Gynecology_Novak

Gynecology_Novak. These groupings are somewhat arbitrary and not entirely exclusive. For example, grafts may be used to reinforce repairs, such as colporrhaphy, or to replace support that is deficient or lacking. Graft use in sacrocolpopexy substitutes for the connective tissues attachments (cardinal and uterosacral ligaments) that would normally support the vaginal apex. In addition to the primary goal of relieving symptoms related to prolapse, urinary, defecatory, and sexual function must be considered in choosing the appropriate procedures.


Gynecology_Novak

Gynecology_Novak. Whether to repair all defects is controversial. Restorative repairs may be less successful than compensatory repairs in patients with generally “poor tissue,” and at times one defect repair may exert more tension on the repair of another defect. Management should be based on the patient’s presentation, expectations, the specific anatomical defects noted (preoperatively and, at times, intraoperatively), and on the presence or absence of lower urinary and bowel dysfunction (51). The Apical Compartment Examination for apical defects is at times difficult. Such defects may be missed when large anterior or posterior defects are present. In cases when apical defects are suspected but not confirmed, surgeons should evaluate the apical support intraoperatively and plan for management of these defects when they are found. Traction on the cervix with a tenaculum or on the vaginal cuff both centrally and laterally with Allis clamps may reveal otherwise unrecognized defects.


Gynecology_Novak

Gynecology_Novak. Transvaginal repairs include extraperitoneal procedures such as sacrospinous suspensions, iliococcygeal suspensions, and high paravaginal suspensions of the apical vaginal fornices to the arcus tendineus at the level of the ischial spine or to the endopelvic fascia, and intraperitoneal suspensions such as uterosacral suspensions and McCall culdoplasties (51). Accepted practice is that the vaginal apex should be resuspended in a posterior cephalad direction to a site or sites posterior and caudad to the sacral promontory. Anterior apical suspensions change the direction of the vaginal axis and may be fraught with a greater incidence of posterior compartment defects, including rectoceles, enteroceles, and sigmoidoceles. The general principles of the repair should include management of the specific apical defects: 1. If present, the attenuated part of the upper vaginal wall (fibromuscular defect) should be repaired or covered by graft material. 2.


Gynecology_Novak

Gynecology_Novak. If present, the attenuated part of the upper vaginal wall (fibromuscular defect) should be repaired or covered by graft material. 2. The vaginal cuff or, in some instances, the cervix should be suspended without excessive tension. 3. Any defect in the attachment of the upper vagina to the rectum at or below its sigmoid junction should be corrected. Enterocele repairs may include: 1. Removal of the peritoneal sac with closure of the peritoneal defect, followed by closure of the fascial or fibromuscular defect or both below it 2. Dissection and reduction of the peritoneal sac and closure of the defect 3. Obliteration of the peritoneal sac from within with transabdominal Halban or Moschcowitz type procedures or transvaginal McCall or Halban procedures (52).


Gynecology_Novak

Gynecology_Novak. Obliteration of the peritoneal sac from within with transabdominal Halban or Moschcowitz type procedures or transvaginal McCall or Halban procedures (52). Historically, the treatment for symptomatic uterine prolapse has been hysterectomy, which is performed vaginally or abdominally in combination with an apical suspension procedure, and repair of coexisting defects. Apical support procedures that have been described for use when the uterus or cervix is to be kept in place include Manchester and Gilliam procedures and fixation of the cervix to the sacrospinous ligament . The other procedures described in this section may also be used in women who desire uterine conservation. Adequate outcome data on such uterine-sparing procedures are not yet available. When the cervix is absent, in addition to repair of fibromuscular defects, both fibromuscular planes anterior and posterior to the vaginal cuff should be attached to whatever suspension is employed.


Gynecology_Novak

Gynecology_Novak. The fixation of the vaginal apex to the sacrospinous ligament, the tendineus component of the coccygeus muscle, was first described in 1958 and was subsequently modified in Europe and the United States (53–56). Access is traditionally extraperitoneal via the rectovaginal space with penetration of the pararectal (Denonvillier’s fascia) at the level of the ischial spine to expose the muscle and ligament. Variations in this approach to the ligament include entrances through an anterior lateral access, an apical passage posterior to the uterosacral ligament, and a laparoscopic approach (57–59). Bilateral sacrospinous ligament suspensions have also been advocated; however, these techniques may impose a greater degree of tension on the sutures and, at times, create a band of apical vagina across the rectum at the level of the suspension (60,61). Whether this can cause defecatory dysfunction remains unknown. The advantages of the sacrospinous fixation procedure include (i) its transvaginal


Gynecology_Novak

Gynecology_Novak. the rectum at the level of the suspension (60,61). Whether this can cause defecatory dysfunction remains unknown. The advantages of the sacrospinous fixation procedure include (i) its transvaginal extraperitoneal approach, (ii) resultant posterior vaginal deﬂection, and (iii) the fact that it is a durable repair if performed correctly. Reported success for apical support has been good (89%–97%) with follow-up times ranging from 1 month to 11 years (51,62). However, there have been subsequent reports of high rates of anterior vaginal prolapse (63,64). It is not clear whether this observation is related to the procedure and its exaggerated posterior vaginal deﬂection or to the fact that many patients with apical descent also have defects in the upper vaginal fibromuscular tissue. Failure to address an anterior defect concurrently with suspension of the posterior apical vagina may predispose the patient to such a defect postoperatively. Other disadvantages of the procedure include (i)


Gynecology_Novak

Gynecology_Novak. to address an anterior defect concurrently with suspension of the posterior apical vagina may predispose the patient to such a defect postoperatively. Other disadvantages of the procedure include (i) relative difficulty in adequately exposing the ligament, (ii) an unnatural lateral vaginal deﬂection toward the fixation site, (iii) an inability to perform without excessive tension when the vaginal length is compromised, as may be the case in repeat procedures, (iv) potential risk for injury to the sciatic nerve or pudendal nerve or vessel, and (v) occasional need to shorten or narrow the upper vagina when a fibromuscular defect involves much of the apical area.


Gynecology_Novak

Gynecology_Novak. Iliococcygeal vaginal suspension involves the attachment, usually bilaterally, of the vaginal apex to the iliococcygeus muscle and fascia (61,65,66). Extraperitoneal access is achieved via the posterior vagina. Compared with other vaginal suspension procedures, the iliococcygeal suspension has the fewest case series in the literature (65–67); however, cure rates appear comparable to the sacrospinous suspension technique (51). The dissection of the area to the ischial spine is approached from a midline posterior vaginal wall incision using the ischial spine as a landmark for identifying the sacrospinous ligament and the iliococcygeal fascia anteriorly and caudad to it. A no. 1 polydioxanone suture is placed through the fascia and attached to the vaginal apex as a pulley stitch. This procedure is more easily performed bilaterally than the sacrospinous suspension and should be considered preferentially in the presence of a shortened vagina. Risk of major vessel, nerve, or ureteral injury


Gynecology_Novak

Gynecology_Novak. is more easily performed bilaterally than the sacrospinous suspension and should be considered preferentially in the presence of a shortened vagina. Risk of major vessel, nerve, or ureteral injury should be relatively low compared with other transvaginal suspensions.


Gynecology_Novak

Gynecology_Novak. Surgical variations of the uterosacral ligament suspension originally described in 1938 have been used prophylactically during hysterectomy or therapeutically for vaginal apical suspension (68).


Gynecology_Novak

Gynecology_Novak. A therapeutic procedure in which the vaginal apex is suspended to the uterosacral ligaments above the level of the ischial spines had excellent success rates in an observational study of 302 participants (69). When access to the posterior cul-de-sac is attained, the uterosacral ligament remnant can usually be found adjacent to the pelvic sidewall peritoneum just cephalad to the palpable ischial spine. Up to three sutures are placed in each ligament and incorporated into the anterior and posterior fibromuscular layer of the vagina. Some surgeons approximate the ligaments in the midline to close the cul-de-sac with the intention to treat or prevent enterocele formation (70). Other surgeons suspend the right and left vaginal apex to the ipsilateral uterosacral ligament, leaving the cul-de-sac open to avoid impinging on the rectum and adversely affecting bowel function.


Gynecology_Novak

Gynecology_Novak. Outcome studies have shown that recurrent apical prolapse occurs in 2% to 5% of cases within the first few years following the procedure, which is a rate comparable or superior to other transvaginal apical repairs, and the incidence of recurrent anterior defects may be less than that reported with sacrospinous suspensions (69,71). The most common serious complication was ureteral obstruction secondary to ureteral kinking or incorporation of an ureter in a suspension stitch. This occurred in as many as 11% of cases (71). Intraoperative cystoscopy— with documentation of ureteral patency after administration of indigo carmine dye, whereby such a problem can be corrected—is recommended.


Gynecology_Novak

Gynecology_Novak. Multiple sutures may increase the incidence of tissue devascularization and necrosis, thus resulting in failure of the suspension. One case series of bilateral single suture uterosacral suspensions demonstrated a 15% stage I and no stage II recurrence among 71 women with a mean follow-up of 21.3 months (72). Exposure can be accomplished through the vaginal cuff after hysterectomy, a transverse incision at the vaginal cuff in cases of vaginal vault prolapse or descent, and, rarely, through a posterior colpotomy when uterine or cervical conservation is desired. When the apical vaginal wall is attenuated, it is excised. The pelvic sidewall, lateral to the sigmoid colon, is exposed using Breisky-Navratil retractors and a pack to hold the small bowel cephalad and to place the sigmoid colon and sidewall peritoneum on stretch (Fig. 27.12A). After palpation of the ischial spine, single permanent sutures of 0 or 1 polypropylene are placed through the peritoneum and adjacent ligament


Gynecology_Novak

Gynecology_Novak. colon and sidewall peritoneum on stretch (Fig. 27.12A). After palpation of the ischial spine, single permanent sutures of 0 or 1 polypropylene are placed through the peritoneum and adjacent ligament approximately 1 cm cephalad to and at the same posterior level as the ischial spines. Traction on the sutures and palpation of the site should reveal that the sutures are firmly attached to the ligamentous structures. The sutures are tagged for use after repair of defects of the anterior compartment. The peritoneum is dissected off the vaginal fibromuscular wall posterior to the vaginal cuff. The suspension sutures are then secured with large bites into the posterior vaginal fibromuscular tissue and anterior fibromuscular tissue, then locked in place to approximate anterior to posterior connective tissue and to fix the suture to the vaginal apex so that it may be moved up to the ligament (Fig. 27.12B). If a rectovaginal enterocele is present, it is dissected, reduced, and closed,


Gynecology_Novak

Gynecology_Novak. connective tissue and to fix the suture to the vaginal apex so that it may be moved up to the ligament (Fig. 27.12B). If a rectovaginal enterocele is present, it is dissected, reduced, and closed, approximating the prerectal fascia or anterior rectal wall to the posterior fibromuscular vaginal tissue just caudad to the suspension sutures. Absorbable cuff closure sutures are placed at each cuff angle and one to two bites are taken to approximate anterior to posterior vaginal cuff over the suspension suture sites. When indicated, plication of the central cuff anterior to the posterior fibromuscular tissue with a box stitch is also performed. These sutures are secured after the suspension (pulley) sutures are tied, then cuff closure is completed from each side with the absorbable sutures in a running fashion. Cystoscopy is performed to document ureteral patency. Ureteral compromise has been noted in only 2 of 150 cases performed. The procedure provides adequate support of POP-Q point C


Gynecology_Novak

Gynecology_Novak. a running fashion. Cystoscopy is performed to document ureteral patency. Ureteral compromise has been noted in only 2 of 150 cases performed. The procedure provides adequate support of POP-Q point C and D in all 58 subjects evaluated more than 1 year postoperatively (72).


