Chapter 15 Common gynaecological procedures and surgery

Colposcopy

Endometrial ablation techniques

Hysteroscopy

Hysterectomy

Continence procedures

Pipelle biopsy

Laparoscopy

Pelvic floor surgery

Colposcopy

Colposcopy is the visualization of the cervix using a magnifying lens.

Three consecutive inadequate samples:

• three tests reported as borderline nuclear change in squamous cells

• one test reported as borderline nuclear change in endocervical cells

• three tests reported as abnormal at any grade in a 10-year period

• one test reported as mild, moderate, or severe dyskaryosis

• one test showing possible invasion

• one test showing glandular neoplasia or

• clinically suspicious cervix.

If the patient satisfies any of the above criteria for referral to colposcopy, an invitation letter and an information leaflet are sent out to the patient. Procedure

• Initial history is taken to enquire about periods, abnormal vaginal bleeding, contraception, etc.

• The patient is positioned in the special colposcopy couch with padded supports for the legs.

• A self-retaining speculum is inserted into the vagina to inspect the cervix.

• Any other associated pathology in the external genitalia/vagina is noted.

• The cervical smear is repeated if necessary.

• The cervix is inspected thoroughly and gently cleansed with a cotton bud moistened with saline if required.

• 3–5% acetic acid is dabbed onto the cervix and any areas acetowhite are noted after satisfactory application.

• The patient should be warned of slight stinging during this part of the procedure.

• Biopsy of any acetowhitened areas may need to be carried out.

• Lugol’s iodine may need to be applied to look for lack of iodine staining in abnormal areas especially before treatment.

• A treatment procedure such as a LLETZ (large loop excision of transformation zone) may need to be carried out in a ‘see and treat’ setting when major grade of CIN (cervical intraepithelial neoplasia) is suspected on colposcopy examination.

• Treatment is usually carried out under local anaesthesia in an outpatient setting.

• Ensure that the patient is not dizzy as she gets off the couch.

• The findings are documented and the patient is counselled regarding the findings and time taken for the results if any.

• Patients must be warned to expect some bleeding for a week after the biopsy or 2 weeks after treatment. They should be encouraged to report heavy bleeding or abnormal discharge, which may indicate infection.

The following data should be recorded at the colposcopic examination:

• reason for referral (100%)

• grade of cytological abnormality (90%)

• whether the examination is satisfactory; this is defined as the entire squamocolumnar junction having been seen and the upper limit of any cervical lesion also being seen (100%)

• the presence or absence of vaginal and/or endocervical extension

• the colposcopic features should be recorded

• the colposcopic impression of lesion grade. Further reading

www.bsccp.org/docs/public/pdf/nhscsp20.pdf Patient resources

www.bsccp.org/docs/public/pdf/thecolposcopyexamination.pdf

Endometrial ablation techniques

Heavy menstrual bleeding is a very common health problem affecting quality of life and leading to anaemia. Medical treatment is frequently ineffective, although the introduction of the Mirena intrauterine system has led to a reduction in the number of surgical procedures. Hysterectomy has been the standard treatment for women with menorrhagia: it has high satisfaction rates and improved quality of life. Hysterectomy is a major operation with a relatively long recuperation period and potentially serious complications (Cooper et al.

Endometrial ablation (EA) is a minimally invasive alternative to hysterectomy, which can be performed as a day case procedure. The aim is to completely destroy or remove the endometrial basalis layer leading to amenorrhoea. Compared to hysterectomy, endometrial ablation offers effective treatment with high satisfaction rates, and shorter operating and recovery times. The cost is significantly lower but retreatment maybe needed in the long-term, reducing cost-effectiveness (Lethaby et al. 2004). First-generation techniques

First-generation techniques were introduced in the early 1980s as alternatives to hysterectomy. Laser, transcervical resection of the endometrium (TCRE) and rollerball are the gold standard techniques. All these methods are performed under direct visualization with hysteroscopy, and the outcome is dependent on the skill and experience of the surgeon. They are effective techniques but have a steep learning curve during training. They are performed with the patient under general anaesthetic using glycine for distension. Glycine is non-ionic but absorption can lead to fluid overload, resulting in hyponatraemia, pulmonary and cerebral oedema leading to seizures, coma, and death (Cooper et al. 2000). The use of bipolar technology using saline distension is now a better option avoiding absorption complications. The MISTLETOE study audited complications associated with first-generation techniques and reported a total complication rate of 4.4% including two deaths. Rollerball was associated with fewer complications than laser or resection (Overton et al. 1997). Long-term complications include haematometra and pain. Second-generation techniques

Second-generation techniques were introduced to provide safer, quicker, and more effective treatment. These techniques require less training and skill than first-generation procedures and have similar clinical outcomes. The operating time is shorter, and there is a low risk of uterine perforation.

Complications of second-generation techniques

Minor postoperative complications are common, including pelvic pain, nausea, vomiting, endometritis, and urinary tract infection. Equipment failure is also more common but there is less chance of perforation than with first-generation techniques.

Endometrial preparation

Studies have shown that most second-generation techniques do not require endometrial thinning (Jack et al. 2005) except hydrothermablation and the ELITT systems.

