Surgical management of Genital prolapse

 

Medical Management options for women with symptomatic pelvic organ prolapse include observation, 1)  pelvic floor muscle training, and 2) mechanical support (pessaries).

 

1)       Pelvic muscle floor training Pelvic floor muscle training, the systematic contraction of the muscles of the pelvic floor, may improve pelvic function. These exercises, commonly known as Kegel exercises, can be accomplished by conscious contractions, electrical stimulation, or via biofeedback training.

 

2)       The use of Kegel cones (weighted cones used to help women isolate pelvic floor muscles) can also help. However, the effectiveness of pelvic floor muscle training in reversing or treating pelvic organ prolapse has not been studied. Pelvic floor muscle training has been shown to significantly improve symptoms associated with stress, urge, and mixed urinary incontinence.

 

 

 

How helpful are pessaries?? Unfortunately, there are no randomized trials to guide pessary selection for any particular type of device, indications, pattern of replacement, follow-up care, or degree of pelvic organ prolapse.

Traditionally, pessaries have been used for short-term symptom relief in women awaiting surgery or for long­ term treatment in women with higher stages of prolapse, who are poor surgical candidates, or who have declined surgery. However, pessaries can be used in almost all cases, when a nonsurgical option is desired,  less frequent follow-up may also be safe if she resides near the clinic. Patients should be asked if they have experienced any vaginal discharge, bleeding, pain, or discomfort. The pessary is palpated in situ then removed to check the vagina for ulcerations or erosions. The pessary can be washed with soap and water, dried, and reinserted. If vaginal lesions are noted, the pessary should be removed until the lesions have healed. Although there is no evidence on the effectiveness of vaginal estrogen creams in the treatment of pelvic organ prolapse, it may be appropriate for postmenopausal women who have significant vaginal atrophy if no contraindications exist.

  Tips for effective long lasting correction of prolapse by Surgical management of Genital prolapse :- Apical suspension procedure is key of prolapse surgery .-

For in most symptomatic Genital Prolapse primary treatment is surgical. The surgical management of uterine prolapse warrants an apical suspension procedure, with or without uterine removal. Options in the surgical treatment of uterine prolapse encompass the A) vaginal approaches B) laparoscopic, or C) open laparotomy.

Vaginal apical suspension procedures include the A) uterosacral vaginal vault suspension,  B) sacrospinous ligament fixation, C)  iliococcygeus fascia suspension, and the D) McCall or Mayo culdoplasty.

However, the abdominal sacral colpopexy may be performed via laparotomy or laparoscopy. Uterine preservation techniques include the a) Manchester procedure, b) sacrospinous hysteropexy, c) laparoscopic sacral hysteropexy and d) laparoscopic uterosacral vault suspension.

 

Which route and what type of corrective surgery? Ans: This depends on the optimal procedure to treat uterine prolapse depends on 1) her specific defects that are present, as well as 2) expertise , training  experience and skill of the surgeon. Considerations such as the patient’s age, comorbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, as well as the skill and comfort level of the surgeon with the particular surgery.

The choice of surgery depends upon —

1)     desire for preservation of Reproductive Function, 2) desire for preservation of Menstrual Function

2)     women completed Reproductive Function and not interested in Menstrual Function 3 ) to take in to account of vaginal vault prolapse

3)     Concomittant Intrapelvic Disease

The surgeries for uterine prolapse are also clearly differentiated by the route of surgery used

Vaginal route

Abdominal route

Vaginal route —

anterior colporhaphy with posterior colpoperineorrhaphy (AP Repair)

Fothergill’s surgery

Amputation of the cervix with posterior repair

Enterocoel repair

Mayo — wards hyterectomy

Recent Advances in vaginal repairs — Apogee and Perigee systems

TVTs and Mesh procedures for SUI repairs

ANTERIOR COLPORHAPHY AND POSTERIOR COLPO-PERINEORHAPHY (A - P Repair)

This procedure is indicated when the patient is younger, has less parity, presents only with vaginal wall prolapse, has no uterine prolapse, no associated local or systemic factors, and desires all sexual, reproductive and menstrual functions

Fothergill’s operation

 

Have member’s watched Sturmdorf suture in Fothergill operation? Can any member describe please ?

 Principles of Fothergill open are as follows :-

Dilatation & Curettage

Shortening of cardinal ligament

Partial amputation of cervix

Sturmdorf suture

Anterior colporrhaphy

Posterior colpoperineorrhaphy

Fothergill’s procedure is not recommended in women desiring reproductive function because

It can cause Cervical stenosis,

lead to Infertility, Incompetent Os

or even Cervical Dystocia

Additionally recurrence of prolapse can occur after vaginal delivery.

 

What is Shirodkar Extended Manchester operation done vaginally? Have any member watched such conservatives but very effective surgery without doing amputation of CX??

It is a new conservative surgical technique because of so many draw backs of and  disadvantages of Fothergill- Manchester operation especially pertaining to future child bearing were realized. Dr. Shirodkar in 1946 came up with the novel approach of utilizing A) uterosacral ligament for the repair of prolapse without amputation of cervix and   B) ) concomitant enterocele repair which give a good success rate. This technique known as Shirodkar Extended Manchester Repair is a simple conservative vaginal surgical procedure for genital prolapse in young women with II/III degree uterine prolapse with/without Cystocele or rectocoele, interested in child bearing or preserving menstruation with no cervical elongation and good uterosacral ligament strength. It is also less invasive than abdominal sling operation. As no amputation of cervix is done, complications like abortion, premature labour, cervical stenosis, infertility due to loss of cervical mucus, cervical dystocia during labour are not seen. Here, instead of Mackenrodt’s ligament, uterosacral ligaments with its peritoneal attachment which forms a strong band of tissue, are utilized as slings.

Hence the occurrence of prolapse is less. As it is a conservative vaginal procedure, it has advantages over the abdominal sling operations .

It permits restoration of a functional vagina with a normal horizontally inclined upper vaginal axis atop the levator plate, thereby decreasing the chances of recurrence of vault eversion. To conclude , It is a shorter procedure than the abdominal operation and requires less duration and depth of anesthesia.

Finally, post-operative ileus, intestinal obstruction, incisional pain and other hazards of trans abdominal surgeries are decreased.

Thus, this operation seems to have a definite place in the treatment of the genital prolapse especially during the reproductive age, where child-bearing function has to be preserved