40 Case Presentations with Expert Discussions
Case: A 26-year-old G1P0 woman with a normal intrauterine pregnancy at 22 weeks presents to her obstetrician’s office for discussion about delivery options. She has no medical problems, is a full-time working accountant, and plans to have two children. She would like to discuss the advantages and disadvantages of vaginal delivery versus scheduled cesarean section, including her doctor’s opinion about what she should do.
As a maternal-fetal medicine specialist, my initial reaction to the concept of elective primary cesarean section to prevent future pelvic floor dysfunction was that of significant skepticism. Granted, women are living longer and preservation of bladder, bowel, and sexual function are significant quality-of-life issues, but is elective cesarean section really the answer? What will the trade-offs be?
On a pragmatic level, there are good patient and provider reasons for elective cesarean section. The patient exercises her autonomy; that is, she gets what she wants. This can lead to a higher degree of patient satisfaction. She may be more accepting of an untoward outcome (DVT, for instance) if the decision were hers. Contrast this with how she would feel after an untoward outcome from a labor (e.g., shoulder dystocia) that she did not want. Beyond the execution of autonomy, she is allowed to exert some control over her birthing experience. She gets to be delivered by her own obstetrician. She can pick the day and time. She bypasses the unpredictable nature of labor and delivery. Finally, she avoids the pain of childbirth.
From the physician’s perspective, there are also significant advantages to elective cesarean. It is a scheduled surgery “in the light of day” when all hospital teams are at their best. It provides a degree of predictability for the physician’s schedule and for unit staffing and readiness. If a patient is delivered at 9 A.M. on Tuesday, that’s one less delivery at 3 A.M. on Sunday. Finally, it avoids obstetric misadventures of “sweating out” a protracted labor with an equivocal fetal heart rate tracing, difficult vacuum or forceps application, emergent cesarean section for terminal bradycardia, shoulder dystocia, and the like.
Cesarean birth may be protective to the fetus and newborn by decreasing the risk of vertical transmission of Group B Strep, hepatitis, and HIV. It likely decreases the incidence of intracerebral hemorrhage. It certainly decreases risk for shoulder dystocia and birth asphyxia and, compared with other “acceptable” indications for cesarean section, such as recurrent herpes, suspected macrosomia and certain fetal anomalies, primary cesarean section appears to be safe and cost-effective.
So, what is the controversy? The controversy is that although primary elective cesarean section may be as safe and cost-effective as an attempt at vaginal delivery, every cesarean section after that is not.
Most women in the United States have more than one child. Repeat cesarean sections are associated with increased operative morbidity, such as infection, wound breakdown, ileus, and bowel obstruction. There is clearly increased OR time that translates to greater resource consumption of OR space and surgeon’s, nurses’, and anesthesia time. There is an increased risk for transfusion and hysterectomy and an increased risk for thromboembolism, including pulmonary embolism. Abundant evidence shows that cesarean section leads to abnormal placentation, in particular, placenta previa and placenta accreta. The diagnosis of placenta previa fundamentally changes the course of the pregnancy (pelvic rest for 5 to 6 months) but can also result in antepartum hemorrhage, prolonged hospitalization and bed rest, emergent operative intervention with transfusion, and so on. Additionally, the incidence of placenta accreta, increta, and percreta increases with the number of uterine scars. As with placenta previa, this can lead to the need for increased antenatal surveillance and a high likelihood of antepartum hemorrhage, resulting in prolonged hospitalization and bed rest. Most importantly, the delivery of a patient with a placenta previa, with accreta, can result in massive obstetric hemorrhage, often results in hysterectomy, and may need to be performed emergently (and certainly not by the urogynecologists who advocate elective cesarean section). Finally, we know that the risk of uterine rupture increases with the number of uterine scars. Uterine rupture may occur early in labor and can have catastrophic consequences. A patient who underwent elective primary cesarean section with her first baby could now change her mind about vaginal birth and want a trial of labor, now a VBAC with its associated risks.
Cesarean section has some negative impact on the newborn. Transient tachypnea of the newborn results in the need for increased neonatal monitoring and separation from the parents immediately after delivery. Iatrogenic preterm birth remains a rare problem as obstetricians attempt to perform the cesarean section before the onset of labor. Finally, some evidence suggests that there is an increased risk of unexplained stillbirth with cesarean over vaginal delivery.
In my opinion, evidence showing that elective primary cesarean section will prevent pelvic floor dysfunction is insufficient to advocate its use. In essence, we are exchanging a theoretic risk (urinary incontinence in the eighth decade) with known obstetric complications that are probably more likely to occur, and in the near future. The best that we can do is educate our patients of what we know now and expand its boundaries with ongoing investigation.
Patient-choice or elective cesarean section has been a topic of much discussion and heated debate of late in the lay press and in the medical literature. It is of particular interest to urogynecologists and pelvic surgeons because much of the focus has been on the potential to prevent pelvic floor disorders by avoiding vaginal delivery. When comparing modes of delivery, obstetricians, historically, have compared the short-term morbidity and mortality of vaginal delivery to those of cesarean section. Such a comparison strongly favors vaginal delivery and would seem to preclude elective cesarean section as a viable option. However, for the scenario listed previously, this traditional risk comparison is flawed. First, with the widespread adoption of regional anesthesia, prophylactic antibiotics, and antithrombotic compression devices, the risk of cesarean section has declined. Second, it is not the risk of cesarean section in general that should be considered, but rather the risks of elective cesarean section without labor. A cesarean section that occurs before the onset of labor and before or early after rupture of membranes has a substantially lower risk of morbidity and mortality than cesarean section performed after laboring for several hours or cesarean section performed emergently. Current evidence suggests that a scheduled cesarean section performed before the onset of labor has a mortality rate similar to that of a vaginal delivery (Lewis et al., 2001). Third, not all women who attempt a vaginal delivery are able to do so successfully. Approximately 10% to 15% will require an operative vaginal delivery, and 10% to 25% will require a cesarean section after laboring for some period of time, each of which have an increased risk of morbidity. Thus, it is not the risk of vaginal delivery that should be considered, but rather the risk of a planned vaginal delivery or trial of labor. Fourth, traditional risk comparisons have focused on short-term risks of each mode of delivery and have failed to account for long-term morbidity or quality-of-life considerations. Therefore, when counseling this patient, the risks and benefits of a scheduled cesarean section performed before labor should be weighed against those of a trial of labor, and both short and long-term morbidity should be considered.