Outpatient endometrial ablation

Most techniques can be performed on an outpatient basis under local anaesthetic, sedation, or no anaesthetic. The procedures with smaller diameter requiring less cervical dilatation and with shorter treatment times are generally better tolerated. MEA and balloon ablation have been studied on an outpatient basis and are well tolerated. Conclusion

Endometrial ablation techniques have improved with time, becoming easier to use and safer. Rapid recovery and return to normal activities after treatment have made it a popular choice for women with menorrhagia. The outcomes for the different second-generation techniques are very similar and choice of device is personal. Cost analysis of MEA and balloon ablation concluded that these techniques were more cost-effective than first-generation techniques but further well-designed randomized controlled trials are needed. References

Cooper JM, Bain C, et al. A randomised comparison of microwave endometrial ablation with transcervical resection of the endometrium; follow up at a minimum of five years. Br J Obstet Gynaecol 2005;112:470–5.

Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynaecol Clin Am 2000;27:347–66.

Garside R, Stein K, et al. A cost–utility analysis of microwave and thermal balloon endometrial ablation techniques for the treatment of heavy menstrual bleeding. Br J Obstet Gynaecol 2004;111:1103–14.

Goldrath MH. Evaluation of HydroThermAblator and rollerball endometrial ablation for menorrhagia 3 years after treatment. J Am Assoc Gynaecol Laparosc 2003;10:505–11.

Jack SA, Cooper KG, et al. A randomised controlled trial of microwave endometrial ablation without endometrial preparation in the outpatient setting: patient acceptability, treatment outcome and costs. Br J Obstet Gynaecol 2005;112:1109–16.

Kucuk M, Okman TK. Intrauterine instillation of trichloroacetic acid is effective for the treatment of dysfunctional uterine bleeding. Fertil Steril 2005;83:189–94.

Lethaby A, Shepperd S, et al. Endometrial resection and ablation versus hysterectomy for heavy menstrual bleeding. Cochrane Database Syst Rev 2004; 4.

Overton C, Hargreaves J, et al. National survey of the complications of endometrial destruction techniques for menstrual disorders: the mistletoe study. Minimally invasive surgical techniques-laser, endothermal or endoresection. Br J Obstet Gynaecol 1997;104:1351–9.

Perino A, Castelli A, et al. Randomised comparison of endometrial laser intrauterine thermotherapy and hysteroscopic endometrial resection. Fertil Steril 2004;82:731–4.

Townsend DE, Duleba AJ, et al. Durability of treatment effects after endometrial cryoablation versus rollerball electroablation for abnormal uterine bleeding: two year results of a multicenter randomised trial. Am J Obstet Gynaecol 2003;188:699–701.

National Institute of Health and Clinical Excellence. Menstrual bleeding: fluid-filled thermal balloon and microwave endometrial ablation. Technology Appraisal 78. London: NICE 2004: www.guidance.nice.org.uk/TA78/guidance/pdf/English

Hysteroscopy

Hysteroscopy visualizes the cervical canal and uterine cavity internally with an endoscope and is used for diagnostic and operative procedures.

• Postmenopausal bleeding

• Menstrual irregularities

• Menorrhagia

• Dysmenorrhoea

• Intermenstrual and post-coital bleeding

• Subfertility

• Contraceptive procedure

• Misplaced intrauterine contraceptive device. Types of hysteroscopy

1. Diagnostic: mainly performed as part of the investigation process in a patient.

2. Operative laparoscopy: aims to treat intrauterine pathology to improve the symptoms/outcome in a patient. General make-up of a hysteroscope

The two types of hysteroscope are rigid and flexible. The rigid hysteroscope is made up of a telescope with a lens (0, 12, 30 or 70°) attached to it and an inner/outer sheath, which ranges between 5 and 10 mm. The hysteroscope come in sizes from 1.7 to 4 mm (Fig. 15.3.1). Smaller diameter hysteroscopes are used for office procedures. Some of these hysteroscopes have additional channels or operating sheaths to introduce scissors, grasping and biopsy forceps. The space between the telescope and the inner/outer sheath is necessary for the inward and outward flow of the distension medium through the telescope. A resectoscope is a special operating hysteroscope that can incorporate special instruments like an electrode (rollerball, loop, knife, or ellipsoid) or laser. These instruments allow procedures to be carried out within the uterine cavity using electric current or laser energy. The inner sheath carries the telescope, the inward flow of the medium, and the electrode. The outer sheath with perforations at the end are used for the return flow of the medium, blood, and tissue debris (Fig. 15.3.2).

Fig. 15.3.1 2- and 4-mm hysteroscopes used for diagnostic hysteroscopy.

The flexible hysteroscope is a soft semi-rigid telescope. It is mainly used as an outpatient/office procedure. It uses carbon dioxide gas as a distension medium. Procedures carried out at operative hysteroscopy

• Resection/ablation of the endometrium

• Resection of a submucous myoma

• Resection of a polyp

• Resection of uterine septum

• Adhesiolysis of uterine synechiae in Ashermann’s syndrome

• Removal of misplaced intrauterine contraceptive device

• Tubal sterilization (Essure procedure). Need for distension medium

The anterior and posterior walls of the uterus are close to each other. To obtain visualization of the uterine cavity the walls need to be separated (Fig. 15.3.3). This is achieved by the distension medium. The pressure required for good visualization is around 75 mm of Hg with carbon dioxide gas (Valle 1998; Petrozza et al. 2006) and 70-100 mm of Hg with normal saline (Varol et al. 2002). Higher pressures will increase the risk of intravasation of the medium through the open vascular channels leading to fluid overload and pulmonary oedema. The distension medium will help to flush any blood or small tissue, which aids visualization. Over dilatation of the cervix may produce a leakage around the hysteroscope leading to lower intrauterine pressure with poor visualization.

