaginal enterocele repair and the McCall culdoplasty, and abdominal approaches discussed include the Moschcowitz procedure, Halban procedure, and uterosacral ligament plication. VAGINAL ENTEROCELE REPAIR Patients rarely have an isolated enterocele; hence, concurrent vaginal vault suspension, with or without cystocele and rectocele repair, is often necessary. The technique of vaginal repair of an apical or posterior enterocele is as follows: 1. The patient is positioned as for a posterior colporrhaphy. A midline posterior vaginal wall incision is made over the enterocele sac up to the vaginal apex and extended to the perineum, if a rectocele is also present. Dissection of the posterior vaginal wall from the enterocele sac, the anterior rectal wall, and the rectovaginal fascia is accomplished sharply and bluntly. The dissection should extend laterally to the medial margins of the levator ani muscles (Fig. 21-3, A). 2. The enterocele sac should be mobilized from the vaginal walls and rectum. When the enterocele sac is difficult to distinguish from the anterior rectum, differentiation is aided by a rectal examination with simultaneous dissection of the enterocele sac from the anterior rectal wall (Fig. 21-3, B). At times, distinguishing the enterocele sac from a large cystocele may prove difficult. In this situation, placement of a probe into the bladder or transillumination with a cystoscope may prove helpful. 3. After the enterocele sac has been dissected from the vagina and rectum, traction is placed on it with two Allis clamps and the sac is entered sharply (Fig. 21-3, C). The enterocele sac is explored digitally to ensure that no small bowel or omental adhesions are present (Fig. 21-3, D); if encountered, they are dissected to the level of its neck. 4. Under direct visualization, two or three circumferential, nonabsorbable, purse-string sutures are used to close the enterocele sac (Fig. 21-3, E). The cardinaluterosacral ligaments are incorporated as well. Once

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placed, the sutures are tied in sequence. Care should be taken to avoid kinking the ureter. 5. Posterior colporrhaphy and vaginal vault suspension are performed as indicated (Fig. 21-3, F). MCCALL CULDOPLASTY McCall (1957) described the technique of surgical correction of enterocele and a deep cul-de-sac at the time of vaginal hysterectomy. The advantage of the McCall culdoplasty is that it not only closes the redundant cul-de-sac and associated enterocele but also provides apical support and lengthening of the vagina. Many authors advocate using this procedure as part of every vaginal hysterectomy, even in the absence of enterocele, to minimize future hernia formation and vaginal vault prolapse. The technique is as follows (Fig. 21-4): 1. After the vaginal hysterectomy is completed, the surgeon places a finger into the posterior cul-de-sac to evaluate vaginal depth. Lateral traction is placed on the previously tagged uterosacral ligaments. 2. With the patient in Trendelenburg’s position, a large pack is placed intraperitoneally to prevent descent of the omentum or bowel into the field. A permanent suture is initially passed through one uterosacral ligament as high as possible. Successive bites are then taken at 1- to 2-cm intervals through the anterior serosa of the bowel, until the opposite uterosacral ligament is reached. This suture is left untied, and successive identical sutures are placed as needed, progressing toward the posterior vaginal cuff. The number of internal McCall sutures placed depends on the size and depth of the enterocele or cul-desac. The goal is obliteration of the entire dependent portion of the cul-de-sac. 3. After all of the internal permanent sutures have been placed and their ends held laterally without tying, one or two sutures of delayed absorbable No. 0 suture are placed. These are inserted from the vaginal lumen just below the middle of the cut edge of the posterior vaginal cuff, through the peritoneum, and through the right uterosacral ligament. Successive bites are taken across the cul-de-sac as before and into the left uterosacral ligament. This suture is passed through the peritoneum and vaginal epithelium, adjacent to the point of entry. 4. The permanent sutures are tied in sequence. The vaginal cuff is then closed. Finally, the delayed absorbable sutures are tied in a manner to bring the posterior vagina up to the level of the uterosacral ligaments. The complications as reported by Given (1985) after McCall culdoplasty are shown in Table 21-1. He reported ureteral injury in 1 of 48 McCall culdoplasty procedures. Stanhope et al. (1991) also found that culdoplasty sutures were implicated in ureteral obstruction after vaginal surgery. To ensure ureteral patency, cystoscopy should be routinely considered after the McCall culdoplasty. When there is excessive redundancy of the posterior vaginal wall and peritoneum, a modification of the McCall

Figure 21-3 ■ Dissection and vaginal repair of enterocele. A. The enterocele sac has been completely mobilized of the vaginal epithelium. B. A finger in the rectum facilitates sharp dissection of the enterocele sac off the anterior wall of the rectum. C. The enterocele sac is sharply entered. D. The peritoneum has been excised and the cul-de-sac is exposed. E. A series of purse-string sutures incorporating the distal ends of the uterosacral ligaments are placed to close the defect at its neck. F. The vaginal apex is attached to the plicated uterosacral ligaments.

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include the ureter in the purse-string sutures or to allow the ureter to be kinked medially when tying the sutures. Halban described a technique to obliterate the cul-desac using sutures placed sagittally between the uterosacral ligaments. Four or five sutures are placed sequentially in a longitudinal fashion through the serosa of the sigmoid, into the deep peritoneum of the cul-de-sac, and up the posterior vaginal wall (Fig. 21-6, B). The sutures are tied, obliterating the cul-de-sac. Transverse plication of the uterosacral ligaments can be used to obliterate the cul-de-sac (Fig. 21-6, C). Three to five sutures are placed into the medial portion of one uterosacral ligament, into the back wall of the vagina, and into the medial portion of the opposite uterosacral ligament. The lowest suture incorporates the anterior rectal serosa to bring the rectum adjacent to the uterosacral ligaments and vagina. Care must be taken to avoid entrapment or kinking of the ureter. Relaxing incisions can be made in the peritoneum lateral to the uterosacral ligaments to release the ureters, if necessary.

Figure 21-4 ■ McCall culdoplasty technique. Internal and external McCall sutures are placed. The lowest suture (external McCall) incorporates the posterior vaginal wall, providing additional support.

Table 21-1

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Complications After McCall Culdoplasty*

Complication Removal of silk suture Postoperative cuff infection High rectocele Partial prolapse of vaginal vault Shortened vagina Introital stenosis Pulmonary emboli Nerve palsy Ureteral obstruction

Percent of Patients (N = 48) 10 4 4 4 4 2 2 2 2

*Follow-up was 2 to 22 (average 7) years. From Given FT. “Posterior culdeplasty”: revisited. Am J Obstet Gynecol 1985;153:135, with permission.

culdoplasty, in which a wedge of posterior vaginal wall and peritoneum is excised, can be considered (Fig. 21-5). ABDOMINAL ENTEROCELE REPAIRS Three techniques of abdominal enterocele repair have been described: Moschcowitz and Halban procedures and the uterosacral ligament plication. The Moschcowitz procedure is performed by placing concentric purse-string sutures around the cul-de-sac to include the posterior vaginal wall, the right pelvic side wall, the serosa of the sigmoid, and the left pelvic side wall (Fig. 21-6, A). The initial suture is placed at the base of the cul-de-sac. Usually, three or four sutures completely obliterate the cul-de-sac. The purse-string sutures are tied so that no small defects remain that could entrap small bowel or lead to enterocele recurrence. Care should be taken not to

VAGINAL PROCEDURES THAT SUSPEND THE APEX When mild forms of isolated uterovaginal prolapse (descent of the cervix not beyond the midportion of the vagina) are present, vaginal hysterectomy and culdoplasty, with anterior and posterior colporrhaphy, are usually sufficient to relieve the patient’s symptoms and restore normal vaginal function. However, more severe apical prolapse requires separate operations to re-suspend the apex. In Figure 21-7, A an isolated apical enterocele is shown with a wells-supported anterior and posterior vaginal walls. In such a case, no formal vaginal vault suspension is necessary because simple excision and closure of the enterocele sac will result in a wellsupported vagina of adequate length. As more of the anterior and posterior vaginal walls become everted, the more complex the repair becomes (Fig. 21-7, B, C).

Sacrospinous Ligament Suspension SURGICAL ANATOMY To perform this procedure correctly and safely, the surgeon must be familiar with pararectal anatomy as well as the anatomy of the sacrospinous ligament and its surrounding structures (Fig. 21-8). The sacrospinous ligaments extend from the ischial spines on each side to the lower portion of the sacrum and coccyx. Nichols and Randall (1989) described the sacrospinous ligament as a cordlike structure lying within the substance of the coccygeus muscle. However, the fibromuscular coccygeus muscle and sacrospinous ligament are basically the same structure and thus called the coccygeus-sacrospinous ligament (C-SSL). The coccygeus muscle has a large fibrous component that is present throughout the body of the muscle and on the anterior surface, where it appears as white ridges. The C-SSL can be identified by palpating the ischial spine and tracing posteriorly and medially the flat triangular thickening to the sacrum The fibromuscular

Figure 21-5 ■ Modified McCall culdoplasty. A. The cul-de-sac is digitally palpated, and excessive peritoneum and posterior vaginal wall are noted. B. A wedge of tissue (dotted line), which includes full thickness vaginal wall and peritoneum, is excised to decrease the caliber of the upper portion of the posterior vaginal wall. C. External McCall stitches are placed in a traditional fashion. D. Tying of these sutures obliterates the cul-de-sac, supports the vaginal cuff, and increases posterior vaginal wall length.

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Figure 21-6 plication.

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Techniques of enterocele repair via the abdominal route. A. Moschcowitz procedure. B. Halban procedure. C. Uterosacral ligament

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Ischial spine

Vaginal length = 9 cm

coccygeus is attached directly to the underlying sacrotuberous ligament. Posterior to the C-SSL and sacrotuberous ligament are the gluteus maximus muscle and the fat of the ischiorectal fossa. The pudendal nerves and vessels lie directly posterior to the ischial spine. The sciatic nerve lies superiorly and laterally to the C-SSL. Also superiorly lies an abundant vascular supply that includes inferior gluteal vessels and hypogastric venous plexus. SURGICAL TECHNIQUE

A

Vaginal length = 4.5 cm

B

Level of ischial spine

Urethra

Cystocele

C Rectocele

Enterocele with vault eversion

Figure 21-7 ■ Various degrees of vaginal vault eversion. A. Isolated enterocele with well-supported anterior and posterior vaginal walls. Note that surgical repair would only require excision of the sac and closure of the defect because the vaginal cuff is already at the level of the ischial spine. B. Note that vaginal cuff is at –4.5 cm; thus, surgical repair should ideally require suspension of vaginal cuff to or above the level of the ischial spine. C. Note complete eversion of the vagina, with the vaginal cuff prolapsed well beyond the hymen; also note coexistent cystocele and rectocele. Surgical repair becomes much more complicated if the goal is to create a well-supported vagina of sufficient length.

Before this operation is initiated, one should have preoperatively recognized the ischial spine and C-SSL on pelvic examination. Preoperative estrogen replacement therapy should be given liberally, if appropriate. We prefer to use a preoperative vaginal estrogen cream for 4 to 6 weeks. The performance of this operation almost always requires simultaneous correction of the anterior and posterior vaginal walls and enterocele repair. Displacing the prolapsed vaginal apex to the sacrospinous ligament to see whether the anterior and posterior vaginal wall prolapse disappears with a Valsalva maneuver helps determine whether cystocele and rectocele repairs are needed. The patient should be consented routinely for these repairs because many times it is difficult preoperatively to discern the extent of the various defects. The technique of unilateral sacrospinous fixation is as follows: 1. With the patient in dorsal lithotomy position, the vaginal area is prepped and draped. Prophylactic perioperative antibiotics are given routinely. 2. The apex of the vagina is grasped with two Allis clamps, and downward traction is used to determine the extent of the vaginal prolapse and associated pelvic support defects. The vaginal apex is then reduced to the sacrospinous ligament intended to be used. Although bilateral sacrospinous fixations have been described, most surgeons prefer unilateral fixation of the vaginal vault. At times, the apex of the vagina is foreshortened and will not reach the intended area of fixation. This is commonly associated with a shortened anterior vaginal wall and a prominent enterocele. The apex should be moved to a portion of the vaginal wall over the enterocele, thus allowing sufficient vaginal length for suspension to the sacrospinous ligament. The intended apex is tagged with two sutures for its later identification. 3. If the patient has complete eversion of the vagina and requires anterior vaginal wall repair and/or bladder neck suspension, we prefer doing this portion of the operation first. During this procedure, one can separate the bladder base away from the vaginal apex, thus lowering the risk of cystotomy. After these procedures are completed, the anterior vaginal wall is closed with a continuous running suture. 4. The posterior vaginal wall is then incised. After a transverse perineal incision, a midline posterior vaginal wall incision is made just short of the apex of the vagina, leaving a small vaginal bridge approximately 3 or 4 cm wide. In the majority of cases, an enterocele sac is present. This sac should be dissected off the posterior vaginal wall and closed with a high purse-

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Figure 21-8 ■ Close-up view of the coccygeussacrospinus complex to demonstrate close proximity of various nerves and blood vessels. Hypogastric artery and vein Inferior gluteal artery Hypogastric plexus

Sciatic nerve

External iliac artery and vein

Sacrospinous ligament

Obturator neurovascular bundle

Ischial spine

5.

6. 7.

