Paravaginal Repair Research Articles

Laparoscopic Uterine Suspension in Patients With Cervical Elongation

The objective of this study was to describe an alternative technique to the Manchester procedure for uterine suspension of a uterus with an elongated cervix, which is applicable for patients undergoing laparoscopic repair of multiple pelvic floor defects. This study consisted of a retrospective review of 2 patients who underwent vaginal trachelectomy combined with laparoscopic uterine suspension using a high uterosacral fixation technique. Two patients with stage II prolapse of an elongated cervix, each of whom desired conservation of her uterus, underwent transvaginal partial trachelectomy combined with a laparoscopic suspension of the uterus using a high uterosacral fixation technique. They then underwent concomitant laparoscopic paravaginal repair, antiincontinence surgery, and posterior repair. No intraoperative complications were noted. The patients were discharged within 24 hours. In patients undergoing laparoscopic repair of multiple pelvic floor defects, and who have protrusion of an elongated cervix, transvaginal partial trachelectomy combined with laparoscopic uterine suspension is a safe and effective alternative to the Manchester procedure.

104: A Modified Laparoscopic Paravaginal Repair for Patients with Complicated Paravaginal Cystocele

To describe a surgical technique for laparoscopic paravaginal defect repair in patients with extensive or complicated paravaginal defects. A description of surgical technique in forty-eight cases of laparoscopic paravaginal repair. Community and referral based gynecologic laparoscopic specialty clinic. Forty-eight patients (mean age 56 years) with paravaginal defect cystocele deemed to be extensive or complicated at intraoperative assessment. Laparoscopic pelvic floor reconstruction with modified paravaginal defect repair. Two hundred fifty charts were reviewed from a ten year period. Forty-eight patients were identified who had a modified laparoscopic paravaginal repair incorporating Cooper’s ligament. All patients had additional pelvic floor reconstructive procedures. The three types of defects warranting the modification were 1) arcus tendineous fascia pelvis separated from the pelvic sidewall, 2) weakness of the endopelvic fascia based on intraoperative assessment, 3) large, paravaginal defect. There were no major intraoperative complications. Five (10%) patients required a period of self-catheterization postoperatively. Four (8%) patients had de novo stress urinary incontinence. Four (8%) patients had de novo detrussor instability. Five (10%) patients had recurrent prolapse in any compartment with two (4%) patients having recurrent cystocele. Only three (6%) patients with recurrent prolapse required treatment. Incorporating Cooper’s ligament into a laparoscopic paravaginal repair is a safe and effective technique for surgical management in patients with extensive fascial defects or poor tissue for repair.

Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: Report of early results, outcomes, and patient satisfaction with a new technique

Baden-Walker classification grade III–IV (pelvic organ prolapse quantification [POP-Q] system stage III–IV) cystocele is associated with a constellation of abnormalities including urethral hypermobility, lateral defect, central defect, and concomitant vault and posterior wall prolapse. We describe a new transvaginal paravaginal technique to correct this group of abnormalities and report on our early results. We prospectively evaluated patients with high-grade cystocele who underwent repair with the new transvaginal paravaginal repair. Preoperative evaluation included history and physical examination, dynamic pelvic magnetic resonance imaging, urodynamics, and symptom questionnaire. All patients first underwent a distal urethral polypropylene sling surgery. After repair of the central defect of the cystocele, a paravaginal repair of the lateral defect was performed by using a circular 5 cm × 5 cm soft polypropylene mesh attached proximally to the sacrouterine/cardinal ligament, distally to the bladder neck, and laterally to the infralevator obturator fascia. Postoperative evaluation at 3-month intervals included history and physical examination using the POP-Q system, a voiding dysfunction and incontinence symptom questionnaire, the validated short form of the Urogenital Distress Inventory (UDI-6), a validated global quality-of-life question, and a postvoid residual. We performed the repair in 98 patients with a mean age of 65 years (range, 40 to 86 years). Of these, 26% underwent concomitant vaginal hysterectomy, 45% had enterocele repair, and 94% had rectocele repair. There were 2 complications, including transient ureteral obstruction due to bladder wall hematoma and 1 patient who presented with a recurrent enterocele requiring surgical repair. No patient experienced urinary retention. De novo stress urinary incontinence was seen in 3 patients; de novo urge incontinence was seen in 2 patients. Postoperative POP-Q scores showed 85% of patients with stage 0–I, 13% with stage II, and 2% with stage III anterior vaginal wall prolapse. Of patients with preoperative stress urinary incontinence, 70% reported never experiencing symptoms under any circumstances. Quality of life improved from 4.7 to 1 ( P <0.005). Transvaginal paravaginal repair of grade III–IV cystocele using soft polypropylene mesh fixed to the obturator fascia, sacrouterine ligaments, and bladder neck area provides excellent support of the central defect repair as well as repair of the lateral defect. The operation is safe, simple, and outpatient based, and provides excellent anatomic results with minimal complications. Concomitant distal polypropylene sling did not increase the rate of complications and did not compromise results of stress urinary incontinence surgery.