Gynecology_Novak

Gynecology_Novak. Figure 27.12 Diagrams illustrating open vaginal apical area with (A) exposure of site for suture placement or lateral pelvic side wall and (B) suture placement through ligament then through the posterior and anterior paravaginal tissue where they are locked to enable pulley action to the ligaments when tied. (Redrawn from an image by J. Taylor.) Figure 27.12 (continued ) The Anterior Compartment


Gynecology_Novak

Gynecology_Novak. Anterior Vaginal Anatomic correction of an anterior defect or cystocele will generally relieve symptoms Colporrhaphy of protrusion and pressure and usually will improve micturition function when abnormal micturition is associated temporally with the defect and if there is no associated neuropathy. If a single, well-defined midline defect is recognized, excision of the weak vaginal wall and an imbricating closure of the defect may be performed. Most central anterior defects require a more extensive dissection of the vesicovaginal space. Following this dissection, many surgeons then separate the vaginal mucosa and submucosal layers from the fibromuscular layer out to a point lateral to the defect, followed by midline plication of this tissue, then excision of excess epithelium, and closure (72–78). It appears important to maintain the continuum of repaired fibromuscular tissue to a well-supported vaginal apex. If the repair is being performed simultaneously with a vaginal apical


Gynecology_Novak

Gynecology_Novak. (72–78). It appears important to maintain the continuum of repaired fibromuscular tissue to a well-supported vaginal apex. If the repair is being performed simultaneously with a vaginal apical suspension, the anterior colporrhaphy is typically performed after the apical support sutures have been placed and prior to tying them down. The dissection is carried out starting from the everted vaginal cuff edge and dissecting toward the bladder neck. A high central defect may also be corrected via a transabdominal approach by dissecting between the base of the bladder and the upper one-third of the anterior vaginal wall. The defective tissue may then be wedged out and the defect closed with running or interrupted sutures. This approach may be of use when performing transabdominal procedures for apical suspension.


Gynecology_Novak

Gynecology_Novak. If the patient has significant stress incontinence (based on report or the presence of occult or potential incontinence), an appropriate bladder neck suspension may be performed simultaneously with the anterior repair. When performing midurethral sling procedures, it may be preferable not to extend the repair procedure below the urethra, but instead to make a separate incision for the sling. Maintaining some degree of the urethrovesical angle may improve the results of any incontinence procedure. If the patient has voiding dysfunction (reports of incomplete emptying and a high residual urine) and stress incontinence, appropriate urodynamic evaluation should be performed before a procedure is selected, and the patient should be made aware of the potential for continued problems after surgery (78).


Gynecology_Novak

Gynecology_Novak. Recurrence rates of traditional “fibromuscular plication” anterior repairs vary from 3% to 92%; however, studies define recurrence in numerous ways, from minimal prolapse to stage III descent (63,73–81). The clinical significance of recurrent mild cystoceles (stage I) that are asymptomatic is debatable because many of these defects do not progress to larger ones. When traditional anterior repairs are performed in patients with POP-Q stage II or greater cystoceles (frequently concurrently with other procedures), a 20% recurrence rate of stage II or greater prolapse is not uncommon, although overall recurrence rates as low as 3% have been reported (76). Many studies do not define how the participants were evaluated postoperatively and vary with respect to patient populations, type and severity of defects, presence of concurrent defects, surgical technique, and follow-up time and length. Some studies have suggested higher recurrence rates when these repairs are performed concurrently


Gynecology_Novak

Gynecology_Novak. of defects, presence of concurrent defects, surgical technique, and follow-up time and length. Some studies have suggested higher recurrence rates when these repairs are performed concurrently with sacrospinous suspensions and hypothesize that this type of apical suspension may predispose the repaired anterior wall to greater pressure transmission (63,64). These studies may show higher failure rates because patients having such concurrent repairs may be more likely to have more complicated forms of prolapse or more extensive pelvic ﬂoor defects than other patients.


Gynecology_Novak

Gynecology_Novak. Paravaginal Repair The paravaginal or “lateral defect” repair involves reattachment of the anterior lateral vaginal sulcus to the obturator internus fascia and, in some cases, muscle at the level of the arcus tendineus pelvis (“white line”) (82,83). It is usually performed as a bilateral procedure via transvaginal or retropubic (abdominal or laparoscopic) access. The procedure essentially restores normal anatomy; however, because it is not practical to rebuild the defective endopelvic–fascial bridge to the pelvic sidewall, it attaches the vaginal wall itself. Observational studies have reported good success with this procedure (80%–95%); however, long-term data on durability and function are lacking (12,84–88). Most women with anteriolateral detachments usually have separation of the upper vaginal fornices from the arcus tendineus immediately adjacent to the ischial spine (Fig. 27.13) (89). Thus, it is important to resuspend those specific areas.


Gynecology_Novak

Gynecology_Novak. It is difficult to achieve optimal results when the paravaginal repair is used in combination with traditional central repairs because of the creation of tension on opposing suture lines. A repair that removes a weakened central vaginal wall may decrease the side-to-side dimensions of the anterior vaginal wall, making it difficult to suspend its lateral points more laterally. When large central defects coexist with lateral defects, one option is an extensive central repair accompanied by an apical support procedure. This changes the shape of the vagina to a more cylindrical structure. Another choice is placement of a graft to span the entire anterior rhomboid-shaped plate, thus augmenting anterior paravaginal tissue strength. The graft with tension adjusted may be anchored to the arcus tendineus along with the adjacent vaginal wall from the level of the pubic rami to the ischial spine (88).


Gynecology_Novak

Gynecology_Novak. Figure 27.13 Schematics illustrating normal attachments of the anterior fibromuscular vaginal plane (A and C) and bilateral detachments of that plane from the arcus tendineus up to the level of the ischial spines (B and D). Note: For B and D to occur, there will either be concurrent apical descent or a detachment of the upper fibromuscular plane from the apical structures. (From Delancey JO. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;187:93–98, with permission.) Although most reports indicate that repair of anterior defects with all of these procedures relieves symptoms directly related to prolapse, there are very few data on patient satisfaction and qualityof-life improvement over time (88).


Gynecology_Novak

Gynecology_Novak. as much of this tissue as possible attached laterally to the levator fascia. After obvious defects in the rectal muscularis are repaired, the fascia is then plicated in the midline with interrupted or continuous sutures. The authors prefer delayed absorbable sutures for this plication. Permanent nonbraided suture material also can be used. Braided permanent suture material is associated with a greater incidence of stitch infection and formation of granulation tissue (91). The vaginal epithelium is trimmed and closed with absorbable sutures.


Gynecology_Novak

Gynecology_Novak. When a defective perineal body or perineal membrane is present, reconstruction is performed after accompanying posterior colporrhaphy. The superficial muscles of the perineum and bulbocavernous fascia are plicated in the midline and the skin closed as in an episiotomy repair. Detachments of the inferior portion of the Denonvillier’s fascia from the perineal body are also corrected. The puborectalis muscles are plicated concurrently with these procedures by some surgeons, but this approach is associated with a high incidence of sexual dysfunction and thus is not recommended routinely (91). It may be worth consideration in patients who have severe prolapse accompanied by a large genital hiatus with palpable levator weakness or who are unable to contract their pelvic ﬂoor muscles. Sutures should be placed carefully through the puborectalis muscles at least 3 cm or greater posterior to their insertion on the pubic rami, thereby decreasing the tension of the plication. For those women with


Gynecology_Novak

Gynecology_Novak. be placed carefully through the puborectalis muscles at least 3 cm or greater posterior to their insertion on the pubic rami, thereby decreasing the tension of the plication. For those women with an enlarged hiatus and weakened puborectalis muscles who desire sexual function, an attempt can be made to plicate the muscles far enough posteriorly to allow two fingers to easily pass through the vaginal introitus and to reconstruct the distal posterior vagina and perineum, whereby there will not be a ledge at the site of the puborectalis plication (91). Outcome data on such procedures are inadequate to make conclusions regarding its efficacy; however, it is reasonable to postulate that pelvic ﬂoor defects producing an enlarged genital hiatus are common reasons for failure of support procedures, and puborectalis plication may decrease the incidence of such failures.


Gynecology_Novak

Gynecology_Novak. A complete review of rectocele, anorectal functional disorders, and various repairs can be found elsewhere (92). Reported anatomic cure rates for traditional posterior colporrhaphy have ranged from 76% to 90% with variable follow-up intervals (93–97). Most studies show a benefit in ease of defecation if patients are using splinting preoperatively; however, overall defecatory dysfunction (defined as constipation) was not relieved in most patients and increased (approximately 30%) after the procedure in one study (95). These repairs appear to have little to no benefit in the treatment of fecal incontinence. It is not surprising that the repairs are not particularly effective for defecatory dysfunction related to disorders of constipation or for fecal incontinence because these problems have multifactorial causes. De novo dyspareunia is reported to occur in 8% to 26% of sexually active patients who have traditional posterior colporrhaphy and is not always associated with levator


Gynecology_Novak

Gynecology_Novak. have multifactorial causes. De novo dyspareunia is reported to occur in 8% to 26% of sexually active patients who have traditional posterior colporrhaphy and is not always associated with levator plication procedures (93–96,98,99). Potential causes for dyspareunia, other than vaginal strictures or introital tightness, include scarring with immobility of the vaginal wall, levator spasm, and neuralgia associated with sutures or dissection. Dyspareunia also may occur when a Burch procedure or other procedures that anteriorly displace the vaginal canal are combined with a posterior repair (96). Careful surgical technique and appropriate choice of procedure should decrease the incidence of postoperative dyspareunia.