8.

string suture, as previously described (see Fig. 21-3). Once the enterocele has been incised and ligated, one is ready to begin the sacrospinous fixation. The first step is entry into the perirectal space. The right rectal pillar separates the rectovaginal space from the right perirectal space. The rectal pillar is areolar tissue that extends from the rectum to the arcus tendineus fasciae pelvis and overlies the levator muscle. It has two layers and may contain a few small muscle fibers and blood vessels. In the majority of cases, entry into the perirectal space is best achieved by breaking through the fibroareolar tissue just lateral to the enterocele sac at the level of the ischial spine. This maneuver can usually be accomplished bluntly by mobilizing the rectum medially. At times, however, the use of gauze on the index finger or a tonsil clamp is necessary to break through into this space. Once the perirectal space is entered, the ischial spine is identified and, with dorsal and medial movement of the fingers, the C-SSL is palpated. Blunt dissection is used to further remove tissue from this area. The surgeon should take great care to ensure that the rectum is adequately retracted medially. At this time, we recommend performing a rectal examination to ensure that no inadvertent rectal injury has occurred. Two techniques have been popularized for the actual passage of sutures through the ligament (Fig. 21-9). The first is the technique of Randall and Nichols (1971), using a long-handled Deschamps ligature carrier and nerve hook (Fig. 21-10, A). Long, straight retractors are used to expose the coccygeus muscle. Heaney retractors or Breisky-Navratil retractors (Fig. 21-10, B) are preferred. One must

Pudendal artery and vein

take great care not to let the tip of the retractor be pushed across the anterior surface of the sacrum, risking potential damage to vessels and nerves. If the right sacrospinous ligament is to be used, the middle and index fingers on the left hand are placed on the medial surface of the ischial spine and, under direct vision, the tip of the ligature carrier penetrates the C-SSL at a point two fingerbreadths medial to the ischial spine. When pushing the ligature carrier through the body of the C-SSL, considerable resistance should be encountered; this must be overcome by forceful yet controlled rotation of the handle of the ligature carrier. If visualization of the C-SSL is difficult, the muscle and ligament can be grasped in the tip of a long Babcock or Allis clamp, which helps isolate the tissue to be sutured from underlying vessels and nerves. After suture passage, the fingers of the left hand are withdrawn. The retractor is suitably repositioned, and the tip of the ligature carrier is visualized. The suture is then grasped with a nerve hook (see Fig. 21-10, A). A second suture is similarly placed 1 cm medial to the first. To avoid a second passage of the ligature carrier, the original long suture can be cut in the center and each end of the cut loop paired with its respective free suture. This obtains two sutures through the ligament, with only one penetration of the ligature carrier. To ensure that an appropriate bite of tissue has been obtained, one should be able to gently move the patient with traction of the sutures. A second technique that has been popularized for passing the sutures through the C-SSL is the technique of Miyazaki (1987), using a Miya hook ligature carrier (Fig. 21-11). The

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Figure 21-9 ■ A. Passage of Deschamps ligature carrier with suture through C-SSL. Note that the needle-tip is passed in superior direction. Retrieval of suture is with nerve hook. B. Passage of Miya hook through C-SSL. Note that needletip is passed inferiorly. Retrieval of suture is facilitated by using notched speculum.

Figure 21-11 ■ Miya hook, notched speculum, and suture hook for use during sacrospinous ligament fixation.

Figure 21-10 ■ A. Long-handled Deschamps ligature carrier and nerve hook. Note slight bend near the tip to facilitate suture placement into the C-SSL. B. Breisky-Navratil retractors, various sizes.

proposed advantage of this technique is that it is safer and easier because the ligature carrier enters the C-SSL under direct palpation of distinct landmarks and is then pulled down into the safe perirectal space below. To perform this modification, the right middle fingertip is placed on the C-SSL just below its superior margin, approximately two fingerbreadths medial to the ischial spine. The Miya hook, in the left hand in a closed position, is slid along the palmar surface of the right hand. The hook point should come to rest just beneath the previously positioned tip of the right middle finger. The handles are then opened and lowered to a near horizontal position. This points the

hook into the C-SSL at about a 45-degree angle. If a high perineum prevents lowering the handle, an episiotomy should be performed. With the tip of the middle finger, the hook point is placed two fingerbreadths medial to the ischial spine, approximately 0.5 cm below the superior edge. With experience, the hook point can be passed above the superior edge. With the middle and index fingers, apply firm pressure downward just behind the hook hump so that the hook point penetrates the C-SSL (see Fig. 21-9, B). Downward pressure with two fingers on the top, plus traction with the back of the thumb on the back handle, produces enough force to penetrate the ligament. Close and elevate the handles of the Miya hook, and, with the index and middle fingers, push the tissue from the hook point to make the suture clearly visible. If too much tissue is in the hook, simply back out the hook a little and take a smaller bite. An assistant should hold the elevated handles in a closed position. A long retractor is then placed medially to mobilize the rectum, and a notched speculum is inserted by palpation underneath the hook point. A nerve hook is then used to retrieve the suture. In addition to these techniques, two instruments have been designed to facilitate passage of a suture through the ligament. These are shown in Figure 21-12.

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remains in the vagina. We recommend a No. 0 delayed absorbable suture. After the sutures have been brought out through the vagina, the upper portion of the posterior vaginal wall is closed with interrupted or continuous No. 3-0 sutures. The vaginal vault suspension stitches are then tied, thus elevating the apex of the vagina to the C-SSL. It is important that the vagina comes into contact with the coccygeus muscle and no suture bridge exists, especially if delayed absorbable sutures are being used. While tying these sutures, it may be useful to perform a rectal examination to detect any suture bridges. Figure 21-12 ■ Two specially designed instruments to facilitate passage of sutures through the sacrospinous ligament. A. Capio Device (Boston Scientific, Natick. Capio is a trademark of Boston Scientific Corp., Waltertown, MA). B. Nichols-Veronikis ligature carrier. (Courtesy of CooperSurgical, Trumbull, CT.)

9. Now the surgeon is ready to bring the stitches out to the apex of the vagina. Again, two methods have been popularized for this maneuver (Fig. 21-13). The first involves bringing the vaginal apex to the surface of the C-SSL with the use of a pulley stitch. After the stitch has been placed in the ligament, one end of the suture is rethreaded on a free needle, sewn into the full thickness of the fibromuscular layer of the undersurface of the vaginal apex, and tied by a single half-hitch, while the free end of the suture is held long (see Fig. 21-13, A). Traction of the free end of the suture pulls the vagina directly onto the muscle and ligament. A square knot then fixes it in place. With this type of fixation, a permanent suture should be used because the suture is not exposed through the epithelium of the vagina. Some surgeons prefer a second technique, especially if the vaginal wall is thin or if greater vaginal length is desired. This method inserts each end of the suture through the vaginal epithelium (see Fig. 21-13, B). When this method is used, a delayed absorbable suture should be used because the knot

10. After the sutures are tied, the posterior colpoperineorrhaphy is completed, as needed, and the vagina is packed with a moist gauze for 24 hours. RESULTS AND COMPLICATIONS The results of sacrospinous fixation are difficult to evaluate because few studies report long-term follow-up (Table 21-2). The largest published series to date is by Nichols (1982), who performed the operation on 163 patients and followed them for at least 2 years. He reported only a 3% incidence of recurrent vaginal eversion and did not specify whether other pelvic support defects recurred. Morley and DeLancey (1988) reported on 100 patients who underwent sacrospinous fixation, with or without anterior and posterior vaginal wall repairs. Subjective 1-year follow-up was available on 71 patients; only 3 had recurrent vaginal vault prolapse. These authors did note, however, that 22 patients had recurrent or persistent mild-to-moderate anterior vaginal wall relaxation or symptomatic cystoceles. Shull et al. (1992) reported the results of sacrospinous ligament fixation, as well as other pelvic reconstructive surgery, in 81 patients. The authors performed preoperative sitespecific analysis of pelvic support defects and at consecutive postoperative visits. The findings at 6 postoperative weeks and at subsequent visits were noted for each of five sites: urethra, bladder, vaginal cuff, cul-de-sac, and rectum. The most common site for recurrent prolapse was the anterior vaginal wall. Sze et al. (1997) reported on 75 women who underwent sacrospinous ligament fixation in conjunction with other

Figure 21-13 ■ Technique of fixing vaginal apex to C-SSL. A. Pulley stitch. Permanent sutures should be used. B. Stitches are placed through the vaginal epithelium and tied in the vaginal lumen. Delayed absorbable sutures should be used.

163 92 11 31 48 61 51 22 155 81 23 63§ 76 36 24 30 14 75 1137

≥2 yr 1 mo–11 yr 8–21 mo

6 mo–5.6 yr — 2–5 yr — 2 mo–1 yr — 15–79 mo 4–26 mo Median = 48 mo 3–6 mo 7–72 mo 1 mo–11 yr

8 mo–3.2 yr 1 mo–8.6 yr

81

1–10 yr

?/4 20/36

3/5 0/0

5/5 3/3 1/1 2/6 0/1 1/1 0/0 0/0 0/4 0/1 2/2 1/1

2/2

Vault

?/1 4/25

0/1 4/6

0/1 0/0 0/0

4/20 0/1 0/16 ?/1 1/3 0/0 0/2 ?/16 7/96

0/2 0/2 0/0 0/2

0/0 0/0

0/10

Posterior Wall

0/5 0/6 0/3 0/1

2/11 0/0

0/12

Anterior Wall

From Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466, with permission. *Subjective assessment, based on telephone interview or questionnaire; objective assessment, based on findings from pelvic examination. †Cure rate applies to vaginal vault support only; does not include support defect at other site. ‡Extrapolated from text. §Includes 11 patients whose uteri were preserved. ||Includes 33 patients with anterior vaginal wall defects, 3 vaginal vault prolapses, and 8 posterior vaginal wall relaxations.

Richter and Albright (1981) Richter (1982) Nichols (1982) Morley and DeLancey (1988) Brown et al. (1989) Keetel and Herbertson (1989) Cruikshank and Cox (1990) Monk et al. (1991) Backer (1992) Heinonen (1992) Imparato et al. (1992) Shull et al. (1992) Kaminski et al. (1993) Carey and Slack (1994) Porges and Smilen (1994) Holley et al. (1995) Sauer and Klutke (1995) Peters and Christenson (1995) Elkins et al. (1995) Sze et al. (1997) Total

Investigator

?/1 0/57

0/1

0/2 0/33||

0/11 0/6

0/3

Unspecified/ Multiple Sites

Surgical Repair Required/Recurrent Pelvic Relaxation (n)

158 (97)† 75 (82) 10 (91) 25 (81) 40 (83) 52 (85) 48 (94) 19 (86) 140 (90) 53 (65) 20 (87) 46 (73) — 3 (8) 15 (63) 23 (77) 12 (86) 53 (71)

57 (70)

No. Cured (%)

Subjective/objective Objective Subjective/objective Objective‡ Objective Objective Objective Objective Objective Objective Objective Objective‡ Objective Objective‡ Subjective/objective Objective‡ Objective‡

Objective

Cure Assessment

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No. Available for Follow-Up

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Duration of Follow-Up

Table 21-2 ■ Long-Term Complications, Follow-Up, and Recurrence of Prolapse After Sacrospinous Ligament Suspension Surgical Repair Required/Recurrent Pelvic Relaxation (n)

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reconstructive surgery. Fifty-four of the women had stress incontinence and also underwent a needle suspension procedure. Patients were objectively followed for an average of 2 years. The rate of recurrence of symptomatic prolapse was 33% in the needle suspension group and 19% in the remainder of the patients. Table 21-2 reviews these and other studies that have reported the long-term follow-up and recurrence of prolapse after sacrospinous ligament suspension. Miyazaki (1987) reported on 74 cases of sacrospinous fixation, using the Miya hook. Results with regard to treatment of the prolapse were not discussed, but the safety of the technique was documented. No patients had injuries to the bladder, rectum, nerves, or blood vessels, and no blood transfusions were performed. Average blood loss was approximately 75 mL. To date there have been three randomized trials for the management of apical vaginal prolapse that included sacrospinous suspension. All three trials compared unilateral or bilateral sacrospinous suspension to abdominal sacral colpopexy. Benson et al. (1996) and Lo and Wang (1998) reported a higher success with abdominal sacral colpopexy, whereas Maher et al. (2004) reported similar success in the two groups. These studies are discussed, in more detail, in the section on surgical approaches (vaginal vs abdominal). Although infrequently reported, serious intraoperative complications can occur with sacrospinous fixation. Potential complications of the procedure follows. Hemorrhage. Severe hemorrhage can result from overzealous dissection superior to the coccygeus muscle or lateral to the ischial spine. This can result in hemorrhage from the inferior gluteal vessels, hypogastric venous plexus, or internal pudendal vessels. Hemorrhage from these vessels can be difficult to control. For this reason, we prefer using the Capio device or the technique described by Miyazaki in which the needle tip is passed downward into the safe ischiorectal space, rather than the technique using the Deschamps ligature carrier in which the needle tip is passed superiorly toward an abundant vasculature. If severe bleeding occurs in the area around the coccygeus muscle, we recommend initially packing the area. If this does not control the bleeding, visualization and attempted ligation with clips or sutures should be performed. This area is difficult to approach transabdominally, so bleeding should be controlled vaginally, if possible. Buttock Pain. It has been our experience that approximately 10% to 15% of patients experience moderate-tosevere buttock pain on the side on which the sacrospinous suspension was performed. The probable cause is injury of a small nerve that runs through the C-SSL. This nerve injury is always self-limiting and should resolve completely by 6 postoperative weeks. Reassurance and anti-inflammatory agents are usually all that are necessary. Nerve Injury. Because of the close proximity of the sciatic nerve to the C-SSL, the potential for its injury is present. Although it is rarely reported, if this injury occurs, reoperation with removal of suture material may be necessary. Rectal Injury. Rectal examination should be performed frequently during this operation because of the close prox-

275

imity of the rectum to the C-SSL. Rectal injury can occur during entering of the perirectal space as well as during mobilization of tissue off of the C-SSL. If a rectal injury is identified, it can usually be repaired primarily transvaginally by conventional techniques. Stress Urinary Incontinence. This may occur after vaginal vault suspension procedures and is probably secondary to straightening of the vesicourethral junction coincident with restoration of vaginal length and depth. Stress incontinence should be tested preoperatively by performing a stress test in the standing position with reduction of the vaginal prolapse. Vaginal Stenosis. Stenosis may occur if too much anterior and posterior vaginal wall tissue is trimmed or if too tight a posterior colporrhaphy is performed. We recommend postoperative use of estrogen vaginal cream in these patients in the hope of preventing or decreasing the incidence of this problem. Recurrent Anterior Vaginal Wall Prolapse. As mentioned earlier, the pelvic support defect that recurs with the highest incidence is that of the anterior vaginal wall. Approximately 20% of patients return with a moderate anterior vaginal wall prolapse within a year after surgery. This defect probably results from the alteration of the vaginal axis in an exaggerated posterior direction.

