POP / Pelvic Reconstrutive Surgery Flashcards
The most common prolapse?
Anterior vaginal prolapse
Loss of apical support is usually present !
The most common complication after radical hysterectomy:
Bladder atony, so it used to left foley catheter there for 5-7 days or supra-pubic catheter
Overwt increase risk of POP by …%
40%
Prevalence of 3rd and 4th degree tearing at 1st birth by forceps
6.7%
Prevalence of 3rd and 4th degree tearing
- overall incidence
- primi
- multipara
- with forceps
- with vacuum
- overall incidence 2.9
- primi 6.1
- multipara 1.7
- with forceps 8-12 %
- with vacuum 4-8 %
Green top Guidelines No. 29, 2015
operative vaginal birth raises the odds for POP —fold
operative vaginal birth raises the odds for POP sevenfold
In the Women’s Health Initiative trial, being overweight increased the POP rate by – to – percent, and being obese raised the POP rate by 40 to 75 percent (Hendrix, 2002)
In the Women’s Health Initiative trial, being overweight increased the POP rate by 31 to 39 percent, and being obese raised the POP rate by 40 to 75 percent (Hendrix, 2002)
The levator ani muscle is a pair of striated muscles composed of three regions, which are the
iliococcygeus muscle, pubococcygeus muscle, and puborectalis muscle.
Levels of Vaginal Support
Level I support suspends the upper or proximal vagina. Level II support attaches the midvagina along its length to the arcus tendineus fascia pelvis. Level III support results from fUsion of the distal vagina to adjacent structures. Defects in each level of support result in identifiable vaginal wall prolapse.
Level I vaginal support is
the attachment of the cardinal and uterosacral ligaments to the cervix and upper vagina.The cardinal ligaments fan out laterally and attach to the parietal fascia of the obturator internus and piriformis muscles, the anterior border of the greater sciatic foramen, and the ischial spines. The uterosacral ligaments are posterior fibers that attach to the presacral region at the level of S2 through S4. Together, this dense visceral connective tissue complex maintains vaginal length and horizontal axis. It allows the vagina to be supported by the levator plate and positions the cervix just superior to the level of the ischial spines. Defects in this support complex can lead to apical prolapse. This is frequently associated with small bowel herniation into the vaginal wall, that is, enterocele.
Level II vaginal support consists of
the paravaginal attachments that are contiguous with the cardinal/uterosacral complex at the ischial spine. These are the connective tissue attachments of the lateral vagina anteriorly to the arcus tendineus fascia pelvis and posteriorly to the arcus tendineus rectovaginalis. Detachment of this connective tissue from the arcus tendineus fascia pelvis leads to lateral or paravaginal anterior vaginal wall prolapse.
Level III support is composed of
the perineal body, superficial and deep perineal muscles, and fibromuscular connective tissue. Collectively, these support the distal one third of the vagina and introitus. The perineal body is essential for distal vaginal support and proper fUnction of the anal canal. Damage to level III support contributes to anterior and posterior vaginal wall prolapse, gaping introitus, and perineal descent.
Classification of Vesicovaginal Fistulas
- Simple: Size <2 to 3 em Located near the cuff (supratrigonal) No prior radiation or malignancy Normal vaginal length
- Complicated: Prior radiation therapy Pelvic malignancy present Vaginal length shortened Size >3 cm Located distant from cuff or has trigonal involvement
type I fistulas are
those that do not involve the urethral closure mechanism,
type II fistulas are
divided into: (A) without or (B) with subtotal or total urethra involvement.
Type liB fistulas are further subdivided as: (a) without or (b) with a circumferential configuration around the urethra.
This new classification divides genitourinary fistulas into four main types, depending on the distance of the fistula’s distal edge from the external urinary meatus. These four types are further subclassified by the size of the fistula, extent of associated scarring, vaginal length, or special considerations.
Type 1: Distal edge of fistula >3.5 cm from external urinary meatus
Type 2: Distal edge of fistula >2.5-3.5 vm from external urinary meatus
Type 3: Distal edge of fistula >1.5 to 2.5 cm from external urinary meatus
Type 4: Distal edge of fistula <1.5 cm from external urinary meatus
(a) Size <1.5 cm, in the largest diameter
(b) Size 1.5-3 cm, in the largest diameter
(c) Size >3 cm, in the largest diameter
i. None or only mild fibrosis (around fistula and/or vagina) and/or vaginal length >6 cm, normal capacity
ii. Moderate or severe fibrosis (around fistula and/or vagina) and/or reduced vaginal length and/or capacity
iii. Special consideration, e.g., postradiation, ureteric involvement, circumferential fistula, or previous repair
The claasic triad of Urethral diverticula
postvoid dribbling, dysuria, and dyspareunia
When early postpartum perineal laceration breakdown occurs, three potential management strategies exist:
1) immediate debridement and resuturing after resolution of infection, 2) immediate debridement and healing by secondary intention, or 3) immediate debridement and delayed resuturing at 6 weeks to 3 months postpartum.
Forceps-assisted delivery is associated with a – - –fold higher risk of obstetric anal sphincter injury than vacuum-assisted delivery.
Forceps-assisted delivery is associated with a 1.5–4-fold higher risk of obstetric anal sphincter injury than vacuum-assisted delivery.
persistent occiput posterior position has a —fold higher risk of obstetric anal sphincter injury than occiput anterior.
persistent occiput posterior position has a twofold higher risk of obstetric anal sphincter injury than occiput anterior.
the rate of ureteral obstruction after a vaginal uterosacral ligament suspension was shown to be as high as
11%
Sacrospinous ligament fixation (SSLF) attaches the vaginal apex to this coccygeous scarispinous ligament (C-SSL) complex and often selected to which prolapse cases ?
Apical prolapse repair
Operative vaginal birth raises the odds for POP by ——fold
sevenfold
the posterior vaginal wall support system
the posterior vaginal wall with associated fibromuscular tissue and is bounded by the uterosacral/cardinal ligaments, arcus tendineus fascia pelvis and rectovaginalis, levator ani muscles, and the perineal body and membrane. Posterior compartment prolapse, also called posterior vaginal wall prolapse, is any support defect in this posterior vaginal wall support that allows the rectum (rectocele), small bowel (enterocele), sigmoid colon (sigmoidocele), or perineal body (perineocele) to protrude into the vagina