Laparoscopic exploration of obturator nerve

Obturator nerve injury is a recognised potential complication of paravaginal repair (Scotti et al., Am J Obstet Gynecol 179:1436, 1998). Non-absorbable sutures are utilised for a paravaginal repair in order to provide permanent support, and they can induce a fibrotic reaction, thereby contributing to the integrity of the repair. We present a case in which we hypothesise that the fibrotic reaction induced resulted in the tethering of the obturator nerve. This was released laparoscopically with immediate resolution of symptoms.

Surgical management of anterior vaginal wall prolapse: an evidencebased literature review

The aim of this review is to summarize the available literature on surgical management of anterior vaginal wall prolapse. A Medline search from 1966 to 2004 and a hand-search of conference proceedings of the International Continence Society and International Urogynecological Association from 2001 to 2004 were performed. The success rates for the anterior colporrhaphy vary widely between 37 and 100%. Augmentation with absorbable mesh (polyglactin) significantly increases the success rate for anterior vaginal wall prolapse. Abdominal sacrocolpopexy combined with paravaginal repair significantly reduced the risk for further cystocele surgery compared to anterior colporrhaphy and sacrospinous colpopexy. The abdominal and vaginal paravaginal repair have success rates between 76 and 100%, however, no randomized trials have been performed. There is currently no evidence to recommend the routine use of any graft in primary repairs, and possible improved anatomical out-comes have to be tempered againstcomplications including mesh erosions, infections and dyspareunia.

The distance between the perceived and the actual arcus tendineus fascia pelvis during vaginal paravaginal repair

This study was undertaken to determine whether the arcus tendineus fascia pelvis (ATFP) can be accurately identified from the paravaginal space (PVS) without entering the retropubic space (RPS). Eight patients undergoing vaginal paravaginal repair were enrolled. The paravaginal dissection was completed to the most cephalad portion of the PVS without entering the RPS. The apex of each PVS was stained with methylene blue. The RPS was entered, the ATFP visualized, and 4 sutures were placed along its length to be used for the repair. The perpendicular distance between each suture and the most cephalad area of stain was measured. The mean distance from the perceived to actual ATFP at each suture point (1-4) was 3.5 cm, 2.75 cm, 2.0 cm, and 0.91 cm, respectively. In these 8 cases, the RPS had to be entered to accurately identify the ATFP. The degree of error increases as the ischial spine is approached (P < .001).

Uncommon complications of sacrospinous fixation for treatment of vaginal vault prolapse

The present study was undertaken to evaluate uncommon complications following transvaginal sacrospinous colpopexy for treatment of vaginal vault prolapse. A series of three patients who developed uncommon complications following sacrospinous fixation are reported. A 64-year-old patient undergoing bilateral sacrospinous colpopexy for the treatment of an ICS stage III vaginal vault prolapse developed a perineal necrotizing infection. Another patient, a 69-year-old woman with total vaginal vault prolapse and anterior vaginal wall defect (ICS stage II), underwent a right transvaginal sacrospinous colpopexy and anterior repair, presenting postoperatively with a perineal hernia. The third case consisted of a 71-year-old woman who underwent a right sacrospinous colpopexy with paravaginal repair, rectocele repair, and perineorrhaphy for treatment of an ICS stage III post-hysterectomy vaginal vault prolapse, stage II cystocele secondary to a bilateral paravaginal defect, and a stage II rectocele. Six months later the patient developed a left lateral enterocele, which was successfully repaired with a left sacrospinous ligament fixation. Etiological factors and treatment considerations for these uncommon complications of sacrospinous colpopexy are discussed in detail, and prophylactic measures, when applicable, are emphasized.