Gynecology_Novak

Gynecology_Novak. Defect or site-specific posterior repairs are restorative procedures by which posterior defects are corrected. These repairs begin with midline posterior vaginal incision through the epithelium and continue with separation of the epithelium from the fibromuscular wall. After irrigation to provide better exposure, a finger is inserted into the rectum to help define defects of the rectal wall and the fibromuscular layer that has been dissected from the vaginal wall submucosa. The specific defects are closed with either interrupted or running sutures (preferably the delayed absorbable type). Defect closure is accomplished in such a way as to minimize tension on the surrounding tissue and may involve vertical, horizontal, or oblique approximation. When fibromuscular tissue has separated from the perineum, the upper anterior rectum, or a well-supported cervix or vaginal cuff, it is important to reapproximate these connections. Repairs of coexistent perineal and apical support defects are


Gynecology_Novak

Gynecology_Novak. the perineum, the upper anterior rectum, or a well-supported cervix or vaginal cuff, it is important to reapproximate these connections. Repairs of coexistent perineal and apical support defects are important. The object of the surgery is to reestablish an intact plane of connective tissue that positions the rectum against the pelvic ﬂoor and obliterates any potential space between a well-supported cervix or vaginal cuff and the cephalad edge of the tissue plane and upper rectum. The technique should minimize tension and potential strictures, which may be more likely to occur with traditional posterior colporrhaphy (97).


Gynecology_Novak

Gynecology_Novak. Initial case series reveal anatomical cure rates with mean follow-up times less than 18 months from 82% to 100% and de novo dyspareunia rates of 2% to 7%, which are much lower than those seen with traditional repairs (99–103). Symptom relief appears to be as good or better than that seen with traditional repairs. The greatest concern with these and other procedures has been durability. A recent report indicates that the recurrence rate of rectocele beyond the midvaginal plane was higher with defect-specific posterior repairs than with side-to-side plication procedures using laterally attached fascia pulled to the midline (33% vs. 14%) and beyond the hymenal ring (11% vs. 4%) (97). The study was not randomized; however, the procedures were performed during the same period with consistent follow-up evaluations 1 year after surgery. Symptoms (dyspareunia, constipation, and fecal incontinence) after surgery did not differ between the two groups. Long-term follow-up of previously reported


Gynecology_Novak

Gynecology_Novak. evaluations 1 year after surgery. Symptoms (dyspareunia, constipation, and fecal incontinence) after surgery did not differ between the two groups. Long-term follow-up of previously reported case series that had good short-term success or prospective randomized trials looking at modifications of traditional repairs versus defect-specific repairs should clearly delineate durability of these procedures.


Gynecology_Novak

Gynecology_Novak. The aim of transanal rectocele repair, usually performed by colorectal surgeons rather than gynecologists, is to remove or plicate redundant rectal mucosa, to decrease the size of the rectal vault, and to plicate the rectal muscularis. The rectovaginal adventitia and septum are plicated as well, probably along with the posterior vaginal muscularis. The vaginal epithelium is not incised or excised with this procedure, which probably accounts for the reported lack of adverse affects on sexual function in contrast to the vaginal approach to posterior repair. Two randomized trials and several case series from transanal repairs with mean follow-up intervals of 12 to 52 months report anatomic cure rates of 70% to 98%, improved constipation and fecal incontinence, with less need for vaginal digitation to expel stool (104–108). Complications included infections and rectovaginal fistulas, which are surprisingly rare in the reported series. From the gynecologic perspective, transanal posterior


Gynecology_Novak

Gynecology_Novak. to expel stool (104–108). Complications included infections and rectovaginal fistulas, which are surprisingly rare in the reported series. From the gynecologic perspective, transanal posterior repair is an option only when the procedure is performed for defecatory dysfunction and not for prolapse of the posterior vaginal wall. The question remains whether the transanal approach with defect excision and repair improves defecatory dysfunction better than a defect-specific transperineal or transvaginal approach with imbrication of tissues to correct palpable weakness in the rectal wall and its adjacent connective tissues.


Gynecology_Novak

Gynecology_Novak. Graft materials have been employed in repairing defects or hernias throughout the body. The purpose of grafts is to either completely replace “weak” tissue by spanning across that tissue or to provide a scaffold for fibroblast infiltration. The patient’s own connective tissue may grow into the graft, and, if the graft is degradable, replace the graft as a supportive structure. An ideal graft material should (i) be nonantigenic, (ii) exhibit a low infection rate, (iii) decrease or negate recurrence of anatomic defects, (iv) cause no harm with respect to bowel or renal function, and (v) be relatively inexpensive. Graft materials include autologous tissues, cadaveric allografts and fascia, dermis and other connective tissues, xenografts from animal sources, and various synthetic materials. Allografts and xenografts are treated with processes to remove living cells, thus negating their antigenic potential and allowing them to serve as a temporary connective tissue scaffold. It is assumed


Gynecology_Novak

Gynecology_Novak. and xenografts are treated with processes to remove living cells, thus negating their antigenic potential and allowing them to serve as a temporary connective tissue scaffold. It is assumed that fresh, autologous grafts work similarly; however, there may be some fibroblast survival in fresh harvested tissue. Autologous grafts have limitations in size and shape compared with tissue taken from cadaveric or animal sources. Synthetic grafts are permanent and, as long as the tissues to which they are secured retain their position and strength, they should be durable. Autografts, allografts, and xenografts depend on adequate tissue growth from the subject and potentially may have higher failure rates than synthetic ones. Synthetic grafts are more subject to erosion. Graft erosion may produce bothersome discharge, pain, and sexual dysfunction with vaginal scarring. This may be more likely to occur in women with attenuated, scarred, or less vascular tissue at the time of the repair. More


Gynecology_Novak

Gynecology_Novak. bothersome discharge, pain, and sexual dysfunction with vaginal scarring. This may be more likely to occur in women with attenuated, scarred, or less vascular tissue at the time of the repair. More loosely woven polypropylene meshes appear to exhibit fewer problems with erosion and infection than the synthetic graft material that was previously used (109–113).


Gynecology_Novak

Gynecology_Novak. Midurethral sling procedures that use such mesh have reported erosion rates of 1% or less as compared with rates as high as 6% with more tightly woven polypropylene and polyethylene grafts (109–113). A greater incidence of graft infection has been reported when other synthetic grafts are used. One would expect higher rates of erosion and infection when large pieces of graft material are used adjunctively to the vaginal wall; however, there have been favorable reports in which loosely woven polypropylene mesh was used in this manner. Small areas of eroded polypropylene graft may be removed with the surrounding tissue to the point where there is good tissue growth into the graft, and the defect can then be closed. Graft erosion into the bladder, urethra, or rectum is less common than into the vagina. When erosion occurs, however, management is more difficult and long-term adverse effects more common. Numerous surgeons have been reticent to use synthetic graft materials to augment


Gynecology_Novak

Gynecology_Novak. into the vagina. When erosion occurs, however, management is more difficult and long-term adverse effects more common. Numerous surgeons have been reticent to use synthetic graft materials to augment paravaginal musculoconnective tissue support because of complications from erosion. There remains a need for long-term follow-up on patients who have repairs with graft material, not only to assess anatomical results and complications, but also to assess subsequent sexual function, presence and absence of pain, and patient satisfaction.


Gynecology_Novak

Gynecology_Novak. Synthetic transvaginal mesh kits have become commonplace in the treatment of pelvic organ prolapse. These devices were quickly adopted by many surgeons in an effort to improve outcomes, particularly in patients who had failed native tissue repairs. Studies have provided mixed results as to the effectiveness of these devices. There may be a lower recurrence rate in the anterior compartment when compared with native tissue repairs; however, mesh erosions occur in 2% to 19% of those treated (109–113). The severity of mesh erosions ranges from subclinical to severe dyspareunia requiring surgical resection. Small mesh erosions are sometimes successfully managed with vaginal estrogen alone. As with anterior compartment procedures, graft materials have been used to improve the success of posterior compartment repairs. One recent systematic review concluded that there is insufficient evidence to evaluate the use of synthetic mesh in the repair of pelvic organ prolapse (114). It is also


Gynecology_Novak

Gynecology_Novak. compartment repairs. One recent systematic review concluded that there is insufficient evidence to evaluate the use of synthetic mesh in the repair of pelvic organ prolapse (114). It is also notable that the U.S. Food and Drug Administration (FDA) has recently released a warning about complications that may arise from the use of transvaginal mesh procedures for pelvic organ prolapse.


Gynecology_Novak

Gynecology_Novak. The FDA recommendations are that physicians should: 1. Obtain specialized training for each mesh placement technique, and be aware of its risks. 2. Be vigilant for potential adverse events from the mesh, especially erosion and infection. 3. Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder, and blood vessel perforations. 4. Inform patients that implantation of surgical mesh is permanent, and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication. 5. Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring, and narrowing of the vaginal wall (in POP repair).


Gynecology_Novak

Gynecology_Novak. In summary, transvaginal mesh procedures that are currently in use utilize predominantly synthetic materials. These devices may reduce recurrence of pelvic organ prolapse and are associated with some risk of vaginal mesh extrusion and chronic pain or dyspareunia. Patients should be counseled extensively about the risks and benefits of the use of these devices. Surgeons who use these devices should carefully follow their cases to identify complications.


Gynecology_Novak

Gynecology_Novak. Abdominal uterosacral colposuspension has been used prophylactically after hysterectomy and therapeutically for apical prolapse with cardinal/uterosacral defects (115). It can be performed through laparotomy incisions or by laparoscopic techniques. For the therapeutic procedure, a no. 1 polypropylene or delayed absorbable suture is placed cephalad and at the same level posterior as the ischial spines, which may be palpated transabdominally or with a vaginal finger to push a vaginal fornix to the spine under observation with a laparoscope. One technique is to place one or two permanent sutures through one ligament, then, after reefing across the culde-sac peritoneum at the sigmoid border, through the contralateral ligament, and then through the fibromuscular tissue just anterior to the vaginal cuff. Tying the suture suspends the vaginal cuff and obliterates any enterocele defect. Another technique employs separate sutures placed at the same level into each uterosacral ligament and


Gynecology_Novak

Gynecology_Novak. vaginal cuff. Tying the suture suspends the vaginal cuff and obliterates any enterocele defect. Another technique employs separate sutures placed at the same level into each uterosacral ligament and anchored anteriorly and posteriorly to the ipsilateral side of the vaginal cuff, similar to procedures performed transvaginally. Cystoscopy is performed after the procedure to document ureteral patency. One study found subjective and objective recurrence rates to be low (12% and 5%, respectively) (115).