Endopelvic Fascia Repair (Modified McCall Culdoplasty) Between 1952 and 1981, two groups of investigators performed a total of 367 surgeries for vaginal eversion by suturing the prolapsed vagina to the endopelvic fascia with few complications (Lee and Symmonds, 1972; Phaneuf, 1952; Symmonds and Pratt, 1960; Symmonds and Sheldon, 1965; Symmonds et al., 1981). More recently, Webb et al. (1998) reported on 660 women who underwent primary endopelvic fascia repair for posthysterectomy vault prolapse between 1976 and 1987. The technique of this repair is as follows: 1. An elliptical wedge of vaginal mucosa is excised initially from the anterior and posterior walls of the prolapsed vagina to narrow the vault and to allow access to the lateral apical supports of the vagina and rectum. The width and length of the excised wedge are determined by the desired dimensions of the reconstructed vagina. 2. The enterocele sac is isolated and excised, and the ureters are identified by palpation or dissection. 3. Up to three modified McCall stitches are placed (see Fig. 21-5). Each suture incorporates the full thickness of the posterior vaginal wall, the cul-de-sac peritoneum, the remains of the uterosacral-cardinal complex laterally, and the fascial tissue lateral and posterior to the upper vagina and rectum. 4. Sutures are then tied, resulting in fixation of the prolapsed vaginal vault to the uppermost portion of the endopelvic fascia as well as high closure of the culde-sac peritoneum.

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The results and complications of this technique were discussed in a review article by Sze and Karram (1997). Of the initial studies reporting 367 patients, 322 (88%) received postoperative follow-up ranging from 1 to 12 years, with a cure rate of 88% to 93%. Thirty-four (11%) patients developed recurrent pelvic relaxation, including 9 with vaginal vault prolapse, 2 with anterior vaginal wall defects, 11 with posterior vaginal wall relaxations, and 12 patients with pelvic support defects at multiple or unspecified sites. The subsequent study by Webb et al. (1998) reported results on 660 women, most of whom were followed up with a questionnaire. Information about recurrent prolapse was available on 504 women (72.7%). Fifty-eight (11.5%) patients complained of a “bulge” or “protrusion” at the time of questioning. The question about satisfaction with the operation was answered by 385 patients, and 82% indicated that they were satisfied. Forty-two of 189 (22%) sexually active women complained of dyspareunia.

Iliococcygeus Fascia Suspension In 1963, Inmon described bilateral fixation of the everted vaginal apex to the iliococcygeal fascia just below the ischial spine in three patients with atrophied uterosacral ligaments. The technique of this repair is as follows: 1. The posterior vaginal wall is opened in the midline as for a posterior colporrhaphy, and the rectovaginal spaces are dissected widely to the bilateral levator muscles. 2. The dissection is extended bluntly toward the ischial spines. 3. With the surgeon’s nondominant hand depressing the rectum downward and medially, an area 1 to 2 cm caudad and posterior to the ischial spine in the iliococcygeus muscle and fascia is exposed (Fig. 21-14). A single No. 0 delayed absorbable suture is placed deeply into the levator muscle and fascia. Both ends of the suture are then passed through the ipsilateral posterior vaginal apex and held with a hemostat. This is repeated on the opposite side. 4. The posterior colporrhaphy is completed, and the vagina is closed. Both sutures are tied, elevating the posterior vaginal apices. This repair is often done in conjunction with a culdoplasty or uterosacral suspension. From 1981 to 1993, Shull et al. (1993) and Meeks et al. (1994) used the Inmon technique to treat 152 patients with posthysterectomy vault prolapse or total uterine procidentia. Four intraoperative complications occurred, including one rectal and one bladder laceration and two cases of hemorrhage requiring transfusion. Thirteen (8%) patients developed recurrent pelvic support defects at various sites at 6 weeks to 5 years after the initial procedure; two had vault prolapse, eight had anterior vaginal wall relaxation, and three had posterior wall defects. More recently, Maher et al. (2001) performed a matched case control study to compare iliococcygeus suspension and sacrospinous colpopexy for vaginal vault prolapse. They

found the procedures to be equally effective with similar complication rates.

High Uterosacral Ligament Suspension A relatively new approach to the management of enterocele and vault prolapse is based on the anatomic observations of Richardson (1995), who believed that the connective tissue of the vaginal tube does not stretch or attenuate but rather breaks at specific definable points. This repair may be superior to previously discussed repairs in that it can be performed vaginally, abdominally, or laparoscopically, and it suspends the apex of the vagina into the hollow of the sacrum and thus does not create any significant distortion of the vaginal axis. 1. The vaginal apex is grasped with two Allis clamps (Fig. 21-15, A) and incised with a scalpel. The vaginal epithelium is dissected off the enterocele sac up to the neck of the hernia. The enterocele is opened, and the hernia sac is excised (Fig. 21-15, B). 2. Numerous moist tail sponges are placed in the posterior cul-de-sac. A wide Deaver retractor is used to elevate the packs and the intestines out of the operative field. 3. The ischial spines are palpated transperitoneally. The remnants of the uterosacral ligaments are found posteriorly and medially to the ischial spine, and the ureter can usually be palpated along the pelvic side wall, anywhere from 2 to 5 cm ventral and lateral to the ischial spine. 4. Upward traction on Allis clamps placed at approximately the 4 o’clock and 7 o’clock positions allows easy palpation of the uterosacral ligaments (Fig. 2115, C). 5. Usually, two to three delayed absorbable sutures are passed through the ligament on each side. To ensure adequate vaginal length, the highest suture should be close to the level of the ischial spine (Fig. 21-15, D). 6. The distal remnants of the uterosacral ligaments are plicated across the midline, with one to three permanent sutures. Tying of these sutures completely obliterates the cul-de-sac (Fig. 21-15, D). 7. The delayed absorbable sutures that had been passed high up through the uterosacral ligaments are then passed through the full thickness of the posterior vaginal wall (Fig. 21-15, E). 8. If necessary, an anterior colporrhaphy is performed. The vagina is trimmed and closed with a 3-0 delayed absorbable suture (Fig. 21-15, F, G). 9. Tying of the vault suspension sutures elevates the vagina high up into the hollow of the sacrum (Fig. 21-15, H, Fig. 21-16, A, B). In 2000, Shull et al. reported on 298 patients; 35 (12%) had evidence of an anterior wall defect in the form of cystocele or urethrocele. However, 25 of these defects were noted to be only grade 1. Eleven (4%) patients developed posterior wall defects. In all, 38 patients (13%) had development of one or more support defects; however, 24 of these were grade 1 only. Two patients required another surgery for recurrent prolapse.

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Ischial spine

Site of vaginal fixation

Needle placed deep into levator muscle and fascia Cystocele

A

Fingers pressing rectocele

Bilateral iliococcygeus fixation

B Figure 21-14 ■ Iliococcygeus fascia suspension. A. With the surgeon’s finger pressing the rectum downward, the right iliococcygeus fascia suture is placed. Approximate location of the iliococcygeus fascia sutures (inset). B. Bilateral iliococcygeus fascia suspension.

Small intestine

Uterosacral ligament

Ureter (phantom)

Peritoneum Posterior vaginal wall Peritoneum Sigmoid colon

C A

B

Vaginal wall

Traction on uterosacral ligaments

Cystocele Anterior vaginal wall

Obliteration of posterior cul-de-sac

D

F

E Anterior vaginal wall Midline plication

G

H

Figure 21-15 ■ High uterosacral ligament suspension. A. Apex of the vagina is grasped with two Allis clamps. Level of vaginal cuff is marked (dotted line). B. Enterocele sac has been dissected off the vaginal wall and sharply entered. C. Bowel is packed and lifted out of the cul-de-sac with a large retractor. Traction on Allis clamps placed at approximately 4 o’clock and 7 o’clock allows palpation of uterosacral ligaments. D. Numerous (usually two to three on each side) delayed absorbable sutures are passed through the uterosacral ligaments. Ideally, the highest suture should be at the level of the ischial spine to ensure adequate vaginal length. Permanent sutures are used to plicate the cul-de-sac distal to the uterosacral suspension sutures. E. The delayed absorbable uterosacral suspension sutures are individually passed through the full thickness of the posterior vaginal wall. The previously placed permanent sutures are tied, obliterating the distal portion of the cul-de-sac. F. If a cystocele is present, a midline anterior vaginal wall dissection is initiated. G. Repair of the cystocele has been completed. H. The anterior vaginal wall and vaginal cuff are closed with a 3-0 delayed absorbable suture. Tying of the uterosacral suspension sutures suspends the vagina high up into the hollow of the sacrum (inset).

Vaginal apex

Pubocervical fascia Peritoneum

A

Rectovaginal fascia

Vaginal apex

B

Figure 21-16 ■ A. Cross-section of pelvis demonstrating enterocele and vaginal vault prolapse. B. Cross-section of pelvis after excision of enterocele sac and suspension of vaginal apex to uterosacral ligaments.

Barber et al. (2000) reported on 46 women who underwent vaginal site-specific repair with suspension of the vaginal cuff to the proximal uterosacral ligaments. Symptomatic prolapse (two apical, one anterior, and one proximal) developed in four patients (10%), and three of them underwent reoperation. Karram et al. (2001) reported on 202 patients; 168 patients were available for follow-up either by phone or by office visit; 89% of patients indicated that they were happy or satisfied with the procedure; the reoperation rate was 5.5%. The most commonly reported complication of this procedure is ureteral injury or kinking. Karram et al. (2001) reported a 2.4% risk, Barber et al. (2000) reported an 11% risk (with most obstructions relieved intraoperatively), and Shull et al. (2000) reported a 1% risk. It is imperative that intraoperative cystoscopy be done to ensure ureteral patency. If ureteral spill is not observed, then the suspension sutures on that side should be cut and removed and the ureter reevaluated. Often, the suture can be replaced using a more medial placement into the uterosacral ligament complex. Other rare complications have included pelvic abscess, hemorrhage with subsequent transfusion, bowel and bladder injury, and postoperative small bowel obstruction.

Infracoccygeal Sacropexy The infracoccygeal sacropexy was initially described as a minimally invasive surgical option to restore vaginal vault support (Petros, 1997). The first prospective study using this procedure reported cure rates of 94% for vault prolapse, with a 5.3% tape erosion rate (Petros, 2001). In 2002 Farnsworth reported on 93 infracoccygeal sacropexy procedures performed on patients with advanced vaginal vault prolapse. Cure of prolapse was stated to be 87% but was not explicitly defined. Complications included one rectal perforation and one mesh erosion into the rectum. The technique of the procedure involves subjects undergoing placement of a U-shaped mesh using a tunneler (trocar device) in an effort to establish artificial uterosacral neoligaments. The trocar is

introduced through two small buttock incisions, into the ischiorectal fossa and through the levator ani muscles toward the ischial spine (Fig. 21-17). The trocar tip is then deviated medially, where it briefly passes through the perirectal space and into the posterolateral aspect of the vagina, beneath the vaginal epithelium (Fig. 21-18). A mesh tape is introduced onto the trocar tip and pulled back through the trocar’s path. A similar passage is performed on the opposite side, completing the U-shape. The intravaginal mesh is sutured to the apex of the vagina in the precise bilateral position of the atrophied uterosacral ligaments, in an effort to reestablish support for the vagina apex. The vaginal epithelium is then closed. The two ends of the tape are gently stretched at the buttock incisions and are left in a tension-free fashion. The guidelines used to adjust tension on the tape are unclear. So far, no comparative trials of efficacy have been performed using the infracoccygeal sacropexy. Since the original description of the infracoccygeal sacropexy, complete vaginal mesh repairs have been described. Several kits are currently available to facilitate the performance of these procedures. In the authors’ opinions the benefits of the techniques are not yet proven, and the procedure introduces the risk of bilateral perirectal needle insertion into the ischiorectal fossa. Vaginal mesh erosions of 5% to 12% have been reported. More data on efficacy and risk are needed.