Management of prolapse of the anterior compartment

A wide range of techniques have been attempted to repair the prolapsing anterior vaginal wall. Geradin tried denudation of vaginal mucosa for the management of prolapse in 1823 on a cadaver. This was first performed on a living patient in 1830. By 1866 J.M. Simm had performed a series of denudation operations very similar to a modern anterior repair. The majority of historical papers describing the aetiology of, and treatment for, the cystocoele regard the condition as analogous to a herniation of the anterior abdominal wall. Consequently all the surgical techniques concentrate on excision of the redundant vaginal tissue with plication of the cut ends of the fascia in the midline. George White in 1909 wrote of his frustration with the suboptimal outcome of operations for the repair of the cystocoele. He believed that the practice of removing part of the anterior wall before suturing the cut ends together was irrational and destined for failure. In this paper he made the first reference to the lateral supports of the anterior wall. He proposed that injuries at parturition produced tears in the fibres of the white line allowing the anterior wall to dislocate from its attachments and present as a cystocoele. His proposed solution was a vaginal technique allowing attachment of the lateral sulci of the vagina to the white line using absorbable sutures (the technique described is not dissimilar to the current abdominal paravaginal repair described by Richardson). Nineteen cases with no recurrence at 3 years were described. White appreciated that the operation, in addition to correcting the prolapse, did not compromise the capacity of the vagina. The prevailing belief at the time was that a cystocoele represented a central herniation of the bladder through the anterior fascia and therefore would not be served by an operative procedure, which only approached the lateral supports. As a consequence the procedure was largely ignored until its resurrection by Richardson in 1981. In the interim surgeons concentrated their efforts on improving the outcome of the midline procedures. Attention was given to correction of midline ‘fascial’ defects by ‘lapping’ techniques. The abdominal approach was introduced in 1939 and underwent subsequent modifications. Macer concluded that the procedure was superior to the vaginal approach. Various techniques originally described for the management of stress incontinence have been tried for anterior wall defects but have failed to make any real impact; the condition continues to be managed by vaginal plication by most surgeons. However, with the re-introduction of the paravaginal repair by Shull and Richardson it seems as if the management of the problem has gone ‘full circle’. Most surgeons are less than satisfied with the outcome of operations for prolapse. Richard TeLinde wrote

Abdominal sacrocolpopexy: a comprehensive review.

To summarize published data about abdominal sacrocolpopexy and to highlight areas about which data are lacking. We conducted a literature search on MEDLINE using Ovid and PubMed, from January,1966 to January, 2004, using search terms "sacropexy," "sacrocolpopexy," "sacral colpopexy," "colpopexy," "sacropexy," "colposacropexy," "abdominal sacrocolpopexy" "pelvic organ prolapse and surgery," and "vaginal vault prolapse or surgery" and included articles with English-language abstracts. We examined reference lists of published articles to identify other articles not found on the electronic search. We examined all studies identified in our search that provided any outcome data on sacrocolpopexy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data. Follow-up duration for most studies ranged from 6 months to 3 years. The success rate, when defined as lack of apical prolapse postoperatively, ranged from 78-100% and when defined as no postoperative prolapse, from 58-100%. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range 0-18.2%) and 4.9% (range 1.2% to 30.9%), respectively. The overall rate of mesh erosion was 3.4% (70 of 2,178). Some reports found more mesh erosions when concomitant total hysterectomy was done, whereas other reports did not. There were no data to either support or refute the contentions that concomitant culdoplasty or paravaginal repair decreased the risk of failure. Most authors recommended burying the graft under the peritoneum to attempt to decrease the risk of bowel obstruction; despite this, the median rate (when reported) of small bowel obstruction requiring surgery was 1.1% (range 0.6% to 8.6%). Few studies rigorously assessed pelvic symptoms, bowel function, or sexual function. Sacrocolpopexy is a reliable procedure that effectively and consistently resolves vaginal vault prolapse. Patients should be counseled about the low, but present risk, of reoperation for prolapse, stress incontinence, and complications. Prospective trials are needed to understand the effect of sacrocolpopexy on functional outcomes.

