transvaginal apical repair (non-mesh) bob l. shull, m.d. professor of obstetrics and gynecology...

Transvaginal Apical Repair (non-mesh)

Bob L. Shull, M.D.

Professor of Obstetrics and Gynecology

Scott & White Clinic and Hospital

Texas A&M University Health Sciences Center

Temple, Texas

Learning Objectives

1. At the end of the discussion the participant will be able to:

2. To describe the key steps of uterosacral ligament suspension

3. To describe how to minimize the risk of ureteral injury

Choice of Operative Procedure

• Vaginal repair

•Abdominal suspension

•Combined abdomino-vaginal repair

Sacrospinous Ligament Suspension

1898 - Zweifel - Sacrotuberous ligament

1914 - White - Tendinous arch

1951 - Amreich - Sacrotuberous ligament

1958 - Sederl - Sacrospinous ligament

1971 - Randall & Nichols - Sacrospinous ligament

% of Recurrences VaginaAuthor No. Pts Apex Other sites too small S.U.I.

Richter 69 0% 22% 12% 4%

Nichols 163 3% ? 2% 6%

Morley 71 4% 20% 6% 6%

Kettel 31 19% ? ? ?

? - Information not reported

Shull BL, Capen CV, Riggs MW, Kuehl TJAmer J Obstet Gynecol, 1992: 166(6-1):1764-68

Pre- and Post-Operative Analysis of Site-Specific Pelvic Support Defects in 81 Women Treated by Sacrospinous

Ligament Suspension and Pelvic Reconstruction

Conclusion: The principal support

loss during the follow-up period

was the bladder.

“RETROVERSION of the vagina…

a step towards prolapse of the

anterior vaginal wall”

Victor Bonney, 1934

Bilateral Attachment of the

Vaginal Cuff to Iliococcygeus

Fascia: An Effective Method

of Cuff Suspension

Shull BL, Capen CV, Riggs MW, Kuehl TJAmerican J Obstets Gynecol, 1993, 168:1669-

77.

Conclusion

Ninety-five percent of women experienced

no persistence or recurrence of cuff

prolapse in follow-up from six weeks to

five years.

Meeks GR, Washburne JF, McGehee RP, Wiser WL. Am J Obstet Gynecol 1994; 171:444-54

Repair of Vaginal Vault Prolapse by Suspension of the Vagina to Iliococcygeus

(Prespinous) Fascia

• 110 patients

•Minimum follow-up 3 years

• 4 patients with recurrent defects - all anterior segment

Peters III WA. Christenson NL. Am J Obstet Gynecol 1995; 172:1894-202

Fixation of the Vaginal Apex to the

Coccygeus Fascia during Repair of

Vaginal Vault Eversion with Enterocele

• 121 patients with posthysterectomy vault eversion

• 81 coccygeus fascia, 30 sacrospinous ligament fixation

• Projected cure at 2 years

• Coccygeus 96%

• Sacrospinous 80%

Webb MJ, Aronson MP, Ferguson LK, Lee RA. Obstet Gynecol 1998;92:281-5.

Posthysterectomy Vaginal Vault Prolapse:

Primary Repair in 693 Patients

Study Period 1976-1987

• 693 underwent primary repair of posthysterectomy vaginal vault prolapse. 95% of procedures were performed with Mayo culdoplasty.

Webb MJ, Aronson MP, Ferguson LK, Lee RA. Webb MJ, Aronson MP, Ferguson LK, Lee RA. Obstet Gynecol 1998;92:281-5.Obstet Gynecol 1998;92:281-5.


Primary Repair in 693 Patients

Complications

Visceral injury 2.3%

Vault hematoma 1.3%

Cuff infection 0.6%

Ureteral complication 0.6%

Webb MJ, Aronson MP, Ferguson LK, Lee RA. Obstet Gynecol 1998;92:281-5.


Primary Repair in 693 PatientsOutcomes

• 504 patients available for follow-up examination or survey

• Satisfied 85%

• Bulge or Protrusion 16%

• Reoperated 7%

A Transvaginal Approach to

Repair of Apical and Other

Associated Sites of Pelvic

Organ Prolapse Using

Uterosacral Ligaments

Shull BL, Bachofen C, Coates KW, Kuehl TJAm J Obstet Gynecol, 2000: 183;1365-1374.

Study Design

• Jan 1, 1994 - Dec 31, 1998302 consecutive patients

• 289 returned for follow-up

• Morbidity: transfusion, visceral injury, death

• Durability: life table analysis

Objective

• To describe a group of women with pelvic organ prolapse associated with apical loss of support using the Baden-Walker halfway system preoperatively, intraoperatively, and postoperatively

• To describe the operative repair of the support defects

• To report the morbidity associated with the operative repair

• To access the durability of the repair at each site

Buller JL, Thompson JR, Cundiff GW, et. al.Obstet Gynecol 2001; 97:873-9.

Uterosacral Ligament: Description of Anatomic Relationships to

Optimize Surgical Safety

Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the urterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament.


Results

The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean ± standard deviation distance from ureter to uterosacral ligament was 0.9±0.4, 2.3±0.9, and 4.1±0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9±2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure.

Conclusion

Our findings suggest that optimal site for fixation is the intermediate portion of the uterosacral ligament 1 cm posterior to its most anterior palpable margin, with the ligament on tension


Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC.Am J Obstet Gynecol 2000; 183: 1402-11

Bilateral Uterosacral Ligament Vaginal Vault Suspension With Site-specific Endopelvic Fascia Defect Repair for Treatment of Pelvic Organ Prolapse

Objective: The anatomic and functional

success of suspension of the vaginal

cuff to the proximal uterosacral

ligaments is described.

Barber MD, Visco AG, Weidner AC, Amundsen CL, Bump RC. Am J Obstet Gynecol 2000; 183: 1402-11

Conclusion: Suspension of the vaginal vault to the proximal uterosacral ligaments combined with site-specific repair of endopelvic fascia defects provides excellent anatomic and functional correction of pelvic organ prolapse in most women. The risk of ureteral injury with this technique makes intraoperative cystoscopy essential.

The underlying concepts for this repair are based on the

anatomy of the support defects. The repair can be performed

vaginally, abdominally, or laparoscopically

transvaginal apical repair (non-mesh) bob l. shull, m.d. professor of obstetrics and gynecology...

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