ABDOMINAL PROCEDURES THAT SUSPEND THE APEX Abdominal Sacral Colpopexy Suspension of the vagina to the sacral promontory via the abdominal approach is an effective treatment for uterovaginal prolapse and vaginal eversion and can offer several advantages over vaginal surgical approaches. This approach is the procedure of choice for patients who have other indications for abdominal surgery, such as ovarian masses. The laparotomy

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Figure 21-17 ■ Lithotomy view demonstrating the infracoccygeal sacropexy trocar passing from the skin surface at insertion point into the ischiorectal fossa through the inferior rectal branches of the pudendal vessels. It is bordered medially by the external anal sphincter, pubococcygeus, iliococcygeus, and rectum; laterally by the ischial tuberosity and obturator internus; and inferiorly by the gluteus maximus and sacrotuberous ligament (not shown). (Reprinted with the permission of The Cleveland Clinic Foundation.)

incision also offers the advantage of performing simultaneous retropubic procedures, such as the Burch colposuspension and the paravaginal defect repair. Sacral colpopexy can also be done laparoscopically as discussed in Chapter 17. Many different materials, both autologous and synthetic, have been used for the graft in the sacral colpopexy. Natural materials that have been used include fascia lata, rectus fascia, and dura mater. Synthetic materials include polypropylene mesh, polyester fiber mesh, polytetrafluoroethylene mesh, Dacron mesh, and Silastic silicone rubber. A recent randomized trial (Culligan et al., 2005), comparing objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh, noted Prolene mesh to be superior to fascia lata in terms of Pelvic Organ Prolapse Quantification (POPQ) points, POPQ stage, and objective anatomic failure rates. As was noted earlier, the normal vaginal axis directs toward sacral segments S3 and S4 in the nulliparous woman. Although some authors have advocated connecting the graft

material at this level, Sutton et al. (1981) encountered lifethreatening hemorrhage from presacral vessels at this low level on the sacrum. As these authors suggest, we recommend fixing the graft to the upper one third of the sacrum, near the sacral promontory, thus improving safety without sacrificing outcome or future vaginal function. The technique of abdominal sacral colpopexy using graft placement is as follows (Figs. 21-19 and 21-20): 1. The patient should be placed in Allen stirrups or in frog-leg position so that the surgeon has digital access to the vagina during the operation. A sponge stick or end-to-end anastomosis (EEA) sizer can be placed in the vagina for manipulation of the apex, if desired. A Foley catheter is placed into the bladder for drainage. Prophylactic perioperative antibiotics are used during this procedure. 2. A laparotomy is performed through a low transverse or midline incision. The small bowel is packed into

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Figure 21-18 ■ Upright-oblique view of the pelvis illustrating the pathway of the infracoccygeal sacropexy trocar through the inferolateral vagina. Mean total vaginal length was 8.7 cm and mean vaginal entry depth was only 4.8 cm from the hymenal ring. (Reprinted with the permission of The Cleveland Clinic Foundation.)

the upper abdomen, and the sigmoid colon is packed into the left pelvis as much as possible. The ureters are identified bilaterally for their entire course into the bladder. If the uterus is present, a hysterectomy should be performed and the vaginal cuff closed. The depth of the cul-de-sac and the length of the vagina are estimated when completely elevated. 3. While the vagina is elevated cephalad with a sponge stick or EES sizer, the peritoneum over the vaginal apex is incised transversely and the bladder dissected from the anterior vaginal wall (this may have already been done if the uterus was removed). The peritoneum over the posterior vaginal wall into the cul-de-sac is incised longitudinally and dissected bilaterally for several centimeters. The vaginal apex is elevated bilaterally with clamps or guide sutures. 4. Five to eight pairs of nonabsorbable No. 0 sutures are placed transversely in the posterior vaginal wall, 1 to 2 cm apart. Sutures are placed through the full fibromuscular thickness of the vagina but not into the vaginal epithelium. The sponge stick is

removed to ensure that no sutures have perforated the sponge. Sutures are then fed through the graft in pairs and tied. The graft should extend at least halfway down the length of the posterior vaginal wall. We prefer to attach a second smaller piece of mesh to the upper part of the anterior vaginal wall. This piece of mesh is then sewn to the posterior piece of mesh, which will be attached to the sacrum (see Fig. 21-19). Other potential configurations of mesh attachment are reviewed in Figure 21-20. 5. A Moschcowitz or Halban procedure is performed to obliterate the lower cul-de-sac (see Fig. 21-6). 6. A longitudinal incision, approximately 6 cm long, is made in the peritoneum over the sacral promontory. At this point, the surgeon should carefully palpate the aortic bifurcation and common and internal iliac vessels and mobilize the sigmoid colon and right ureter so that these structures can be avoided. The left common iliac vein is medial to the left common iliac artery and is particularly vulnerable to damage during this procedure. The middle sacral artery and vein should be identified.

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Figure 21-19 ■ Abdominal sacral colpopexy. Note that Halban technique is used to obliterate cul-de-sac below graft. Graft connects vagina to sacrum and lies without tension in the deep pelvis (inset).

7. Blunt and sharp caudal dissection may be used to create a subperitoneal tunnel into the full depth of the cul-de-sac so that the graft can then be tunneled retroperitoneally or placed above the previous Halban or Moschcowitz cul-de-sac closure. The surgeon can then extraperitonize the mesh by sewing the serosa of the sigmoid colon to the lateral peritoneum of the cul-de-sac. 8. The bony sacral promontory and anterior longitudinal ligaments are directly visualized for approximately 4 cm by using blunt and sharp dissection through the subperitoneal fat. Special care should be taken to avoid the delicate plexus of presacral veins that is often present, especially as one dissects caudally. 9. With stiff but small half-curved tapered needle with permanent No. 0 suture, two to four sutures are placed through the anterior sacral longitudinal ligament, over the sacral promontory. The graft should be trimmed to the appropriate length. The sutures are then fed through the graft in pairs and tied. The appropriate amount of vaginal elevation should provide gentle tension without undue traction on the vagina. 10. The peritoneum over the presacral space is closed with a running absorbable suture. The bladderflap peritoneum is also closed transversely over the graft.

11. When appropriate, retropubic urethropexy or paravaginal repair should be accomplished at this time, followed by placement of a suprapubic catheter, if desired, and closure of the abdomen. 12. Posterior colporrhaphy and perineoplasty can be performed to treat any remaining rectocele and perineal defect. If attention has been paid to repairing all of the support defects of the vagina at the time of sacral colpopexy, recurrences of vaginal vault prolapse are uncommon. Addison et al. (1989) reported three cases of recurrent vaginal prolapse after the sacral colpopexy with Mersilene mesh. In two patients, the mesh separated from the vaginal apex. In the remaining patient, the posterior vaginal wall ruptured distally to the attachment of the mesh to the vagina. These authors and others believe that failures of this procedure can be minimized by suturing the suspensory mesh to the posterior vagina and anterior vaginal apex over as extended an area as possible. This is the justification for suturing the graft to the posterior vagina, with numerous pairs of permanent sutures. Some investigators (Cundiff et al., 1997) advocated attaching the mesh along the entire posterior vaginal wall and fixing the mesh to the perineum (see Fig. 21-20, E), thus performing an abdominal sacral colpoperineopexy. A recent review of abdominal sacral colpopexy (Nygaard et al., 2004) noted the success rate when defined as lack of

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283

Figure 21-20 ■ A. Cross-section of the pelvis demonstrating large enterocele and vaginal vault prolapse. B. EEA sizer placed in vagina to elevate apex. (C–F) Obliteration of cul-de-sac with examples of various configurations for mesh attachment to the vagina. C. Mesh attached to upper half of posterior vaginal wall. D. Mesh attached as in C; second piece of mesh attached to upper part of anterior vaginal wall and sewn to posterior piece of mesh E. Mesh attached along entire length of posterior vaginal wall and fixed to perineum. F. Vaginal end of mesh is divided and fixed to upper parts of the anterior and posterior vaginal walls.

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postoperative apical prolapse ranged from 78% to 100%. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range, 0% to 18.2%) and 4.9% (range, 1.2% to 30.9%), respectively. No data either supported or refuted the contentions that concomitant culdoplasty or paravaginal repair decreased the risk of failure. Few studies rigorously assessed pelvic symptoms, bowel function, or sexual function. To date, two out of three randomized controlled trials have reported significantly better outcomes with abdominal sacral colpopexy when compared with vaginal sacrospinous suspension (Benson et al., 1996; Lo and Wang, 1998), whereas one study (Maher et al., 2004) reported similar outcomes between the two procedures. Intraoperative complications are uncommon but can be life threatening. When bleeding occurs from presacral vessels, hemostasis can be difficult to achieve because of the complex interlacing of the venous network, both beneath and on the surface of the sacral periosteum. When these veins have been damaged, they can retract beneath the bony surface of the anterior sacrum and recede into the underlying channels of cancellous bone. Communications with adjacent pelvic veins, especially the left common iliac vein, can be particularly troublesome. Packing of the presacral space may temporarily control bleeding, but it often recurs when the pack is removed, and packing may further lacerate delicate veins. Sutures, metallic clips, cautery, and bone wax should be used initially. If these measures are not successful, sterilized stainless steel thumbtacks can be placed on the retracted bleeding presacral vein to treat lifethreatening hemorrhage that has not responded to other measures. Other complications that have been reported after abdominal sacral colpopexy tend to be similar to those of procedures that require laparotomy, retropubic surgery, and extensive pelvic dissection. The complications include enterotomy, ureteral damage, cystotomy, proctotomy, extrafascial wound infections, and persistent granulation tissue in the vaginal vault. Remarkably, graft rejections are exceedingly rare. Lansman (1984) reported a small bowel obstruction after colpopexy that was caused by a loop of ileum adherent to a hole in the posterior peritoneum, near the side wall of the pelvis. The median rate (when reported) of small bowel obstruction requiring surgery is 1.1% (range, 0.6% to 8.6%). This problem underscores the importance of reperitonization to prevent small bowel from getting trapped in the cul-de-sac or behind the graft. The most common long-term complication is erosion of synthetic mesh through the vagina, which has been reported to occur in 3.4% of cases. This complication almost always requires partial or complete removal of the mesh. Mesh erosion after sacral colpopexy is further discussed in Chapter 40.

High Uterosacral Ligament Suspension The vaginal and laparoscopic approaches to this repair have been discussed previously. The abdominal repair involves the same concepts.

1. The remnants of the uterosacral ligaments are identified and tagged at the level of ischial spines. 2. The ureters are identified on each side, and the enterocele is addressed by abdominal obliteration of the cul-de-sac. 3. The peritoneum over the apex of the vagina is opened, and the endopelvic fascia of the anterior and posterior vaginal walls are identified and approximated. 4. Nonabsorbable sutures are then used to suspend the prolapsed vagina with its fascia to the uterosacral ligaments.

SURGICAL APPROACHES—VAGINAL VERSUS ABDOMINAL To date, very little scientific evidence is available to base the decision on which route of surgery to perform for advanced uterovaginal or posthysterectomy vaginal vault prolapse. Benson et al. (1996) randomly assigned 88 women to undergo either sacrocolpopexy or bilateral sacrospinous vault suspension. Numerous concomitant procedures were performed based on the surgeon’s judgment. Outcomes were termed optimal when women were free of prolapse symptoms, the vaginal apex remained above the levator plate, and no part of the vagina prolapsed beyond the hymen; satisfactory when women were free of prolapse symptoms and the prolapse was improved from the preoperative status but did not meet the criteria for optimal surgical effectiveness; and unsatisfactory if they had symptomatic vaginal apex descent more than 50% of its length or vaginal protrusion beyond the hymen. Enrollment was halted earlier than planned when interim analysis showed disparity in outcomes between the groups. Mean follow-up was 2.5 years. The vaginal group experienced 29% optimal, 38% satisfactory, and 33% unsatisfactory surgical outcomes compared with the abdominal group that had 58% optimal, 26% satisfactory, and 16% unsatisfactory outcomes. Surgical failures occurred sooner in the vaginal group, with a mean of 11.2 months, compared with the abdominal group with a mean of 22.1 months. Lo and Wang (1998) randomly assigned 138 women with stage III or greater vaginal vault or uterine prolapse to either a unilateral sacrospinous ligament suspension or to abdominal sacrocolpopexy. Optimal effectiveness was defined as postoperative prolapse less than stage III. Optimal effectiveness was significantly less in the vaginal group (80.3%) than in the abdominal group (94.2%). Maher et al. (2004) randomly allocated 95 women with posthysterectomy vaginal vault prolapse, to or beyond the hymen, to undergo either abdominal sacrocolpopexy or sacrospinous ligament suspension. Objective success was defined as no vaginal prolapse beyond the halfway point of the vagina during examination, using the POPQ system. Women with no symptoms of prolapse were considered subjective successes. The investigators found no statistically significant difference in either objective or subjective success 2 years after the procedure, with respective rates of 76% and 94% in the abdominal group, and 69% and 91% in the vaginal group. Mean patient satisfaction with the

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surgery was 85% in the abdominal group and 81% in the vaginal group. A recent Cochrane Database Review (Maher et al., 2005) noted abdominal sacral colpopexy to be associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach. Women with prolapsed foreshortened vaginas, previous vaginal failures, and young women with advanced prolapse are probably better managed with abdominal sacral colpopexy. Roovers et al. (2004) randomized 82 women undergoing surgical correction of uterine prolapse stages II to IV to either vaginal hysterectomy (combined with anterior and/or posterior colporrhaphy and possible needle suspension) to sacrocolpopexy with uterine preservation, culdoplasty, and possible Burch colposuspension. Their main outcome measure was the domain scores of the Urogenital Distress Inventory (UDI) at 1 year after surgery. Scores on the discomfort/pain domain, overactive bladder domain, and obstructed micturition domain were significantly higher in the abdominal group than in the vaginal group. Reoperation was performed or planned in 9 of the 41 patients who underwent abdominal surgery and in 1 of the 41 patients who underwent vaginal surgery. This study concluded that vaginal hysterectomy with repairs is preferable to abdominal sacral colpopexy, with uterine preservation in patients with stages II to IV uterine prolapse.

UTERINE PRESERVATION DURING SURGERY FOR UTEROVAGINAL PROLAPSE Traditionally, uterine preservation in women with uterovaginal prolapse was considered only if future fertility was desired. Recently, more women are requesting uterine preservation for other reasons, most notably the perception that sexual function is improved if the cervix is not removed. Vaginal, abdominal, and laparoscopy techniques have all been described. A recent literature search on this topic (Diwan et al., 2004) concluded that uterine preservation during surgery for uterovaginal prolapse may be an option in appropriately selected women who desire it; however, prospective randomized trials are needed to corroborate this. Recent studies have reported excellent results with laparoscopic suture hysteropexy (Krause et al., 2005; Maher et al., 2001) and sacrospinous hysteropexy (van Brummen et al., 2003).