Fig. 15.3.2 Trolley set up for operative hysteroscopy. Types of distension medium

CO₂

Used in flexible hysteroscopes, hence useful for office hysteroscopy. It has a refractory index of 1 and hence good visualization of the cavity. Absorbed into the body and removed by the lungs. Does not mix with blood and can cause poor views due to bubbling. Special insufflators are needed with maximum pressure of 100 mm of Hg and flow rates of 40–60 mL/minute (Valle 1998; Petrozza et al. 2006). Higher pressures can lead to cardiac arrhythmias, cardiac arrest, and gas embolism.

Normal saline

Clear isotonic low viscosity fluid. Commonly used for diagnostic procedures; however, it can be used with bipolar diathermy (Versapoint Gyne-care, SurgMaster Ethicon) and laser. Because of the presence of electrolytes, its conductive properties cannot be used with monopolar diathermy. It mixes with blood reducing the visibility, thus needing larger quantities during use.

Fig. 15.3.3 Normal uterine cavity. See also colour plate section.

Glycine 1.5%

Clear hypotonic fluid. Does not mix with blood, giving better vision if bleeding. Non-conductive and can be used with monpolar diathermy. Because of its hypotonic properties, fluid overload can lead to significant hyponatraemia with haemodilution and pulmonary oedema. Careful intraoperative working balance of the inflow and outflow needs to be maintained to prevent complications. Degraded to ammonia; hence, needs care in patients with hepatic and renal disease. Other solutions like 5% Mannitol and 3% Sorbitol can also be used and have similar properties. Dextran 70 is a high viscosity non-electrolyte and poor conductive fluid; however, because of its viscosity the instruments can get damaged. It also causes significant fluid overload and anaphylactic reaction, and can lead to disseminated intravascular coagulopathy. Hence, it is not commonly used. Types of energy

1. Mechanical: scissors to divide adhesions, biopsy forceps to take directed biopsies.

2. Electrical: monopolar diathermy using cutting and coagulation current to resect tissues. Bipolar diathermy has similar use as monopoplar; however, can be used with isotonic solutions like Normal saline solution.

3. Laser: commonly the Nd:YAG laser is used which destroys tissue up to a depth of 5 mm. It passes easily through clear fluid.

Procedure for diagnostic hysteroscopy

• Check the indication for the procedure

• Consent and explanation of risks

• Lithotomy position.

Office hysteroscopy

Use flexible hysteroscope or small diameter rigid hysteroscope (1.7–3 mm). Cusco’s speculum is used to expose the cervix. Sometimes the hysteroscope may negotiate the cervical canal without the need to grasp the cervix, otherwise use a tenaculum or littlewoods forceps to hold the anterior lip of the cervix. If dilatation is needed a paracervical block with 10 ml of 1% lignocaine would be sufficient. Introduce the scope gently under vision allowing the distension medium to fill the uterine cavity. Explain to the patient the risk of shoulder pain due to the CO₂ gas. Evaluate the uterine cavity and cervical canal in a systematic way to avoid missing any pathology.

Inpatient hysteroscopy

Commonly performed under general anaesthetic with larger scopes of 4 mm. Expose the cervix using a Sim’s speculum and hold the anterior lip of the cervix with a tenaculum or vulsellum. Dilate the cervix depending on the size and type of hysteroscope. If it is a single channel scope with no outflow sheath, then cervical dilatation up to 8 Hegar’s dilator may be needed. In a dual channel hysteroscope dilatation up to 5–6 Hegar’s may suffice. Beware of overdilatation as the medium will leak around the telescope, leading to poor intrauterine pressures and poor visibility. Procedures for operative hysteroscopy

At operative hysteroscopy larger diameters scopes are used for introducing instruments, hence the cervix needs to be dilated up to No. 9–10 Hegar’s dilator. In transcervical resection of the endometrium (TCRE) a rollerball electrode is used to ablate the endometrium on the fundus and cornual areas of the uterine cavity (Fig. 15.3.4). The uterine wall thickness is the thinnest at the cornual ends measuring around 5.5 mm (range 4–7 mm) (Petrozza et al. 2006); thus, precautions need to be taken during TCRE as deeper resection will perforate through the uterus. Following that the endometrium is then resected using a loop electrode which has a diameter of 4 mm. Starting on the posterior wall of the uterus the resection is done in a systematic manner either clockwise or anti-clockwise removing the endometrium all around the uterine cavity. The resection is done up to the level of the internal cervical os as further resection into the cervix can lead to significant bleeding and scarring. The medium used is usually glycine and a running balance needs to be maintained throughout the procedure. If the fluid deficit is 500–1000 mL the procedure should be rapidly completed or suspended; if the deficit is more than 1500 mL the procedure should be stopped (O’Connor and Magos 1999). It is advisable to thin the endometrium prior to the resection by GnRH analogues a month before the procedure. GnRH analogues are also useful in reducing the size and vascularity of submucosal myomas before their resection. The chips of the endometrium are removed and sent for histology. The pressure of the uterine cavity is reduced to check for any bleeding, which can be controlled using the rollerball electrode diathermy.

