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![]() Laparoscopic Reconstructive Bladder Prolapse Surgery in the Female
Dirk Drent
There
are many different operations for pelvic organ prolapse. This article
deals with the techniques and views currently practised by the author as
inspired by world renowned surgeons in the field of female reconstructive
surgery.1, 2, 3, 4, 5
The
basic principle of this approach is to support weak and prolapsed tissue
by suturing it to bone, either directly or indirectly by interpositioning
of mesh. The aim is to restore the anatomy as close to the original
anatomy as possible.
Anatomy
The bladder is supported by a specific part of the endopelvic fascia called the pubocervical fascia.
The pubocervical fascia extends from the pubis anteriorly to the cervix
of the uterus posteriorly. The pubocervical fascia acts like a hammock to
support the bladder in the correct position. The anterior (front) end of
the pubocervical fascia supports the bladder neck and urethra and the posterior
(back) end of the pubocervical fascia supports the bladder.
![]() ![]() The anatomy and function of the bladder may be affected when either the support of the anterior (front) end of the hammock is damaged by a process such as pregnancy and child birth or increased collagenase activity. The same may happen if the support of the posterior (back) end of the hammock is damaged (uterine or vaginal vault prolapse) or if both are damaged. ![]() ![]() ![]() ![]() ![]() When the bladder neck support is deficient, the bladder neck drops down and the most common symptom is urinary stress incontinence. Patients may also develop urge incontinence, frequency and nocturia. (DeLancey Level III defect) 6 ![]() When
the posterior support is deficient, the bladder drops down with the uterus
or vaginal vault. The most common urinary symptoms are urgency and
frequency. Patients may also have nocturia, a poor urinary flow and
feeling of incomplete bladder emptying. They often do not have incontinence
due to kinking of the urethra or due to the prolapsed uterus supporting the
bladder. (DeLancey Level I defect) 6
![]() The
pubocervical fascia may get dislodged from it’s lateral attachments to the
arcuate tendons (Arcus tendineus fasciae pelvis) on the pelvic side
walls. This causes anterior vaginal wall and bladder prolapse
with the clinical picture of a cystocele. (DeLancey Level II
defect) 6
Surgical correction of insufficient bladder neck support:
A. Significant prolapse (descent) of the bladder neck and urethra. 4, 5, 7
(Hypermobility of the urethra)
1. Laparoscopic Burch colposuspension:
The
operation of choice is the laparoscopic Burch colposuspension, where the
pubocervical fascia lateral to the bladder neck is elevated and fixed to
the pelvic wall. This restores the normal posterior urethrovesical
angle.
2. Laparoscopic paravaginal repair:
If
there is associated anterior vaginal wall and bladder prolapse, then a paravaginal
repair is also performed. With this procedure lateral defects in the
pubocervical fascia are repaired with nonabsorbable sutures. This procedure
supports the bladder and vaginal wall proximal to the urethrovesical junction.
![]() ![]() 3. ? Suburethral slings:
Treating
significant bladder prolapse with a suburethral sling, without correcting
the prolapse, does often not give good results in my opinion, because if
the sling is only loosely around the urethra, the patients may still be incontinent.
If the sling is pulled tighter, the patients may have difficulty passing
urine due to kinking of the urethra, and may develop urgency and frequency
with incomplete bladder emptying. Fortunately this complication can
be corrected by a laparoscopic paravaginal repair and Burch colposuspension,
as these procedures address both the concurrent anterior vaginal wall and
bladder prolapse and associated urinary stress incontinence secondary to
urethral hypermobility.
B. Minimal prolapse (descent) of the bladder neck and urethra. 7
(Minor degree of hypermobility or intrinsic sphincter deficiency)
This
is often seen after a previous anterior repair or other bladder neck surgery
where the posterior urethrovesical angle looks quite normal but the intrinsic
urethral sphincter mechanism is deficient.
1. Suburethral Sparc sling 8:
Suburethral slings such
as the Sparc
sling, give excellent support and cure of incontinence in this situation.
The Sparc sling is similar to other tensionless vaginal tapes,
but the needles are thinner and are inserted from the suprapubic area
in a posterior direction and guided with a finger inserted through a
small suburethral incision. The tape is made of polypropylene.
![]() ![]() 2. Periurethral injections:
Periurethral
injections such as Macroplastique could be used as a last resort, but are
rarely used due to the excellent results of the Sparc sling.
Surgery to support the posterior end of the prolapsed pubocervical fascia hammock.
A. Uterine prolapse
1. Uterine preservation
a. Laparoscopic sacrohysteropexy. 1, 2
Retaining the cervix at prolapse surgery may be advantageous in offering a physiologic cornerstone for attachment of the pubocervical fascia, rectovaginal fascia and uterosacral-cardinal ligament complex. 9 ![]() With this procedure Prolene mesh is attached to the uterosacral ligaments and isthmus of the uterus or taken around the uterus and fixed to the pubocervical fascia. The other end of the mesh is stapled onto the ligament covering the promontory of the sacrum and then covered with peritoneum. This
procedure is indicated in young patients with uterine prolapse who do not
have children, or who want more children, or patients who refuse a hysterectomy
and wish to retain their uterus 2. Uterine preservation
is only considered in women if they have normal cervical cytological findings,
acceptable uterine ultrasound and no abnormal uterine bleeding. 9
b. Laparoscopic suture hysteropexy. 9
The
cranial portion of the uterosacral ligament is plicated and shortened. This
technique is used for minor degree uterine prolapse where there is sufficient
uterosacral ligament present.
