e. Vaginal pressure or pain

.Which statement regarding vaginal kits is TRUE?

a.There is ample evidence to support their use.

b.The presence of total vaginal mesh turns a single compartment repair into a multicompartmental repair.

c.The volume of mesh used is less than that for traditional interposition repairs.

d.The use of trocars reduces the complication rates.

e.Complications associated with kit repairs are the same as those associated with traditional repairs.

.Which structure is NOT used as a fixation point or point of reference for vaginal kits?

a.Sacrospinous ligament

b.Cardinal uterosacral ligament complex

c.Ischial spine

d.Obturator internus fascia

e.Arcus tendineus fasciae pelvis

.Complications that seem more likely when utilizing vaginal kits to repair pelvic organ prolapse include all of the following EXCEPT:

a.pelvic hematoma.

b.recurrent prolapse.

c.vaginal extrusion of mesh.

d.groin pain.

e.visceral perforation.

.Failure rates of standard anterior colporrhaphy:

a.are less than those for augmented mesh repairs.

b.are the same as those for mesh augmented repairs.

c.are less than those for abdominal sacrocolpopexy.

d.are the same as those for abdominal sacrocolpopexy.

e.depend on the definition of failure used.

Answers

1.b. Pelvic organ prolapse is a manifestation of discrete descent of the female pelvic viscera. Pelvic organ prolapse occurs because of defects within the support structures of the pelvic floor. Because the support is contiguous and boundaries are often difficult to delineate, conceptualizing the various

regions of the vagina as compartments facilitates the current understanding of the pelvic floor. Multiple compartments are often involved in pelvic organ prolapse, and multiple defects can be seen in a single compartment.

2.d. Arcus tendineus levator ani. The spinous process serves as an anchoring point for the first three structures and is an important landmark for surgeons who operate on the pelvic floor.

3.a. Level I support provides a primarily vertical support of the upper vagina and cervix by the cardinal uterosacral ligament complex. Level I support originates from the greater sciatic foramen, the sacroiliac region, and the lateral sacrum. It has vertical support suspending the upper vagina and cardinal uterosacral ligament complex. Level II support has mid-length fibers and supports the mid-vagina. Level III support has no intervening paracolpium, fuses the urethra anteriorly, and blends into the perineal body posteriorly.

4.c. The endopelvic fascia is easily divided into the various regions, which are readily identified at surgery. The endopelvic fascia is one contiguous unit, in which distinct areas are named. However, it is often difficult to identify where one region ends and the other begins. It should be considered as a unit. The challenge of the endopelvic fascia in its use as a supportive structure is that there is inherent weakness created by its structure of fibrous tissue embedded in a matrix in contrast to the fascial covering of skeletal muscle.

5.d. Pubocervical fascia. The perineal body is a condensation of fibromuscular tissue and collagen. It is located in the midline between the vagina and the anus. The pubocervical fascia is an anterior structure that does not insert into the perineal body.

6.c. Failure to reconstitute the vaginal vault at the time of hysterectomy will lead to immediate vault prolapse. The upper vagina is supported by two structures: the cardinal uterosacral ligament complex and the broad ligament. Therefore vaginal vault prolapse does not occur immediately after hysterectomy if the cardinal uterosacral ligaments are not reattached to the vaginal vault at the time of hysterectomy, owing to the support of the broad ligaments.

7.b. Objective measures of surgical success. In their study, Kenton and colleagues (2007)* found that patient perception of perioperative events and bother from recurrent symptoms resulted in dissatisfaction with prolapse surgery in the presence of high objective cure rates. Patient-perceived

complications included postoperative pain, minor effects of anesthesia, hospital discharge with a catheter, constipation, and urgency incontinence. Preoperative counseling is a key time in which one may educate and affect postoperative patient satisfaction.

8.e. Routine use of vaginal douches. The Agency for Healthcare Research and Quality identified perioperative interventions to improve patient safety, which include asking the patient to recall and state what was discussed during informed consent, administering appropriate preoperative antibiotics, and deep venous thrombosis prophylaxis. Postmenopausal patients may be treated with local estrogen therapy, which may increase vascularity and promote wound healing. Most surgeons do not use vaginal douches preoperatively.

9.b. All synthetic grafts are biologically inert. Synthetic grafts are not

biologically inert. All grafts will become involved in the wound healing process. Physical factors of each biologic graft or synthetic mesh will have different effects on the resultant scar tissue matrix.

.c. The graft functions as a permanent mechanical support. Tissue incorporation must occur for long-term success of a biologic graft or synthetic mesh. The important concept is that the graft, synthetic or biologic, serves as a scaffold to facilitate tissue ingrowth, rather than functioning as permanent mechanical support.

.e. Remodeling. Incorporation through a process called graft remodeling is needed for long-term graft survival.

.a. Tissue harvesting. The other techniques can all induce variability in tissue strength and incorporation. Aldehyde cross-linking is cytotoxic in high concentrations, attracting gelatinases to the wound that may increase the rate of graft degradation. Fenestrations may decrease seroma formation and increase both angiogenesis and tissue ingrowth. Freeze drying demonstrated

reduced maximum load to failure and stiffness of cadaveric fascia lata, in addition to variability of strength and stiffness throughout the graft.