Unfortunately, there are no randomized trials directly comparing purely elective cesarean section to trial of labor to provide an unbiased comparison of risks. Perhaps the best available comparison is the Term Breech Trial, which randomized women at term with breech presentation to “planned vaginal delivery” versus “planned cesarean section.” The overall morbidity rates in this trial, including infection, postpartum hemorrhage, and blood transfusions, were not significantly different between the two modes of delivery (OR 1.24 [95% CI 0.78 to 1.95]) (Hannah et al., 2000). Regarding fetal risks, the available evidence suggests that cesarean section performed before labor may decrease the risk of cerebral hemorrhage and brachial plexus injury but increase the risk of transient tachypnea of the newborn (TTN) when compared to vaginal delivery (Morrison et al., 1995; Towner et al., 1999). However, the risk of TTN is minimized, if the cesarean section is performed at 39 weeks of gestation or greater (Morrison et al.).
The long-term morbidity of vaginal delivery is primarily the risk of future pelvic floor disorders. Although the etiology of most pelvic floor disorders is undoubtedly multifactorial, vaginal childbirth is an established risk factor for each of the most prevalent disorders, including stress urinary incontinence (SUI), anal incontinence, and pelvic organ prolapse, particularly in reproductive aged women. Data from the study by Rortveit et al. (2003) suggest that the attributable risk of vaginal delivery for the development of moderate to severe SUI is approximately 50%. Lukacz et al. (2005) recently reported that the attributable risk of vaginal delivery for stress incontinence, overactive bladder (OAB), pelvic organ prolapse, and anal incontinence ranges from 37% to 46%. The authors estimated that five unlabored cesarean sections would be needed to prevent one pelvic floor disorder. Thus, elective cesarean section moderately reduces, but does not eliminate, the risk of a woman developing one or more pelvic floor disorder(s) during her life. The long-term morbidity of elective cesarean section is primarily related to the risks associated with repeat cesarean sections and includes an increased risk of placenta previa, placenta accreta, and uterine dehiscence/rupture. The risk of each of these conditions increases with each subsequent cesarean section, so a discussion of planned family size should be an important consideration when counseling a woman about mode of delivery.
In my opinion, a comparison of the currently available evidence regarding the short- and long-term risks of scheduled elective cesarean section to that of planned vaginal delivery (trial of labor) is relatively balanced. It does not, however, support a routine recommendation for elective cesarean section. Patients who request an elective cesarean section or who, as in this case, request information about the advantages and disadvantages of each mode of delivery should be thoroughly counseled about what is known and not known regarding the short- and long-term risks of each option and allowed to make an informed choice. Although there is considerable controversy about whether or not a woman should be able to choose an elective cesarean section without any obstetric or medical indication, perhaps the best argument for allowing a woman this choice is an ethical one. In today’s society, patient autonomy holds considerable, if not preeminent, weight. Society and the medical establishment regularly allow patients to undergo procedures, such as cosmetic surgery, that have little or no medical benefit and can have considerable risk, in some cases, as much or more risk as a cesarean section. Given this, it seems difficult to not allow an informed pregnant woman to choose which mode of delivery (and which associated risks) she prefers.
There is a considerable need for research to improve our knowledge about the relative risks and benefits of elective cesarean section. Ideally, risk assessment tools will be developed that will allow a woman to individualize her risk, including the risk of future pelvic floor disorders so that she can make a truly informed choice about which mode of delivery is best for her and her child.
Hannah ME, Hannah WA, Hawson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356:1375.
Although there are no randomized controlled trials to help resolve this issue, there are many studies that address the various risk factors for both successful and adverse outcomes after childbirth to help form a decision. As might be expected, the urogynecologist focused on the obstetric risk factors for future pelvic floor disorders to help justify “C-section on demand,” whereas the maternal-fetal-medicine specialist questioned this practice by focusing on the important obstetric issues involved, including the increased risk of future placenta previa and accreta. Both discussants agree, however, that patient autonomy is paramount in that the woman should have the ability to make the final decision about the route of her delivery after she has been fully informed of the risks and benefits.
Case: The patient is a 35-year-old para 4 woman with severe pelvic pressure and mild stress incontinence. She has had a tubal ligation. On examination, there is complete uterine procidentia with eversion of the anterior vaginal wall (Fig. 40-1). Subtracted urodynamics revealed mild urodynamic stress incontinence (USI), without evidence of intrinsic sphincter deficiency (ISD). She is not interested in using a pessary and insists on uterine preservation.
I would perform reconstructive surgery and accept the stipulation of uterine preservation. If the patient had not completed childbearing, I would have some reservations. I, personally, have not seen corrective surgery survive a subsequent pregnancy. However, there is literature documenting that delivery can occur with the repair remaining intact (Kovac and Cruikshank, 1993). The patient’s complaints of pelvic pressure, urinary incontinence, and uterovaginal prolapse must be addressed. Before surgery, I would assess all potential sites of pelvic organ prolapse with the uterine prolapse reduced. I would determine whether the anterior vaginal wall had a central defect or a lateral detachment. Certainly, some lateral detachment is likely with complete prolapse, and an enterocele is often present. I would assess the posterior wall for detachment from the perineal body and from the vaginal apex, as well as the rectovaginal fascia for site-specific defects.