Gynecology_Novak

Abdominal Approach to Posterior Repair

Gynecology_Novak. Abdominal Approach to Posterior Repair


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Gynecology_Novak. When abdominal sacrocolpopexy is planned for apical vaginal prolapse and concomitant rectocele is present, some have advocated extending the posterior graft down the posterior vaginal wall to correct the defect (116). The technique of sacral colpoperineopexy is used to replace the normal vaginal suspensory ligaments and to augment or replace the posterior fibromuscular plane with graft material that runs from the sacrum to the perineal body (116). Its purpose is to correct the posterior compartment defects and to suspend the perineal body, thus preventing descent and opening of the genital hiatus. It has been performed transabdominally or as a combined abdominal and vaginal procedure with both Mersilene mesh and dermal allografts (116,117). Mesh erosion occurred frequently when the vagina was open: 16% for vaginal placed sutures and 40% for transvaginally placed mesh (117). The use of dermal allografts results in an anatomical cure rate of 82% with short-term follow-up and a mean of


Gynecology_Novak

Gynecology_Novak. was open: 16% for vaginal placed sutures and 40% for transvaginally placed mesh (117). The use of dermal allografts results in an anatomical cure rate of 82% with short-term follow-up and a mean of 12 months following surgery (116,117). Significant improvements also were seen in bowel symptoms. One author reported results on 205 of 236 subjects who underwent an abdominal sacral colpoperineopexy with polypropylene mesh (Marlex) without opening the vagina (118). This procedure included two straps of mesh attached from the lateral anterior vagina to Cooper’s ligament. Ten-year satisfaction rates were 68%, and erosion rates were 5%.


Gynecology_Novak

Gynecology_Novak. Laparoscopic Approach Laparoscopic rectocele repair involves the dissection of the rectovaginal space to the perineal to Posterior Repair body with either plication of levator fascia or suturing absorbable or permanent mesh in place (119,120). A few small case series have been reported with variable results.


Gynecology_Novak

Gynecology_Novak. The standard approach to transabdominal apical vaginal suspension procedures is the abdominal sacrocolpopexy. A complete review of published data on these procedures developed by the Pelvic Floor Disorders Network, which is sponsored by the National Institute of Child Health and Human Development (NICHD), has been published (121). These procedures use graft material attached to the prolapsed region of the anterior and posterior vaginal walls at or encompassing the vaginal apex and suspended to the anterior longitudinal ligament of the sacrum. Cervical sacral suspensions may also be performed when uterine or cervical conservation is desired. Surgical variations abound and include configuration of the graft on the vagina, the extent to which the anterior and posterior vagina are attached to the graft, variable graft and suture materials, presence or absence of peritoneal closure over the graft, and obliteration of the culde-sac for treatment or prevention of the enterocele or


Gynecology_Novak

Gynecology_Novak. to the graft, variable graft and suture materials, presence or absence of peritoneal closure over the graft, and obliteration of the culde-sac for treatment or prevention of the enterocele or sigmoidocele. A thorough preoperative evaluation is important to exclude more distal defects or stress incontinence, which should be repaired concurrently, and other lower urinary tract or anorectal problems. In published reports, cure rates for apical prolapse range from 78% to 100% (most greater than 90%); when cure is defined as no postoperative prolapse, the range widens from 56% to 100%, although subsequent anterior or posterior vaginal prolapse has not been as consistently reported as has apical prolapse (122–131). Potential advantages of this procedure over transvaginal procedures are less paravaginal scarring and denervation than may be present with transvaginal approaches, and fixation of the entire vaginal apical area by a permanent piece of material to a stable structure (the anterior


Gynecology_Novak

Gynecology_Novak. scarring and denervation than may be present with transvaginal approaches, and fixation of the entire vaginal apical area by a permanent piece of material to a stable structure (the anterior sacral ligament), which may be more durable than the transvaginal techniques that use the patient’s own connective tissue.


Gynecology_Novak

Gynecology_Novak. Complications of these procedures include (i) erosions of graft material or suture material, which may be caused by graft or suture infection usually secondary to vaginal wall penetration, or performing the procedure adjacent to a vaginal incision, or securing the graft to an attenuated avascular wall with inadequate fibromuscular tissue (3.4%); (ii) significant intraoperative hemorrhage (especially in the presacral space) (4.8%); (iii) postoperative ileus, which may be secondary to the need for excessive packing of the bowel or to extensive Halban or Moschcowitz culdoplasty procedures (3.6%); (iv) small bowel obstruction, requiring reoperation (1.1%); (v) development of intra-abdominal adhesions with resultant pain and bowel dysfunction (unknown incidence); and (vi) wound complications, such as seromas and infections (4.6%) (120).


Gynecology_Novak

Gynecology_Novak. Several management techniques have been advocated to minimize these problems. Empiric ways to prevent graft erosions include (i) preoperative tissue optimization with vaginal administration of estrogen and treatment of vaginitis and infection of eroded areas; (ii) the use of small-gauge monofilament sutures placed in the fibromuscular tissue, thus avoiding full thickness passage; and (iii) excision of a portion of the vaginal apex when the vaginal wall is thin and depleted of its fibromuscular layer and vascularity. Graft attachment to “healthy” fibromuscular tissue rather than to thin avascular tissue should help prevent erosion. If such excision is necessary, or if the suspension is to be performed concurrently with a hysterectomy, good approximation of the fibromuscular layers above the mucosa, thorough irrigation, prophylactic use of antibiotics, and avoidance of graft placement across the suture line may decrease the likelihood of graft erosion. Choice of graft material may also


Gynecology_Novak

Gynecology_Novak. mucosa, thorough irrigation, prophylactic use of antibiotics, and avoidance of graft placement across the suture line may decrease the likelihood of graft erosion. Choice of graft material may also be important. One would expect synthetic grafts to have greater durability than tissue grafts; however, erosion rates are more serious with the synthetic grafts. Anecdotally, some surgeons are convinced that less porous graft material, such as GORE-TEX, has a greater likelihood of becoming infected and eroding than do macroporous, filamentous polypropylene meshes. Numerous case series report serious episodes of hemorrhage from the presacral venous plexus (mean incidence 4.8%; range 0.18%– 16.9% of sacrocolpopexies requiring, at a minimum, transfusion) (121). This problem is less likely if dissection and graft fixation is limited to the level of S1 and S2 just caudad to the promontory and with the use of good light and meticulous dissection techniques to expose the anterior sacral ligament.


Gynecology_Novak

Gynecology_Novak. Careful tissue handling and packing technique may minimize postoperative ileus and adhesions. Incorporation of the sigmoid into a closure of the cul-de-sac posterior to the graft may also slow bowel function postoperatively. Small bowel obstruction has resulted from direct adhesive processes involving grafts to small bowel (120). Complete extra peritonealization of the graft using ﬂaps of peritoneum dissected from the prolapsed area and the peritoneum anterior to the sacral promontory and lateral to the right side of the sigmoid colon should prevent this complication. However, loops of bowel have been seen to prolapse through small defects in peritoneal closure with the same effect. Careful technique with adherence to basic surgical principles may help prevent this and other complications related to laparotomy.


Gynecology_Novak

Gynecology_Novak. As with most pelvic operations, sacrocolpopexy has been successfully accomplished by the laparoscopic and robotic route and has the potential to offer patients the benefits of less postoperative discomfort and faster recovery as well as potential lower risks for adhesions and ileus. Outcomes depend on the expertise and experience of the surgeon; “cutting corners” to shorten the procedure could affect anatomical success. The applicability of the laparoscopic technique is limited by the need for a relatively high level of technical skill. In the authors’ experience, ipsilateral suturing (through same sided ports) is preferred to contralateral suturing. The authors have also found that straight self-righting needle drivers and non-self-righting curved needle drivers are useful in attaching the mesh to the vagina. The Carter-Thompson suturing device is sometimes helpful to aid in elevating the sigmoid colon away from the pelvic cul-desac by tagging the peritoneal edge. The robot has


Gynecology_Novak

Gynecology_Novak. the mesh to the vagina. The Carter-Thompson suturing device is sometimes helpful to aid in elevating the sigmoid colon away from the pelvic cul-desac by tagging the peritoneal edge. The robot has provided an easier platform for a minimally invasive approach to the sacrocolpopexy. Data about its use are limited to several case series that demonstrate comparable short-term results with open and laparoscopic techniques (121).


Gynecology_Novak

Gynecology_Novak. For sacrocolpopexy, whether through laparotomy or laparoscopy, the pelvis should be completely exposed with the lower sigmoid colon stretched cephalad (Fig. 27.14). 1. With a vaginal obturator (an EEA sizer) placed vaginally to visualize the area that is not covered by the bladder or rectum, the peritoneum is dissected from the underlying vaginal fibromuscular layer anteriorly to bladder reﬂection and posteriorly at least to the level of the sigmoid rectal junction, creating bilateral peritoneal ﬂaps. Laterally, vascular bundles are visible. 2.


Gynecology_Novak

Gynecology_Novak. 2. Two separate loosely woven polypropylene mesh grafts are shaped similar to boat paddles. The “paddle” portions are shaped to cover the areas anterior to the apex and posterior to the apex, respectively, and the “handles,” which are approximately 8 to 10 cm in length and 1 cm wide, are anchored to the anterior sacral ligament. The paddle portions are secured circumferentially to the fibromuscular layers anteriorly and posteriorly with six to eight monofilament 3-0 nylon sutures and one or two sutures placed centrally (Fig. 27.14A). 3. When the fibromuscular tissue in the area is attenuated, a portion of the vaginal wall is excised and closed, as noted previously. 4. The peritoneum overlying sacral vertebrae 1 and 2 is incised while retracting the sigmoid colon to the left, and careful dissection is employed down to the anterior ligament. Care is taken to stay well medial to the right ureter and hypogastric vessels.


Gynecology_Novak

Gynecology_Novak. Figure 27.14 Sacrocolpopexy. A: Illustrates (i) graft attachment to the posterior area of prolapsed vagina to or below the rectal-sigmoid junction after the overlying peritoneum has been dissected and ﬂapped laterally and (ii) exposure of the presacral space with suture placement through the anterior sacral ligament. An appropriately shaped second graft is placed anteriorly. B: Illustrates attachment of both grafts without tension to the sacrum. Prevention of subsequent enterocele and/or sigmoidocele is accomplished by box closure of the cul-de-sac peritoneum lateral to the left side of the sigmoid, attachment of the presigmoid fat to the graft centrally, and reperitorealization of the graft through the right side of the cul-de-sac. EEA, end-to-end anastomosis sizer. (Redrawn by J. Taylor.) 5.