Fig. 15.3.4 Endometrial ablation using the roller ball. See also colour plate section. Complications of hysteroscopy

Complications at diagnostic hysteroscopy are divided into (RCOG 2008).

Serious

• uterine perforation (0.76%)

• pelvic infection

• failure to visualise the uterine cavity

• damage to uterus, bladder, bowel, blood vessel

The overall serious risk at diagnostic hysteroscopy is approximately 2 in 1000 women, which is very uncommon.

Cervical stenosis, acute anteversion/retroversion, previous resection of endometrium, adhesions, and the presence of lower uterine and cervical fibroids are the common causes which lead to false passage and uterine perforation. In such cases, smaller lacrimal dilators can be used to dilate the cervix. Irrigation fluid maintained at the external os may sometimes help with hydrodilatation of the cervix and distension of the uterine cavity.

Frequent risks

• Vaginal bleeding and discharge

• Pelvic or shoulder pain

Complications at Operative hysteroscopy are more serious and can be divided as set out below.

Procedure related

• Uterine perforation leading to thermal damage of bowel, bladder, ureters and blood vessels

• Primary and secondary haemorrhage

• Cervical lacerations

Medium related

• CO₂ gas embolism

• Air embolism

• Fluid overload with hypotonic distension fluid such as glycine leading to hyponatraemia, hypokalaemia, hypoosmolarity leading to pulmonary oedema. Electrolyte imbalances can also lead to cardiac arrythmias and cardiac arrest.

• TURS (transurethral resection syndrome) syndrome due to hyerammonaemia from the metabolism of glycine to ammonia in the body can cause coma (Hamilton and Barlow 1989; Motashaw and Dave 2001).

Delayed complications

• Dysmenorrhoea

• Haemato/pyometra

• Pregnancy

• Uterine rupture

• Delay in diagnosis in endometrial carcinoma. Training in hysteroscopy

It is very important to be familiar with the instruments before undertaking hsyteroscopic surgery. Good hand–eye coordination needs to be developed for operative procedures. Understanding and working of the different energy sources should be mandatory. Trainees need to attend courses, lectures and need supervision when embarking on these procedures. Training on hysteroscopy trainers should be performed before carrying out procedures such as resection of the endometrium and fibroids. Training for diagnostic and minor operative hsyteroscopic procedures can be attained during the Basic and Intermediate training as outlined by the Royal College of Obstetricians and Gynaecologists (RCOG). Advanced training can be attained by completing the Advanced Training Skills Module (ATSM): ‘Benign Gynaecological Surgery: Hysteroscopy’ in the final years of speciality training under the supervision of RCOG preceptors. Further reading

Valle RF. 1st edn. New York: Parthenon Publishing 1998: 22.

Petrozza J, Makai G, Sikking E. Hysteroscopy. eMedicine from WebMD. July 2006.

Varol N. Maher P, Vancaillie, et al. A literature review and update on the prevention and management of fluid overload in endometrial resection and hysteroscopic surgery. Gynaecol Endoscopy 2002;11:19–26.

O’Connor H, Magos A. How to avoid complications at hysteroscopic surgery., 20. Churchill Livingstone. 1999: 201–14

Diagnostic Hysteroscopy under General Anaesthesia. Royal College of Obstetricians and Gynaecologists. Consent Advice 1. December 2008.

Hamilton SA, Barlow IM. Metabolic effects of prostatectomy. J R Soc Med 1989;82:725–8.

Motashaw N, Dave S. Complications of hysteroscopy. Gynaecological Endoscopy 2001;10:203–10.

Hysterectomy

Hysterectomy is the most common major gynaecological surgery performed worldwide and in the UK (Department of Health 2007). It is the definitive treatment for many benign gynaecological disorders. It has very high satisfaction rate, improved quality of life, decreased depression and anxiety levels, and low morbidity rates.

The indications for hysterectomy with or without bilateral salpingo-opherectomy are

• fibroid uterus (34%)

• heavy menstrual bleeding not responding to medical or ablative surgical techniques (19%)

• uterine prolapse (16%)

• stage 1 endometrial cancer/cervical cancer early stages (11%)

• severe premenstrual syndrome (are similar to that of abdominal hysterectomy. In addition, there is increased risk of vaginal cuff infection, which may lead to pelvic cellulitis, septicaemia, abscesses, and vault haematoma. Laparoscopic hysterectomy

There are various ways to perform hysterectomy by the laparoscopic route. These procedures are clearly described by Garry et al. (1994). Hysterectomy via laparoscopic route

Laparoscopic assisted vaginal hysterectomy (LAVH)

This is vaginal hysterectomy performed after laparoscopic adhesiolysis, excision of endometriosis, or oophorectomy. The infundibulopelvic ligaments are also secured with staples or bipolar desiccation. The lower attachments of uterus such as cardinal and uterosacral ligaments and uterine vessels are approached vaginally.

Diagnostic laparoscopy with vaginal hysterectomy Laparoscopy is performed prior and after the vaginal hysterectomy. The rational is to confirm the absence of suspected pathology before vaginal hysterectomy. Also, after vaginal hysterectomy is performed it assures complete haemostasis and allows clot evacuation if needed.