After clearly defining the defects, one must decide on the surgical approach—vaginal, abdominal, or a combination. Correction of the defects should eliminate the uterine prolapse and pressure symptoms. A specific incontinence procedure is needed for USI.
Four approaches have been described for treating prolapse with uterine preservation. The first is the Manchester procedure: vaginal shortening of the uterosacral and cardinal ligaments with cervical amputation. The Manchester procedure has a recurrent prolapse rate in excess of 20% within the first few months. Chances for subsequent pregnancy are severely compromised and, even if conception occurs, pregnancy wastage of 20% to 50% due to cervix dysfunction has been reported. Some pregnancy complications may be avoided if cervix amputation is not performed. This procedure is rarely performed because of frequent recurrence.
The third approach involves anchoring the uterus and cervix, or both, to the sacrum with either natural or synthetic materials. A video publication details this technique (Cholhan, 1998). Recent reports have compared results with and without hysterectomy (Barranger et al., 2003; Leron and Stanton, 2001). Outcomes are comparable in both groups. Another abdominal option, which may lessen the risk of complications, is to suspend the uterine fundus to the pectineal ligament with synthetic mesh (Joshi, 1993).
The fourth approach is to anchor the cervix to the sacrospinous ligaments. Richardson et al. (1989) described a transvaginal approach in which the uterosacral ligaments were attached to the sacrospinous ligaments. A needle procedure was used to treat incontinence. The authors described a high degree of success with this technique and also reported that subsequent pregnancies occurred without recurrence of the prolapse. Two recent articles have compared hysterectomy and hysteropexy when performed in combination with sacrospinous ligament suspension for uterovaginal prolapse (Hefni et al., 2003; Maher et al., 2001). Results are comparable with both techniques.
In this patient, the presence of USI requires the addition of a specific anti-incontinence procedure. Options for urinary incontinence include retropubic urethropexy, pubovaginal sling, Kelly’s plication, or a transvaginal or transobturator synthetic mesh tape. At this time, I favor transvaginal tape.
I remain a proponent of the vaginal approach to prolapse repair and would recommend it for this patient. I would use the technique described by Richardson et al. (1989) to suspend the uterus, but I would substitute a transvaginal tape for USI. I would also repair the enterocele, reattach the pubocervical fascia to its lateral attachments, and perform a site-specific posterior colporrhaphy.
Hefni M, El-Toukhy T, Bhaumik J, Katsimanis E. Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: an evolving concept. Am J Obstet Gynecol. 2003;188:645.
As patients have become more involved in their health care decisions, our specialty has been rightly challenged to justify the performance of hysterectomy. For many women the uterus is an important aspect of body image relative to health and sexuality. At present, the ideal management of this patient is uncluttered by data.
In the early history of reconstructive pelvic surgery, hysterectomy was a relatively morbid procedure, and many ingenious techniques were invented to suspend the uterus. Kelly described a technique for uterine suspension in his 1906 text, Operative Gynecology, in which the fundus was sewn to the anterior abdominal wall fascia above the symphysis to prevent upper vaginal and uterine prolapse following colpoperineorrhaphy. In the late nineteenth century Donald of Manchester described treating uterine prolapse by amputating the cervix and performing a cystocele repair. Fothergill’s modification, in which he included ligating the uterosacral and lower cardinal ligaments, became the most widespread treatment performed for uterine prolapse into the middle of the twentieth century. Around the same time, Watkins reported treating uterine prolapse and cystocele by delivering the fundus through an anterior colpotomy and suturing it between the bladder and vagina. Although these procedures were vaginal-sparing alternatives to the Le Fort’s colpectomy with colpocleisis, none provided discrete apical support. TeLinde commented in the first edition of Operative Gynecology in 1946 that “an operation that hangs up the prolapsed uterus is less satisfactory than those that build up support from below,” but he did note that in young women who desire pregnancy, a suspension procedure might be considered. Throughout the mid-twentieth century, uterine suspension procedures were performed for a host of problems, including dysmenorrhea, infertility, venous congestion, and, particularly, uterine retroflexion. These procedures included a modification of the Gilliam round ligament plication, in which the round ligaments are sutured to the rectus fascia, shortening the uterosacral ligaments by plicating them to the posterior fundus, ventral fixation of the fundus to the rectus fascia (Olshausen’s procedure), and often a combination of these procedures. These procedures are still mentioned in TeLinde’s fiftieth anniversary edition with laparoscopic variations. A review of the current scientific literature reveals a paucity of information concerning uterine suspension for prolapse other than a few case series, with limited follow-up of laparoscopic variations of the previously described procedures and some apocryphal experimental procedures.
Given the absence of definitive surgical literature, it would be reasonable to discuss a uterine-sparing procedure with this patient if she agreed to take the risks of poorly delineated efficacy and complications. The above trachelectomy/transposition procedures are of historical interest but rarely performed in the United States. The anterior fixation would seem to place the patient at high risk of a “contra coup” posterior compartment prolapse. The laparoscopic round ligament and uterosacral ligament procedures are attractive given their simplicity and potentially lower perioperative morbidity, but they seem flimsy given the severity of this woman’s prolapse. Similarly, uterosacral or sacrospinous ligament suspension could be entertained but would seem unlikely to provide a durable result for this healthy young woman. It is also important that she understand that the surgery may increase the difficulty and risks of future hysterectomy and may preclude a vaginal approach.