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Gynecology_Novak. Hemoclips are placed caudad and cephalad on the middle sacral vessels if it is felt that this will allow more optimal suture placement. The peritoneal incision is extended into the right cul-de-sac area adjacent to the sigmoid. 6. Closure of the cul-de-sac lateral to the sigmoid on the left and approximation of the distal presigmoid fat to the distal edge of the posterior graft is accomplished with box stitches of 0-delayed absorbable sutures. It is thought that these procedures and the retroperitonealization of the graft through the right side of the cul-de-sac will prevent posterior enterocele and sigmoidocele as well as a Halban or Moschcowitz procedure. Figure 27.14 (continued ) 7. The two “handle” ends of the graft are then brought to the point of sacral attachment, where their length is adjusted to remove any tension on the vaginal sutures and secured to the anterior sacral ligament with no. 1 permanent braided nylon sutures (Fig. 27.14B). 8.


Gynecology_Novak

Gynecology_Novak. 8. Reperitonealization of the graft is then performed using the right cul-de-sac peritoneum and peritoneal ﬂaps dissected from the vaginal apical area; occasionally presigmoid fat is used. Following this procedure, adjunctive procedures, such as paravaginal repair, Burch procedure, midurethral sling, and any transvaginal procedure that is indicated, are performed. When rectocele and pelvic ﬂoor defects are present, one option is the sacral colpoperineopexy, as discussed in the posterior compartment section (116). A vaginal pack is inserted for approximately 24 hours to ensure that the graft is well applied to the fibromuscular layer at points other than where sutures are placed.


Gynecology_Novak

Gynecology_Novak. Colpocleisis or vaginal narrowing procedures may be appropriate choices for debilitated patients who do not desire vaginal function, because complete vaginal reconstructive procedures may last several hours and are associated with potentially higher blood loss and increased morbidity (132,133). Many variations exist, from partial colpocleisis (where some portion of the vaginal epithelium is left to provide drainage tracts for cervical or upper genital discharge) to total colpectomy (where all of the vaginal epithelium is removed from the hymen posteriorly to within 0.5–2 cm of the external urethral meatus anteriorly). If hysterectomy is performed, blood loss is greater and operative time is longer than procedures without hysterectomy (134). These techniques should include a high perineorrhaphy and often a plication of


Gynecology_Novak

Gynecology_Novak. Management of Urinary Symptoms with Pelvic Organ Prolapse Repair the puborectalis muscles to reinforce posterior support and to reduce the genital hiatus, with the goal of decreasing the chance of recurrent prolapse. Case series have reported success rates as high as 100%, although the population of patients, by nature of their relatively short life expectancy and limited activity, are probably at lower risk for recurrence. In some instances in which most of the defects are anterior and posterior, a modified anterior and posterior colporrhaphy may be performed, whereby relatively large portions of the anterior and posterior vaginal wall are removed and closed, creating a narrow (1–2 cm diameter) cylindrical vagina. As with the colpocleisis, the success of the procedure is augmented by an extensive perineorrhaphy and puborectalis plication. Such a procedure may be performed quickly and with relatively low morbidity. The prevention or treatment of stress incontinence, voiding


Gynecology_Novak

Gynecology_Novak. by an extensive perineorrhaphy and puborectalis plication. Such a procedure may be performed quickly and with relatively low morbidity. The prevention or treatment of stress incontinence, voiding dysfunction, and colorectal dysfunction in the context of these procedures can be problematic. Careful preoperative history and evaluation, if indicated, is important so that additional conservative therapies or operative techniques such as pubourethral plications or less invasive tension-free slings may be employed.


Gynecology_Novak

Gynecology_Novak. All women who are undergoing surgery for repair of pelvic organ prolapse should be evaluated for urinary incontinence. Women who report stress urinary incontinence and who demonstrate it on preoperative examination and have no contraindications to a continence procedure should have concomitant procedures for the treatment of these symptoms. Women who do not report stress urinary incontinence may also benefit from a prophylactic procedure if they demonstrate incontinence with reduction of their prolapse. There is also evidence that the addition of a continence procedure in the absence of any evidence of urinary incontinence may improve outcomes without significantly increasing the number of complications (135). The addition of continence procedures to prolapse procedures in patients who have both significant stress incontinence and voiding dysfunction remains controversial. Comparison of Abdominal versus Vaginal Approaches


Gynecology_Novak

Gynecology_Novak. In recent years there has been controversy as to whether transvaginal or transabdominal procedures are best for prolapse. One cannot discern which is optimal from reports of retrospective and prospective case series because of the considerable differences in numerous factors, including follow-up, characteristics of the subjects, definitions of success and failure, and the expertise or experience of the surgeons performing the procedures. Three prospective randomized trials have compared sacrocolpopexy and sacrospinous suspension procedures (136–138). All three trials showed some increased durability in the sacrocolpopexy group; however, in one of these studies the differences were not statistically significant (138). In the study in which sexual function was examined, there was a greater incidence of dyspareunia in the transvaginal group (137). Most case series reveal that the incidence of serious complications, such as small bowel obstructions, significant hemorrhage, presacral graft


Gynecology_Novak

Gynecology_Novak. of dyspareunia in the transvaginal group (137). Most case series reveal that the incidence of serious complications, such as small bowel obstructions, significant hemorrhage, presacral graft infections, pulmonary embolus, and short-term problems (i.e., ileus, hernias, wound seromas or infections, and longer hospitalizations), are more likely to occur in the group undergoing sacrocolpopexy. Vaginal scarring, strictures, and vaginal wall erosions or granulation tissue appear more likely in the group undergoing transvaginal surgery. To date, there is no randomized comparison of vaginal procedures using high uterosacral suspensions and innovative repairs of the fibromuscular tissues, which are less likely to produce strictures than was the case 10 or more years ago.


Gynecology_Novak

Gynecology_Novak. Most pelvic surgeons would agree that (i) older, less healthy individuals who are more likely to have surgical and medical complications and cannot or will not tolerate a pessary would derive greater benefit from transvaginal approaches and occasionally obliterative approaches, and (ii) relatively healthy, sexually active women with relatively short vaginas and apical prolapse or with isolated apical defects would derive greater benefit from sacrocolpopexy. For the remainder of the patients with apical prolapse, with or without more distal defects, it would be ideal if surgeons were equally skilled, knowledgeable, and experienced in both abdominal and vaginal approaches to provide care that is truly individualized, rather than emphasizing one approach to the exclusion of another. 5. Luber KM, Boero S, Choe JY. The demographics of pelvic ﬂoor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496–1501. 6.


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Gynecology_Novak. 5. Luber KM, Boero S, Choe JY. The demographics of pelvic ﬂoor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496–1501. 6. Brubaker L. Controversies and uncertainties: abdominal versus vaginal surgery for pelvic organ prolapse. Am J Obstet Gynecol 2005;192:690–693. 7. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;186:1160–1166. 8. Gurel H, Gurel SA. Pelvic relaxation and associated risk factors: the results of logistic regression analysis. Acta Obstet Gynecol Scand 1999;78:290–293. 9. Swift SE, Pound T, Dias JK. Case-control study of etiologic factors in the development of severe pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:187–192. 10.


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Gynecology_Novak. 9. Swift SE, Pound T, Dias JK. Case-control study of etiologic factors in the development of severe pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2001;12:187–192. 10. Fornell EU, Wingren G, Kjolhede P. Factors associated with pelvic ﬂoor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiologic study. Acta Obstet Gynecol Scand 2004;83:383–389. 11. Moalli PA, Ivy SJ, Meyn LA, et al. Risk factors associated with pelvic ﬂoor disorders in women undergoing surgical repair. Obstet Gynecol 2003;101:869–874. 12. Young SB, Daman JJ, Bony LG. Vaginal paravaginal repair: one-year outcomes. Am J Obstet Gynecol 2001;185:1360–1366. 13. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568–573. 14. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976–983. 15.


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Gynecology_Novak. 14. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976–983. 15. Samuelsson EC, Arne Victor FT, Tibblin G, et al. Signs of genital prolapse in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180:299–305. 16. Beck RP. Pelvic relaxational prolapse. In: Kase NG, Weingold AB, eds. Principles and practice of clinical gynecology. New York: John Wiley & Sons, 1983:677–685. 17. Brubaker L, Bump R, Jacquetien B, et al. Pelvic organ prolapse. In: Abrams P, Cardozo L, Khoury S, et al., eds. Incontinence, 21st ed. Paris: Health Publications, 2005:243–265. 18. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:122–127. 19.


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Gynecology_Novak. 18. Mouritsen L, Larsen JP. Symptoms, bother and POPQ in women referred with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2003;14:122–127. 19. Ellerkman RM, Cundiff GW, Melick CF, et al. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol 2001;185:1332–1338. 20. Burrows LJ, Meyn LA, Walters MD, et al. Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol 2004;104:982– 988. 21. Silva WA, Kleeman S, Segal J, et al. Effects of a full bladder and patient positioning on pelvic organ prolapse assessment. Obstet Gynecol 2004;104:37–41. 22. Baden WF, Walker T. Genesis of the vaginal profile. Clin Obstet Gynecol 1972;15:1048–1054. 23. 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;175:10–17. 24.


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Gynecology_Novak. 23. 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;175:10–17. 24. Lemos NL, Auge AP, Lunardelli JL, et al. Validation of the pelvic organ prolapse quantification index (POPQ-I): a novel interpretation of the POP-Q system for optimization of POP research. Int Urogynecol J Pelvic Floor Dysfunct 2008;19:995–997. 25. The American Urogynecology Society. Available at www.augs.org. 26. Brinks CA, Wells TJ, Samprelle CM, et al. A digital test for pelvic muscle strength in women with urinary incontinence. Nurs Res 1994;43:352–356. 27. Noblett K, Lane FL, Driskill CS. Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and 1 prolapse? Int Urogynecol J 2005;16:268. 28. Walters MD, Diaz K. Q-tip test: a study of continent and incontinent women. Obstet Gynecol 1987;70:208. 29.