Vaginal anterior colposuspension (VACS) for cystocele

Cystoceles are mainly treated by anterior colporrhaphy paravaginal repair Burch colposuspension and even sacrocolpopexy. In general suspension procedures deliver improved results compared to vaginal procedures (mainly anterior colporrhaphy). Would it therefore be possible to perform a suspension procedure vaginally on a cystocele? A vaginally performed para-vaginal repair is such a procedure but in this report we describe a different suspension procedure known as vaginal anterior colposuspension (VACS). Twenty-eight patients with cystoceles and rectoceles were treated by VACS and posterior colporrhaphy. Inclusion criteria included elderly or compromised patients not qualifying for abdominal procedures or younger people with previous abdominal surgery where prepeat laparotomy was considered a risk to the patient. (excerpt)

Laparoscopic Treatment of Pelvic Floor Defects in Women of Reproductive Age

Study Objective To evaluate the efficacy of conservative laparoscopic treatment of genital prolapse in women of reproductive age. Design Retrospective analysis (Canadian Task Force classification II-2). Setting University hospital, Center of Reconstrutive Pelivc Endosurgery, Reproductive Medical Unit, S. Orsola Hospital, Bologna, Italy. Patients Patients. Fifteen women of reproductive age with genital prolapse. Intervention Interventions. Conservative laparoscopic surgical correction of genital prolapse. Apical prolapse was corrected by sacral colpohysteropexy. Burch colposuspension was always included to treat evident or latent stress urinary incontinence. Anterior compartment defects were treated by laparoscopic paravaginal repair and by the interposition of an intervesicouterine prosthesis. Posterior compartment defects were corrected by a prosthetic reconstruction of the rectovaginal support structure. Measurements and Main Results Measurements and Main Results. All patients underwent surgery between January 1998 and December 2000. They were prospectively evaluated for a minimum of 24 months of follow-up. No woman underwent additional surgery during the follow-up period. All women had resolution of the apical prolapse. In one woman, anterior compartment correction (i.e., correction of the anterior part of endopelvic fascia, including correction of bladder and anterior vaginal wall prolapse) was reported. No woman underwent additional prolapse surgery during the follow-up period. Three women became pregnant after surgery: one had an abortion at 8 weeks' gestation; the other two completed term pregnancies and delivered by cesarean section. Conclusion Laparoscopic therapy of genital prolapse is a desirable procedure in patients of reproductive age because it respects the anatomic structures and maintains the function of the organs. Furthermore, laparoscopic treatment is feasible and well-tolerated and produces good results.

Laparoscopic colposuspension versus urethropexy: a case-control series

Laparoscopic colposuspension (LC) was first described in the early 1990s as a technique distinct from open Burch colposuspension. Subsequently, however, LC was closely modelled along the lines of the Burch technique, and the distinct features of the original urethropexy (UP) were largely disregarded. In this case-control series the authors aimed to compare symptoms and anatomical outcomes after standard LC and urethropexy +/- paravaginal repair. The design was a clinical retrospective case-control trial. The setting was the urogynaecology and endogynaecology services of tertiary hospitals. Fifty patients after LC and 50 women after UP surgery, matched for age, body mass index, previous surgery, pre-existing urge incontinence and length of follow-up (1.01 year, range 0.02-3.54 years) for LC and 0.98 years (range 0.06-3.55 years) for UP). Intervention consisted of standardised interview and translabial ultrasound imaging. There were no significant differences for subjective cure of stress incontinence (80% for UP vs. 74% for LC), postoperative urge incontinence, frequency and nocturia. Significantly more UP patients complained of voiding dysfunction (p=0.01). Significant differences were found for urethral rotation, position of the bladder neck on Valsalva and bladder neck descent on Valsalva (all p<0.001). Both procedures were shown to be effective in curing stress incontinence. The incidence of bladder symptoms was comparable, with the exception of voiding difficulty. Significant differences were observed regarding anatomical appearances, with urethropexies showing more recurrent bladder neck hypermobility and cystocele.