Laparoscopic hysterectomy (LH)

This procedure involves the laparoscopic ligation of uterine vessels by ligature sutures, staples, and bipolar desiccation. All surgical steps are done either vaginally or laparoscopically.

Total laparoscopic hysterectomy (TLH)

This involves the laparoscopic dissection of all vascular pedicles and all ligaments are freed from the uterus. Then, the uterus is removed vaginally or laparoscopically (morcellator). The vagina is closed with laparoscopically placed sutures.

Laparoscopic supra cervical hysterectomy

In this procedure, the uterine fundus is removed with preservation of cervix (Lyons, 1993). The uterus is removed via morcellation or by culdotomy. It is useful in women with a history of dysfunctional uterine bleeding with regular negative smears.

The advantages of laparoscopic hysterectomy are reduced blood loss, less postoperative pain, short hospital stay, quick recovery, The complications include infection, bleeding, injury to bowel, ureteric injury, bladder injury, injury to abdominal wall vessels, (2%), injury to large vessels (iliac, aorta, and inferior vena cava), subcutaneous emphysemas due to absorption of carbon dioxide in subcutaneous tissues, trocar site incisional hernias (Reich 1998). Should the ovaries be removed or retained at the time of hysterectomy?

There is no established or acceptable standard on whether the ovaries should be retained or conserved at the time of hysterectomy. The ovaries continue to function and play an active role in secretion of oestrogen, progesterone, and androgens in a cyclical fashion until the natural menopause. Ovarian hormones influence the function of metabolic processes in liver, brain, bone, lung, skin, and other organs. Hence, absence of hormones may have an impact on these systems. Studies have revealed that bilateral oophorectomy before menopause is associated with several negative outcomes. There is an increased risk of premature death, coronary heart disease (Lobo 2007), cognitive impairment or dementia, Parkinsonism (Rocca 2008), osteoporosis and bone fractures, decline in psychological wellbeing, and decline in sexual function. There is a short-term mortality benefit following bilateral prophylactic salpingo-oophorectomy in BRCA1/2 mutation carriers and in Lynch’s syndrome (Domchek 2007) and hence potential benefits for the risk of cancer reduction in women at average risk of ovarian cancer. This should be carefully weighed against the potential adverse effects of prophylactic bilateral oophorectomy on cardiovascular health, neurological health, bone health, and quality of life Further reading

Monaghan JM, Lopes T, Naik R.. Oxford: Blackwell publishing.

Monaghan JM, et al. Total abdominal hysterectomy. In:, 10th edn. Oxford: Blackwell publishing 66–73.

Monaghan JM et al. Vaginal hysterectomy and radical vaginal hysterectomy. In: 10th edn. Blackwell publishing 95–108.

Department of health. Hospital episode statistics: 2005-2006. London (UK): Information centre, 2007: http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Hospitalepisodestatistics/index.htm.

Domchek SM, Rebbeck TR. Prophylactic oophorectomy in women at increased cancer risk. Curr Opin Obstet Gynecol 2007;19:27–30.

Garry R, Reich H, Liu CY. Editorial. Laparoscopic hysterectomydefinitions and indications, Gynaecological Endoscopy 1994;3:1–3.

Johnson N, Barlow D, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Re. 2006, 19; 2: CD003677.

Lethaby A, Ivanova V, Johnson NP. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database Syst Rev 2006 19; 2:CD004993.

Lobo RA Surgical menopause and cardiovascular risks. Menopause. 2007 May-Jun; 14 (3 Pt 2): 562–6. Review.

Reich H. Laparoscopic hysterectomy. In: Hulka JF (ed) Textbook of laparoscopy, 3rd edn. Philadelphia: Saunders 443–9.

Rocca WA, Bower JH, Maraganore DM, et al. Increased risk of Parkinsonism in women who underwent oophorectomy before menopause. Neurology 2008; 15;70:200–9.

Thakar R, Ayers S, Srivastava R, Manyonda I. Removing the cervix at hysterectomy: an unnecessary intervention? Obstet Gynecol 2008;112:1262–9. Patient resources

The Hysterectomy Association: www.hysterectomy-association.org.uk

Continence procedures Definition

Stress urinary incontinence is defined as the involuntary leakage of urine on effort or exertion. Urodynamic stress incontinence is noted during urodynamics as the involuntary leakage of urine during increased abdominal pressure, in the absence of detrusor contractions.

The prevalence of stress urinary incontinence increases with age with the average age for surgical treatment around 50 years. Treatment of stress incontinence

Treatment should be initially conservative and includes

• lifestyle advice: weight reduction, treating chronic coughs, and smoking cessation.

• pelvic floor exercises: this may include biofeedback, electrical stimulation, and use of vaginal cones

• drug therapy: duloxetine is a selective serotonin reuptake inhibitor that acts to increase urethral sphincter activity. It has 60–70% efficacy; however, its clinical use is limited by side-effects such as nausea.

Surgery may be considered for

• failed conservative treatment

• declined/unsuitable for conservative treatment

• severe symptoms.