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Gynecology_Novak. 28. Walters MD, Diaz K. Q-tip test: a study of continent and incontinent women. Obstet Gynecol 1987;70:208. 29. Poma PA. Nonsurgical management of genital prolapse: a review and recommendations for clinical practice. J Reprod Med 2000;45:789– 797. 30. Bump RC, Norton PA. Epidemiology and natural history of pelvic ﬂoor dysfunction. Obstet Gynecol Clin North Am 1998;25:723–747. 31. Hagen S, Stark D, Maher C, et al. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2004;2:CD003882. 32. Davilla GW, Bernier F. Multimodality pelvic physiotherapy treatment of urinary incontinence in adult women. Int Urogynecol J 1995;6:187–194. 33. Thakar R, Stanton S. Management of genital prolapse. BMJ 2004;324:1258–1262. 34. Davilla GW. Vaginal prolapse management with nonsurgical techniques. Postgrad Med 1996;99:171–185. 35.


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Gynecology_Novak. 33. Thakar R, Stanton S. Management of genital prolapse. BMJ 2004;324:1258–1262. 34. Davilla GW. Vaginal prolapse management with nonsurgical techniques. Postgrad Med 1996;99:171–185. 35. Mimura T, Roy AJ, Storrie JB, et al. Treatment of impaired defecation associated with rectocele by behavioral retraining (biofeedback). Dis Colon Rectum 2000;43:1267–1272. 36. Clemons J, Aguilar VC, Tillinghast TA, et al. Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse. Am J Obstet Gynecol 2004;190:1025–1029. 37. Brincat C, Kenton K, Fitzgerald MP, et al. Sexual activity predicts continued pessary use. Am J Obstet Gynecol 2004;191:198–200. 38. Clemons JL, Aguilar VC, Tillinghast TA, et al. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004;190:345–350. 39.


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Gynecology_Novak. 38. Clemons JL, Aguilar VC, Tillinghast TA, et al. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004;190:345–350. 39. Cundiff GW, Weidner AC, Visco AG, et al. A survey of pessary use by members of the American Gynecologic Society. Obstet Gynecol 2000;95:931–935. 40. Sulak PJ, Kuehl TJ, Shull BJ. Vaginal pessaries and their use in pelvic relaxation. J Reprod Med 1993;38:919–923. 41. Handa VL, Jones M. Do pessaries prevent the progression of pelvic organ prolapse? Int Urogynecol J 2002;13:349–352. 42. Richter HE, Burgio KL, Brubaker L, et al. Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: a randomized controlled trial. Obstet Gynecol 2010;115:609–617. 43. Adams E, Thomson A, Maher C, et al. Mechanical devices for pelvic organ prolapse in women. Cochrane Database Syst Rev 2004;2:CD004010. 44.


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Gynecology_Novak. 43. Adams E, Thomson A, Maher C, et al. Mechanical devices for pelvic organ prolapse in women. Cochrane Database Syst Rev 2004;2:CD004010. 44. Wu V, Farrell SA, Basket TF, et al. A simplified protocol for pessary management. Obstet Gynecol 1997;90:990–994. 45. Farrell SA, Singh B, Aldakhil L. Continence pessaries in the management of urinary incontinence in women. J Obstet Gynaecol Can 2004;26:113. 46. Harris TA, Bent AE. Genital prolapse with and without urinary incontinence. J Reprod Med 1990;35:792–798. 47. Meinhardt W, Schuitemaker NEW, Smeets MJGH, et al. Bilateral hydronephrosis with urosepsis due to neglected pessary. Scand J Urol Nephrol 1993;27:419–420. 48. Ott R, Richter H, Behr J, et al. Small bowel prolapse and incarceration caused by a vaginal ring pessary. Br J Surg 1993;80:1157–1159. 49. Palumbo MV. Pessary placement and management. Ostomy Wound Manage 2000;46:40. 50. Bush K. Review of vagina pessaries. Obstet Gynecol Surv 2000;55: 465. 51.


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Gynecology_Novak. 49. Palumbo MV. Pessary placement and management. Ostomy Wound Manage 2000;46:40. 50. Bush K. Review of vagina pessaries. Obstet Gynecol Surv 2000;55: 465. 51. Sze EHM, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol 1997;89:466–475. 52. Shull BL, Bachofen CG. Enterocele and rectocele. In: Walters M, Karram MM, eds. Urogynecology and reconstructive pelvic surgery. 2nd ed. St. Louis, MO: Mosby, 1999:221–234. 53. Sederl J. Zur operation des prolapses der blind endigenden sheiden. Geburtshilfe Frauenheilkd 1958;18:824–828. 54. Richter K, Albright W. Long term results following fixation of the vagina on the sacrospinous ligament by the vaginal route. Am J Obstet Gynecol 1981;141:811–816. 55. Randall C, Nichols D. Surgical treatment of vaginal inversion. Obstet Gynecol 1971;38:327–332. 56. Nichols D. Sacrospinous fixation for massive eversion of the vagina. Am J Obstet Gynecol 1982;142:901–904. 57.


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Gynecology_Novak. 56. Nichols D. Sacrospinous fixation for massive eversion of the vagina. Am J Obstet Gynecol 1982;142:901–904. 57. Miyazaki FS. Miya tool ligature carrier for sacrospinous ligament suspension. Obstet Gynecol 1987;70:286–288. 58. Morley GW, DeLancey JO. Sacrospinous ligament fixation for eversion of the vagina. Am J Obstet Gyencol 1988;158:872–881. 59. Sharp TR. Sacrospinous suspension made easy. Obstet Gynecol 1993;82:873–875. 60. Imparato E, Aspesi G, Rovetta E, et al. Surgical management and prevention of vaginal vault prolapse. Surg Gynecol Obstet 1992;175: 233–237. 61. Nichols D. Massive eversion of the vagina. In: Nichols DH, ed. Gynecologic and obstetric surgery. St, Louis, MO: Mosby, 1993:431– 464. 62. Morgan DM, Rogers MA, Huebner M, et al. Heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse: a systematic review. Obstet Gynecol 2007;109:1424–1433. 63.


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Gynecology_Novak. 62. Morgan DM, Rogers MA, Huebner M, et al. Heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse: a systematic review. Obstet Gynecol 2007;109:1424–1433. 63. Holley RL, Varner RE, Gleason BP, et al. Recurrent pelvic support defects after sacrospinous ligament fixation for vaginal vault prolapse. J Am Coll Surg 1995;180:444–448. 64. Shull BL, Capen CV, Riggs MW, et al. Preoperative and postoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 1992;166:1764–1771. 65. Inmon WB. Pelvic relaxation and repair including prolapse of vagina following hysterectomy. South Med J 1963;56:577–582. 66. Shull BT, Capen CV, Riggs MW, et al. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: an effective method of cuff suspension. Am J Obstet Gynecol 1993;168:1669–1677. 67.


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Gynecology_Novak. 66. Shull BT, Capen CV, Riggs MW, et al. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: an effective method of cuff suspension. Am J Obstet Gynecol 1993;168:1669–1677. 67. Meeks GR, Washburne JF, McGeher RP, et al. Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia. Am J Obstet Gynecol 1994;171:1444– 1454. 68. McCall ML. Posterior culdoplasty: surgical correction of enterocele during vaginal hysterectomy: a preliminary report. Am J Obstet Gynecol 1938;36:94–99. 69. Shull BL, Bachofen C, Coates KW, et al. 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– 1373. 70. Karram M, Goldwasser S, Kleeman S, et al. High uterosacral vaginal vault suspension with fascial reconstruction for vaginal repair of enterocele and vaginal vault prolapse. Obstet Gynecol 2001;185:1339–1342. 71.


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Gynecology_Novak. 71. 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;183:1402–1411. 72. Wheeler TL 2nd, Gerten KA, Richter HE, Duke AG, Varner RE. Outcomes of vaginal vault prolapse repair with a high uterosacral suspension procedure utilizing bilateral single sutures. Int Urogynecol J Pelvic Floor Dysfunct 2007;18:1207–1213. 73. Goff BF. An evaluation of the Bissell operation for uterine prolapse: a follow-up study. Surg Gynecol Obstet 1933;57:763–771. 74. Macer GA. Transabdominal repair of cystocele, a 20 year experience, compared with the traditional vaginal approach. Am J Obstet Gynecol 1978;131:203–207. 75. Stanton SL, Hilton P, Norton C, et al. Clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence. Br J Obstet Gynaecol 1982;89:459–463. 76.


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Gynecology_Novak. 76. Porges RF, Smilen SW. Long-term analysis of the surgical management of pelvic support defects. Am J Obstet Gynecol 1994;171:1518– 1528. 77. Kohli N, Sze EHM, Roat TW, et al. Incidence of recurrent cystocele after anterior colporrhaphy with and without concomitant transvaginal needle suspension. Am J Obstet Gynecol 1996;175:1476–1482. 78. Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and technique of surgical repair. Obstet Gynecol 1997;89: 311–318. 79. Smilen SW, Saini J, Wallach SJ, et al. The risk of cystocele after sacrospinous ligament fixation. Am J Obstet Gynecol 1998;179: 1465–1472. 80. Weber AM, Walters MD, Piedmonte MR, et al. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299–1306. 81. Sand PK, Koduri A, Lobel RW, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184:1357–1364. 82.


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Gynecology_Novak. 81. Sand PK, Koduri A, Lobel RW, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001;184:1357–1364. 82. White GR. Cystocele: a radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA 1909;21:1707– 1710. 83. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57:357–362. 84. Goetsch C. Suprapubic vesicourethral suspension as a primary means of correcting stress incontinence and cystocele. West J Surg 1954;62:201–204. 85. Shull BL, Baden WF. A six-year experience with paravaginal defect repair for stress urinary incontinence. Am J Obstet Gynecol 1989;160:1432–1435. 86. 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;171:1429–1436. 87.


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Gynecology_Novak. 87. Bruce RG, El-Galley RES, Galloway NTM. Paravaginal defect repair in the treatment of female stress urinary incontinence and cystocele. Urology 1999;54:647–651. 88. Mallipeddi PK, Steele AC, Kohli N, et al. Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior vaginal wall prolapse. Int Urogynecol J 2001;12:83–88. 89. DeLancey JOL. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol 2002;18:93–98. 90. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol 1959;77:490–502. 91. Varner RE, Holley RL, Richter HE, et al. Infections related to placement of permanent braided and mono-filament suture material through vaginal mucosa. J Pelvic Surg 1998;4:71–74. 92. Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403–1421. 93.


