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Pelvic Organ Prolapse(POP) Treatment : A Urogynecology Perspective. Case Study M . Zargham MD Isfahan university MC 2013. A 38-yr-old pregnant women presented with urinary incontinence and perineal mass . Uterine Prolapse Apical Prolapse S4.

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pelvic organ prolapse pop treatment a urogynecology perspective

Pelvic Organ Prolapse(POP) Treatment:A Urogynecology Perspective

Case Study

M .Zargham MD

Isfahan university MC

2013

uterine prolapse apical prolapse s4
Uterine ProlapseApical Prolapse S4

38 years old pregnant women

PI: Gestational age 24 week.

She wears pads all time and change them 5 times a day Perineal mass

.

clinical and paraclinical evaluation
Clinical and paraclinical evaluation

PI: Gestational age 24 week. She wears pads all time and change them 5 times a day Perineal mass

PMH: Gravid 2/para 1/ab 0

Sono: Renal and bladder showed bilateral hydroureteronephrosis(LT-G 1,Rt-G2)

U/A :microscopic hematuria and pyuria.

U/C :Neg.

CBC: normal

Cr: 1.2 mg/dl

apical prolapse enterocele s4
Apical ProlapseEnterocele S4

The enterocele bulge is outside the

introitus.

various types of pessaries
Various types of pessaries.

Various types of pessaries.

what is the best method of delivery
What is the best method of delivery?

A total of 1.4 million women were investigated!

pelvic organ prolapse and method of delivery

The benefits and

potential risks of a cesarean section

with resultant uterine scar have to be

weighed against the risk of developing pelvic organ prolapse.

pelvic organ prolapse andmethod of delivery,

Liu S, et al:Severe morbidity associated with low-risk planned cesarean delivery versus planned vaginaldelivery at term. CMAJ 2007

VillarJ,et al. Maternaland neonatal individual risks and benefits associated with cesarean delivery: multicentre prospective

study. BMJ 2007

case study 2 years after vaginal delivery
Case study:2 years after vaginal delivery

40-years old female, presented with perineal mass ,sever sexual dysfunction, and mild SUI?

PMH: 4 month ago she had underwent A-P repair that was failed one month after surgery.6 month ago her inguinal hernia was repaired.

PE :She suffered from advanced prolapse and vaginal apex reaches significantly above the ischial spines on vaginal exam.

lab.: bilateral HUN, Cr=2.1

uterine prolapse
Uterine prolapse

vaginal apex reaches significantly above the ischial spines on vaginal exam .

She refused hysterectomy!

why is hysterectomy unnecessary in the treatment of uterine prolapse1
Why is hysterectomy unnecessary in the treatment of uterine prolapse?

Level 1 is represented by the parametrial ligaments, which continue down the sides of the upper vagina as the paracolpium. Damage to this level of support will lead to apical (i.e. uterine and upper vaginal) prolapse.

The uterus itself plays a passive role in this process and its removal does not address the underlying pelvic organ support weakness or improve the outcome of the repair procedure.

Marana H, Andrade J, Marana R et al. Vaginal hsyterectomy for correcting genital prolapse. J Reprod Med 1999; 44: 529–534.

Diwan A, Rardin CR & Kohli N. Uterine preservation during surgery for uterovaginalprolapse.

slide16

At least 20% of hysterectomies were performed for the primary indication of POP. 57.4%, 45.0%, and 40.1% of all admissions for POP surgery included a hysterectomy.

what is the best surgical treatment for uterine sparing techniques
What is the best surgical treatment for “uterine-sparing” techniques?

Vaginal approach?

Abdominal approach?

Laparoscopic approach?

Should prostheses be considered for primary repairs,or secondary repairs?

abdominal sacrocolpopexy with mesh
Abdominal Sacrocolpopexy with mesh

Abdominal Sacrocolpopexy

elevation of the vaginal apex to the sacral promontory with a mesh bridge.

sacrospinous colpopexy and pop
Sacrospinouscolpopexy and POP

Sacrospinous vaginal vault suspension has also been associated with recurrent anterior segment prolapse theoretically because of the exposure of the anterior segment to increased pressure caused by the fixed retroversion of the vagina

Holley RL, Varner RE, Gleason BP, Apffel LA, Scott S. Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse. J Am CollSurg 1995; 180:444–448.

tissue fixation system tfs vaginal sacral colpopexy
Tissue Fixation System(TFS):Vaginal sacral colpopexy

The synthetic prostheses for sacrocolpopexy

are well established

yet remain controversial for

repairing isolated anterior and posterior compartment

defects.

sling and pop
Sling and POP

Conversely, concomitant suburethral slings at the time of reconstructive vaginal surgery have been shown to significantly reduce the recurrence of anterior vaginal wall prolapse.

Goldberg RP, Koduri S, Lobel RW, Culligan PJ, Tomezsko JE, Winkler HA, Sand PK. Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation. Am J ObstetGynecol 2001; 185:1307–1313.

slide22
The AUA strongly reinforced the need to differentiate between the use of mesh to treat POP versus SUI
mesh extrusion
Mesh extrusion

Described methods:

observation alone?

use of topical estrogen or antiseptics?

systemic or topical antibiotics?

Office based trimming of the extruded material?

operative excision?

6 month latter she complain of constipation fecal incontinence and vaginal discomfort

6 month latter she complain of constipation, fecal incontinence and vaginal discomfort

rectocele and enterocele apical and posterior vaginal wall prolase s4
Rectocele and EnteroceleApical and posterior vaginal wall prolase S4

She complain of fecal incontinence ,incomplete emptying of rectom and vaginal discomfort.

defecography proctography
DefecographyProctography

Constipation,

Melanosis Coli, Stercoral Ulcer,

Obstructed Defecation (Anismus),

Short-Segment Hirschsprung's Disease,

Intestinal Pseudo-obstruction (Ogilvie's Syndrome),

ProctalgiaFugax(Levator Spasm),

Coccygodynia

slide36

Rom the posterior IVS procedure lies from pelvic side wall,to pelvic sidewall allowing the vaginal cuff to be supported by neo cardinal ligaments.

how to manage prolapse once the decision has been made for surgery

How to manage prolapse once the decision has been made for surgery?

Plication and interposition procedures are both reasonable options, and interposition can be accomplished with biologic or synthetic materials, based upon surgeon experience, patient preference and presenting anatomic and functional disorder

slide39

Roger R. Dmochowski, MDDepartment ofA1302 Medical Center NorthNashville, TN 37232-2765, USAMickey Karram, MDThe Christ Hospital2123 Auburn Avenue, Suite 307Cincinnati, OH 45219, USA Urologic SurgeryVanderbilt University Medical Center