1160: Early Results with Transvaginal Paravaginal Repair of Central and Lateral Defects of Grade IV Cystocele Repair with Concomitant Suburethral Sling: Surgical Outcome and Satisfaction Determined by Patient Driven Questionnaires

You have accessJournal of UrologyPodium, Monday, May 10, 2004, 1:00- 3:00 pm1 Apr 20041160: Early Results with Transvaginal Paravaginal Repair of Central and Lateral Defects of Grade IV Cystocele Repair with Concomitant Suburethral Sling: Surgical Outcome and Satisfaction Determined by Patient Driven Questionnaires Raviender Bukkapatnam, Sovrin M. Shah, Larissa V. Rodriguez, and Shlomo Raz Raviender BukkapatnamRaviender Bukkapatnam More articles by this author , Sovrin M. ShahSovrin M. Shah More articles by this author , Larissa V. RodriguezLarissa V. Rodriguez More articles by this author , and Shlomo RazShlomo Raz More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)38397-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1160: Early Results with Transvaginal Paravaginal Repair of Central and Lateral Defects of Grade IV Cystocele Repair with Concomitant Suburethral Sling: Surgical Outcome and Satisfaction Determined by Patient Driven Questionnaires." The Journal of Urology, 171(4S), p. 306 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 171Issue 4SApril 2004Page: 306 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Raviender Bukkapatnam More articles by this author Sovrin M. Shah More articles by this author Larissa V. Rodriguez More articles by this author Shlomo Raz More articles by this author Expand All Advertisement PDF downloadLoading ...

Vaginal paravaginal repair with an AlloDerm graft

Objective This study was undertaken to describe outcomes of a technique of vaginal paravaginal repair that used AlloDerm graft (LifeCell, Branchburg, NJ) in women with recurrent stage II or with primary or recurrent stage III/IV anterior vaginal wall prolapse. Study design This was an observational study. Thirty-three women underwent a vaginal paravaginal repair using AlloDerm graft. Anterior vaginal wall prolapse was staged using the pelvic organ prolapse quantification system preoperatively and every 6 months after surgery. Recurrence of prolapse, changes in functional status (urinary symptoms, prolapse symptoms, and sexual activity), and complications were recorded. Objective failure was defined as recurrent anterior vaginal wall prolapse, stage II or greater, and subjective failure as symptomatic recurrent anterior vaginal wall prolapse. Life-table analysis evaluated objective and subjective failure. Risk factors for recurrent anterior vaginal wall prolapse were evaluated. Results The mean age was 65.2 years and 93% of the women were white. Preoperatively, 6 women had recurrent stage II, 24 women had stage III, and 3 women had stage IV anterior vaginal wall prolapse. The median length of follow-up was 18 months. Postoperatively, 12 women had asymptomatic stage II anterior vaginal wall prolapse (not beyond the hymen) develop, and 1 woman had symptomatic stage II prolapse develop. Thus, there were 13 (41%) objective failures and 1 (3%) subjective failure. Life-table analysis demonstrated the cumulative probability of an objective failure was 0.24 at 1 year and 0.50 at 2, 3, and 4 years. The cumulative probability of a subjective failure was 0.00 at 1 and 2 years and 0.11 at 3 and 4 years. No risk factors for objective failure were identified. Voiding complaints resolved in 11 of 14 (79%) women ( P = .004), incontinence symptoms resolved in 17 of 19 (89%) women ( P<.001), and urgency symptoms resolved in 20 of 23 (87%) women ( P<.001) (all two-tailed Fisher exact test). Twenty-one women (64%) were sexually active, and none complained of postoperative dyspareunia. Complications included 1 case of febrile morbidity, 1 cystotomy, and 1 anterior wall breakdown secondary to hematoma formation caused by heparin therapy. No other erosions or rejections were seen. Conclusion Vaginal paravaginal repair with AlloDerm graft in women with recurrent stage II or stage III/IV anterior vaginal wall prolapse is safe and has good subjective but only fair objective success within the first 2 years.

What's new in prolapse surgery?