SUMMARY The prevalence of vaginal prolapse appears to be increasing, partly because of the increased longevity of women and also probably as a result of inadequate recognition and repair of pelvic organ support defects when pelvic surgery has been performed. The standard use of cul-de-sac plication and uterosacral ligament suspension to provide appropriate support of the vaginal apex at the time of hysterectomy would most likely decrease the prevalence of later entero-

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cele and posthysterectomy apical prolapse. More education and research into the understanding of the anatomy of vaginal support and the pathogenesis of prolapse, and in the principles of pelvic and vaginal reconstructive surgery, are needed to improve care to all affected women.

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DEMOGRAPHICS AND PREVALENCE Boyles SH, Weber AM, Meyn L. Procedures for pelvic organ prolapse in the United States, 1979–1997. Am J Obstet Gynecol 2003;188:108. Brown JS, Waetjen LE, Subak LL, et al. Pelvic organ prolapse surgery in the United States, 1997. Am J Obstet Gynecol 2002;186:712. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 2004;175:10. Handa VL, Garrett E, Hendrix S, et al. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol 2004;190:27. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501. Sajan F, Fikree FF. Perceived gynecological morbidity among young evermarried women living in squatter settlements of Karachi, Pakistan. J Pak Med Assoc 1999;49:92. Samuelsson EC, Arne Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in Swedish population of women in 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180(2 Pt 1):299.

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Silva WA, Kleeman S, Segal J, et al. Effects of a full bladder and patient positioning on pelvic organ prolapse assessment. Obstet Gynecol 2004;104:37. Subak LL, Waetjen LE, van den Eeden S, et al. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol 2001;98:646. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000;183:277. U.S. Census Bureau. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Retrieved June 28, 2005, from http://www.census.gove/ipc/www/ usinterimproj.

ENTEROCELE Francis WJ, Jeffcoate TN. Dyspareunia following vaginal operations. Br J Obstet Gynaecol 1961;68:1. Given FT. “Posterior culdeplasty”: revisited. Am J Obstet Gynecol 1985;153:135. Haase P, Skibsted L. Influence of operations for stress incontinence and/or genital descensus on sexual life. Acta Obstet Gynecol Scand 1988;67:659. Harris RL, Cundiff GW, Theofiastous JP, et al. The value of intraoperative cystoscopy in urogynecologic and reconstructive pelvic surgery. Am J Obstet Gynecol 1997;177:1367. McCall ML. Posterior culdoplasty. Obstet Gynecol 1957;10:595. Moschcowitz AV. The pathogenesis, anatomy, and cure of prolapse of the rectum. Surg Gynecol Obstet 1912;15:7. Stanhope CR, Wilson TO, Utz WJ, et al. Suture entrapment and secondary ureteral obstruction. Am J Obstet Gynecol 1991;164:1513. Torpin R. Excision of the cul-de-sac of Douglas for the surgical care of hernias through the female caudal wall, including prolapse of the uterus. J Int Coll Surg 1955;24:322. Tulikangas PK, Lukban JC, Walters MD. Anterior enterocele: a report of three cases. Int Urogynecol J 2004;15:350. Waters EG. Vaginal prolapse: technique for correction and prevention at hysterectomy. Obstet Gynecol 1956;8:432.

VAGINAL PROCEDURES THAT SUSPEND THE APEX Amreich I. Atiologie und operation des scheiden stump prolapses. Wien Klin Wochenschr 1951;65:74. Backer MH. Success with sacrospinous suspension of the prolapsed vaginal vault. Surg Gynecol Obstet 1992;175:419. Barber MD, Visco AG, Weidner AC, et al. Bilateral uterosacral ligament vaginal vault suspension with site specific endopelvic fascia defect repair for treatment of pelvic organ prolapse. Am J Obstet Gynecol 2000;183:1402. Brown WE, Hoffman MS, Bouis PJ, et al. Management of vaginal vault prolapse: retrospective comparison of abdominal versus vaginal approach. J Fla Med Assoc 1989;76:249. Burrows LJ, Meyn LA, Walters MD, Weber AM. Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 2004;104:982. Carey MP, Slack MC. Transvaginal sacrospinous colpopexy for vault and marked uterovaginal prolapse. Br J Obstet Gynaecol 1994;101:536. Cruikshank SH. Sacrospinous fixation: should this be performed at the time of vaginal hysterectomy? Am J Obstet Gynecol 1991;164:1072. Cruikshank SH, Cox IN. Sacrospinous fixation at the time of vaginal hysterectomy. Am J Obstet Gynecol 1990;162:1611. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166:1717. Elkins TE, Hopper JB, Goodfellow K, et al. Initial report of anatomic and clinical comparison of the sacrospinous ligament fixation to the high McCall culdoplasty for vaginal cuff fixation at hysterectomy for uterine prolapse. J Pelvic Surg 1995;1:12. Farnsworth BN. Posterior intravaginal slingplasty (infracoccygeal sacropexy) for severe posthysterectomy vaginal vault prolapse—a preliminary report on efficacy and safety. Int Urogynecol 2002;13:4. Farrell SA, Scotti RJ, Ostergard DR, et al. Massive evisceration: a complication following sacrospinous vaginal vault fixation. Obstet Gynecol 1991;78:560. Funt MI, Thompson JD, Birch H. Normal vaginal axis. South Med J 1978;71:1534. Heinonen PK. Transvaginal sacrospinous colpopexy for vaginal vault and complete genital prolapse in aged women. Acta Obstet Gynecol Scand 1992;71:377.

Holley RJ, Varner RE, Gleason BP, et al. Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse. J Am Coll Surg 1995;180:444. Imparato E, Aspesi G, Rovetta E, et al. Surgical management and prevention of vaginal vault prolapse. Surg Gynecol Obstet 1992;175:233. Inmon WB. Pelvic relaxation and repair including prolapse of vagina following hysterectomy. South Med J 1963;56:577. Kaminski PF, Sorosky JI, Pees RC, et al. Correction of massive vaginal prolapse: an older population. J Am Geriatr Soc 1993;41:42. Karram MM, Goldwasser S, Kleeman S, et al. High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse. Am J Obstet Gynecol 2001;185:1339. Keetel LM, Hebertson RM. An anatomic evaluation of the sacrospinous ligament colpopexy. Surg Gynecol Obstet 1989;168:318. Kovac SR, Cruikshank SH. Successful pregnancies and vaginal deliveries after sacrospinous uterosacral fixation in five of 19 patients. Am J Obstet Gynecol 1993;168:1778. Lee RA, Symmonds RE. Surgical repair of posthysterectomy vault prolapse. Am J Obstet Gynecol 1972;112:953. Mädakinen J, Söderström K, Kiilholma P, et al. Histologic changes in the vaginal connective tissue of patients with and without uterine prolapse. Arch Gynecol 1986;239:17. Maher CF, Murray CJ, Carey MP, et al. Iliococcygeus or sacrospinous fixation for vaginal vault prolapse. Obstet Gynecol 2001;98:40. Maher CF, Cary MD, Slack MC, et al. Uterine preservation or hysterectomy at sacrospinous colpopexy for uterovaginal prolapse. Int Urogynecol J 2001;12:381. McCall ML. Posterior culdoplasty. Obstet Gynecol 1957;10:595. Meeks GR, Washburne JF, McGeher RP, et al. Repair of vaginal vault prolapse by suspension of the vagina to ileococcygeus (prespinous) fascia. Am J Obstet Gynecol 1994;171:1444. Miyazaki FS. Miya hook ligature carrier for sacrospinous ligament suspension. Obstet Gynecol 1987;70:286. Monk BJ, Ramp JF, Montz FJ, et al. Sacrospinous fixation for vaginal vault prolapse. Complications and results. J Gynecol Surg 1991;7:87. Morley G, DeLancey JO. Sacrospinous ligament fixation for eversion of the vagina. Am J Obstet Gynecol 1988;158:872. Nagata I, Kato K. Sacrospinous ligament fixation of vaginal apex for repair operation of uterine prolapse: operative procedure and postoperative outcome evaluated with score system and x-ray subtraction colpography. Acta Obstet Gynaecol Jpn 1986;38:29. Nichols D. Massive eversion of the vagina. In Gynecologic and Obstetric Surgery. Mosby, St. Louis, 1993. Nichols DH, Randall CL. Vaginal Surgery, 3rd ed. Williams & Wilkins, Baltimore, 1989. Peters WA, Christenson ML. Fixation of the vaginal apex to the coccygeus fascia during repair of vaginal vault eversion with enterocele. Am J Obstet Gynecol 1995;172:1894. Petros PE. New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge, and abnormal emptying. Int Urogynecol J 1997;8:270. Petros PE. Vaginal prolapse II: restoration of dynamic vaginal supports by infracoccygeal sacropexy. An axial day-case vaginal procedure. Int Urogynecol J 2001;12:296. Phaneuf TE. Inversion of the vagina and prolapse of the cervix following suprapubic hysterectomy and inversion of the vagina following total hysterectomy. Am J Obstet Gynecol 1952;64:739. Porges RF, Smilen SW. Long-term analysis of the surgical management of pelvic support defects. Am J Obstet Gynecol 1994;171:1518. Randall C, Nichols D. Surgical treatment of vaginal inversion. Obstet Gynecol 1971;38:327. Richardson DA, Scotti RJ, Ostergard DR. Surgical management of uterine prolapse in young women. J Reprod Med 1989;34:388. Richter K. Massive eversion of the vagina: pathogenesis, diagnosis, and therapy of the “true” prolapse of the vaginal stump. Clin Obstet Gynecol 1982;25:897. Richter K, Albright W. Long-term results following fixation of the vagina on the sacrospinal ligament by the vaginal route. Am J Obstet Gynecol 1981;151:811. Ridley JH. A composite vaginal vault suspension using fascia lata. Am J Obstet Gynecol 1976;126:590. Sauer HA, Klutke CG. Transvaginal sacrospinous ligament fixation for treatment of vaginal prolapse. J Urol 1995;154:1008.

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Surgical Treatment of Vaginal Vault Prolapse and Enterocele

Seigworth GR. Vaginal vault prolapse with eversion. Obstet Gynecol 1979;54:255. Sharp TR. Sacrospinous suspension made easy. Obstet Gynecol 1993;82:873. Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol 2000;183:1365. Shull BL, Capen CV, Riggs MW, et al. Preoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 1992;166:1764. Shull BT, Capen CV, Riggs MW, et al. Bilateral attachment of the vaginal cuff to ileococcygeus fascia: an effective method of cuff suspension. Am J Obstet Gynecol 1993;168:1669. Symmonds RE, Pratt JH. Vaginal prolapse following hysterectomy. Am J Obstet Gynecol 1960;79:899. Symmonds RE, Sheldon RS. Vaginal prolapse after hysterectomy. Obstet Gynecol 1965;25:61. Symmonds RE, Williams TJ, Lee RA, et al. Posthysterectomy enterocele and vaginal vault prolapse. Am J Obstet Gynecol 1981;140:852. Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466. Sze EH, Miklos JR, Partoll L, et al. Sacrospinous ligament fixation with transvaginal needle suspension for advanced pelvic organ prolapse and stress incontinence. Obstet Gynecol 1997;89:94. Thakar R, Stanton S. Management of genital prolapse. Br Med J 2004; 324:1258. Thompson JD, Rock JA, eds. TeLinde’s Operative Gynecology, 7th ed. JB Lippincott, Philadelphia, 1992. van Brummen HJ, van de Pol, Aulders CI, et al. Sacrospinous hysteropexy compared to vaginal hysterectomy as primary surgical treatment for a descensus uteri: effects on urinary symptoms. Int J Urogynecol 2003;14:350. Webb MJ, Aronson MP, Ferguson LK, et al. Posthysterectomy vaginal vault prolapse: primary repair in 693 patients. Obstet Gynecol 1998;92:281.

ABDOMINAL PROCEDURES THAT SUSPEND THE APEX Addison WA, Livengood CH, Parker RT. Posthysterectomy vaginal vault prolapse with emphasis on management by transabdominal sacral colpopexy. Postgrad Obstet Gynecol 1988;8:1. Addison WA, Livengood CH, Sutton GP, et al. 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. Addison WA, Timmons CM, Wall LL, et al. Failed abdominal sacral colpopexy: observations and recommendations. Obstet Gynecol 1989;74:480. Angulo A, Ligman I. Retroperitoneal sacrocolpopexy for correction of prolapse of vaginal vault. Surg Gynecol Obstet 1989;169:319. Bai SW, Kim EH, Shin JS. A comparison of different pelvic reconstruction surgeries using mesh for pelvic organ prolapse patients. Yonsei Med J 2005;46:112. Baker KR, Beresford JM, Campbell C. Colposacropexy with Prolene mesh. Surg Gynecol Obstet 1990;171:51. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol 1996;175:1418. Carey MP, Dwyer PL. Genital prolapse: vaginal versus abdominal route of repair. Curr Opin Obstet Gynecol 2001;13:499. Cowan W, Morgan HR. Abdominal sacral colpopexy. Am J Obstet Gynecol 1980;138:348. Creighton SM, Stanton SL. The surgical management of vaginal vault prolapse. Br J Obstet Gynaecol 1991;98:1150. Culligan PJ, Blackwell L, Goldsmith LJ. A randomized controlled trial comparing fascia lata and synthetic mesh for sacral colpopexy. Obstet Gynecol 2005;106:29. Cundiff GW, Harris RL, Coates K, et al. 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. Diwan A, Rardin CR, Kohli N. Uterine preservation during surgery for uterovaginal prolapse: a review. Int J Urogynecol 2004;15:286.

