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Pentti KiilholmaDosentti, Osastonylilääkäri

TYKS, Naistenklinikka

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Level 1: The cardinal-uterosacral ligament complex provides apical attachment of uterus and vaginal vault to the bony sacrum. Uterine prolapse occurs when that complex breaks or is attenuated.

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Level 2: The arcus tendineus (=jännekaari) fascia pelvis and the fascia overlying the levator ani muscles provide support to the middle part of vagina.

Level 3: The urogenital diaphragm (perineal membrane) and perineal body provide support to the lower part of the vagina.

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[http://www.archives.gov/media_desk/press_kits/picturing_photo_gallery_2.html]: Photo by Lewis Hine, 1930. "Old-timer, -- keeping up with the boys. Many structural workers are above middle-age. Empire State [Building].<br> New York City, New York.<br> 199

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    [1]: Photo by Lewis Hine, 1930."Old-timer, -- keeping up with the boys. Many structural workers are above middle-age. Empire State [Building].New York City, New York.

1998 print."                    

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VH has been the traditional surgical treatment for urogenital prolapse.

Most commen indication for hysterectomy in women over 55 years of age in the USA (Wilcox et al 1994).In Finland 28 % (2006)

Conventional wisdom that maintenance of uterus increases the risk of recurrences has now been questioned.

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McCall culdoplasty (+ Ant. and post. repair). Uterosacral ligament suspension Iliococcygeus suspension Sacrospinous fixation; uni- (right side) or

bilateral). Posterior IVS (Idea was ok, but mesh was not

ideal) Implants (Apogee, Prolift, Avaulta). Sacrocolpopexy (open or laparoscopic)

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VAGINAL: Manchester procedure. Transvaginal uterosacral suspension/plication. Sacrospinous hysteropexy. (Colpocleisis or colpectomy)

ABDOMINAL: Sacrohysteropexy/sacrocervicopexy. Pectineal (Cooper)ligament suspension

LAPAROSCOPIC: Round ligament plication/suspension Uterosacral plication/suspension. Sacrohysteropexy

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Total mesh

Much like rebar in concrete, the stress at any one point is distributed over the

entire area of the graft

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No proper randomised trial of hysterectomy vs. no-hysterectomy in uterine prolapse repair has not been done.

Maher et al. Uterine presevation or hysterectomy at sacrospinous colpopexy for uterine prolapse. Int. Urogyn. J. 12:381-385, 2001. Retrospective. With patients` preference.

--------------------------------------------------------- Dietz et al.(etc. Van der Vaart). Functional outcome

after sacrospinous hysteropexy for uterine descensus. Int. Urogyn. J. 19:747-752, 2008.

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Maher et al 1991: Retrospective study. 36 with VH and SSF vs 34 SS hysteropexy Follow-up 33 months vs. 26 months. The subjective (86 % vs 78 %) and objective (72 %

vs 74 %) success rates were equal. Patient-determined satisfaction rate was similar

86 % vs 85 %. Two pregancies; both underwent Cesarean

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55-year-old, P4, postmenopausal,with bothersome pelvic pressure and voiding difficulties. No HRT, no bleeding; Papa normal.Sexually active.

POP-Q:Aa+1,Ba+3,C+3,gh4,pb3,tlv8,Ap 0,Bp 0, and D -4.

Normal uterus; continent with pessary. Absolutely does not desire a hysterectomy. What to do ? TREATMENT OPTIONS: ??.

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Sacrospinal hysteropexy; right side. Armed obturator mesh kits (Anterior Prolift or

Perigee). Important to avoid excess tension. Native tissue central fascial plication for

posterior compartment. Flooding ! the ant. and post. compartments

with local anesthetic.

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Sacrospinous hysteropexy Anterior approach,Capio suturing device Bilateral suspension. Implant (synthetic or biological). Posterior colporraphy or site-specific

repair through a separate incision.

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ANTERIOR MESH POSTERIOR MESH

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Less invasive surgery Excellent attachment point for mesh Potential for reduced risk of cuff erosion Potential for reduced risk of cuff infection Potential for reduced risk of mesh

extrusion

Bonney 1934: Uterus has passive role in uterovaginal prolapse.

Nichols 1996: A dropped uterus is the result and not the cause of a genital prolapse.

Goldberg & Sand 2008: Prolapsed uterus is an ”innocent bystander”.

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Hysterectomy as a part of a prolapse repair is probably overused and perhaps should no longer be considered absolutely routine.

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If the uterus is prolapsed but to be conserved in a reconstructive surgery, some form of mesh prosthesis will likely needed for a long-lasting cure; both vaginal and open/laparoscopic options are presented.

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The decision will be determined by both patients`s preference and the surgeon`s skill and experience.

The use on common sense is allowed as regards the uterine preservation or removal.

The use of synthetic mesh will increase the rate of uterine preservation and probably will produces better long-term success.

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