If she desires surgery with these disclaimers, I would perform an abdominal sacral hysteropexy and urethropexy. I would attach a strip of Mersilene mesh to the posterior lower uterine segment, using two rows of No. 2-0 Prolene suture, fix the other end just inferior to the sacral promontory, and perform a concomitant Halban culdoplasty with attachment of the mesh to the sigmoid serosa to reduce the risk of small bowel incarceration. There are no validated guidelines to determine whether this woman will require concomitant anterior colporrhaphy and/or paravaginal repairs once her apical support is corrected, but women with stage III or IV anterior vaginal prolapse (more than 1 cm beyond the hymenal ring with straining) usually require additional level II repairs. These can be performed vaginally with a pubovaginal sling or abdominally with a Burch urethropexy.
Uterine preservation at prolapse surgery is increasingly being considered by women due to a delay in childbearing to a later age, a belief that the uterus plays a role in sexual satisfaction, and the successful use of conservative treatments for the control of menorrhagia. In women who wish uterine preservation, various surgical options are available, including the vaginal Manchester repair and sacrospinous hysteropexy and the abdominal uterosacral hysteropexy and sacral hysteropexy with mesh. Because continence surgery can be safely and effectively performed via a colposuspension or suburethral tape, it is likely that the choice of the abdominal or vaginal approach to uterine preservation surgery will determine the choice of continence surgery.
The Manchester repair has largely been abandoned due to recurrence of prolapse in excess of 20% in the first few months, decrease in fertility, and pregnancy wastage as high as 50%. In addition, future sampling of the cervix and endometrium can be difficult due to vaginal reepithelialization or cervical stenosis. The sacrospinous hysteropexy is a safe and effective procedure as compared to vaginal hysterectomy and sacrospinous colpopexy for uterine prolapse. Two comparative studies of 165 women, with at least a mean 2-year review, are available and demonstrate that operating time, blood loss, and complications are reduced in the hysteropexy (versus hysterectomy) group, with success rates of 90% being reported (Hefni et al., 2003; Maher et al., 2001b). Only limited data are available on pregnancy outcome following sacrospinous hysteropexy, especially since Hefni et al. (2003) who contributed 109 women to the literature, reported in women only over 60 years. Seven pregnancies have been reported with two women (29%) undergoing further prolapse surgery, one each following vaginal and cesarean delivery (Kovac and Cruikshank, 1993; Maher et al., 2001b).
Alternative abdominal approaches include laparoscopic suture hysteropexy and sacral hysteropexy. We described the laparoscopic suture hysteropexy in which the plicated uterosacral ligaments and cardinal ligaments are resutured to the cervix (Maher et al., 2001a). The objective success rate was 79% after an average of 12 months. Two women completed pregnancies; both delivered abdominally and reported no recurrence of prolapse. The success rate of this surgery may be improved by incorporating partial cervical amputation to the surgery because cervical elongation rather than uterine prolapse represented a significant proportion of the failed group. The operation is simple, effective, and uses native tissue. I would use this procedure in those women considering future pregnancy and in those with mild to moderate uterine prolapse undergoing other pelvic floor surgery. This surgery would not be considered for the women with total uterine procidentia in whom the integrity of the uterosacral ligaments is suspect.
Several authors have reported objective success rates of over 90% with sacral hysteropexy (Barranger et al., 2003; Leron and Stanton, 2001), in which mesh secures the cervix to the sacrum. In a randomized controlled trial comparing sacral hysteropexy with vaginal hysterectomy and repair, Roovers et al. (2004) reported a significantly higher reoperation rate for prolapse in the hysteropexy group. Individual site-specific results were not available, but one suspects that the incorporation of a full anterior and posterior mesh extension as used in the sacral colpopexy after hysterectomy would be difficult and may account for the lower success rate. Younger women who subsequently require hysterectomy or develop future upper vaginal prolapse will be problematic with the removal of the mesh from the cervix and sacrum being challenging. Although mesh introduced abdominally to the pelvis is associated with relatively few mesh complications, I remain uncomfortable with the introduction of mesh to the pelvis for primary prolapse when alternative native tissue repairs exist with equivalent success rates.
The reconstructive gynecologic surgeon has various surgical options available in this case. The sacrospinous hysteropexy is widely described and has excellent outcomes. A suburethral tape could be easily incorporated to manage the concomitant SUI. Anterior compartment prolapse has been problematic after sacrospinous colpopexy and may also be a problem after the sacrospinous hysteropexy. An alternative abdominal approach would be the laparoscopic suture hysteropexy with partial cervical amputation and colposuspension. This option would be especially attractive in those women with significant anterior compartment prolapse where more lateral paravaginal sutures could be placed, and in those wishing to avoid vaginal surgery. Although I reserve the mesh sacral hysteropexy for those women who have recurrent uterine prolapse, this remains an acceptable option for primary uterine prolapse.
Hefni M, El Toukhy T, Bhaumik J, Katsimanis E. Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: an evolving concept. Am J Obstet Gynecol. 2003;188:645.
The case presented is very timely because uterine preservation is being requested by significantly more patients throughout the world who have severe uterine prolapse. All Discussants clearly bring out that few data in this area are available to guide decisions. Most pelvic surgeons would agree that the recurrence rate seems to be higher when the uterus is preserved versus performing a hysterectomy in conjunction with the reconstructive procedures, although data are lacking to support even this statement. At present, in the United States, I would guess that the majority of reconstructive pelvic surgeons would manage this case with some form of abdominal sacral hysteropexy. There is also some new enthusiasm to perform a complete vaginal mesh repair with uterine preservation in this type of patient. Unfortunately, again, few clinical studies currently exist to support any of these recommendations.
