Laparoscopic Management of Genitourinary Prolapse

 

Female genitourinary prolapse is a common gynecological disorder with varying severity. Women often have vaginal result with a combination of other symptoms (for example, urine, feces and sex). Surgery is the main treatment, but the pathogenesis is not understood. Prolapse is defined as a protrusion of organs or structures above normal anatomical boundaries. The term agreed the most suitable international female urogenital prolapse is female pelvic organ prolapse sex (POP). Recent demographic studies have shown that the prevalence of any degree of POP in women varies around the age of 20 years and 54 years is 31 percent, two percent were considered serious enough to warrant surgical treatment of prolapse, In addition, it is estimated that every woman has a lifetime risk 11 percent suffer an operation prolapse and incontinence.

Treatment of Genital Prolapse

Although surgery is considered the primary treatment of prolapse, conservative measures, such as a ring pessary or tablet should be offered to women with symptomatic prolapse. It has been shown to reduce the progression of prolapse, to provide symptomatic relief and can delay or even prevent the need for surgery. Patients should be informed about treatment options, so you can make an informed decision. Good management of POPs and their symptoms in secondary care often involves a multidisciplinary team tactics, including gynecologists, physiotherapists, continence nurse specialist, colorectal surgeons, urologists and radiologists.

Conservative Treatment

Physiotherapy

Supervised exercise the pelvic floor muscles can help prevent the progression of mild prolapse and relieve the symptoms of pelvic discomfort. However, it is useful for the simplest prolapse.

Vaginal Cream

Vaginal cream is used to relieve the symptoms of prolapse in women who are waiting for surgery; but it can also help those who do not like or are not candidates for surgery. Furthermore, can be used to detect occult preoperative incontinence. After successfully using vaginal pessary often it depends on the motivation and the choice of the patient.

Both vaginal cream electricity available in the UK are vaginal pessary, vaginal ring and tablets. Pesar type and size used depends on the type of prolapse. Pesar plate is not suitable for women who are sexually active, but it is better preserved, moreso among females that has prolapse posthysterectomy. Yet, it is difficult to remove. Sex is possible with the ring pessary on the spot, but some women like to remove them before sex, and then cleaned and again.

Prolapse Surgery

Prolapse return after surgery is relatively high. It is estimated that 29 percent of women undergoing surgery for prolapse and / or urinary incontinence, be repeated at some point. It is therefore important that women surgery for prolapse properly advise on the process, expectations and possible outcomes.

Surgery is indicated if vaginal pessary test failed or refused by the patient, and for women who want a more definitive treatment, or those associated with urinary or bowel dysfunction. The goal of surgery is to restore normal vaginal anatomy and maintain normal function of the bladder and bowel, and sexual function, if necessary. It is very crucial to know may be the patient is sexually energetic, and if the family is complete. Most women a combination of surgical procedures that require vaginal prolapse often occurs in more than one site (as mentioned above), therefore the need for clinical assessment and screening. Surgical options are available for each of the vaginal section described below.

Front Compartment of the Vagina

Previous Colporrhaphy (repair): Front vaginal repair is usually performed to correct cystocoeles. This is a dissection of the front vaginal wall, fascial connection between the bladder and vaginal wall and vaginal excision of redundant skin. cystocoeles anatomical relapses may occur up to 30 percent of women one year after surgery. Recent developments to improve the outcome of surgery include the use of synthetic mesh; This, however, can increase surgical morbidity without necessarily improving results. The results of years of research is expected. Previous repair is considered an appropriate treatment for urodynamic stress incontinence.

Women with prolapse and urinary incontinence surgery need additional anti-incontinence, as well as tension-free vaginal tape (TVT) or Transobturator tape transaction (TOT) or colposuspension.

Colposuspension:

This used to be considered the ‘gold standard’ surgery for treating urodynamic stress incontinence and supporting the anterior vaginal wall. Its role has diminished with the advent of the newer anti-incontinence operations (TVT, TOT). Nevertheless, it remains an option for treating urinary incontinence associated with severe cysto-urethrocoele, and for women requiring other surgical procedures by the abdominal route.