2. Hysterectomy
With
any abnormalities in the uterus, a hysterectomy with proper fixation of the
vaginal vault structures, performed by a Gynaecologist, is the treatment
of choice. This is a popular treatment option even in the absence of
abnormalities.
B. Vaginal vault prolapse (Following previous hysterectomy) (DeLancey Level I defect) 6
1. Laparoscopic Sacrocolpopexy
If
a patient had a previous hysterectomy for uterine prolapse then there is
an 11.6% incidence of vaginal vault prolapse and if the hysterectomy was
done for other benign causes then the incidence of vault prolapse is only
1.8%. 3 This significant difference clearly indicates
that if the ligaments were too weak to support the uterus, they are often
also too weak to support the vaginal vault.
![]() This
approach yields a durable and satisfactory anatomical and functional result.
Sacrocolpopexy gave the best long-term outcome for vault prolapse in
a 20-year study. 3
All
patients undergoing a sacrohysteropexy should have a laparoscopic Burch colposuspension,
with or without paravaginal repair (for significant bladder neck descent)
or Sparc sling (for minimal bladder neck mobility) at the same time, as pulling
on the pubocervical fascia may cause incontinence postoperatively.
If
a sacrocolpopexy is performed, the best option may be a paravaginal repair
and Sparc sling as the Burch colposuspension fails to prevent incontinence
in a significant number of patients in this situation. 11
In
a patient who has had a previous Burch colposuspension, who develops uterine
or vaginal vault prolapse at a later date, a Sparc sling should be inserted
at the same time as the sacrohysteropexy or sacrocolpopexy as people may
develop incontinence again despite the previous Burch colposuspension, as
the urethrovesical angle is altered due to traction on the pubocervical fascia.
2. Laparoscopic Apical Vault Repair. (Posterior Culdoplasty)
With
this procedure the uterosacral ligaments are shortened and fixed to the vaginal
vault. This is used in minor degree vaginal vault prolapse where there
is sufficient uterosacral ligament present.
3. Sacrospinous vaginal vault fixation.
In
elderly people or in people with severe intra-abdominal adhesions, it is
often impossible to do a laparoscopic sacrocolpopexy and in these patients
a sacrospinous fixation of the vaginal vault transvaginally is a better option.
The
disadvantage of this procedure is the proximity of the sacrospinous ligament
to the sciatic nerve and inferior gluteal and pudendal vessels and nerves,
which may cause significant buttock and leg pain and haemorrhage. 2 There is also a higher incidence of recurrent anterior vaginal wall prolapse reported. 10
4. Posterior Intravaginal slingplasty (IVS)
This
is the latest addition to transvaginal vault repair surgery, but will not
be done by the author until more clinical data on long term postoperative
bladder function and recurrence of anterior and posterior vaginal vault prolapse
is available.
Summary:
Repair of pelvic organ prolapse must have a triple goal: 1
1.
The uterus or vaginal vault must be suspended, returning it to a physiologically
normal position with restoration of a firm subvesical floor. This eliminates
a high cystocele.
2.
Evident or latent stress urinary incontinence must be treated. Treatment
of the uterine prolapse (hysterocele) alone is not sufficient because once
the prolapse has been corrected, the effect of a subvesical mass will disappear
and in many cases reveal urinary incontinence.
3.
Steps must be taken in the posterior compartment to reconstitute the rectovaginal
support structure and to reinforce the posterior vaginal wall with synthetic
mesh 1, 3.
REFERENCES
1 Wattiez A, et al. Promontofixation for the treatment of prolapse. Urologic Clinics of North America 2001;28(1):151-157.
2 Leron E, Stanton SL. Sacrohysteropexy with synthetic mesh for the management of uterovaginal prolapse. British Journal of Obstetrics and Gynaecology 2001;108:629-633.
3 Marinkovic SP, Stanton SL. Sacrocolpopexy with anterior and posterior mesh extensions. Issues in Incontinence. 2002:1:1+8-11.
4 Miklos JR, Kohli N. Laparoscopic paravaginal repair plus Burch colposuspension: Review and descriptive technique. Urology 2000;56(Supplement 6A):64-69.
5 Ross JW. Apical Vault Repair, the Cornerstone of Pelvic Vault Reconstruction. Int Urogynecol J 1997;8:146-152.
6 DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166(6):1717-1728.
7 Rosenblatt PL, Kohli N. Laparoscopic Burch or TVT: Choosing between two minimally invasive techniques for stress incontinence. Issues in Incontinence. 2002:1:1+5-7.
9 Maher CF, Carey MP, Murray CJ. Laparoscopic suture hysteropexy for uterine prolapse. Obstetrics & Gynecology 2001;97(6):1010-1014.
10 Buller JL, et al. Uterosacral Ligament: Description of Anatomic Relationships to Optimize Surgical Safety. Obstetrics & Gynecology 2001;97(6):873-879.
11 Lefranc JP, et al. Longterm Follow Up of Posthysterectomy Vaginal Vault Prolapse Abdominal Repair: A report of 85 cases. J Am Coll Surg 2002;195(3):352-358 |
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