83

Vaginal and Abdominal Reconstructive Surgery for Pelvic Organ Prolapse

J. Christian Winters; Ariana L. Smith; Ryan Krlin

Questions

1.Which of the following statements is FALSE?

a.Pelvic organ prolapse occurs because of defects in the supporting tissues.

b.Pelvic organ prolapse is a manifestation of discrete descent of the female pelvic viscera.

c.Pelvic organ prolapse occurs as compartmental defects, and multiple compartments may be affected.

d.The aim of surgical management is restoration of normal anatomy while maintaining visceral and sexual function.

e.Pelvic organ prolapse essentially represents hernias within the pelvic floor.

2.Which structure does not insert onto the spinous process?

a.Arcus tendineus fasciae pelvis

b.Sacrospinous ligament

c.Coccygeus muscle

d.Arcus tendineus levator ani

3.With regard to three levels of vaginal support as described by DeLancey, which of the following is TRUE?

a.Level I support provides a primarily vertical support of the upper vagina and cervix by the cardinal uterosacral ligament complex.

b.Level II support includes the shortest fibers and anchors the midvagina.

c.Level III support has intervening paracolpium and supports the most distal portion of the vagina.

d.Level I support originates from the greater sciatic foramen, the medial sacrum, and the sacroiliac region.

e.Level III support does not fuse the urethra anteriorly and the perineal body posteriorly.

4.Which statement about the endopelvic fascia is FALSE?

a.The endopelvic fascia is a composite of fibrous tissues, embedded in a matrix.

b.The tissues are supportive and contractile.

c.The endopelvic fascia is easily divided into the various regions, which are readily identified at surgery.

d.The endopelvic fascia lacks the organization of the fascial coverings of skeletal muscle.

e.The endopelvic fascia has different regions that are specifically named.

5.Which structure does not attach to the perineal body?

a.Rectovaginal fascia

b.Levator ani muscles

c.Transverse perinei muscles

d.Pubocervical fascia

e.External anal sphincter

6.Which of the following statements about apical compartment prolapse is FALSE?

a.Vaginal vault prolapse can occur after hysterectomy if support is not reconstituted to the cardinal uterosacral ligament complex.

b.An apical defect may result in uterine prolapse, vaginal vault prolapse, and prolapse of the peritoneum cul-de-sac.

c.Failure to reconstitute the vaginal vault at the time of hysterectomy will lead to immediate vault prolapse.

d.Total procidentia includes apical prolapse of the vagina in addition to multiple compartment defects.

e.Enteroceles may occur with or without vaginal vault prolapse.

7.Patient satisfaction is NOT highly correlated with which of the following?

a.Patient readiness to undergo surgery

b.Objective measures of surgical success

c.Resolution of the symptoms of pelvic organ prolapse

d.Lack of patient-perceived complications

e.Achievement of patient-selected goals

8.Preoperative patient preparation does NOT include which of the following?

a.Asking the patient to state what the planned procedure(s) is and its purpose

b.Administering preoperative antibiotics

c.Deep venous thrombosis prophylaxis

d.Local estrogen therapy in women with vaginal atrophy

e.Routine use of vaginal douches

9.Which statement is FALSE regarding biologic and synthetic grafts?

a.Wound healing follows a stepwise cascade regardless of material type.

b.All synthetic grafts are biologically inert.

c.There is no ideal prosthetic implant.

d.Biologic grafts are classified as autologous, allografts, and xenografts.

e.Synthetic grafts may be absorbable.

.Which statement is FALSE regarding wound healing and grafts/mesh?

a.The amount of foreign body reaction is proportional to the surface area of the material exposed to the host.

b.The degree of response and amount of tissue ingrowth is determined by the nature of the material.

c.The graft functions as a permanent mechanical support.

d.Host tissue integration leads to long-term graft function.

e.The graft/mesh acts as a scaffold to facilitate tissue ingrowth.