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Drutz HP, Cha LS. Massive genital and vaginal vault prolapse treated with abdominal-vaginal sacropexy with use of Marlex mesh: review of the literature. Am J Obstet Gynecol 1987;156:387. Feldman GB, Birnbaum SJ. Sacral colpopexy for vaginal vault prolapse. Obstet Gynecol 1979;53:399. Given FY, Muhlendorf TK, Browning GM. Vaginal length and sexual function after colpopexy for complete uterovaginal eversion. Am J Obstet Gynecol 1993;169:284. Grunberger W, Grunberger V, Wierrani F. Pelvic promontory fixation of the vaginal vault in sixty-two patients with prolapse after hysterectomy. Surg Gynecol Obstet 1994;178:69. Iosif CS. Abdominal sacral colpopexy with use of synthetic mesh. Acta Obstet Gynecol Scand 1993;72:214. Kohle N, Walsh P, Roat TW, et al. Mesh erosion following abdominal sacral colpopexy. Obstet Gynecol 1998;92:999. Krause HG, Groh JT, Sloane K, et al. Laparoscopic sacral suture hysteropexy for uterine prolapse. Int Urogynecol J 2006;17:378. Lansman HH. Posthysterectomy vault prolapse: sacral colpopexy with dura mater graft. Obstet Gynecol 1984;63:577. Lo T-S, Wang AL. Abdominal colposacropexy and sacrospinous ligament suspension for severe uterovaginal prolapse: a comparison. J Gynecol Surg 1998;14:59. Maher CF, Qatawney AM, Dwyer PL, et al. Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol 2004;190:20. Maher CF, Carey MP, Murray CJ. Laparoscopic suture hysteropexy for uterine prolapse. Obstet Gynecol 2001;97:1010. Maher C, Bassler K, Glazener CM, et al. Surgical management of pelvic organ prolapse in women. The Cochrane Database of Systemic Reviews; The Cochrane Library Oxford Press, vol. 4, 2005. Maloney JC, Dunton CJ, Smith K. Repair of vaginal vault prolapse with abdominal sacropexy. J Reprod Med 1990;35:6. Nichols DH. Fertility retention in the patient with genital prolapse. Am J Obstet Gynecol 1991;164:1155. Nygaard IE, McCreery R, Brubaker L, et al. for the Pelvic Floor Disorders Network. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104:805. Paraiso MF, Walters MD, Rackley RR, et al. Laparoscopic and abdominal sacral colpopexies: a comparative cohort study. Am J Obstet Gynecol 2005;192:1752. Roovers JP, van der Vaart CH, van der Bom JG, et al. A randomized controlled trial comparing abdominal and vaginal prolapse surgery: effects for urogenital function. BJOG 2004;111:50. Rust JA, Botte JM, Howlett RJ. Prolapse of the vaginal vault. Improved techniques for management of the abdominal approach or vaginal approach. Am J Obstet Gynecol 1976;125:768. Snyder TE, Krantz KE. Abdominal-retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Obstet Gynecol 1991;77:944. Sutton GP, Addison WA, Livengood CH, et al. Life-threatening hemorrhage complicating sacral colpopexy. Am J Obstet Gynecol 1981;140:836. Tancer ML, Fleischer M, Berkowitz BJ. Simultaneous colpo-recto-sacropexy. Obstet Gynecol 1987;70:951. Timmons MC, Addison WA, Addison SB, et al. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele. J Reprod Med 1992;37:323. Timmons MC, Kohler MF, Addison WA. Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application. Obstet Gynecol 1991;78:313. Todd JW. Mesh suspension for vaginal prolapse. Int Surg 1978;63:91. Traiman P, De Lucia LA, Silva AA, et al. Abdominal colpopexy for complete prolapse of the vagina. Int Surg 1992;77:91. Valaitis SR, Stanton SL. Sacrocolpopexy: a retrospective study of a clinician’s experience. Br J Obstet Gynaecol 1994;101:518. van Lindert AC, Groenendijk AG, Scholten PC, et al. Surgical support and suspension of genital prolapse, including preservation of the uterus, using Gore-Tex soft tissue patch. Eur J Obstet Gynecol Reprod Biol 1996;50:133. Visco AG, Weidner AC, Barber MD, et al. Vaginal mesh erosion after abdominal sacral colpopexy. Am J Obstet Gynecol 2001;184:297. Vitranen H, Hirvonen T, Makinen J, et al. Outcome of thirty patients who underwent repair of posthysterectomy prolapse of the vaginal vault with abdominal sacral colpopexy. J Am Coll Surg 1994;178:283.

Obliterative Procedures for Vaginal Prolapse

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William Andre Silva and Mickey M. Karram

HISTORICAL PERSPECTIVES 288 PREOPERATIVE EVALUATION 288 LE FORT PARTIAL COLPOCLEISIS 289 TOTAL COLPECTOMY AND COLPOCLEISIS 290 URINARY FUNCTION AFTER OBLITERATIVE PROCEDURES QUALITY OF LIFE AND REGRET OF LOSS OF SEXUAL FUNCTION 293 CONCLUSION 294

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As women live longer and healthier lives, pelvic floor disorders are becoming even more prevalent and an increasingly important health and social issue. An estimated 63 million women will be 45 years old or greater by 2030, and 33% of the population will be postmenopausal by 2050. Over 10% of women will undergo surgery for pelvic organ prolapse or incontinence in their lifetime; the reoperation rate for failure is approximately 30%. Due to an increasing number of women entering the eighth and ninth decades of life, many of these individuals will present with pelvic organ prolapse, often after unsuccessful trials of conservative treatment or surgeries. These women frequently have concomitant medical issues and are not sexually active, making extensive surgery not suitable. This chapter discusses the use of obliterative procedures as a surgical option for pelvic organ prolapse in this patient population.

HISTORICAL PERSPECTIVES Before the introduction of operative procedures, uterine prolapse had been treated unsuccessfully with various techniques, including vaginal packing and instillation with caustic substances. Early forms of surgical treatment were later promoted in the form of introital narrowing and/or excision of the prolapsing areas. Gerardin of Metz, in 1823, first described the reapproximation of denuded vaginal mucosa as an obliterative procedure. As noted by Tauber (1947), the procedure was first performed by Neugebauer of Warsaw, in 1867, by suturing the anterior and posterior vaginal walls together after removing a 6 × 3 cm rectangu-

lar area of vaginal mucosa in each segment. Leon Le Fort of Paris popularized the procedure in 1877 and modified the previous description by Neugebauer by creating a narrower and longer area of mucosal removal and the addition of a posterior colpoperineoplasty at 8 postoperative days (Taft, 1889). In 1881, Berlin reported the first three American cases performed at the New England Hospital for Women. In the early twentieth century, reports in the literature were mainly technical descriptions with brief mention of outcome data. Baer and Reis, in 1928, reported a 100% success rate in a group of 14 women who received Le Fort colpocleisis. Phaneuf, in 1935, had two vault recurrences and one anterior vaginal prolapse in a total of 20 patients. In 1936, Adair and DaSef published their series of 38 patients, one of whom developed a recurrence of uterine prolapse through a lateral channel, and two had recurrence of cystoceles. Collins and Lock (1941) had a 94% success rate in 31 patients, whereas Mazer and Israel (1948) reported a 97% success rate in 38 women. Martin (1898) from Europe has been credited for the initial use of hysterectomy and complete vaginectomy for the correction of uterovaginal prolapse. Total colpocleisis with levator plication was first reported in 1901 in the English literature by Edebohls. He described four cases of panhysterocolpectomy, which involved vaginal hysterectomy, vaginectomy, and visceral reduction via purse-string sutures. The incorporation of levator plication into the procedure was described by Phaneuf, in 1935, in five subjects. Masson and Knepper, in 1938, published a case series of 23 patients who underwent vaginectomy, with or without hysterectomy, purse-string reduction of the viscera, levator plication, and perineorrhaphy. No recurrences were observed in a series of 60 cases of vaginal hysterectomy with vaginectomy and levatorplasty by Williams in 1950.

PREOPERATIVE EVALUATION The evaluation and staging of pelvic organ prolapse are described in Chapters 5 and 6. Most gynecologists would

Chapter 22

agree that optimal treatment is contingent upon obtaining a thorough history and physical examination findings as well as an understanding of the relationship between pelvic prolapse and coexisting functional derangements. This may commonly require ancillary testing. The role of preoperative imaging to detect hydronephrosis or ureteric compromise in the setting of advanced prolapse is controversial. Beverly et al. (1997) showed that the prevalence of hydronephrosis increases with worsening stage of prolapse. In women with severe prolapse, preoperative imaging may document preexisting hydronephrosis or ureteric obstruction that might otherwise be confused with iatrogenic ureteric injury at time of surgery. In addition, if preoperative radiographic studies demonstrate complete ureteric obstruction, a pessary with or without a ureteral stent may be placed if definitive surgery cannot take place promptly. The role of urodynamic testing in the medically fragile population, with severe prolapse, has not been determined. Occult or “potential” stress incontinence can be masked by the presence of pelvic organ prolapse. Not infrequently, incontinent women may note the decrease or disappearance of stress incontinence episodes as the degree of prolapse worsens. The office demonstration of the sign of urine loss is facilitated by the use of a speculum or pessary to reduce the prolapse while a stress maneuver is performed. Its presence may influence management options given to the patient. However, the method to reduce vaginal prolapse to evaluate latent incontinence is not universally agreed upon or standardized at this time. Some authors have not incorporated voiding diaries and urodynamics in their assessment because of the advanced age of their population and lack of compliance. In contrast, others advocate routine urodynamic testing in the setting of preoperative urinary symptoms or selective usage, depending on mitigating medical issues or excessive patient travel time. In a study by von Pechmann et al. (2003), 75 of 92 subjects underwent multichannel preoperative urodynamics; 36 (48.0%) had stress incontinence, 13 (17.3%) had detrusor overactivity, and 16 (21.3%) had mixed incontinence. Thus, treatment for clinical stress and urge incontinence must be incorporated into the treatment plan. In addition, FitzGerald and Brubaker (2003) found that 27% of patients without preoperative symptoms of stress incontinence developed new onset stress incontinence after surgery. Last, elderly patients with advanced prolapse are at higher risk for voiding dysfunction and retention when an anti-incontinence procedure, such as a suburethral sling, is performed.

LE FORT PARTIAL COLPOCLEISIS An obliterative procedure in the form of a Le Fort partial colpocleisis is an option if the patient has her uterus and is no longer sexually active. Because the uterus is retained, it will be difficult to evaluate any future uterine bleeding or cervical pathology. Therefore, endovaginal ultrasound, endometrial biopsy, and Papanicolaou smear must be done before surgery. Denehy et al. (1995) reported two patients who were considered for a Le Fort procedure but were found to have stage IA endometrial carcinoma during the work-up phase.

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The procedure is started by placing the cervix on traction to evert the vagina. The vaginal mucosa is injected with 0.025% bupivacaine or 2% lidocaine with 1:200,000 epinephrine just below the epithelium. A Foley catheter with a 5- to 10-mL balloon is placed in the bladder for identification of the bladder neck. A marking pen is used to mark out the areas that are to be denuded anteriorly and posteriorly. The area should extend from about 2 cm from the tip of the cervix to 4 to 5 cm below the external urethral meatus. A mirror image on the posterior aspect of the cervix and vagina should also be marked out. The previously marked areas are removed by sharp dissection (Fig. 22-1, A,B). The surgeon should leave the maximum amount of muscularis behind on the bladder and rectum. Hemostasis is an absolute must. After reducing the cervix 3 to 4 cm, the cut edges of the anterior and posterior vaginal walls are sewn together with interrupted delayed absorbable sutures (Fig. 22-1, C). The knots should be turned into the epithelium-lined tunnels that were created bilaterally. The uterus and vaginal apex are gradually turned inward. After the vagina has been inverted, the superior and inferior margins of the incisions can be sutured together (Fig. 22-1, D). In the author’s opinion, a plication of the bladder neck should be routinely performed because of the high incidence of postoperative stress incontinence (Fig. 22-1, A, inset). Also, because there is no real support to the repair, an aggressive perineorrhaphy with a distal levator plication should be done to narrow the introitus and build up the perineum. In general, about 90% to 95% of patients have relief of symptoms and good anatomic results. Complete breakdown or partial recurrence can be expected in 2% to 5% of patients. This is due to mostly either poor hemostasis with hematoma formation or infection. Goldman et al. (1985) reported on results and complications from a modified Le Fort procedure in 118 patients. Ninety-one percent of patients had good anatomic results, whereas 85% had relief of symptoms, 2.5% had recurrence of their prolapse, 10.2% developed incontinence or worsening of their incontinence, and 1.8% had late vaginal bleeding. These patients typically have other medical problems that may need to be addressed and closely monitored. Denehy et al. (1995) compared two cohorts of medically compromised women, of whom 21 received a modified Le Fort partial colpocleisis with Kelly plication and posterior colpoperineoplasty and 42 received a vaginal hysterectomy, anterior colporrhaphy, and posterior colpoperineoplasty. No differences were present in median hospital stay or postoperative decrease in hemoglobin. Complications among the patients in the Le Fort group included one arrhythmia, three urinary tract infections, and one death at 42 postoperative days due to end-stage biliary cirrhosis. The hysterectomy group consisted of one pulmonary embolus, three urinary tract infections, and one arrhythmia (Denehy et al., 1995). Glavind and Kempf (2005) presented the results of 25 patients who underwent Le Fort colpocleisis and 17 patients who had colpectomy. The colpocleisis group experienced one case of postoperative bleeding that required resuturing in the operating theater and one case of severe vaginal discharge. No reported complications were found in the colpectomy group.