Case: A 49-year-old para 5 woman complains of pelvic pressure and the feeling that she does not completely empty her bladder. She had an anterior colporrhaphy (without hysterectomy) 7 years ago. On examination, she has recurrent anterior vaginal wall prolapse that descends beyond the hymen, with straining in the supine position (Fig. 40-2). The cervix descends to the hymen, and a small enterocele and rectocele are also noted. On spontaneous uroflowmetry, the patient voided 240 mL, with a 10-mL postvoid residual urine volume. Time to void was 42 seconds with a maximum flow rate of 12 mL/sec. Filling subtracted cystometry showed a stable cystometrogram to a maximum capacity of 440 mL. Despite numerous provocative maneuvers in the standing position, no stress incontinence could be demonstrated. A static maximum urethral closure pressure (MUCP) with prolapse unreduced was 53 cm H2O. The prolapse was then gently reduced using a Sims’ speculum (Fig. 40-3), and leakage was demonstrated with coughing and straining, with a Valsalva leak point pressure (LPP) of 45 cm H2O and MUCP of 30 cm H2O. The patient desires surgical correction of her prolapse.
Figure 40-3 The same patient after the prolapse is reduced with a Sims’ speculum. The aim of this reductive maneuver is to determine whether underlying “occult” or “potential” stress incontinence is present.
It is well recognized that women with advanced stages of pelvic organ prolapse rarely complain of the symptom of stress urinary incontinence (SUI). Advanced anterior segment prolapse, when accentuated by stress, descends and mechanically obstructs the urethra, preventing the occurrence of SUI (Bump et al., 1988). Preoperative reduction of the prolapse, by using devices such as a pessary, a vaginal pack, or a speculum prevents this stress-activated urethral obstruction and reveals so-called potential stress incontinence in 36% to 80% of women with advanced prolapse (Bump et al., 1996). Although barrier testing has been suggested for determining which women should have a urethropexy or sling procedure performed concurrently with prolapse correction surgery, the predictive value of these barrier tests is poor as long as the prolapse surgery addresses the support defect of the urethra and bladder neck that is usually part of the anterior segment prolapse (Bump et al., 1996). In a randomized prospective comparison of needle urethropexy versus bladder neck endopelvic fascia plication, for the prevention of stress incontinence in women who underwent vaginal reconstruction for stage III or IV prolapse, preoperative prolapse reduction testing predicted USI in 67% (10 of 15) who underwent the latter procedure; however, USI was observed in only 7% (1 of 15) at 6 months (Bump et al., 1996). In the entire study population, ISD was predicted in 25% (8 of 32) but was observed postoperatively in only two subjects (6%), of whom one had been predicted preoperatively, although no prophylactic slings were performed. In this study, the positive predictive value of barrier testing was 20% for urodynamic stress incontinence (USI) and 12.5% for ISD. To put the risk of potential incontinence into some perspective, one should remember that the risk of de novo USI after vaginal prolapse surgery (7% to 10%) is lower than the risk of persistent USI after a Burch colposuspension or sling performed to cure USI (8% to 15%).
I am always aware that severe prolapse may mask potential SUI; one major goal of my prolapse surgery is for the patient to leave the operating room with durable and preferential dynamic support to the bladder neck or mid-urethra so that the prolapse-derived urethral occlusion with stress can be replaced by another compensatory mechanism. In some instances, this surgical goal can be achieved with endopelvic fascia plication and in others it may be necessary to perform a formal urethropexy or a tension-free midurethral sling such as TVT. However, I have abandoned the notion that preoperative barrier testing dictates the route or type of surgery.
A recently completed randomized clinical trial confirmed the predictable risk of surgically ignoring the support defect of the urethra and bladder neck that usually accompanies advanced stage pelvic organ prolapse at the time of abdominal sacral colpopexy. In this trial, women with advanced pelvic organ prolapse without symptoms of SUI who underwent abdominal sacrocolpopexy were randomly assigned to concomitant Burch colposuspension or to no Burch colposuspension. Three months after surgery, women in the no Burch group were more likely to report bothersome symptoms of stress incontinence than those in the Burch group who had stress incontinence (24.5% vs 6.1%, P < .001; Brubaker et al., 2006).
Several considerations have an impact on my choice of surgical route for reconstructive surgery, including the precise defects responsible for prolapse, the cause of the defects, whether the inciting and promoting events are continuing processes, and the patient’s desires and expectations. About 60% of women whom I see with prolapse have discrete endopelvic fascia defects and low-risk profiles for recurrence; in this situation, I perform a vaginal route anatomic repair that corrects all defects (inferior, lateral, superior, and midline) of the indigenous tissues. However, there are circumstances that I think compromise the longevity of these repairs, which are intended to realign the pelvic organs over a relatively normal pelvic floor and to withstand normal physical stresses. Vaginal approaches using endogenous tissues depend on normal pelvic floor muscle support, and I avoid them in women with poor muscle function following attempts at pelvic floor rehabilitation or in women with overwhelming neuromuscular dysfunction, such as spinal cord injuries. Extreme attenuation of native tissues may also compromise the success of these repairs, and I will use mesh or fascial substitutions for the endopelvic fascia in these situations, via either an abdominal or vaginal approach. Finally, women with rapidly recurrent prolapse, extremely active lifestyles, significant perineal descent, or chronic ongoing causes for prolapse (e.g., obesity, refractory constipation, chronic obstructive pulmonary disease) require a repair with more strength than is offered by my anatomic vaginal repair using endogenous tissues. Under these circumstances, I perform a compensatory repair that will include an abdominal sacral colpoperineopexy, combined usually with a Halban culdoplasty, retropubic paravaginal repair and bladder neck suspension, and often with a perineal reconstruction and distal posterior fascial repair and reattachment. However, early reports of transvaginal tension-free meshes to replace the endopelvic fascia anteriorly, posteriorly, and/or superiorly suggest that these evolving techniques may have comparable efficacy with reduced acute morbidity in these patients who are at high risk for recurrent prolapse.
Bump RC, Hurt WG, Theofrastous JP, et al. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. Am J Obstet Gynecol. 1996;175:326.