.Which of the following processes must occur for long-term graft survival?

a.Rejection

b.Degeneration

c.Encapsulation

d.Absorption

e.Remodeling

.Which tissue-processing technique causes the least amount of variability in tissue quality of allografts and xenografts?

a.Tissue harvesting

b.Cross-linking

c.Freeze drying

d.Tissue fenestration

e.Solvent dehydration

.The most important characteristic of a synthetic mesh is: a. type of mesh (synthetic or absorbable).

b.pore size.

c.filament type (monofilament or multifilament).

d.mesh construct (woven or knitted).

e.flexibility.

.Which of the following statements regarding anterior colporrhaphy is FALSE?

a.Anterior colporrhaphy is not used to treat stress incontinence.

b.Recent series report a 40% recurrence rate for standard anterior colporrhaphy.

c.The most likely contributing factor for failure of anterior compartment repairs is the concomitant presence of other compartmental defects.

d.Cystoscopy with indigo carmine is not routinely necessary.

e.Ensuring that the bladder is drained before perforating the endopelvic

fascia may decrease bladder injuries.

.Paravaginal repairs are used to repair which of the following anterior compartment defects?

a.Lateral

b.Central

c.Anterior

d.Posterior

e.Distal

.Which of the following statements is FALSE regarding high-grade anterior compartment prolapse?

a.Urethral kinking or compression may occur.

b.Occult stress urinary incontinence may be unmasked by reducing the prolapse.

c.No method to reduce the prolapse is superior in evaluating occult stress urinary incontinence.

d.All women with high-grade anterior compartment prolapse should undergo a prophylactic anti-incontinence procedure.

e.Intervention for complications of mid-urethral slings equals the risk of having to perform a secondary sling.

.A 50-year-old woman presents with symptoms of voiding difficulty and vaginal bulging. She has had no prior pelvic surgery. In the supine position she demonstrates anterior vaginal wall prolapse that extends 4 cm beyond the hymen. The cervix does not descend with straining during the supine examination. The least likely diagnosis is:

a. cystocele only.

b.uterine prolapse and cystocele.

c.uterine prolapse and enterocele.

d.uterine prolapse, enterocele, and cystocele.

e.uterine prolapse, widened genital hiatus, and enterocele.

. Which statement is FALSE regarding apical defects?

a.Failure to recognize an apical defect at the time of prolapse repair will increase the risk of recurrence.

b.Apical defects may involve the bladder and rectum.

c.Hysterectomy with suspension of the vaginal apex to the cardinal uterosacral ligaments and attaching the pubocervical fascia to the rectovaginal fascia will ensure the apical support.

d.Enteroceles always contain small bowel.

e.Enteroceles are thought to occur by several mechanisms.

. Which of the following statements is TRUE regarding uterosacral ligament suspensions?

a.The ureter courses closer to the uterosacral ligament proximally.

b.Suture placement in the most medial portion of the uterosacral ligament will avoid fibers of the sacral plexus.

c.The ureters are found consistently in the same location regardless of the degree of prolapse.

d.The sutures should be tied before performing a cystoscopy.

e.The suspensory sutures should be trimmed before the cystoscopy.

. What method is NOT used to identify the cardinal uterosacral ligaments?

a.Traction of the dimples of the vaginal apex

b.Placing an Allis clamp at the 5-o'clock and 7-o'clock positions of the vaginal vault

c.Direct visualization

d.Tugging on the suture tied to the cardinal uterosacral ligaments at the time of hysterectomy

e.Randomly grasping a condensation of tissue along the pelvic side wall

. Which of the following statements about apical repairs is TRUE?

a.Uterosacral suspension restores the vaginal apex.

b.With respect to durability, abdominal sacrocolpopexy has not been shown to be superior to sacrospinous ligament suspension.

c.Sacrospinous ligament suspension does not change the vaginal axis.

d.With abdominal uterosacral ligament suspension, one does not need to place as many sutures on the ligament.

e. Iliococcygeus repairs always foreshorten the vaginal length.

.A disadvantage of sacrospinous ligament fixation is:

a.it requires a retroperitoneal approach.

b.the sacrospinous ligament is not a reliable structure on which to anchor the vaginal apex.

c.the procedure may only be approached anteriorly.

d.the hospital stay is equivalent compared with abdominal sacrocolpopexy.

e.there may be posterior or caudal displacement of the vagina.