There is some debate regarding investigations required prior to consideration for surgery. The recent NICE guidelines do not advocate that urodynamics are required in those with symptoms of pure stress incontinence. However, at present, in patients with mixed incontinence (both stress and urge incontinence), those who have had previous procedures and in those with high suspicion of voiding dysfunction, urodynamics are generally performed to confirm a diagnosis of urodynamic stress incontinence (NICE 2006). Surgical treatment

The aims of surgery are to elevate the bladder neck and proximal urethra and/or to increase urethral outlet resistance. To date, over 100 continence procedures have been described using abdominal, vaginal, and laparoscopic routes (Jarvis 1994; Black and Downs 1996). However, over the last decade there has been a paradigm shift in continence surgery with the development of the newer minimally invasive procedures such as the midurethral and tension-free vaginal slings.

One of the difficulties in evaluation of the procedures available is that there are few good-quality studies with long-term follow-up. Previous procedures such as the anterior repair and needle suspension techniques have now been abandoned due to poor long-term results and the higher efficacy of newer procedures. The data on traditional operations such as the colposuspension and fascial slings, although greater than 10 years, have limitations as they are mainly retrospective (Alcalay et al. 1995). This is important as the choice of first procedure is important as it has much higher cure rates than subsequent repeat surgery, and there is now increasing emphasis on long-term prospective evaluation of new procedures using subjective and objective validated outcome measures.

Abdominal procedures

The Burch colposuspension was first described in 1961 and was considered the gold standard of continence surgery, with a subjective success rate of over 90%. It involves elevation of the bladder neck by placement of sutures between the lateral vaginal fornices and the ileopectineal ligament and can be performed as an open or laparoscopic procedure. Although the laparoscopic route results in less hospital stay and faster recovery, it has a longer operating time and higher complication rate and only similar efficacy if done by experienced laparoscopic surgeons. The Marshall–Marchetti–Krantz procedure is similar to this; however, it has been abandoned due to the risk of osteitis pubis, as the sutures are placed into the periosteum of the pubic bone.

Risks associated with the open colposuspension include voiding dysfunction and enterocele formation.

Sling procedures

Sling procedures were developed over 100 years ago. Slings can consist of autologous fascia or synthetic materials. They have good efficacy with continence rates of 80–90%; however, there is a high incidence of voiding dys-function and de novo detrusor overactivity. Slings made with synthetic material are also associated with erosion.

Minimally invasive mid-urethral slings

Tension-free vaginal tape

The tension-free vaginal tape (TVT) was first described in 1996 and involves the placement of a monofilament polypropylene sling under the midurethra with the ends tunnelling retropubically. It can be performed under local, regional, or general anaesthetic and so may be performed in a day case setting. The TVT has the most robust evaluation of all of the newer invasive sling procedures with long-term cure rates of up to 90% at 10 years with little decline in efficacy over time (Nilsson et al. 2008). The UK randomized controlled trial of colposuspension compared with TVT showed similar efficacy of both procedures at 24 months (Ward et al. 2008). Although the complication rate is low, major bowel, bladder and vascular complications have been reported as well as erosion of mesh into the vagina, urethra, and bladder.

Transobturator procedures

Since the development of the TVT, there have been numerous similar slings with varying success rates. However, due to the risk of vascular and bladder complications with the TVT, the transobturator tape was proposed as an alternative technique. This has a similar placement under the midurethra; however, the ends are tunnelled through the obturator space rather than retropubically. The majority of tapes involve placement of the tape through the obturator foramen into the vaginal incision (‘outside-in’) versus the TVT-O (‘inside-out’ (Gynecare)), which places the tape via the vagina tunnelling out into the obturator space (Figs 15.5.1–15.5.3). There are a number of tapes on the market, some of which have had poor long-term evaluation. The data to date would suggest they have similar short-term efficacy to the TVT, although long-term data are still required (Latthe et al. 2007). However, although the risk of bladder injury is lower, other complications include tape erosion (~3%) and thigh pain (~15%), which is thought to be neuralgic in origin.

Recently NICE has recommended that these mid-urethral tapes should be performed in settings that allow audit of outcome and clinical governance procedures. It also recommends that to reduce the risk of erosion, a type 1 monofilament tape is used.

Fig. 15.5.1 Transobturator tape with needle. See also colour plate section.

Minitapes

There are several tapes that are being tested which only involve a suburethral vaginal incision, but the results are awaited. The big potential advantage is these tapes can be performed as an outpatient procedure

Injection of bulking agents

There are a number of injectable agents that have been injected periurethrally or transurethrally and aim to increase urethral closure by bulking the tissue around the bladder neck. The initial agents on the market, such as Teflon, phenol, and fat, all had limited success and complications, and as such fell out of favour. More recently, new materials, such as glutaraldehye cross-linked collagen and silicone (Macroplastique), have been developed with a better long-term success rate of around 60%.

As these agents can be injected under local anaesthetic with little associated morbidity, they are an option to consider in patients

• unfit for surgery/too frail for surgery

• women deferring definitive surgery till childbearing is complete, and those who have had children

• after previous failed procedures or with fixed scarred urethras.

