Recent advances in POP

Dr. Bernhard Uhl

Department for Obstetrics and Gynecology

St. Vinzenz-Hospital Dinslaken

Germany

Level of pelvic floor supportLevel of pelvic floor support

Level I

apical

Level II

transverse/

horizontal

Level III

Perineum

Central DCentral Damageamage

�Pulsion Cystocele

�Lateral Sulci conserved

�Cross folds (Rugae) flat

Paravaginal defectParavaginal defect

� Cross folds (Rugae)

conserved

� Lateral Sulci

flattened

Operation methods• Anterior or posterior colporrhaphy

• Sacrospinal Fixation

• Hystero-/Colpo-Sacrofixation (open or laparoscopic)

• Vagina

• Cervix

• Lateral Colpofixation

• Pectinopexie

• Bilateral sacrospinal Cervicofixation (BSC)

• Meshrepair

Coloprhaphia anteriorColoprhaphia anterior

Indication:

Pulsion cystozele

�Tightening of the anterior vaginal

wall

�Readaptation of the pelvic fascia

�Success rate of primary surgery

�64% in combination with apical

fixation

�56% without apical fixation

Colporrhaphy posteriorColporrhaphy posterior

� Tightening of the

posterior vaginal wall

� Readaptation of the

posterior pelvic fascia

� Combining the connective

tissue of both sides next to

the rectum

� Combining the levator

muscle increases the risk of

dyspareunia � don´t do

this!!

� Success rate 86%

Notice:•Often there is no isolated recto- or cystocel

•Combination with level I (apical) defect

•No treatment of level I defect

� Recurrence rate after colporhaphia increases

Sacrospinal Fixation

Lig. sacrotuberaleOs sacrum

Indications:

•Apical descent•Subtotalprolapse•Totalprolapse

Success rate: 79—97%

Using non-resorbable suture� Risk of dyspareunia increases

Sacrospinal Fixation

HysteroHystero-- /Vagina/Vagina--

Sacrofixation Sacrofixation

= Lifting and reattachment of the

prolapsed vagina or uterus

Vaginopexy/Hysteropexy on the

sacrum with and (without) mesh

interposition (by abdominal or

laparoscopic surgery)

Success rate 90—100%

Vaginal mesh erosion in 3.5-8%

Enddarm=

Rectum

Gebär-

mutterhals

= Cervix

Blase=

bladder

Paravaginal defect

Lateral repairLateral repair

Lateral repairLateral repair

� Defect Level II

� Paravaginal Colpopexy

Abdominal

Vaginal

Success rate: 76—100%

Success rate: 78—100%

Notice:

• Look for symptoms of paravaginal defect

• Only colporhaphia anterior

• Paravaginal defect is enlarged

• Recurrence rate of cystocele is increased

Bilateral sacrospinal

Cervicopexie•Treatment of level I (apical) Defect•Vaginal approach•Combination with colporhaphia possible

Pectopexie

Laparoscopic treatment of apical prolapse (no standard)

Transvaginal Meshrepair

• In case of recurrence

• In case of severe prolaps and old patient

• Risk of (FDA Alert)

• Arrosion

• Pelvic pain

• Dyspareunia

• Second surgery necessary

• Only for experienced surgeons

• Not in case of not completed family planning

• Before and after surgery local treatment with estriol (for lifetime)

Attachmentpoints for meshrepairAttachmentpoints for meshrepair

Foramen

Obturatum

anterior transobt. point

posterior transobt. point

Posterior point

Anterior MeshAnterior Mesh

Possible Attachementpoints

Posterior MeshPosterior Mesh

Possible AttachmentpointsAlternatives

Some examples for external fixated meshes

Transobturatic external

fixated Mesh

Bladderneck

Vagina

Tuber ischiadicum

Internal Fixation

Single inscision technic by vaginal approach•By suture•By anchor

Notice:

• Transobturatory Fixation

• Shortened functionaly the vagina

• Risk of dyspareunia

• More risk of recurrence than in apical fixation

• Better results with apical fixation

Mesh-complications

12—17De novo-SUI

1—22Re-OP-rate

7—33Recurrence

2—44De novo Dyspareunia

3—18Pain

1—19Arrosion

Prevalence (%)Complication

Datas of FDA and American College of Obstreticans and Gynecologists (ACOG)

Problems of the literature basing the

FDA Alert• Many studies refer to anatomical results and less on

functionality and quality of life

• Primary and recurrent surgeries are not separated

• Mix with various additional procedures complicate comparability

• Different definitions and reports on adverse events

• Very few studies have follow up> 2 years

• underrepresented second-generation meshes with apical fixation (less risk of dyspareunia)

• Results highly dependent on surgeon

• Treatment with local estriol is not reported

Last but not least:

Pessary-treatment

•Should be offered as a first step•Alternative, of surgery is not possible

www.st-vinzenz-hospital.de

Email: bernhard.uhl@st-vinzenz-hospital.de

Thank you for your attention