Surgical Treatment of Pelvic Organ Prolapse

Question 1

Posterior colporrhaphy

Answer 1

Traditional methods may narrow the width of the posterior vaginal wall and is associated with dyspareunia. Now do site specific repair

Question 2

Uterosacral Ligament Suspension

Answer 2

High USLS suspends the vaginal apex to uterosacral
ligaments bilaterally
 Palpate the uterosacral ligaments
 1 - 3 delayed absorbable or permanent sutures placed
through ligament than vaginal and than check cysto prior to tying down sutures

Advantages:
– Vaginal approach
– Vaginal axis is not distorted
– Success rates: 81% for anterior; 98% for apical

 Disadvantages:
– Ureteral injury ~ 1.8% but reported as high as 11%
(Re: cystoscopy prior to tying down sutures)

Question 3

Modified McCall culdoplasty

Answer 3

suture uterosacral ligaments
higher, or more proximal, and attach to vaginal cuff
– The more proximal the sutures, the more prolapse
reduction

Question 4

Sacrospinous Ligament Suspension

Answer 4

Place stitch 2 – 3
cm medial to spine and .5 cm below superior edge 
 Stitch vaginal apex
to sacrospinous
ligament

Pudendal vessels and sciatic nerve behind ligament
(Packing and IR if clipped)

2ndary vessels- inferior gluteal and hypogastric venous plexus

Question 5

Abdominal Sacrocolpopexy

Answer 5

Uses graft material to suspend vaginal apex to the anterior
longitudinal ligament of the sacrum (right under promontory)

Incise peritoneum over
sacrum. Dissect until
anterior ligament of
sacrum.
 Careful attention to
sacral veins and middle
sacral artery (branch off aorta)
 2 - 3 permanent
sutures on ligament
(avoid disc)
- Adjust mesh tension
 Reperitonealize over mesh

Less dyspareunia and apical failure
mesh erosion (3%)
ileus (6%)

Question 6

Osteitis Pubis

Answer 6

Symphyseal tenderness, pain on pelvic compression,
thigh adductor spasm, limitation of abduction,
waddling gait

• ESR elevation, normal initial x-rays, lytic, “moth
  eaten” changes after weeks
   Needle biopsy and culture to rule out pyogenic
  arthritis or osteomyelitis if refractory

Bed rest, analgesia, corticosteroids
Physical therapy
 Direct injection with steroids/anesthetics

Question 7

Osteomylitis

Answer 7

Same signs/symptoms of osteitis pubis PLUS signs of overt bacterial
infection
 Management
 Very early diagnosis
 Oral antibiotics may be adequate

 Advanced chronic cases
 Surgical drainage/removal of permanent materials
 Debridement
 IV antibiotics

Question 8

Most common ureteral injury

Answer 8

Most bladder and ureteral injuries occur during
simple, “uncomplicated” hysterectomy2
 Ureter at IP, uterine artery, vaginal angles
 Bladder during dissection and at cuff closure
 Significantly higher detection with cystoscopy

Question 9

Bladder Injury

Answer 9

 Evaluate ureters/ureteral location
 Small (< 1 cm) cystotomy at dome may be drained
 Other cystotomies should undergo layered closure
 1st layer approximates bladder mucosal edges
 2nd layer incorporates muscularis
 Test for water-tight closure
 Drainage for 7-14 days
 Imaging with cystogram optional

Question 10

Ureteral injury managment

Answer 10

kinking or minor crush- ureteral stent

transection, major crush or thermal injury - surgical repair

Most injuries involve lower third of ureter
 Ureteroneocystotomy procedure of choice
 Injury within 4-5 cm of UVJ
 Kelly clamp used to make puncture at
bladder base and 1 cm of ureter brought into
bladder, spatulated and sutured in place
 Repair stented at surgeon discretion
 Drained

NO TENSION- poas hitch if needed

Question 11

Ureteroureterostomy

Answer 11

• Injuries at least 3-4 cm proximal to UVJ
   Viable ureter ends spatulated for 0.5 cm to
  prevent stenosis
   Ureteral stent inserted and ureteral ends
  sutured together
   Repair stented and drained

Question 12

mechanism and predisposition for urinary retention

Answer 12

Edema, inflammation, hematoma
 Pain
 Pelvic floor spasm
 Valsalva voiders and women with hypoactive
detrusors may be more likely to experience postcontinence
surgery voiding dysfunction

Question 13

Fistula Evaluation

Answer 13

Physical Exam
 Vaginal vault with urine pooling on exam
 Visual evidence of urinary leakage from
fistula
 Area of inflammation / granulation tissue

Ancillary tests
 Dye testing
 Cystoscopy

 Assess status of ureters
 IVP, retrograde pyelogram, CT urogram

 Tissue quality
 Early v. delayed repair
 Location of defect relative to ureteral orifices

Question 14

Vesicovaginal repair

Answer 14

Try antibiotics and estrogen with foley in place for 4-6 weeks and reevalute for closure

Excision of tract with closure
Multiple layers, no tension, vascular tissue

Post-op Management
 Foley drainage
 Cystogram 7-10 days post-repair
 Complications
 Recurrence,

Question 15

Urethral Diverticulum

Answer 15

post-void dribble, dysuria, urinary incontinence,vaginal mass

F/U with MRI

Conservative
 Surgical
 Concern for malignancy (6-9%)15
 Most common malignancy is
adenocarcinoma

 Marsupialization
 Diverticulectomy

complications:
Recurrent diverticulum
 Urethrovaginal fistula
 Failure to divert urine with catheter
 Failure to close in multiple layers without
tension
 New onset urinary incontinence
 Significant dissection of proximal diverticulum
may result in injury to innervation of urethral
sphincter
 Urethral stricture

Question 16

Constipation after sacrocolpopexy

Answer 16

If you place the sutures too low eg S3, S4
you will disrupt the parasympathetic
innervation with resulting constipation or
unmasked underlying rectocele