Paravaginal Repair:

Although originally described in 1909, the paravaginal operation has remained less popular than the much simpler anterior repair. It involves lateral reattachment of the vaginal wall to its original support the arcus tendinueus fasciae pelvis (the ‘white line’). The process can be performed through a vaginal or abdominal approach. It appears to be more effective than anterior repair alone, but is associated with more surgical morbidity such as haemorrhage.

Uterine Prolapse

Vaginal Hysterectomy: Vaginal hysterectomy is the main operation for uterine prolapse. It is often necessary to perform the operation in combination with other procedures.

Manchester Repair:

This involves cervical amputation with retention of the uterine body. It is rarely performed, but may be necessary if there is cervical elongation and a vaginal hysterectomy is impossible or technically difficult.

Sacrohysteropexy:

This is appropriate in young women who require surgery for uterine prolapse but who wish to retain their uterus for future pregnancies. It involves support of the uterus with a mesh from the back of the uterus and uterosacral ligaments attached to the anterior longitudinal ligament over the sacrum. The long-term results and effects on subsequent conditions are not visible.

Posthysterectomy Vaginal Vault Prolapse

Sacrocolpopexy: In this abdominal route operation, the surgeon utilises a mesh to suspend the vaginal vault from the anterior longitudinal ligament over the sacrum. It has a relatively high success rate of around 90 per cent for the amendment of vaginal vault prolapse, nevertheless around is a small risk of mesh erosion. It can be performed as an ‘open’ procedure or laparoscopically.

Sacrospinous Ligament Fixation: This is performed vaginally and it involves attachment of the prolapsed vaginal vault to the uterosacral ligament, usually unilaterally on the right side, but it can be performed bilaterally. It has a good anatomical success rate for correction of vault prolapse and may be performed under regional anaesthesia. Other procedures for suspension of vaginal vault prolapse include uterosacral ligament vault suspension and posterior intravaginal slingoplasty.

Mesh inserted into the vagina is claimed to produce better results than ‘traditional repairs’ by the patient’s personal muscles. Still, these are relatively new processes (eg ‘total vaginal mesh’) and the long-term outcomes and complications are unknown.

Posterior Compartment

Posterior Colporrhaphy (repair) with or without enterocoele treatment: Posterior vaginal repair is the traditional operation for correction of rectocoeles. It involves dissection of the vaginal wall from the rectum and repair of the rectovaginal fascia with or without levator plication. There is a risk of increased dyspareunia after levator plication. In an attempt to improve the success of posterior repair, recent developments involve the use of mesh reinforcement in those patients with poor or severely torn fascia. Conversely, these might increase surgical morbidity without necessarily improving outcome. Studies with long-term follow-up are required.

Colpocleisis (Vaginal Closure)

Through the acknowledgement of the relatively great reappearance of prolapse later after operation, colpocleisis is undergoing a ‘renaissance’ in older women. It involves obliteration of the upper two thirds of the vagina and is appropriate for older women who have undergone previous failed surgery, are no longer sexually active, and are medically unfit for more major surgery. The operating time is short with good outcomes.

Postoperative Care

Patients who have undergone surgery for vaginal prolapse are usually advised to avoid lifting heavy objects, or any other situations that might cause sustained increases in abdominal pressure. Perioperative use of laxatives is often recommended in order to prevent constipation. The immediate perioperative care usually involves prophylactic intraoperative antibiotics to reduce the risk of infection, a vaginal pack to reduce the risk of bleeding and vaginal haematoma, and a urinary catheter to avoid the risk of urinary retention. These are usually removed the day after surgery.

Conclusion

Female genitourinary prolapse is a common gynaecological problem that is often associated with urinary and bowel symptoms and pelvic discomfort. Surgery is the mainstay treatment, but recurrence following surgery remains a problem, and long-term outcomes and complications of several techniques are unvisible. Conventional treatment options such as the use of vaginal ring or shelf pessaries should be made available to women previously before surgical treatment.