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Figure 22-1 ■ Technique of Le Fort partial colpocleisis. A. Anterior vaginal wall has been removed, and suburethral plication stitch is placed at the bladder neck, as indicated (inset). B. Posterior vaginal wall is removed. C. Cut edge of anterior vaginal wall is sewn to cut edge of posterior vaginal wall in such a way that the cervix, uterus, and remaining vagina are inverted. The inset shows that tunnels in the vaginal wall are created bilaterally. D. After the uterus is completely reduced and the anterior and posterior vaginal walls sutured together, a perineorrhaphy is done, and the vaginal epithelium is closed.

TOTAL COLPECTOMY AND COLPOCLEISIS For patients with posthysterectomy vaginal vault prolapse who do not desire coital function and where operative time is to be kept at a minimum, a colpectomy and partial or complete colpocleisis can be done to effectively treat the prolapse.

Colpocleisis can also be performed concurrently with an initial vaginal hysterectomy and closure of the vaginal apex. To perform this operation for complete vaginal vault eversion, the vaginal epithelium is completely excised from the underlying vaginal muscularis and endopelvic fascia (Fig. 22-2, A,B). A series of purse-string sutures are used to

Chapter 22

invert the prolapse (Fig. 22-2, C). Once the prolapse is reduced, a suburethral plication (if indicated), posterior colpoperineorrhaphy, and levator plication are done (Fig. 22-2, D). In cases of vaginal colpectomy, no attempt is made to enter the enterocele sac. The concern regarding the recurrence of apical prolapse in the absence of an enterocele repair has been raised; however, an enterocele does not protrude below the pelvic floor because the vaginal canal is com-

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pletely obliterated after surgery. In addition, the entry into an enterocele may involve a theoretical increase in the rate of postoperative infection, ileus, and other complications. We and others advocate plication of the levator ani with narrowing of the levator hiatus during colpectomy. The levator hiatus is invariably widened in this patient population. The puborectalis and pubococcygeus muscle may be approximated in the midline with delayed absorbable sutures to

Figure 22-2 ■ Technique of vaginal colpectomy. A. The vagina is circumscribed by an incision several centimeters from the hymen. It can be marked in quadrants and portions of the vagina removed sharply, as shown. B. The posterior vaginal wall epithelium is sharply removed. The peritoneal cavity is not entered. C. A series of purse-string sutures are placed, sequentially inverting the vagina by tying sutures 1, then 2, then 3. The apex of the soft tissue is inverted by the tip of a forceps as each purse-string suture is tied. D. A perineorrhaphy is usually performed, and the vaginal epithelium is closed.

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create a shelf above the rectum, thus creating a further barrier to visceral descent (Fig. 22-3). A variation of the procedure involves the performance of separate anterior and posterior colporrhaphies, with two purse-string sutures to close the anterior and posterior segments together, and an extensive perineorrhaphy. Cespedes et al. (2001) reported 38 cases of this multicompartment colpocleisis. No significant complications were present in their series. Mean operating time was 145 minutes; however, some of the patients required an additional anti-incontinence proce-

dure (pubovaginal sling, Kelly plication). At a mean follow-up duration of 24 months, no recurrence in prolapse was noted. Complications of total colpectomy and colpocleisis are similar to those of Le Fort partial colpocleisis and are often related to the fragile medical condition of the patient. Stepp et al. (2005) found that, among women over age 75 with prolapse who underwent a full range of surgeries, including colpectomy, most complications (after bladder infections and blood transfusions) were medical. The most common postoperative medical complications were pulmonary edema

C Figure 22-3 ■ Technique of posterior colporrhaphy and levator plication. A. Widened genital hiatus and vaginal opening, as shown, is frequently found in women with severe pelvic organ prolapse. The inset shows the widened atrophic levator muscles. B. To accomplish the perineorrhaphy, a triangular incision is made in the skin of the perineal body and a midline posterior vaginal incision is done. The vaginal flaps are dissected bilaterally off the rectum until the levator muscles are seen. Inset: Delayed absorbable sutures are used to plicate the distal levator muscles. C. The plication creates a shelf over the rectum and perineal body, narrowing the vaginal introitus (inset) and providing additional support to a prolapse repair. As with other obliterative procedures, a tight levator plication should be done in only women who are not, or are not planning to be, sexually active.

Chapter 22

and congestive heart failure. Preoperative risk factors for complications included length of surgery, coronary artery disease, and peripheral vascular disease. DeLancey and Morley (1997) performed total colpocleisis on 33 women and reported a worsening of congestive heart failure in two women, urinary tract infection in two women, and pneumonia in one woman. Recurrent eversion developed in one patient a year later and required repeat colpocleisis. Harmanli et al. (2003) analyzed the complication rates in 41 women who underwent total colpocleisis, of whom 12 received a vaginal hysterectomy at the same time. Complications occurred at a low rate: febrile morbidity (19.5%), bladder injury (2.4%), and late rectal bleeding (9.8%). No patients required blood transfusion or sustained ureteral or intestinal injury. Von Pechmann et al. (2003) reported on 92 subjects who had total colpocleisis with high levator plication, of whom 37 (40.2%) underwent a simultaneous vaginal hysterectomy. Concurrent hysterectomy was associated with a statistically significant decrease in hematocrit (11.9% vs. 9.5% change; P = .01) and increase in transfusion requirement (35.1% vs. 12.7%; P = .02). Von Pechmann et al. (2003) reported two cases of rectal prolapse after total colpocleisis and high levator plication in 92 patients. It was unclear whether the concurrent risk factors for the development of rectal prolapse (advanced age, female sex, chronic constipation) or the levator plication itself (intra-abdominal pressure finding the path of least resistance) contributed to the development (or unmasking) of rectal prolapse. A small risk (0–2%) of ureteric occlusion or injury may exist with total colpectomy, usually due to kinking in the distal ureter from the purse-string sutures. The majority of cases will resolve with removal of the purse-string or plication stitches. Rare cases of obstruction secondary to intramural ureteral edema, from preoperative placement of ureteric stents, have been reported and they resolved after a second passage of stents. Also, if there is no flow of urine from one ureter after surgery, the possibility of long-standing severe preexisting hydronephrosis from the prolapse, leading to renal cortical atrophy and diminished or absent function, must be considered. Preoperative or intraoperative imaging studies to assess renal function may be helpful in women with long-standing severe prolapse, especially if their serum creatinine is elevated. Rare reports of postoperative infection or vaginal evisceration have been reported in the literature. Kohli et al. (1996) described a patient with pyometra at 8 months postLe Fort that required subsequent hysterectomy. Small bowel evisceration through the vagina at 3 years after colpocleisis has also been reported.

URINARY FUNCTION AFTER OBLITERATIVE PROCEDURES The challenge for the pelvic surgeon is to provide effective treatment for pelvic organ prolapse while maintaining or restoring lower urinary tract function. De novo stress incontinence is a recognized phenomenon after obliterative surgery. In addition, the risk of worsening any preexisting

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urinary retention with an anti-incontinence procedure must be weighed against the risk of post-colpocleisis stress incontinence if an anti-incontinence procedure is not performed. Surprisingly, many elderly women with advanced prolapse have normal urinary tract function but are at high risk for postoperative irritative symptoms and retention, if suburethral sling is performed. Fitzgerald and Brubaker (2003) retrospectively reviewed the results of colpocleisis with particular attention to perioperative stress incontinence. They demonstrated a 36% incidence of elevated postvoid residual volumes (>100 mL) in 64 patients. Stress incontinence was diagnosed in 78% of those tested, and an occult incontinence rate of 33% was noted. Autologous fascial slings were inserted concurrently in 33% of patients, whereas 19% had a Kelly plication as they opted not to undergo a formal anti-incontinence procedure. At a median follow-up time of 12 weeks, all patients with preoperative elevated postvoid residual volumes had normal residual volume after surgery. However, urinary retention persisted in three patients after a sling (14%), and all patients required takedown of the sling. Stress incontinence persisted in six (28%) of the subjects, three who had a sling and three who underwent Kelly plication. The rate of de novo stress incontinence was 27%; one patient had a suburethral plication, and seven had no extra bladder neck procedure. Moore and Miklos (2003) described their experience with 30 women who had colpocleisis and tension-free vaginal tape (TVT) under local anesthesia for stress incontinence and severe uterovaginal prolapse. No intraoperative complications occurred; however, one woman developed a postoperative myocardial infarction. At an average followup period of 19.1 months, 94% were cured of their stress incontinence. One patient required suburethral release of the sling after experiencing acute urinary retention for 5 weeks. The authors concluded that the TVT sling was safe and effective for the concurrent treatment of stress incontinence in a woman having colpocleisis. The use of other midurethral slings, including transobturator slings or transurethral collagen injection in the setting of obliterative surgery, is likely to be effective but remains to be studied. The majority of studies do not describe the outcomes of urgency and urge incontinence after obliterative procedures or make any attempt to differentiate stress from urge incontinence. In their series of 33 women who underwent total colpocleisis, DeLancey and Morely (1997) reported cure of stress incontinence in 4 of 5 women (1 lost to follow-up) who had a concurrent anti-incontinence procedure. Of the six women with preoperative urge incontinence who were available for follow-up, three were either cured or improved.

QUALITY OF LIFE AND REGRET OF LOSS OF SEXUAL FUNCTION Barber et al. (2006) found that obliterative surgery for stage III or IV pelvic organ prolapse significantly improves quality of life, as measured by several standardized questionnaires. Preoperative counseling should involve the discussion of the sexual implications of vaginal obliteration. Harmanli et al. (2003) reported no postoperative cases of regret after 41

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consecutive cases of total colpocleisis. However, von Pechmann et al. (2003) reported regret over loss of coital ability in eight women (12.9%), of whom four stated that they would have still had the procedure if asked again, three were unsure, and one would not have had the procedure. No significant risk factors (age, number of previous prolapse surgeries) were identified for regret in this study. In another study by DeLancey and Morley (1997), 1 of 33 women expressed remorse, stating she had “accepted” her loss of sexual function.

CONCLUSION Obliterative procedures for advanced pelvic organ prolapse are increasing in popularity due to a growing number of women entering the eighth and ninth decades of life, of whom many have concomitant medical issues that make more extensive surgery less suitable. Optimal treatment is contingent upon a thorough assessment of historical and physical examination findings and an understanding of the relationship between advanced pelvic prolapse and coexisting visceral abnormalities. Obliterative surgeries generally have very high rates of cure and satisfaction; most of the morbidity is due to coexistent medical conditions.

Bibliography HISTORICAL PERSPECTIVES Adair F, DaSef L. The Le Fort colpocleisis. Am J Obstet Gynecol 1936;32:218. Adams HD. Total colpocleisis for pelvic eventration. Surg Gynecol Obstet 1951;2:321. Anderson GV, Deasy PP. Hysterocolpectomy. Obstet Gynecol 1960;16:344. Baer J, Reis R. Immediate and remote results in two hundred twelve cases of prolapse of the uterus. Am J Obstet Gynecol 1928;16:646. Berlin F. Three cases of complete prolapsus uteri operated upon according to the method of Leon Le Fort. Am J Obstet Gynecol 1881;14:866. Collins C, Lock F. The Le Fort colpocleisis. Am J Surg 1941;53:202. Edebohls GM. Panhysterocolpectomy: a new prolapsus operation. Med Rec N Y 1901;60:561. Martin A. Ueber estirpatio vaginae. Berl Klin Wschr 1898;35:910. Masson JC, Knepper PA. Vaginectomy. Am J Obstet Gynecol 1938;36:94. Mazer C, Israel S. The Le Fort colpocleisis: an analysis of 43 operations. Am J Obstet 1948;56:944. Phaneuf L. The place of colpectomy in the treatment of uterine and vaginal prolapse. Am J Obstet Gynecol 1935;30:544. Pratt J, Baker R. Urinary incontinence following the Le Fort operation: report of a case. Obstet Gynecol 1960;16:722. Ridley JF. Evaluation of the colpocleisis: a report of fifty-eight cases. Am J Obstet Gynecol 1972;113:1114. Taft C. Le Fort’s operation for complete procidentia of the uterus, with a report of a case. Am J Med Sci 1889;98:128. Tauber R. The modern technique of the Le Fort operation. Ann Surg 1947;125:334.

Thomsen H. Vaginal evisceration trods kolpokleise og kolpoperineoplastik. Ugeskr Laeger 1988;150:867. Ubachs JM, Van Sante TJ, Schellekens LA. Partial colpocleisis by a modification of Le Fort’s operation. Obstet Gynecol 1973;42:415. Williams JT. Vaginal hysterectomy and colpectomy for prolapse of the uterus and bladder. Am J Obstet Gynecol 1950;59:365.