Artificial urinary sphincter

This is an option in those who have had previous failed surgery or after intractable stress incontinence after a radical prostatectomy. It can be placed via a transabdominal or transvaginal route. The device consists of three parts: an inflatable cuff, a pressure-regulating balloon, and a pump. The patient learns to use the sphincter by decompressing the cuff to allow voiding. Although the success rate is high, there is a high erosion rate of up to 29%, and reoperation rate for cuff problems. Counselling

Complications of continence procedures

Because of the number of procedures in use, patients need to be counselled about the risk and benefits of each specific procedure. The benefits of newer procedures may be lower morbidity and reduced postoperative stay; however, this must be considered alongside whether there is equivalent efficacy and if there are specific potential complications.

Specific complications

Immediate

• Bleeding

• Bladder perforation: TVT ~2–18%

• Deep vein thrombosis

• Bladder perforation

• Anaesthetic complications

Short term

• Urinary tract infection

• Wound infection

• Voiding dysfunction ~20%

Long-term

• De novo detrusor overactivity (~20%) and worsening of pre-existing detrusor overactivty in those with mixed incontinence

• Prolapse: 26% reoperation rate for prolapse post colpo-suspension

• Erosion (with synthetic slings/artificial sphincters)

• Leg/groin pain: ~15% post TOT/TVT-O.

Fig. 15.5.2 Placement of tape via the obturator foramen into the vaginal incision. See also colour plate section.

Fig. 15.5.3 Placement of tape via the vaginal tunnelling into the obturator space. See also colour plate section. Further reading

Alcalay M, Monga A, et al. Burch colposuspension: a 10-20 year follow-up. Br J Obstet Gynecol 1995;102:740–5.

Black NA, Downs SH. The effectiveness of surgery for stress incontinence in women: a systematic review. Br J Urol 1996;78:497–510.

Jarvis GJ. Surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994;101:371–4.

Latthe PM, Foon, R, et al. Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications. Br J Obstet Gynaecol 2007;114:522–331.

Nilsson CG, Palva K, et al. Eleven years prospective follow-up of tension-free vaginal tape procedure for treatment of stress urinary incontinence. Int Urogynecol J 2008;19:1043–7.

Ward KL, Hilton P, et al. Tension- free vaginal tape versus colpo-suspension for primary urodynamic stress incontinence: a 5 year follow up. Br J Obstet Gynaecol 2008;115:226–33.

National Institute for Health and Clinical Excellence (NICE). Urinary incontinence: the management of urinary incontinence in women. Clinical Guideline 40, London: NICE 2006: www.nice. org.uk/cg40

National Institute for Health and Clinical Excellence. Transobsturator foramen procedures for stress urinary incontinence. Clinical Guideline 40, London: NICE 2005: www.nice.org.uk/ig107

Cardozoz L, Staskin D (eds) Textbook of female urology and urogynecology, vol. 2, 2nd edn. London 2006: 801–981. Internet resources

www.emedicine.com/checktopic

International Continence Society: www.ics.org Patient resources

Bowel and bladder continence issues: www.bowelfoundation.org

Physiotherapy: www.womensphysio.com

Pipelle biopsy

Endometrial tissue sampling is one of the most common diagnostic procedures for the assessment of women with abnormal uterine bleeding. The main aim of the investigation is to exclude intrauterine pathology, particularly premalignant and malignant endometrial lesions. Inpatient dilatation of the cervix and curettage of the endometrium has been replaced to a large extent by the less invasive and cheaper outpatient endometrial sampling devices.

The pipelle suction aspirator was the prototype for the plastic devices that have followed. It is a flexible polypropylene cannula of 3.1 mm diameter, with a distal side port and an inner piston to generate suction. This design removed the requirement of early devices for external means of generating the necessary negative pressure for aspirating endometrial tissue into the cannula. Procedure

The technique involves the gentle insertion of the pipelle device through the cervix into the uterus until the fundus is reached. Suction created would yield an endometrial tissue specimen into the cannula. The device is then rotated a few times around all the uterine cavity walls, with gentle back and forth movements on withdrawal to achieve a high tissue yield.

Possible difficulties

The most common reasons for failure are

• acute degrees of anteversion or retroversion of the uterus.

• narrow or stenosed cervix.

Manoeuvres to overcome this include

• adequate counselling of the patients about the procedure and what they are likely to experience to reduce failure due to poor compliance

• stabilizing the cervix with a tenaculum

• stabilizing the cannula by applying a sponge forceps to the distal end.

• applying local anaesthetic and performing gentle dilatation of the cervix

• changing to a more rigid sampling device.

Inadequate sampling, despite of good technique can be due to underlying atrophic endometrium. Pipelle biopsy has a failure rate of 3% and an inadequate specimen rate of 1.5%.

Advantages

• Rapid, less time-consuming and cheaper procedure

• Safe and less invasive procedure

• Good acceptability (less than 10% of women complain of severe pain). Diagnostic accuracy

Meta-analysis of 7914 women has shown that pipelle biopsy is superior to other endometrial techniques in the detection of endometrial carcinoma and atypical hyperplasia. The accuracy of the pipelle in detection of endometrial carcinoma is higher in postmenopausal women (sensitivity of 99.6%) than in premenopausal women (sensitivity of 91%). Further reading

Cornier E. The pipelle: a disposable device for endometrial biopsy. Am J Obstet Gynecol 1984;148:109–10.

Dijkhuizen FP, Mol BW, et al. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia. A meta-analysis. Cancer 2000;89:1765–72.