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Gynecology_Novak. 92. Cundiff GW, Fenner D. Evaluation and treatment of women with rectocele: focus on associated defecatory and sexual dysfunction. Obstet Gynecol 2004;104:1403–1421. 93. Arnold MW, Stewart WR, Aguilar PS. Rectocele repair: four years’ experience. Dis Colon Rectum 1990;33:684–687. 94. Mellgren A, Anzen B, Nilsson BY, et al. Results of rectocele repair: a prospective study. Dis Colon Rectum 1995;38:7–13. 95. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Gynaecol Obstet 1997;104:82–86. 96. Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000;182:1610–1615. 97. Abramov Y, Gandhi S, Goldberg RP, et al. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 2005;105:314–318. 98.


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Gynecology_Novak. 97. Abramov Y, Gandhi S, Goldberg RP, et al. Site-specific rectocele repair compared with standard posterior colporrhaphy. Obstet Gynecol 2005;105:314–318. 98. Francis WJA, Jeffcoate TNA. Dyspareunia following vaginal operations. J Opt Soc Am 1961;68:1–10. 99. Cundiff GW, Weidner AC, Visco AG, et al. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol 1998;179:1451–1457. 100. Porter WE, Steele A, Walsh P, et al. The anatomic and functional outcomes of defect-specific rectocele repairs. Am J Obstet Gynecol 1999;181:1353–1359. 101. Kenton K, Shott S, Brubaker L. Outcome after rectovaginal fascia reattachment for rectocele repair. Am J Obstet Gynecol 1999;181:1360–1364. 102. Glavind K, Madsen H. A prospective study of the discrete fascial defect rectocele repair. Acta Obstet Gynecol Scand 2000;79:145– 147. 103.


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Gynecology_Novak. 102. Glavind K, Madsen H. A prospective study of the discrete fascial defect rectocele repair. Acta Obstet Gynecol Scand 2000;79:145– 147. 103. Singh K, Cortes E, Reid WMN. Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse. Obstet Gynecol 2003;101:320–324. 104. Kahn MA, Kumar D, Stanton SL. Posterior colporrhaphy vs. transanal repair of the rectocele: an initial follow up of a prospective randomized trial. Br J Obstet Gynaecol 1998;105:57. 105. Nieminen K, Hiltunen KM, Laitinen J, et al. Transanal or vaginal approach to rectocele repair: a prospective randomized pilot study. Dis Colon Rectum 2004;47:1636–1642. 106. Janssen LWM, van Dijke CF. Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse. Dis Colon Rectum 1994;37:1100–1107. 107.


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Gynecology_Novak. 106. Janssen LWM, van Dijke CF. Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse. Dis Colon Rectum 1994;37:1100–1107. 107. Van Dam JH, Huisman WM, Hop WCJ, et al. Fecal continence after rectocele repair: a prospective study. Int J Colorectal Dis 2000;15:54–57. 108. Ayabaca SM, Zbar AP, Pescatori M. Anal continence after rectocele repair. Dis Colon Rectum 2002;45:63–69. 109. Nieminen K, Hiltunen R, Takala T, et al. Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up. Am J Obstet Gynecol 2010;203:235.e1–e8. 110. Takahashi S, Obinata D, Sakuma T, et al. Tension-free vaginal mesh procedure for pelvic organ prolapse: a single-center experience of 310 cases with 1-year follow up. Int J Urol 2010;17:353– 358. 111.


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Gynecology_Novak. 111. Hiltunen R, Nieminen K, Takala T, et al. Low-weight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial. Obstet Gynecol 2007;110:455–462. 112. Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized controlled trial. Obstet Gynecol 2008;111:891– 898. 113. Carey M, Higgs P, Goh J, et al. Vaginal repair with mesh versus colporrhaphy for prolapse: a randomized controlled trial. BJOG 2009;116:1380–1386. 114. Sung VW, Rogers RG, Schaffer JI, et al. Graft use in transvaginal pelvic organ prolapse repair: a systematic review. Obstet Gynecol 2008;112:1131–1142. 115. Lowenstein L, Fitz A, Kenton K, et al. Transabdominal uterosacral suspension: outcomes and complications. Am J Obstet Gynecol 2009;200:656.e1–e5. 116.


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Gynecology_Novak. 115. Lowenstein L, Fitz A, Kenton K, et al. Transabdominal uterosacral suspension: outcomes and complications. Am J Obstet Gynecol 2009;200:656.e1–e5. 116. Cundiff GW, Harris RL, Coates K, et al. Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associates with vaginal vault prolapse. Am J Obstet Gynecol 1997;177:1345–1355. 117. Visco AG, Weidner AC, Barber MD, et al. Vaginal mesh erosion after abdominal sacral colpopexy. Am J Obstet Gyencol 2001;184:297–302. 118. Sullivan ES, Longaker CJ, Lee PY. Total pelvic mesh repair; a ten-year experience. Dis Colon Rectum 2001;44:857–863. 119. Lyons TL, Winer WK. Laparoscopic rectocele repair using polyglactin mesh. J Am Assoc Gynecol Laparosc 1997;4:381–384. 120. Seracchioli R, Hourcubie JA, Vianello F, et al. Laparoscopic treatment of pelvic ﬂoor defects in women of reproductive age. J Am Assoc Gynecol Laparosc 2004;11:332–335. 121.


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Gynecology_Novak. 120. Seracchioli R, Hourcubie JA, Vianello F, et al. Laparoscopic treatment of pelvic ﬂoor defects in women of reproductive age. J Am Assoc Gynecol Laparosc 2004;11:332–335. 121. Nygaard IE, McCreery R, Brubaker L, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol 2004;104:805– 823. 122. Arthure HG. Vault suspension. Proc R Soc Med 1949;42:388–390. 123. Lane FE. Repair of posthysterectomy vaginal-vault prolapse. Obstet Gynecol 1962;20:72–77. 124. Birnbaum SJ. Rational therapy for the prolapse vagina. Am J Obstet Gynecol 1973;115:411–419. 125. Addison WA, Livengood CH III, 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;153:140–146. 126. Snyder TE, Krantz KE. Abdominal retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Obstet Gynecol 1991;77:944–949. 127.


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Gynecology_Novak. 126. Snyder TE, Krantz KE. Abdominal retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Obstet Gynecol 1991;77:944–949. 127. Addison WA, Timmons MC. Abdominal approach to vaginal eversion. Clin Obstet Gynecol 1993;36:995–1004. 128. Pilsgaard K, Mouritsen L. Follow-up after repair of vaginal vault prolapse with abdominal colposacropexy. Acta Obstet Gynecol Scand 1999;78:66–70. 129. Culligan PJ, Murphy M, Blackwell L, et al. Long-term success of abdominal sacral colpopexy using synthetic mesh. Am J Obstet Gynecol 2002;187:1473–1480. 130. Brizzolara S, Pillai-Allen A. Risk of mesh erosion with sacral colpopexy and concurrent hysterectomy. Obstet Gynecol 2003;102: 306–310. 131. Timmons MC, Addison WA, Addison SB, et al. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele: evolution of operative techniques. J Reprod Med 1992:37;323–327. 132.


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Gynecology_Novak. 132. Harmanli OH, Dandolu V, Chatwani AJ, et al. Total colpocleisis for severe pelvic organ prolapse. J Reprod Med 2003;48:703–706. 133. Von Pechmann WS, Mutone MD, Fyffe J, et al. Total colpocleisis with high levator plication for the treatment of advanced pelvic organ prolapse. Am J Obstet Gynecol 2003;189:121–126. 134. Hoffman MS, et al. Vaginectomy with pelvic herniorrhaphy for prolapse. Am J Obstet Gynecol 2003;189:364–371. 135. Brubaker L, Nygaard I, Richter HE, et al. Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Obstet Gynecol 2008;112:49–55. 136. 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;175:1418–1422. 137.


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Gynecology_Novak. 137. Lo T-S, Wang AC. Abdominal colposacropexy and sacrospinous ligament suspension for severe uterovaginal prolapse: a comparison. J Gynecol Surg 1998;14:59–64. 138. Maher CF, Qatawneh AM, Dwyer PL, et al. Abdominal sacrocolpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol 2004;190:20–26. Robert E. Gutman Geoffrey W. Cundiff Defecatory dysfunction and fecal incontinence are common conditions for women that have tremendous psychosocial and economic implications. The differential diagnosis for anorectal dysfunction is broad and can be classified into systemic factors, anatomic and structural abnormalities, and functional disorders. A thorough history and physical examination are critical for the evaluation of fecal incontinence and defecatory dysfunction, as well as appropriate ancillary testing.


Gynecology_Novak

Gynecology_Novak. A thorough history and physical examination are critical for the evaluation of fecal incontinence and defecatory dysfunction, as well as appropriate ancillary testing. Treatment of anorectal dysfunction should focus on treatment of the underlying condition, with nonsurgical management attempted before surgery. Overlapping sphincteroplasty is the procedure of choice for fecal incontinence caused by a disrupted anal sphincter. Anorectal dysfunction encompasses a variety of conditions that disrupt normal anorectal function. Such conditions can be subdivided as those that cause defecatory dysfunction and fecal incontinence. Although anorectal dysfunction transcends any individual medical specialty, the pathophysiology, evaluation, and management of conditions relevant to obstetricians/gynecologists are presented in this chapter.


Gynecology_Novak

Gynecology_Novak. Anal continence and defecation are complex physiologic processes that require intact and coordinated neurologic and anatomic function, including colonic absorption and motility, rectal compliance, anorectal sensation, and the multifaceted continence mechanism. An understanding of normal physiology and pathophysiology is essential to the treatment of women with anorectal dysfunction. Stool Formation and The colon plays an important role in absorption and regulation of water and electrolytes. As much Colonic Transit as 5 L of water and associated electrolytes can be absorbed in one day. Parasympathetic-mediated peristaltic contraction of colonic smooth muscle transfers fecal material to the rectum. A delay in stool transit at the rectosigmoid region of the colon allows for maximal absorption of water and sodium.


Gynecology_Novak

Gynecology_Novak. Storage As stool accumulates in the rectosigmoid, rectal distention triggers a transient decrease in the internal anal sphincter (IAS) tone and an increase in the external anal sphincter (EAS) tone, known as the rectoanal inhibitory reﬂex. Exposure of the anal canal to fecal matter facilitates sampling, whereby the anal canal and its abundant sensory nerves determine stool consistency (i.e., solid, liquid, or gas). Accommodation occurs as the normally compliant rectal vault relaxes in response to increased volume. This cycle, combined with increased rectal distention, stimulates an urge to defecate. This urge can be voluntarily suppressed through cortical control, resulting in further accommodation and activation of the continence mechanism.