There are very many types of operation for the correction of symptomatic pelvic floor relaxation, and the pelvic surgeon is faced with a difficult task when selecting the most appropriate procedure(s) for an individual patient. Currently, the lifetime risk of undergoing prolapse or continence surgery in France is one in 11; up to 30% of patients will require repeat prolapse surgery, and 10% will require repeat continence surgery. Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for a definitive surgical cure. This review looks at the etiology, presentation and current surgical management of genital prolapse in females. There are three primary routes of access in reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) for the repair of anterior, superior and posterior defects; the choice often depends on the surgeon's experience. Of the abdominal repairs, abdominal sacrocolpopexy with mesh remains the 'gold standard'; the retropubic paravaginal repair and laparoscopic techniques have not gained widespread acceptance. The laparoscopic approach appears to be the least utilized, because of the great degree of technical difficulty associated with laparoscopic suturing. Of the vaginal restorative procedures, uterosacral ligament vault suspension and iliococcygeous and sacrospinous fixation have their proponents. However, there is increasing interest in the use of biological prostheses (allografts/xenografts) and synthetic absorbable meshes. Randomized controlled trials are required to evaluate the role of surgical procedures in reconstructive surgery, to determine which type of prosthesis is most suitable.

Two-Year Experience with Laparoscopic Pelvic Floor Repair

Study Objective To evaluate the cumulative experience at our institution of laparoscopic pelvic floor repair to treat genital prolapse and associated symptoms. Design Retrospective analysis (Canadian Task Force classification II-2). Setting University hospital. Patients Seventy-three consecutive women treated surgically for symptomatic genital prolapse. Interventions Surgical treatment was site specific depending on findings on physical examination. Anterior compartment defects were treated by laparoscopic paravaginal repair, laparoscopic Burch colposuspension, or transvaginal anterior vaginal repair. Defects in the posterior compartment were treated by a combination of laparoscopic supralevator repair, laparoscopic vaginal vault suspension, enterocele sac invagination or excision, and transvaginal posterior vaginal repair. Anatomic defects in the apical compartment were primarily treated by laparoscopic vaginal vault suspension and enterocele sac excision. Patients whose anatomic anomalies contained elements of anterior, posterior, and apical compartments were classified in a global group. Measurements and Main Results Preoperatively, prolapse was considered as an attachment or fascial defect at DeLancey level I, II, or III. Each was then quantified by the pelvic organ prolapse quantification (POPQ) system and compartmentalized according to site of the major defect. Women were assessed by physical examination and repeat POPQ staging 6 weeks postoperatively and every 6 months thereafter. A standard interview was administered to assess functional status. Major complications occurred in 4.1% of women. Objective and subjective cure rates were 90% at 2 years. Conclusion Laparoscopic pelvic floor repair is an effective procedure with low morbidity. It should play a primary role in surgical management of DeLancey levels I and II attachment defects. For fascial defects, in particular DeLancey level II anteriorly and posteriorly, it should be complemented with vaginal repair.

Incontinence and Prolapse—An Integrated View

There is a complex interaction of factors contributing to the development of urogenital prolapse and stress incontinence. These aetiological factors are exactly the same for prolapse as for urinary stress incontinence. These factors include pregnancy and childbirth, collagen status, weight, and chronic airways disease while anti-incontinence surgery itself can be a cause of prolapse. Our understanding of why some women develop stress incontinence, others develop prolapse without stress incontinence, and some develop both, is incomplete. However, the identical aetiologies of the two conditions suggest that an integrated approach to managing stress incontinence and prolapse may be beneficial. This paper looks at the advantages offered by some combined techniques including paravaginal repair and slings, combined cystocoele repair and slings, combining tension-free vaginal tape (TVT) and prolapse repair, combining vault prolapse repair with repair of stress incontinence, combined mesh sling, and a number of combined laparoscopic approaches. Although a combined approach to treatment should be beneficial, there is still insufficient evidence to assess which combined approach is best, which materials to use, and which patients to select.

Pelvic floor dysfunction management practice patterns: a survey of members of the International Urogynecological Association.