. b. Pore size. Increased pore size results in greater flexibility. Pore size of

75 μm is the size that allows for the optimal tissue ingrowth with fibroblasts, blood vessels, and collagen fibrils. Monofilament knitted materials are able to assume a macroporous configuration.

.d. Cystoscopy with indigo carmine is not routinely necessary. Cystoscopy after the administration of indigo carmine or methylene blue is recommended as a routine practice after anterior colporrhaphy. If bluetinged urine is not seen effluxing from each ureteral orifice, catheterization

may be considered before taking down the plication sutures. Appropriate steps must be performed to ensure ureteral patency, including takedown of the sutures.

.a. Lateral. Lateral defects are repaired with paravaginal repairs. This defect may be approached transvaginally or transabdominally.

.d. All women with high-grade anterior compartment prolapse should undergo a prophylactic anti-incontinence procedure. The risks and benefits of prophylactic anti-incontinence procedure on continent women should be reviewed with each patient. The literature supports selective use of an anti-incontinence procedure at the time of pelvic organ prolapse repair. All

women with advanced-stage anterior compartment prolapse should be screened for occult stress urinary incontinence.

.a. Cystocele only. The patient has grade 4 anterior vaginal wall prolapse and the likelihood that the prolapse is bladder only is very low. She has a high likelihood of concomitant uterine prolapse.

.d. Enteroceles always contain small bowel. Enteroceles may involve omentum and small bowel. Large vaginal vault prolapse may involve the bladder and rectum. Enteroceles can occur from causes that may be congenital, from pulsion, from traction, or iatrogenically.

.d. The sutures should be tied before performing a cystoscopy. The sutures of the uterosacral ligament suspension should be tied before cystoscopy to evaluate the patency of the ureters. If cystoscopy is performed before tying the sutures, there may not be enough traction or compression from the sutures to appreciate ureteral obstruction. However, if the sutures need to be taken down, leaving them untrimmed until after the cystoscopy is practical because the tails will facilitate identification of the most lateral suture. They will need to be taken down one at a time until the offending suture is identified. While the

ureter courses distally, it gets closer to the cardinal uterosacral ligament complex, becoming the closest at the level of the cervix. Location of the ureters may vary considerably depending on the degree of prolapse.

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

The cardinal uterosacral ligament complex should be identified by tenting this structure either at the dimples of the vaginal apex or by placing Allis clamps at the vaginal vault, or by tugging on the sutures. Alternatively, they can be

directly visualized intra-abdominally. Random grasping of a condensation of tissue places the ureter at risk.

. a. Uterosacral suspension restores the vaginal apex. The uterosacral

suspension restores the normal anatomy of the vaginal apex. In contrast, right-sided unilateral sacrospinous ligament fixation often results in the vagina being displaced posteriorly and to the right. The abdominal sacrocolpopexy has been demonstrated to be superior to sacrospinous ligament suspension with respect to durability. Although the iliococcygeus repair may foreshorten the vagina, it does not always occur.

.e. There may be posterior or caudal displacement of the vagina. The caudal displacement of the vagina is thought to potentially contribute to the rate of

anterior prolapse recurrence. By displacing the vaginal apex posteriorly, the procedure places the anterior compartment at risk for recurrent prolapse.

.b. Pudendal nerve. The pudendal nerve courses around the ischial spine. Medial placement of the sutures 1.5 cm away from the ischial spine will help

to avoid entrapment of the pudendal nerve. The other structures are farther away from the sacrospinous ligament and are less likely to be injured.

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

.e. Pain is musculoskeletal in origin. The pain from sacrospinous ligament suspension either is gluteal or radiates down the leg posteriorly. It is neuropathic, and it occurs in 15% of patients. The pain may last 2 to 3 months in patients who have delayed absorbable sutures. Injection of the nerve with local anesthetic has been described to alleviate the pain.

.c. The dissection for the iliococcygeus suspension is as extensive as for the sacrospinous ligament fixation. The dissection for the iliococcygeus suspension is not as extensive as that used to access the sacrospinous ligament. Advantages include using either the anterior or posterior approach, maintaining the vagina in a near-normal axis.

.d. Use of a biologic graft. Permanent monofilament mesh has been shown to be superior to both cadaveric fascia lata graft (Culligan et al, 2005) and xenograft (Deprest et al, 2009). Secure fixation of the graft to both the sacral promontory and vaginal cuff, use of a monofilament mesh, and complete reduction of the enterocele with culdoplasty and tensioning so that the rectum is two fingerbreadths away from the mesh are key elements of the repair.

.e. a and d. Severe bleeding can be encountered with shearing of the presacral and middle sacral veins. This may be avoided by placing sutures

higher on the sacral promontory. Careful dissection is essential over the promontory. Sterile tacks may be used to stop the bleeding if encountered.

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

angulation. The Halban culdoplasty involves placing longitudinal sutures, and the Moschowitz culdoplasty involves placing purse-string sutures. The Moschowitz culdoplasty can result in ureteral angulation resulting in obstruction. A culdoplasty prevents enteroceles (not rectoceles) from forming. The end-to-end anastomosis sizer must be angled upward to see the cul-de- sac.