This woman has a common clinical presentation, and, although she “desires surgical correction of her prolapse,” I do not recommend immediate surgery. For many years, clinicians have assumed that the symptom of pelvic pressure is related to the anatomic support defect; however, this is not always the case. Before offering surgical correction, I would offer this patient a trial of a pessary—both for diagnostic and therapeutic considerations. If pessary use greatly relieves the symptom of pelvic pressure, I believe that it is likely that reconstructive vaginal surgery will as well. If the symptom persists when the prolapse is supported by a properly fitting pessary, I would consider further evaluation, such as pelvic ultrasound. With a negative workup, I would initiate a course of pelvic floor physical therapy (PT). Although PT will not treat the prolapse per se, it may relieve the patient’s symptoms.
Similarly, the symptom of incomplete bladder emptying is a frequent presenting complaint and is also assumed to be related to prolapse. However, “incomplete bladder emptying” is a nonspecific symptom and there is often no correlation between objective measures of bladder emptying and the symptom. My experience has been that this symptom does not usually resolve with surgery and that behavioral training and physical therapy techniques provide superior relief as compared with surgery.
Assuming that the patient had symptom relief with the pessary (or declined a pessary trial), I would discuss specifics of the surgical reconstruction with her. The following discussion assumes that this is a sexually active woman who has completed her childbearing and is willing to undergo hysterectomy as part of her reconstruction. My practice is to carefully lay out the risks and benefits of surgery, strongly emphasizing the anticipated perioperative events (including catheter use) and long-term postoperative status (including unwanted side effects of surgery, such as urgency or pelvic pain). Once I am certain that the patient wishes to proceed with surgery and that her expectations are realistic, I further counsel regarding specific procedure choices.
This patient’s primary anatomic defect is at the apex, and it is essential that this be repaired in a durable fashion. Most reconstructive pelvic surgeons would recommend a transvaginal route, with emphasis at apical restoration. Any number of vaginal apical suspensions are suitable for restoration of apical support, and there is no evidence to differentiate between the commonly used sacrospinous ligament suspension or the more recently in vogue uterosacral ligament suspension. It is very important that the apical suspension sutures affix an intact portion of the fibromuscular vaginal wall, both anteriorly and posteriorly.
Apical restoration alone may not completely resolve this patient’s anatomic deficits. Her anterior wall has recurred following a traditional first-line reconstruction. Many gynecologists would be tempted to consider use of ancillary materials, although there is insufficient information about the efficacy and safety of such materials placed transvaginally. I would not recommend use of ancillary graft materials for this young woman.
A final decision regarding the specific reconstructive procedures may depend on the decision to place a concomitant continence procedure. A recently completed randomized clinical trial of women with stages II to IV prolapse, without symptoms of stress incontinence, suggests that when such women undergo sacrocolpopexy without concomitant continence procedures, approximately 40% develop stress incontinence symptoms (Brubaker et al., 2006). Approximately 1 in 4 had moderate or severe bother from stress incontinence symptoms. These risks are reduced about 20% by the concomitant placement of a Burch colposuspension. Whether these risks are the same at the time of a transvaginal reconstruction without concomitant continence procedures is unknown. Most surgeons avoid the combination of vaginal reconstruction and the Burch colposuspension, instead favoring a synthetic tape sling, such as transvaginal tape (TVT). Although there is a randomized trial demonstrating the comparable efficacy of the Burch colposuspension and TVT, we do not have this information for women with prolapse because they were excluded from that trial (Ward and Hilton, 2002).
Preoperative urodynamic testing, with prolapse reduction, is not as useful as formerly thought. In women without symptoms of stress incontinence, prolapse repair alone may unmask postoperative symptoms of stress incontinence. Most clinicians had a favorite preoperative method of testing women with the intent of predicting the need for a concomitant continence procedure. Information from the CARE trial suggests that reduction with swabs most closely mimics the postoperative situation in women without a concomitant procedure. Although asymptomatic women may demonstrate SUI with prolapse reduction, there is a 20% absolute risk reduction with Burch procedure (in women who undergo sacrocolpopexy), regardless of the findings of such testing.
Given the scientific uncertainty in some of these important areas, I would discuss the patient’s preferences for the “downside” of the procedure. This patient has not experienced stress incontinence (or incontinence of any kind). My experience has been that such patients are particularly intolerant of postoperative voiding difficulties or prolonged catheter use following “prophylactic” continence procedures. Therefore, I am inclined to recommend the only continence procedure that has been tested in a “prophylactic” setting—the Burch colposuspension. If she accepts this, then I would recommend that the reconstruction be done through the same incision, abdominal hysterectomy (recommended bilateral salpingo-oophorectomy [BSO]), and the important apical suspension using the uterosacral ligaments and cystoscopy. This combination is likely to give sufficient anterior wall support that I would not have to do any additional anterior repair or paravaginal repair. I would not recommend sacrocolpopexy for this woman, although that would give an optimal anatomic outcome.
If the patient does not have a preference for any form of continence procedure, I would offer this patient transvaginal reconstruction—again, with hysterectomy (recommended BSO), apical repair via uterosacral ligament suspension, and cystoscopy. I would also obtain consent for possible anterior colporrhaphy, although this procedure (for the second time) has uncertain effects on continence, both short-term and long-term.
In either scenario, it is unlikely that I would recommend posterior colporrhaphy because of its high rate of new onset dyspareunia. Because this patient has no symptoms referable to “rectocele,” I would simply optimize bowel management with diet and fluid intake.
Ward K, Hilton P. Prospective multicentre randomized trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. United Kingdom and Ireland Tension-free Vaginal Tape Trial Group. Br Med J. 2002;325:67.