.Which structure is at risk of injury with sacrospinous ligament suspensions?

a.Genitofemoral nerve

b.Pudendal nerve

c.Obturator vessels

d.Ilioinguinal nerve

e.Hypogastric vessels

.Which statement is FALSE regarding the anatomy around the sacrospinous ligament?

a.The pudendal nerves and vessels are in close proximity while they course around the ischial spine.

b.The gluteal vessels course behind the sacrospinous ligament.

c.The highest concentration of sacral nerves is by the ischial spine.

d.The fibers of the sacrospinous ligament fan out closer to the sacrum.

e.The optimal position to place suture for fixation is 1.5 to 2 cm medial to the ischial spine.

.Which of the following is FALSE regarding pain from the sacrospinous ligament suspension?

a.Gluteal pain generally resolves spontaneously in 2 to 3 months.

b.Injection of the nerve with local anesthetic can be done to relieve the pain.

c.Pudendal nerve entrapment causes gluteal pain.

d.Pain may occur in 15% of patients on the ipsilateral side.

e.Pain is musculoskeletal in origin.

.All of the following statements regarding the iliococcygeus suspension are true EXCEPT:

a.The site of fixation may be reached by an anterior or posterior approach.

b.Fixation is 1 cm distal to the ischial spine near the insertion of the

arcus tendineus fasciae pelvis.

c.The dissection for the iliococcygeus suspension is as extensive as for the sacrospinous ligament fixation.

d.The iliococcygeus suspension maintains the vagina in the normal axis.

e.Neuropathy has been reported as a postoperative complication.

.Key elements of the abdominal sacrocolpopexy do NOT include:

a.use of permanent monofilament mesh.

b.secure fixation to the sacral promontory.

c.secure fixation to the vaginal cuff.

d.use of a biologic graft.

e.complete enterocele reduction and culdoplasty.

.Which structures are the sources of severe bleeding with the abdominal sacrocolpopexy?

a.Presacral veins

b.Internal iliac vein

c.Mesenteric veins

d.Middle sacral vein

e.a and d

.Which statement is TRUE regarding culdoplasty?

a.Halban culdoplasty involves placing purse-string sutures.

b.Moschowitz culdoplasty involves placing longitudinal sutures.

c.The risk of the Moschowitz culdoplasty is ureteral obstruction due to angulation.

d.Culdoplasties prevent rectocele formation.

e.Downward retraction of the end-to end anastomosis sizer may help delineate the cul-de-sac.

.Which of the following factors is FALSE regarding advantages of colpocleisis?

a.Shorter operative time

b.Ability to use either regional anesthesia or local anesthesia with sedation

c.Minimal complication rates

d.Appropriate choice for those wishing to maintain sexual activity

e.Decreased recuperative time

.Which postoperative complication of both colpocleisis and partial colpocleisis, if identified preoperatively, may be reduced?

a. Stress urinary incontinence

b.Urinary retention

c.Regret over loss of sexual function

d.Recurrence

e.Infection

.Uterine prolapse represents the loss of:

a.apical support from the broad ligament.

b.anterior support from the arcus tendineus fasciae pelvis.

c.apical support from the cardinal uterosacral ligament.

d.posterior support from the rectovaginal fascia.

e.apical support from the round ligaments.

.Contraindications to performing a vaginal hysterectomy do NOT include:

a.endometriosis of unknown extent.

b.obliteration of the cul-de-sac.

c.size disproportion of the uterus to the introitus.

d.grade II uterine prolapse or greater.

e.malignancy of the uterus or ovaries.

.Which maneuver performed during vaginal hysterectomy is essential to prevent recurrent prolapse?

a.Leaving an adequate stump on the uterine artery

b.Culdoplasty

c.Leaving an adequate stump on the cardinal uterosacral ligament complex

d.Closure of the cul-de-sac

e.b and d

.Which surgical technique of rectocele repair is most associated with postoperative dyspareunia?

a.Levator plication

b.Site-specific repair

c.Site-specific repair with biologic interposition graft

d.Transanal repair of rectocele

e.Perineorrhaphy

.Which symptom changes the least following site-specific posterior colporrhaphy?

a.Dyspareunia

b.Constipation

c.Vaginal mass

d.Splinting