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Female Urology European Urology - Pelvic Organ Prolapse: A Challenge for the Urologist
Female Urology European Urology - Pelvic Organ Prolapse: A Challenge for the Urologist
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| European Urology - Pelvic Organ Prolapse: A Challenge for the Urologist |
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| Monday, 02 April 2007 | ||
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Volume 51, Issue 4, Pages 884-886 (April 2007) Pelvic organ prolapse (POP) is a general term referring to any combination of organ descent, such as bladder, rectum, uterus, and bowel, related to anterior or posterior vaginal wall prolapse with or without maintained cervical support or vaginal apical prolapse. These phenomena encompass a wide variety of clinical conditions including urinary or fecal incontinence, bladder outlet obstruction, constipation, pelvic floor discomfort, frequent lower urinary tract infections, and sexual dysfunctions. A cross-sectional analysis of women ranging in age from 50 to 79 yr who were enrolled in the Women's Health Initiative indicated that 41% of them had some form of POP at baseline, whereas Samuelsson et al reported that 31% of women in general, and 44% of parous women in particular, had POP in a similar study on Swedish women [1], [2]. The exact threshold that justified this diagnosis was not described. Research on POP is, in fact, complicated by the lack of a standardised clinical definition and classification. Of all risk factors that were examined by Mant et al, parity showed the strongest association with risk of requiring surgery for POP (4:1 in women with 1 child and 8.4:1 in women with 2 children compared to nonparous women). In the same study <1% of prolapse occurred in nulliparous women [3]. Samuelsson et al reported that the most prominent factors of etiologic importance for POP were parity, age, and pelvic floor muscle strength, with high birth weight also associated with increased prevalence of POP among parous women [2]. The choice of the optimal treatment depends on the patient's general health status, symptoms, quality-of-life impairment, and prolapse grade. The currently available options are conservative management, use of mechanical intravaginal devices, and surgery. Surgery aims to restore physiologic anatomy as well as preserving lower urinary tract, intestinal, and sexual functions. Surgery for POP repair currently is a true challenge for the modern urologist. The debated points are: (1) vaginal, abdominal, or combined approach; (2) to do a hysterectomy or not; or (3) appropriate use of artificial mesh grafts and slings. The final decision to choose a vaginal or abdominal or combined surgical technique customarily mirrors the surgeon's experience and level of comfort with a specific approach in the context of the patient's condition and indication for surgery. Given the morbidity and recovery associated with a laparotomy incision, every effort should be made to avoid the abdominal approach. Nevertheless, the standard of training in residency programs is currently not providing a level of surgical competency to have confidence with both approaches. Anterior colporraphy is the traditional therapeutic choice for anterior wall prolapse due to a central or lateral defect, although surgical series reports documented success rates from 60% to 100% [4]. Posterior vaginal wall prolapse is treated in relation to the experience of the specialist who performs the surgical procedure. Coloproctologists use a transanal repair, whereas gynecologists and urologists are more experienced in vaginal procedures. The abdominal approach usually includes hysterectomy with vaginal vault suspension and the use of mesh grafts to reduce the risk of recurrent cystocele, rectocele, and enterocele. An abdominal approach may be preferred if the uterus is large or if the woman has had multiple previous pelvic procedures or has extensive endometriosis or other processes that may obliterate the Douglas space. Maher et al presented an interesting meta-analysis on randomised or quasi-randomised controlled trials that included surgical operations for POP. Abdominal sacrocolpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than the transvaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living, and increased cost of the abdominal approach. The use of a polyglactin mesh overlay at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair must be considered better than transanal repair in the management of rectocele in terms of recurrence of prolapse, although there was a higher blood loss and postoperative use of analgesics [5]. The meta-analysis on the impact of POP surgery on continence issues was limited and inconclusive, although about 10% of women developed new symptoms after surgery. Many patients who had undergone POP repair presented an occult stress urinary incontinence (SUI) due to urethral instability and required a subsequent tension-free vaginal tape (TVT) or trans-obturator tape (TOT) positioning [5]. Vaginal vault prolapse is frequently found in patients who have previously undergone transvaginal hysterectomy and usually requires an abdominal approach. Recently Senthiles et al presented an innovative vaginal approach in the treatment of high-grade genital prolapse repair after hysterectomy by using a trans-obturator and infracoccygeal Hammock procedure, with a subjective cure rate of 97.7% [6]. Hysterectomy is the technique mainly used in the treatment of POP repair. Conventional wisdom has suggested that maintenance of the uterus in situ may subject pelvic reconstructive efforts to undue stress and