The challenges of caring for a woman with prolapse who is continent, but has a significant postoperative risk of becoming incontinent with only a prolapse repair, are well addressed by both discussants, who have done some of the best research on this tricky problem. As with most surgeries, the clinician strives to provide optimum anatomic pelvic organ reconstruction, to alleviate any abnormal preoperative symptoms and to not create any new symptoms or adverse effects. Dr. Brubaker presents some new data that show that predicting postoperative continence status with preoperative barrier testing and urodynamics is not particularly valuable and that adding a Burch procedure (in women who undergo sacral colpopexy) lowers the risk of postoperative stress incontinence whether or not the patient was found to have potential preoperative SUI.
Case: The patient is a 56-year-old woman with severe pelvic pressure. She had an abdominal hysterectomy and retropubic repair 20 years ago. She had a history of recurrent stress incontinence; however, over the last 2 years, this resolved, and she currently has to reduce her prolapse to empty her bladder. Complete vaginal eversion was found on examination (Fig. 40-4). Filling cystometry revealed an uninhibited detrusor contraction at maximum capacity, which was less than 200 mL.
The management of patients with symptomatic vaginal vault prolapse must always include historical and physical assessment of the bladder. The historical bladder assessment includes questions regarding voiding dysfunction and urinary incontinence. The physical examination includes assessment of vaginal support defects, degree of urethrovesical junction descent, and the impact of the posterior compartment on the bladder.
Prolapse and incontinence have a shared genesis, because patients with pelvic denervation and reinervation are predisposed to weakness and dysfunction in both areas. Pudendal neuropathy, connective tissue defects, and loss of elasticity with aging may impact both prolapse and incontinence.
A percentage of patients with vaginal prolapse may sustain urinary retention secondary to obstruction from prolapse. Similarly, some patients who demonstrate SUI early in their history may have resolution of symptoms as the prolapse enlarges and subsequently obstructs the urethra, as appears to have occurred in this patient. If these patients do not receive a concomitant incontinence operation at the time of prolapse repair, they will most likely exhibit significant postoperative urinary incontinence.
As reported by Wall et al. (1994), simple office bladder filling has a high positive predictive value for urodynamic SUI when compared with multichannel urodynamic testing. We perform residual urine determination, simple bladder filling, and stress testing with a full bladder in prolapse patients. The patient is asked to perform serial coughing in both the standing and supine positions. Observation includes the presence or absence of immediate, nonsustained urine leakage. We then use a rectal pledget, which gently reduces the prolapse to straighten the urethra. Care is taken not to press on the anterior wall and induce artifact. The presence or absence of leakage is again noted in both the supine and standing positions. A standing rectovaginal examination may be considered to assess for enterocele descent. If the patient demonstrates projectile, immediate, and nonsustained leakage with cough, we perform a urethropexy at the time of vaginal vault surgery.
The suggestion of detrusor contractions at a capacity of less than 200 mL would be an indication for multichannel urodynamic testing. Mixed incontinent patients who demonstrate uninhibited contractions at high volumes (>250 mL) are candidates for surgery without multichannel testing. We counsel the patient that bladder overactivity may not respond to surgery and that there is a small risk of increased urge incontinence after surgery.
If the patient has a history of obstructed defecation or severe constipation, gastrointestinal consultation is considered, with review of bowel motility and rectal outlet assessment with defecating proctography. The patient must reach a point before surgery at which she can empty her rectum without excessive straining.
The surgical approach to prolapse depends on the patient’s history of prolapse surgery, tissue integrity, and presence or absence of SUI. Patients with urinary retention are counseled that bladder emptying after the operation is not completely predictable. Our vaginal enterocele repair consists of a modified McCall’s culdoplasty performed with at least four delayed-absorbable sutures. Patients with concomitant incontinence would receive a transvaginal sling procedure.
If the patient has a history of multiple prolapse operations or a need to maintain the full length of the vagina, we may perform a fascia lata sacrocolpopexy. Sacrocolpopexy has a high success rate for enterocele. The vaginal area with the greatest risk of recurrence is along the proximal anterior vaginal wall. The incontinent patient would receive a paravaginal defect repair and Burch urethropexy at the time of the sacrocolpopexy. The sacrocolpopexy procedure has multiple points of suture attachment to the vagina, including a significant portion of the posterior vaginal wall. It also attaches to the anterior apex of the vault. If possible, we would reapproximate the break in endopelvic fascia before suture placement for the sacrocolpopexy graft material. The fascia lata is sutured to the midline of the sacrum at S1 to S2. The patient’s legs are repositioned after the abdominal aspect of the operation to allow a vaginal approach to residual cystocele and rectocele.
Sacrospinous ligament procedures have limitations. Unless a graft material is used for bridging between the ligament and vagina, there are usually only one or two points of suture attachment to the vagina. In addition, this procedure creates a deviation of the vagina and may predispose to a higher incidence of recurrent cystoceles than other prolapse operations.
This patient has symptomatic pelvic organ prolapse, which has been defined as complete vaginal eversion. Complete vaginal eversion entails vaginal vault prolapse, cystocele, rectocele, and a potential enterocele. The patient also admits to SUI that has resolved over the last 2 years. The patient currently experiences incomplete bladder emptying but can empty her bladder with digital reduction of the prolapse. The recent resolution of her stress incontinence is a result of the kinking effect at the urethrovesical junction due to the descending vaginal vault and the cystocele. The patient also exhibits bladder overactivity at a capacity of 200 mL. Before establishing a treatment protocol for any patient with complete vaginal eversion, it is important to first assess the patient’s bladder function.
A careful physical examination, with emphasis on the site and extent of damage to the endopelvic fascia support system, should be performed. If the patient has complete vaginal eversion, then by definition she not only has breaks in the uterosacral ligament suspension (level I support), but also she must have lateral detachment of the pubocervical fascia from the obturator internus and lateral detachment of the rectovaginal fascia from the levator ani muscle and fascia (level II support).