.d. Appropriate choice for those wishing to maintain sexual activity. Both colpocleisis and partial colpocleisis are only considered for those patients who

are not sexually active and do not wish to maintain the ability to be sexually active. Careful counseling is especially important with these procedures.

.a. Stress urinary incontinence. Patients may give a history of stress urinary incontinence that improved over time as their pelvic organ

prolapse worsened. Before undergoing colpocleisis, all women should be screened for occult stress urinary incontinence.

.c. Apical support from the cardinal uterosacral ligament. Loss of apical support from the cardinal uterosacral ligament complex leads to uterine prolapse. Because the broad ligament also provides a small amount of support, failure to reconstitute the support from the cardinal uterosacral ligament complex at the time of hysterectomy does not lead to immediate apical prolapse.

.d. Grade II uterine prolapse or greater. Endometriosis of unknown extent may make vaginal hysterectomy problematic. Obliteration of the cul-de-sac will preclude accessing the proper plane to identify the parametrium.

.e. b and d. The key elements to prevent recurrent vaginal vault prolapse after vaginal hysterectomy is culdoplasty, which is a closure of the cul-de- sac. Attaching the pubocervical fascia to the rectovaginal fascia closes the cul-de-sac, thus preventing an enterocele. Attaching the vaginal apex to the

cardinal uterosacral ligament complex reconstitutes the apical support.

.a. Levator plication. Levator plication was associated with high rates of de novo postoperative dyspareunia. Therefore it has largely been abandoned.

.b. Constipation. Constipation may be associated with dysmotility disorders of the rectum that do not improve with an anatomic repair. The symptoms most likely to improve are dyspareunia, the need for vaginal splinting, vaginal mass, and pressure.

.b. The presence of mesh turns a single compartment repair into a multicompartmental repair. The mesh placed with vaginal kits often supports both the vaginal apex and the anterior and posterior compartments,

making direct comparisons between kits and traditional repairs challenging. The kits utilizing trocars have complications that are unique to those techniques. The volume of mesh used is more than the amounts used in traditional repairs.

.b. Cardinal uterosacral ligament complex. The systems utilize the other structures as fixation points or references.

.b. Recurrent prolapse. When compared to native tissue repairs, recurrence rate are less with vaginal kits. Vaginal extrusion of mesh is not unique to the

trocar kits. The other complications have been associated with kits involving trocars.

.e. Depend on the definition of failure used. Failure rates depend on the definition of failure used. Weber's data from 2001 concluded a 40% failure rate; however, when it was reanalyzed in 2011 applying alternate failure criteria, the failure rate fell to 10% to 20%. Most modern series define anatomic failure as stage II or greater using the Pelvic Organ Prolapse Quantification (POP-Q) system, yet some patients with recurrent stage II prolapse remain asymptomatic and do not require further surgical correction.

Chapter review

1.The iliococcygeus and the coccygeus muscles fuse in the midline and attach to the coccyx forming a complex called the levator plate that supports the upper vagina and cervix.

2.The urethra is fused to the anterior vaginal wall for much of its length.

3.Vaginal support is provided by the endopelvic connective tissues.

4.The cardinal and uterosacral ligaments provide level I support of the uterus and upper vagina; the endopelvic and pubocervical fascia provide level II support of the mid-vagina while it attaches to the arcus tendineus fasciae pelvis; the distal vagina attaches to the levator ani muscles and perineal body to provide for level III support.

5.Pelvic organ prolapse is for the most part a quality-of-life issue.

6.Anterior compartment defects can be central, lateral, or both.

7.Anterior colporrhaphy and paravaginal repairs are both ineffective alone in the treatment of stress urinary incontinence. They do not suspend the vaginal apex.

8.Sacrospinous ligament fixation may result in posterior displacement of the vaginal apex and increase the risk of anterior compartment prolapse.

9.If either the bladder or rectum is injured during pelvic organ prolapse

repair, mesh should not be used.

10.Twenty-nine percent of women require reoperation for failed incontinence and prolapse surgery.

11.Synthetic mesh grafts erode in 10% of patients in whom they are used for the repair.

12.Sacrospinalis ligament fixation is an effective method of correcting vaginal apical prolapse. It results in posterior displacement of the vaginal apex.

13.Abdominal sacrocolpopexy maximizes functional vaginal length without significant distortion of the anatomic vaginal axis.

14.Colpocleisis obliterates a portion of the vagina and may be used to prevent vaginal vault prolapse. It precludes functional sexual activity.

15.Cystoscopy after the administration of indigo carmine or methylene blue is recommended as a routine practice after anterior colporrhaphy.

16.All women with advanced-stage anterior compartment prolapse should be screened for occult stress urinary incontinence.

17.The pain from sacrospinous ligament suspension is either gluteal or radiates down the leg posteriorly. It is neuropathic, and it occurs in 15% of patients.

* Sources referenced can be found in Campbell-Walsh Urology, 11th Edition, on the Expert Consult website.