EVALUATION, SURGICAL TREATMENT, AND COMPLICATIONS Barber M, Amundsen C, Paraiso M, et al. Quality of life after surgery for prolapse in elderly women: obliterative vs. reconstructive surgery, 2006. In press. Beverly C, Walters MD, Weber AM, et al. Prevalence of hydronephrosis in patients undergoing surgery for pelvic organ prolapse. Obstet Gynecol 1997;90:37. Cespedes RD, Winters JC, Ferguson KN. Colpocleisis for the treatment of vaginal vault prolapse. Tech Urol 2001;7:152. DeLancey JO, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynecol 1997;176:1228. Denehy TR, Choe JY, Gregori CA, Breen JL. Modified Le Fort partial colpocleisis with Kelly urethral plication and posterior colpoperineoplasty in the medically compromised elderly: comparison with vaginal hysterectomy, anterior colporrhaphy, and posterior colpoperineoplasty. Am J Obstet Gynecol 1995;173:1697. Falk HC, Kaufman SA. Partial colpocleisis: the Effort procedure. Obstet Gynecol 1955;5:617. FitzGerald MP, Brubaker L. Colpocleisis and urinary incontinence. Am J Obstet Gynecol 2003;189:1241. Fitzgerald MP, Richter HE, Siddique S, et al. Colpocleisis: a review. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:261–271. Glavind K, Kempf L. Colpectomy or Le Fort colpocleisis—a good option in selected elderly patients. Int Urogynecol J 2005;16:48. Goldman J, Ovadia J, Feldberg D. The Neugebauer-Le Fort operation: a review of 118 partial colpocleises. Eur J Obstet Gynaecol Reprod Biol 1985;12:13. Hanson GE, Keettel WC. The Neugebauer-Le Fort operation: a review of 288 colpocleisis. Obstet Gynecol 1979;34:352. Harmanli OH, Dandolu V, Chatwani AJ, Grody MT. Total colpocleisis for severe pelvic organ prolapse. J Reprod Med 2003;48:703. Kohli N, Sze E, Karram M. Pyometra following Le Fort colpocleisis. Int Urogynecol J 1996;7:264. Lee RA. Atlas of Gynecologic Surgery. WB Saunders Co., Philadelphia, 1992, p. 68. Moore RD, Miklos JR. Colpocleisis and tension-free vaginal tape sling for severe uterine and vaginal prolapse and stress urinary incontinence under local anesthesia. J Am Assoc Gynecol Laparosc 2003;10:276. Nichols DH, Randall CL. Vaginal Surgery, 3rd ed. Williams & Wilkins, Baltimore, 1989. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501. Rosenzweig BA, Pushkin S, Blumenfeld D, Bhatia NN. Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol 1992;79:539. Stepp KJ, Barber MD, Yoo EH, et al. Prevalence of perioperative complications of urogynecologic surgery in elderly women. Am J Obstet Gynecol 2005;192:1630. von Pechmann WS, Mutone M, Fyffe J, Hale DS. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol 2003;189:121.

The Use of Biologic Tissue and Synthetic Mesh in Urogynecology and Reconstructive Pelvic Surgery

23

Marie Fidela R. Paraiso

PROPERTIES OF THE IDEAL GRAFT MATERIAL 295 BIOLOGIC PROPERTIES OF HOST TISSUE 296 PROPERTIES OF SYNTHETIC MATERIAL 296 PROPERTIES OF BIOLOGIC TISSUE 299 UROGYNECOLOGIC PROCEDURES INVOLVING THE USE OF SYNTHETIC MESH AND/OR BIOLOGIC TISSUE 302 CLINICAL RESULTS AND COMPLICATIONS ASSOCIATED WITH SYNTHETIC MESH 302 CLINICAL RESULTS AND COMPLICATIONS ASSOCIATED WITH BIOLOGIC TISSUE 303 CONCLUSION 304

Pelvic organ prolapse and urinary incontinence are common phenomena in women. Eleven percent of the female population will undergo surgery for prolapse or stress incontinence in their lifetime (Olsen et al., 1997). Approximately 30% of these women will need a repeat operation for recurrent prolapse. No standard surgical approach is available to patients who suffer from recurrent pelvic organ prolapse and/or incontinence. Multiple surgical techniques for recurrence, some incorporating surgical implants of synthetic or biologic graft material, have evolved. Some investigators have recommended the use of graft material or prosthesis for recurrent prolapse. Currently, the use of implants, both synthetic and biologic, in reconstructive pelvic surgery is expanding rapidly in spite of a paucity of data supporting their use. Indications for the use of graft implantation in reconstructive pelvic surgery include nonexistent or suboptimal autologous tissue; need to augment weak or absent endopelvic tissue; connective tissue disorder; unavoidable stress on the repair (chronic lifting, chronic obstructive pulmonary disease [COPD], chronic straining to defecate, obesity); need to bridge a space; concern about vaginal length or caliber; and denervated pelvic floor. Some surgeons choose augmentation with graft implants routinely in reconstructive pelvic surgery.

Good evidence supports the use of implantation of synthetic material for abdominal treatment of pelvic organ prolapse, as noted in Chapter 21. Suburethral sling procedures using synthetic materials have been shown to have similar cure rates compared with autologous rectus fascia (ARF) slings. The tension-free vaginal tape (TVT) procedure, a polypropylene mesh midurethral sling, has gained widespread popularity and has proven effectiveness comparable to Burch colposuspension. However, the use of synthetic or biologic implants in transvaginal reconstructive procedures is less clear. Although multiple studies have examined the use of implants for vaginal repair of anterior or posterior compartment prolapse, most are case series or cohort studies, with very few randomized surgical trials. Presently, several manufacturers promote various types of synthetic and biologic materials. No adequate studies comparing implants are known. In this chapter, we will review properties of the ideal graft material, host tissue, and available implants. The surgical procedures that involve mesh implantation, associated clinical results, and complications will also be summarized.

PROPERTIES OF THE IDEAL GRAFT MATERIAL Authors have proclaimed a need for ideal graft materials since the mid-twentieth century, and the search continues today. The ideal graft would be chemically and physically inert, noncarcinogenic, mechanically strong, sterilizable, not physically modified by body tissue, readily available, inexpensive, and have minimal risk of infection and rejection (Box 23-1). In prolapse and incontinence surgery, the optimal implant, once healed, would restore normal anatomy and function to the vagina and surrounding pelvic organs. It would be biocompatible and, if biodegradable, persist long enough to allow a durable and adequate repair and incorporation of the

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PROPERTIES OF THE IDEAL GRAFT MATERIAL

Chemically and physically inert Noncarcinogenic Nonimmunogenic Mechanically strong Not modifiable by host Generally available Inexpensive Resistant to infection Resistant to shrinkage Pliable Various shapes and configurations

surrounding tissue. It would be resistant to mechanical stress or shrinkage and easy to work with and be pliable. Other desired criteria include availability in the desired shapes for various operations, prevention of adhesions at visceral surfaces, and a better, or at least equal, response to implantation compared with autologous tissue. Unfortunately, at present, none of the synthetic or biologic tissue implants meet all of these criteria. To date, no published human articles are known that directly compare synthetic and biologic implants in human subjects, except for two randomized trials: one that compares porcine dermal sling to the TVT procedure; (Arunkalaivanan and Barrington, 2003) and another that compares polypropylene mesh to solvent dehydrated cadaveric fascia lata (Culligan et al., 2005). Literature regarding the physical properties of these materials is confined to animal studies and is rarely comparative, mostly analyzing abdominal wall implantation. Furthermore, few studies are known of the biomechanical properties of graft materials or vaginal wall after implantation. Walter et al. (2003) were successful in using a rabbit vagina model to study graft material tensile strength after implantation.

BIOLOGIC PROPERTIES OF HOST TISSUE Before discussing properties of various implants, the role of connective tissue in the pelvic floor must be described. Cervigni and Natale (2001) eloquently summarized the biologic properties of host connective tissue. This supportive structure contains fibrous elements (collagen and elastin) and a viscoelastic matrix containing proteoglycans (large polysaccharides attached to proteins). Connective tissue cells determine the biomechanical properties of soft tissue and are embedded in the extracellular matrix, which comprises 20% of the tissue volume. Collagen, a protein produced by fibroblasts, is composed of glycine, proline, and hydroxyproline. Glycine allows collagen to form a tight helix while proline and hydroxyproline form cross-links to stabilize the collagen chains. Tensile strength of tissues is attributed to collagen fibers. Two fibers found in tissue that require strength and flexibility are type I (the most plentiful and strongest) and type III (less common and randomly organized with type I). Elastin and laminin are glycoproteins that are thought to play a role in a tissue’s ability to stretch. Several authors have

shown that the metabolism of collagen and/or elastin is disrupted in various pelvic floor disorders. After reconstructive surgery, fibrous protein synthesis and remodeling reestablish tissue strength with collagen playing a central role in wound healing. Immature fibroblasts synthesize and secrete collagen and proteoglycans within 24 hours of surgery. During the first 2 weeks after reparative surgery, type III collagen is the principal type found. With maturation of scar tissue, a stronger type I collagen replaces type III collagen. Elastin is not synthesized and remodeled to the extent that collagen is by humans. Scar tissue resulting from wound healing after surgical repair is never as strong as the original tissue that it replaces. For the scope of this chapter it is important to summarize the reaction of host tissue to implanted materials. Biocompatibility is defined as the capability of a material to cause a favorable reaction in a living system, thus performing, augmenting, or replacing a natural function in the host. Williams (1973) described four types of soft tissue response: (1) minimal response with a thin layer of fibrosis around the implant, (2) chemical response with severe and chronic inflammatory reaction around the implant, (3) physical response with an inflammatory reaction to certain materials and the presence of giant cells, and (4) necrosis resulting from in situ exothermic polymerization. Four stages of histologic reaction to graft implantation have been described by Kaupp et al. (1979). They are: Stage 1—During week 1, an intense inflammatory infiltrate around the implant, capillary proliferation, granular tissue, and the presence of giant cells ensue. Stage 2—Within 2 weeks, granular tissue remains and foamy histiocytes appear. The number of giant cells with foreign body graft fibers may increase or decrease. Stage 3—Up to week 4, the acute inflammation disappears, capillaries are reduced, and the number of foamy histiocytes and giant cells increase. Stage 4—After week 4, a few collections of giant cells are present on the surface of the implant, and dense fibrous tissue is present.

PROPERTIES OF SYNTHETIC MATERIAL The available absorbable synthetic mesh implants are polyglycolic acid (Dexon, Davis & Geck, American Cyanamid, Danbury, CT) and polyglactin 910 (Vicryl, Ethicon Inc., Somerville, NJ). Absorbable implants may be desirable because they promote postoperative fibroblast activity, are not threatened by infection, do not undergo rejection, and are not known to be harmful to viscera. Lamb et al., (1983) showed that fibrous deposition into polyglactin mesh cannot take place before its absorption. Polyglactin 910 starts to hydrolyze during the third week after implantation and loses the majority of its mechanical value after 30 days. Polyglycolic acid requires 90 days for absorption. Macrophage activation results in mesh absorption and subsequent recycling of byproducts into new collagen fibers (Levasseur et al., 1979). The resultant scar tissue is not as strong as the reinforced tissue, as evidenced in animal studies (Klinge et al., 2001).

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Synthetic

Absorbable

Polyglactin 910

Non-absorbable Multi

Polyglycolic acid

Mixed Mono

Vipro Vipro II

Figure 23-1

Table 23-1

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Synthetic graft materials.

Types and Characteristics of Synthetic Graft Materials

Material

Brand Name

Company

Key Properties

Type

Sizes (cm × cm)

Polyglycolic acid

Dexon

Multifilament

17.5 × 22.5

Polyglactin 910

Vicryl

Davis & Geck, American Cyanamid, Danbury, CT Ethicon, Inc., Somerville, NJ

Multifilament

15 × 15

Absorbable

Nonabsorbable Polypropylene

Atrium

Monofilament

I

Marlex

Atrium Medical, Canton, OH CR Bard, Cranston, RI

Monofilament

I

Prolene Prolene-soft Gynemesh PS

Ethicon, Inc., Somerville, NJ Gynecare, Somerville, NJ

Monofilament

I I I

Boston Scientific, Natick, MA

Polyester

Trelex Surgipro Mersilene

Ethicon, Inc., Somerville, NJ

Monofilament Woven polypropylene Multifilament woven Dacron

Polytetrafluoroethylene (PTFE)

Teflon Surgical Membrane

CR Bard, Haverhill, MA; WL Gore, Flagstaff, AZ

Expanded PTFE

Gore-Tex

WL Gore, Flagstaff, AZ

Polypropylene

Surgipro

Monofilament

I III III

7.5 × 15 15 × 15 5 × 10 5 × 30 2.5 × 10 6 × 11 12 × 15 10 × 15 20 × 20 6 × 11

III Configured for apical prolapse Woven polypropylene

II II

5 × 13 5 × 17

III

Composites Expanded PTFE

Dual-Mesh

PTFE

MycroMesh

Silastic mesh Polypropylene

Pelvitex

CR Bard, Covington, GA

Cellguard Preclude pericardial membrane Preclude dura mater substitute

Nonabsorbable (permanent) synthetic mesh implants are either monofilament or multifilament (Fig. 23-1 and Table 23-1). The most important physical properties of synthetic implants are pore size and porosity. Some authors have noted small intrafiber pores (interstices of less than 10 μm) as a theoretic disadvantage of multifilament mesh

Macroporous one side/ II other microporous, antibiotic impregnated Perforated PTFE, III antibiotic impregnated IV Coated with hydrophilic I porcine collagen, lightweight Polypropylene sheeting IV

10 × 15

IV IV

in comparison to monofilament mesh (Brun et al., 1992; Neel, 1983). Most bacteria are less than 1 μm in diameter in comparison to granulocytes and macrophages, which are greater than 10 μm in diameter. The pore size plays an important role in mesh infection prevention and fibrous ingrowth of surrounding tissues. When describing the characteristics

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of synthetic mesh, Bobyn et al. (1982) listed type of polymer, weave, type of filament, weight, and pore size as important. The authors emphasized that the pore size is the key factor in determining inflammatory response, fibrocollagenous tissue ingrowth, angiogenesis, flexibility (or stiffness), and strength. Best mechanical anchorage with collagen infiltration was noted with pore size between 50 and 200 μm. Pourdeyhimi (1989) noted that exact pore sizes of various meshes cannot be quoted because measurement is technique-dependent. Marlex reportedly has the highest flexural rigidity when compared with Mersilene, Teflon, and Prolene. Both Marlex and Prolene are monofilament; however, Prolene is more flexible due to its larger pore size. Magnified views of six types of synthetic mesh are displayed in Figure 23-2. Synthetic mesh has been reclassified as types I to IV, with respect to pore size, as described by Amid (1997). Refer to Table 23-1 for various grafts and associated properties. Type I is macroporous (pore size >75 μm). Type II is microporous (pore size