The authors report results of a survey of the practice patterns of International Urogynecological Association (IUGA) members in the management of urinary incontinence and pelvic organ prolapse. A questionnaire regarding current urogynecological clinical practice was developed by the Research and Development Committee of IUGA and mailed to all members of IUGA. Age, specialty, and geographic location factors were used for response comparisons. One hundred and fifty-two surveys (30%) were returned, 35% from North America, 51% from Europe/Australia/New Zealand, and 14% from elsewhere. The average age of respondents was 47.2 years (SD = 9.5), 89% were gynecologists and 11% were urologists. Overall, the procedures of choice for stress incontinence (SUI) were tension-free vaginal tape (TVT; 48.8%) and Burch colposuspension (44%). There were significant geographic variations noted. For SUI with low-pressure urethra/intrinsic sphincteric deficiency, TVT was used by 44.6% and suburethral sling by 32.3%. Various materials are used for suburethral slings, including autologous fascia (46.5%), Marlex mesh (27.8%) and cadaveric fascia lata (11.6%). Bulking agent injection therapy is used for ISD by 75% of respondents. Traditional reconstructive procedures are performed by the majority of respondents, including sacrospinous fixation (78%), abdominal sacrocolpopexy (77%), paravaginal repair (65%) and vaginal enterocele repair (93%); 6.5% use defecography in evaluating rectoceles and 44% use the POP-Q. Seventy-two per cent use urodynamic evaluation routinely in prolapse cases with no manifest SUI. Most IUGA members perform commonly accepted procedures for surgical therapy of urinary incontinence and genital prolapse. IUGA members do not frequently use anorectal physiology and fluoroscopic investigations to evaluate rectoceles prior to repair.

Vaginal vault prolapse after nonsurgical and surgical treatment of MÄAdullerian agenesis

BACKGROUND: Women with Mayer-Rokitansky-Küster-Hauser syndrome fail to develop müllerian ducts, present with primary amenorrhea, and an absent or rudimentary uterus and vagina. After creation of a neovagina, vaginal vault prolapse may occur because of lack of support to the artificially created vagina. CASES: The first patient presented with vaginal vault prolapse 10 years after her vagina was mechanically dilated. The second patient presented with vaginal vault prolapse 27 years after a McIndoe procedure. CONCLUSION: Women with Mayer-Rokitansky-Küster-Hauser syndrome with an artificially created neovagina by dilatation or surgical procedure with a graft are at risk for vaginal vault prolapse. They can be successfully treated with abdominal sacrocolpopexy and paravaginal repair.

Vaginal paravaginal repair: One-year outcomes

Objective: This study was carried out to determine the efficacy and safety of the vaginal approach to paravaginal repair of symptomatic paravaginal defect cystocele. Methods: This study is an observational case series of 100 consecutive women, referred from December 1996 to August 2000, with symptomatic grade II to IV paravaginal defect cystocele. Preoperative and postoperative pelvic evaluations were performed with the Baden-Walker halfway system. The same surgeon performed all repairs. Fourteen patients had prior anterior repairs, and 530 concomitant procedures were performed. The vaginal approach consisted of a thorough entry from the vesicovaginal space under the inferior pubic ramus into the retropubic space, widely exposing the area of the arcus tendineus. A repair was done bilaterally in 95 patients and unilaterally in 5. Between 1 and 6 Gore-tex CV-0 sutures (W. L. Gore and Associates, Inc, Elkton, Md) were placed widely around the arcus tendineus on either side and fixed to appropriate locations on the bladder fascia and anterior vaginal walls. Tying these sutures resulted in dramatic elevation of the lateral superior sulci. Patients were followed up for 1 to 36 months, with a mean of 10.6 months. Criteria for objective cure were defined as the lateral sulci of the anterior vaginal walls being at grade 0 and firmly apposed to the lateral pelvic sidewalls. Results: Of the 100 patients, 34 had grade II, 54 had grade III, and 12 had grade IV paravaginal defect cystocele. Patients were followed up postoperatively for 1 to 36 months: 84 for more than 6 weeks and 55 for 1 year or longer. Our objective cure rate was 98%. Two asymptomatic patients had a unilateral grade I or a bilateral grade II paravaginal defect cystocele. A recurrent midline cystocele occurred in 22 patients between 3 and 11 months after the operation. Twenty-one patients were asymptomatic and one was symptomatic. Twenty-one patients had grade I-II cystocele and one had grade III cystocele. There were 3 major intraoperative hemorrhagic complications; one of the operations was converted to an anterior colporrhaphy. There were a total of 21 major and 14 minor inpatient complications. Twenty-five subsequent complications included various urinary symptoms in 14 patients, long-term lower extremity neuropathy in 2, bloody discharge from intravaginal sutures in 3, absent coital sensation in 1, and recurrent pelvic organ prolapse in 5, all of which included grade III enterocele between 3 and 25 months. Conclusions: The vaginal approach to the correction of paravaginal defect cystocele is highly effective in our population at a mean of 11 months after the operation. Frequent complications do occur but are largely manageable. (Am J Obstet Gynecol 2001;185:1360–7.)