result in increased risk of prolapse recurrence. Nevertheless, hysterectomy at the time of prolapse surgery has not been proved to improve the durability of the repair and may, in fact, increase morbidity, blood loss, and operative and postoperative recovery times. Additionally it has been suggested that hysterectomy and the associated pelvic floor dissection may increase the risk of pelvic neuropathy and disrupt natural support structures such as the uterosacral-cardinal ligament complex. Moreover, Masters and Johnson suggested that the uterus and the cervix have important roles in orgasm and sexual function. In this sense, hysterectomy can influence both sexual and personal identity. Maher et al reported a surgical series of uterus preservation with success rates >80% although this option should only be considered for selected cases [5]. Young women who want to maintain their fertility and full sexual satisfaction options should be informed about the wide variation of results in case of subsequent pregnancy and delivery and the ongoing possibility of incurring uterine and cervical pathology, and the subsequent need for continued, routine surveillance measures to assess such pathology. The widespread use of hysterectomy in patients affected by POP introduced the concomitant use of mesh grafts both in colposuspension or colporraphy and in the treatment of SUI due to urethral hypermobility. Abdominal mesh graft colposacropexy is the vaginal vault prolapse repair method currently used with a success rate ranging from 78% to 100% of treated cases, with a low overall rate of mesh erosion (3.4%). Nevertheless, erosions are not often mentioned in surgical series. There are few prospective randomised trials that prove the benefit of implanting grafts in vaginal pelvic floor surgery although high success rates were reported by using TVT or TOT in the treatment of SUI. In a recent series Bruce et al assessed 52 consecutive women affected by cystocele who underwent paravaginal defect repair with a success rate of 79% [7]. Meltomaa et al reported the effects of combining placement of TVT and vaginal surgery for POP versus TVT alone, by matching the two groups for age and type of incontinence. The success rate was 87% in the combined group and 92% in the TVT group [8]. In these cases an important question arises in treating women with symptomatic cystocele and occult SUI as to whether the potential incontinence should be treated. De Tayrac et al demonstrated no benefit from placing TVT if preoperative occult SUI exists, but there was a significant risk of causing postoperative voiding dysfunctions in these patients [9]. Groutz et al reported an high rate of persistent urinary symptoms in women with occult urethral hypermobility and severe cystocele treated with combined vaginal POP surgery and TVT at a long term follow-up [10]. During the last few years a laparoscopic approach to POP surgical repair was proposed by several authors with the intent of reducing the psychological and recovery time compared to the abdominal approach. Moreover, magnification of anatomic structures should be seriously considered in reducing the risk of damaging pelvic floor structures. Gaston et al collected a huge series of patients treated with laparoscopic colpoperineosacropexy, reporting a very high success rate. Definitive data are unfortunately still unpublished. Clinical evidence supporting different aspects of the surgical management of POP repair has to be considered very poor. Colpopexy (abdominal or vaginal) is always indicated in case of vaginal vault prolapse and often associated with hysterectomy. Vaginal cystocele repair or posterior colporraphy is always indicated in case of cystocele or rectocele, respectively. Colpopexy and cystocele repair are often sufficient to cure urethrocele and guarantee a subsequent good urinary continence. Concomitant adjunctive surgical treatments on the urethra (slings or urethral stabilisation) are contraindicated. Slings, TVT, and TOT are otherwise indicated after colpopexy in case of persistent urethral hypermobility. An anterior bladder suspension defect suggests the use of TVT, TOT, or slings as a definitive solution to SUI. Regardless of the surgical treatment chosen on the basis of research data, it is essential to base the final decision on the patient's individual clinical characterisation. References . Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186:1160–1166. 2. . 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. 3. . Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol. 1997;104:579–585. 4. . Surgery for pelvic organ prolapse: current status and future perspectives. Curr Opin Urol. 2005;15:256–262. 5. Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 2004;18:CD004014. 6. . Midterm follow-up of high-grade genital prolapse repair by the trans-obturator and infracoccygeal hammock procedure after hysterectomy. Eur Urol. 2007;51:1065–1072. 7. . Paravaginal defect repair in the treatment of female stress urinary incontinence and cystocele. Urology. 1999;54:647–651. 8. . Concomitant vaginal surgery did not affect outcome of the tension-free vaginal tape operation during a prospective 3-year follow-up study. J Urol. 2004;172:222–226. 9. . A prospective randomized trial comparing tension-free vaginal tape and transobturator suburethral tape for surgical treatment of stress urinary incontinence. Am J Obstet Gynecol. 2004;190:602–608. 10. . Tension free vaginal tape (TVT) for the treatment of occult stress urinary incontinence in women undergoing prolapse repair: a prospective study of 100 consecutive cases. Neurourol Urodyn. 2004;23:632–635
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