Gynecology_Novak

Gynecology_Novak. Muscles The key muscles of the continence mechanism are the puborectalis, IAS, and EAS. The puborectalis muscle originates from the pubic rami at the level of the arcus tendineus levator ani and passes laterally to the vagina and rectum in a U-shaped configuration, creating a sling around the genital hiatus. Contraction of the puborectalis muscle narrows the genital hiatus, developing the near 90-degree anorectal angle. The resting tone of the puborectalis muscle serves as the primary continence mechanism for solid stool. The IAS and EAS are essential for continence of ﬂatus and liquid stool. The internal sphincter maintains most of the resting tone for the sphincter complex through autonomic reﬂex arcs and is essential for passive continence. Although the external sphincter also maintains constant resting tone, it is ultimately responsible for preventing fecal urgency and stress incontinence associated with sudden increases in intra-abdominal pressure. This function is under both


Gynecology_Novak

Gynecology_Novak. constant resting tone, it is ultimately responsible for preventing fecal urgency and stress incontinence associated with sudden increases in intra-abdominal pressure. This function is under both voluntary and involuntary control. The anal cushions act as the final anatomic barrier. They fill with blood, causing occlusion of the anal canal.


Gynecology_Novak

Gynecology_Novak. Nerves Many pathologic states disrupt normal function through denervation. The IAS receives its sympathetic supply from L5, which passes through the pelvic plexus via the hypogastric plexus. The parasympathetic supply from S2-4 synapses at the pelvic plexus, where it joins the sympathetic nerves. In addition to the parasympathetic and sympathetic components, the autonomic nervous system of the gut has an enteric nervous system (ENS). The ENS provides local circuitry that can contract or relax the gut muscles, as well as impact absorption and secretion. The autonomic ganglia of the ENS, located in the gut, are interconnected to provide local integration and processing of information. The IAS acts through reﬂex arcs at the spinal cord without voluntary control. The puborectalis (levator ani) is innervated by branches of the S2-4 sacral roots and does not receive direct innervation from the pudendal nerve (1). The EAS is innervated bilaterally by the pudendal nerve (S2-4) via Alcock’s


Gynecology_Novak

Gynecology_Novak. is innervated by branches of the S2-4 sacral roots and does not receive direct innervation from the pudendal nerve (1). The EAS is innervated bilaterally by the pudendal nerve (S2-4) via Alcock’s canal. The pudendal nerve fibers cross over at the level of the spinal cord, allowing preservation of EAS function in the event of unilateral damage. The rich sensory supply from the anal canal travels along the inferior rectal branch of the pudendal nerve.


Gynecology_Novak

Gynecology_Novak. Evacuation Initiation of defecation is normally under cortical control. As previously discussed, delivery of stool to the rectum stimulates the rectoanal inhibitory reﬂex, permitting sampling followed by accommodation. Further rectal distention results in an urge to defecate. Evacuation occurs with voluntary relaxation of the pelvic ﬂoor muscles (puborectalis muscle and EAS) in conjunction with increased intra-abdominal and intrarectal pressure from Valsalva. This results in widening of the anorectal angle and shortening of the anal canal, which facilitates emptying. Coordinated peristaltic activity of the rectosigmoid assists evacuation. After this process is complete, the closing reﬂex is initiated, resulting in contraction of the pelvic ﬂoor muscles and activation of the continence mechanism.


Gynecology_Novak

Gynecology_Novak. The epidemiology of anorectal dysfunction has been best defined in terms of the incidence and prevalence of fecal incontinence. Few studies have been done to assess the incidence and prevalence of defecatory dysfunction.


Gynecology_Novak

Gynecology_Novak. Defecatory Dysfunction The term defecatory dysfunction often is used synonymously with the symptom of constipation. Constipation is an imprecise term used by patients to report a variety of symptoms, including infrequent stools, dyschezia, straining, variation in stool consistency and caliber, incomplete emptying, bloating, and abdominal pain. The most common symptoms associated with constipation are straining and hard stools (2,3). Defecatory dysfunction is defined by many physicians as infrequent stools, typically fewer than three bowel movements per week. This definition is based on stool frequency studies in which 95% of women have more than three bowel movements per week. Using this definition, the prevalence of constipation should be 5% (4). However, the prevalence of constipation has been estimated to range from 2% to 28%, depending on the definition applied (5–7).


Gynecology_Novak

Gynecology_Novak. There is an increased prevalence of constipation among women and elderly individuals, nonwhite individuals, and those with low income and low education levels (5–7). Based on an estimated 2.5 million visits to US physicians per year for constipation, with an average cost of $2,752 per patient, the annual cost for evaluation of constipation would be approximately $6.9 billion (8,9). An estimated 85% of physician visits results in a prescription; including drug costs would increase this amount substantially (8). More recently, evaluation of 76,854 California Medicaid patients without supplemental insurance found somewhat lower annual total direct costs to care for constipation at almost $19 million ($246 per patient) for this subset of the US population (10). Constipation has a detrimental effect on health-related quality of life (3,10). Constipation contributed to decreased mental and physical scores for quality of life on the SF-36 Health Survey in a Canadian-based population (11).


Gynecology_Novak

Gynecology_Novak. Fecal Incontinence The reported prevalence of fecal incontinence varies between 2% and 3% for community-dwelling individuals, 3% to 17% for those of increased age, and 46% to 54% for nursing home residents (12). A prevalence of 28% has been reported among patients seeking benign gynecologic care and 36% of primary care patients surveyed (13,14). The prevalence of fecal incontinence in the United States is expected to increase 59% from 10.6 million in 2010 to 16.8 million in 2050 as the population ages (15). Epidemiologic studies of fecal incontinence are compromised by social stigmata and the lack of a uniform definition. Definitions of fecal incontinence vary with respect to the type of material passed (solid, liquid, or gas), the frequency and duration of events (once in a lifetime to twice a week), and the impact on quality of life. Most authors agree that the true prevalence of this condition is underestimated in the current scientific literature. A large health survey in the


Gynecology_Novak

Gynecology_Novak. to twice a week), and the impact on quality of life. Most authors agree that the true prevalence of this condition is underestimated in the current scientific literature. A large health survey in the United States found age, female gender, physical limitations, and poor general health to be independent risk factors associated with fecal incontinence (16).


Gynecology_Novak

Gynecology_Novak. Fecal incontinence has tremendous psychosocial and economic implications for individuals and society as a whole. The loss of such a basic function can be emotionally devastating, leading to poor self-esteem, depression, social isolation, and decreased quality of life (13,14,17). Fecal incontinence is the second leading reason for nursing home placement in the United States, even though less than one-third of individuals with this condition seek medical attention (13,17). The overall annual cost to treat fecal incontinence is difficult to pinpoint, but accounts for more than $400 million per year in the cost of adult incontinence products alone (17). Symptom-Based Approach to Colorectal Disorders Several medical conditions cause defecatory dysfunction, fecal incontinence, or combined symptoms. Following is the differential diagnosis—a proposed classification system based on systemic factors, anatomic and structural abnormalities, and functional disorders.


Gynecology_Novak

Gynecology_Novak. Disordered Defecation Causes of defecatory dysfunction have traditionally been divided into systemic disorders and idiopathic constipation (all nonsystemic causes). Idiopathic constipation can be subdivided into anatomic and structural abnormalities and functional disorders (Table 28.1).


Gynecology_Novak

Gynecology_Novak. Diabetes, hypothyroidism, and pregnancy are the most common endocrinologic systemic factors that cause constipation, and all have a component of decreased gastrointestinal motility and intestinal transit. In one study, gastrointestinal symptoms were present in 76% of patients with diabetes, including constipation, which occurred in 60% (18). In patients with diabetes, constipation is believed to be secondary to intestinal autonomic neuropathy, resulting in delayed or absent gastrocolic reﬂex and decreased bowel motility. This enteric neuropathy may also cause gastroparesis and diarrhea. Although diabetes has been classified with the endocrinologic causes, it should also be grouped with the enteric neuropathies. Pregnancy is not considered a disease state; however, there is an 11% to 38% prevalence of constipation that is believed to result from the effect of progesterone on smooth muscle (19,20). Iron supplements and prior constipation treatment are also associated with constipation


Gynecology_Novak

Gynecology_Novak. prevalence of constipation that is believed to result from the effect of progesterone on smooth muscle (19,20). Iron supplements and prior constipation treatment are also associated with constipation during pregnancy (20).


Gynecology_Novak

Gynecology_Novak. The neurologic systemic factors can be divided into central and peripheral processes. Spinal cord lesions, multiple sclerosis, and Parkinson disease affect the autonomic nervous system. Trauma to the sacral nerves often leads to severe constipation from decreased left-sided colonic motility, decreased rectal tone and sensation, and increased distention. These findings are also seen in patients with meningomyelocele, damage to the lumbosacral spine, and pelvic ﬂoor trauma (21,22). Higher spinal cord lesions result in delayed sigmoid transit and decreased rectal compliance. In these upper motor neuron lesions, colonic reﬂexes are intact, and defecation can be initiated by digital stimulation of the anal canal (23,24). Individuals with multiple sclerosis can have no gastrocolic reﬂex, decreased colonic motility, decreased rectal compliance, and even rectosphincteric dyssynergia (25,26). Constipation worsens with the duration of illness and may be compounded by the side effects of medical


Gynecology_Novak

Gynecology_Novak. colonic motility, decreased rectal compliance, and even rectosphincteric dyssynergia (25,26). Constipation worsens with the duration of illness and may be compounded by the side effects of medical therapy. Similar findings of rectosphincteric dyssynergia and medication side effects are present with Parkinson disease.


Gynecology_Novak

Gynecology_Novak. Among the peripheral neurogenic disorders, dysfunction occurs at the level of the ENS. The ultimate example of this is congenital aganglionosis (Hirschsprung disease). The absence of intramural ganglion cells in the submucosal and myenteric plexuses of the rectum causes loss of the rectosphincteric inhibitory reﬂex. Patients with this illness usually present with functional obstruction and proximal colonic dilation. In most patients, the condition is diagnosed within 6 months of age, although milder cases can be seen later in life.


Gynecology_Novak

Gynecology_Novak. Other systemic factors to consider are collagen vascular and muscle disorders. Importantly, some of the most commonly used prescription and over-the-counter medications, including aluminum antacids, beta-blockers, calcium channel blockers, anticholinergics, antidepressants, and opiates, cause defecatory dysfunction (Table 28.2). Lifestyle issues, such as inadequate fiber intake and insufficient ﬂuid intake, can exert similar effects independently or in conjunction with other disorders.