The preoperative assessment should also include uroflowmetry and postvoid residual volume measurement (without reduction of the prolapse), complex cystometry, voiding pressure studies, and leak point and urethral closure pressures (with the prolapse reduced). My primary interest is to determine whether this patient has ISD or SUI, the results of which can help me determine whether this patient should have a retropubic urethropexy (i.e., Burch) or a suburethral sling.
After the patient has undergone an evaluation, she should be presented with her diagnosis and potential recommendations. She should be informed that her condition is not life threatening and that only she can make the decision whether her condition is severe enough to warrant surgical correction. The patient should be presented with both the nonsurgical and surgical options. She should be offered a pessary, and if she declines she should then be offered the option of surgery. The surgical technique, cure rate, risks, and benefits of the operation should be discussed. If the patient elects to have surgery, she should have a preoperative chest X-ray, electrocardiogram (ECG), and necessary blood work. She would be instructed on a 48-hour bowel prep before surgical intervention: begin a full liquid diet 48 hours before surgery, followed by a clear liquid diet 24 hours before surgery and a one-half bottle of magnesium citrate. She can have nothing by mouth after midnight before the day of surgery.
The literature supports the use of sacral colpopexy in the treatment of vaginal vault prolapse; however, it says little about its long-term effect on the treatment of cystoceles and rectoceles due to lateral vaginal wall defects. In this patient, I would proceed with an open laparoscopic approach to a sacral colpopexy, using a total of four operative ports, two 10-mm and two 5-mm. After mobilizing the bowel out of the cul-de-sac, I assess the patient for an enterocele. Placing an EEA sizer in the vagina and directing it anteriorly and cephalad allows me to dissect the peritoneum away from the apex of the pubocervical and rectovaginal fascia. If a large enterocele exists, the excess peritoneum and vaginal epithelium are removed using a harmonic scalpel. Identifying and suturing the apex of both the pubocervical and rectovaginal fascia together reapproximate the vaginal cuff. This is accomplished using delayed absorbable suture in an interrupted figure-of-eight fashion. A piece of soft polypropylene mesh fashioned in a Y-shape is then used for the sacral colpopexy. The anterior leaf of the Y-shaped mesh is attached to the pubocervical fascia with six permanent sutures, and the posterior leaf of the Y-shaped mesh is attached with six permanent sutures. The long arm of the Y-mesh graft is taken to the anterior ligament of the sacrum and secured using permanent sutures or a tacking device. An examination is now performed to assess the anterior vaginal wall.
After the sacral colpopexy is performed, it is not unusual for the cystocele to diminish in size or completely disappear. However, despite that the cystocele is no longer apparent does not mean that the paravaginal defects no longer exist. My experience is that a review of the patient’s surgical history and operative report is quite useful. If the patient had a previous retropubic procedure, and it was performed with permanent sutures, the space of Retzius is usually very difficult to access. If this were the case and the anterior vaginal wall is without a notable cystocele, I would stop the operation here and proceed with the vaginal work at this time. I would then perform a rectocele repair and a transobturator or TVT sling. If, however, her previous operative reports show the use of absorbable sutures, it has been my experience that the space of Retzius entry is quite manageable in most cases. I would, therefore, proceed with entry using a harmonic scalpel and perform a paravaginal repair. The paravaginal repair is performed between the ischial spines and the urethrovesical junction. Usually, six sutures are used, and the distal 3 to 4 cm of the vagina is left untouched so that either a Burch or a sling procedure can be placed. If a Burch procedure is done, a total of four more sutures are used—two on each side. One suture is placed laterally to the midurethra and the other is placed laterally to the urethrovesical junction. At this time, a cystoscopy is performed after first giving the patient an ampule of indigo carmine and 10 mg of furosemide. After confirming no sutures in the bladder and ureteral patency, a catheter is reinserted. The space of Retzius is closed, and all port sites are removed under direct vision. The fascia is closed where ports 10 mm or greater in size.
If the patient had primarily ISD, I would not do a Burch but instead do a pubovaginal sling. After performing the sling, I would again perform cystoscopy to determine lower urinary tract integrity. The posterior repair and perineoplasty would complete the surgical procedure.
The discussants differ in their preoperative testing of urinary symptoms, one doing simple office bladder filling and the other doing multichannel urodynamic testing. High quality studies that compare these two preoperative approaches still have not been done to let us know whether performing preoperative multichannel urodynamic testing (compared to simple bladder filling or no testing) leads to improved outcomes after surgery. In mapping out their surgical repairs, both discussants recommend an abdominal sacral colpopexy, although they differ in both the materials used and the surgical approach.
Case: The patient is a 56-year-old woman with severe pelvic pressure. She had an abdominal hysterectomy and retropubic repair 20 years ago. She had a history of recurrent stress incontinence; however, over the last 2 years, this resolved, and she currently has to reduce her prolapse to empty her bladder. Complete vaginal eversion was found on examination. Filling cystometry revealed an uninhibited detrusor contraction at maximum capacity, which was less than 200 mL.
First, the patient should have voided just before my examination. I reduce the prolapse with a rectal swab and have the patient cough while she is in the lithotomy position. If she had a clinical history of urinary incontinence, and she leaks with coughing, I presume that she has incontinence. If her history for urinary incontinence were negative, I presume she may have potential urinary incontinence.
Next, I catheterize her for a postvoid residual volume and check a urine dipstick for leukocyte esterase and nitrites. If the dipstick is positive, I treat her with antibiotics. Another option is to await culture results before starting antibiotic therapy. In either event, cystometry is not performed in the presence of a urinary infection.
If she did not leak urine with the prolapse reduced and the postvoid residual is normal, I prefer to fill the bladder retrograde with a rate of 100 mL/min, planning to reach a volume of approximately 300 mL. After removing the catheter, I reduce the prolapse, and have her cough, observing for leakage with an increase in intra-abdominal pressure.