Clark TJ, Mann CJ, et al. Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial hyperplasia. Acta Obstet Gynecol Scand 2001;80:784–93.

Laparoscopy

Laparoscopy is a procedure carried out through small incisions to view the inside of the abdomen and pelvis. It comes from the Greek words La-para, part of the body between the ribs and hips, and Skopein, to see. Around 250 000 women undergo laparoscopy each year (RCOG 2008). Laparoscopy is one of the most common procedures carried out in gynaecology today and classified as either

• diagnostic or

• operative.

However, minor procedures are now being carried out at the same time of the diagnostic laparoscopy, but appropriate consent needs to be obtained before surgery. Indications for diagnostic laparoscopy

• Pelvic pain

• Subfertility

• Suspected ectopic pregnancy

• Malignancy. Indications for operative laparoscopy

• Endometriosis

• Ovarian cysts

• Pelvic inflammatory disease

• Ectopic pregnancy

• Fibroid uterus

• Dysfunctional uterine bleeding

• Gynaecological malignancy. Assessment before laparoscopic procedure

• Check indication for surgery.

• Informed consent (explain that digital images may be stored in case records).

• General and gynaecological examination. Very thin and obese patients at increased risk of complications. Pelvic examination may suggest need for operative laparoscopy.

• Check history of previous surgery and incisions on the abdomen.

• Pelvic ultrasound.

• Be familiar with the equipment.

• Have access to open surgery in case of complication

• Adequate operative time if prolonged surgery expected. Instruments for laparoscopy

1. Laparoscope: 1.2, 5, 7, or 10 mm with 0 or 30° vision. Smaller diameters are used for diagnostic procedures. Some have an operating channel for 3-mm instruments.

2. CO₂ gas insufflators

3. Light source (usually Xenon light)

4. Camera (some laparoscopes come with integrated camera systems)

5. Veress pneumoperitoneum needle

6. Trocars: 5, 10, 12 mm. There are newer trocars like the optical trocars (visual access systems), which allow visualization of the tissue being cut, radially expanding trocars and bladeless trocars, which separate the tissue rather than cutting it

7. Uterine manipulator

8. Diathermy: monopolar and bipolar

9. Operating instruments such as scissors, graspers (tooth or atraumatic), needle holders, clip applicators for sterilization, suction irrigation, etc. Procedure for laparoscopy

Laparoscopic procedures need a lot of equipment compared with open surgery. To carry out a safe and successful procedure the operating theatre should be set up as shown in Fig. 15.7.1. All the personnel involved should be familiar with the equipment to prevent any accidents.

Positioning of the patient is very important. The patient should be placed in a dorsal lithotomy position as shown in Fig. 15.7.2, during the insertion of the veress needle and the umbilical trocar followed by a Trendelenburg position (supine position with a 45° head down tilt). This is to prevent injuries to the bifurcation of the aorta and the left iliac vein, which get pushed up by the promontory in the Trendelenburg position. The arms of the patient should be placed to her side and not perpendicular as with open surgery as this risks the chance of brachial plexus injury. Techniques and sites of entry

The umbilicus is the preferred site for entry as the distance of the peritoneum to the abdominal skin is the shortest at the base of the umbilicus, which would avoid entry into the pre-peritoneal space (Fig. 15.7.3). A vertical incision should be taken into the base of the umbilicus rather than a subumbilical incision.

The different techniques for gaining entry into the abdominal cavity are discussed below.

Closed technique using the Veress needle

The Veress needle, preferably disposable, is first introduced perpendicular in the base of the umbilicus. Once it has traversed the abdominal wall it is then angulated at 45° aiming towards the perineum. First the Veress needle is aspirated and there should be no blood or faeculent matter aspirated. A saline test is then performed. Saline is introduced at the Veress needle and should be sucked in due to the negative intra-abdominal pressure. This is followed by reaspiration where the saline injected should not come out. Usually two clicks are felt during the insertion of the needle, the first through the rectus sheath and the second through the peritoneum. These steps may indicate a correct placement of the needle. The initial flow of CO₂ should be low, and once the correct placement of the needle is confirmed the flow rate should be increased. The initial pressure should be set between 20 and 25 mm of Hg for placement of the trocars as this helps to produce a large intra-abdominal space (bubble) between the bowel, posterior abdominal, and the anterior abdominal wall, thus reducing the risk of bowel and vascular injuries. The pressure then should be dropped to 12–15 mm of Hg for rest of the surgical procedure, which aids the anaesthetist for ventilation of the patient (Consensus document).

Open or cut down technique known as the Hasson’s technique

Commonly performed by general surgeons the technique involves cutting through the layers of the abdominal wall under vision to gain entry. A blunt trocar is inserted through the peritoneum. Pneumoperitoneum is established once the intra peritoneal position of the trocar is confirmed by visualization through the laparoscope. This prevents any vascular injury however the risk of bowel injury is similar to the closed technique (Hasson 1971, 1999).

Fig. 15.7.1 Operating theatre set up (courtesy of Karl Storz and reproduced with permission).

Fig. 15.7.2 Position of patient (courtesy of Karl Storz and reproduced with permission).

Direct entry technique

In this method the trocar is inserted directly into the abdomen without creating a pnuemoperitoneum. This should be carried out only in selected cases and in experienced hands. Using the newer optical trocars the different layers of the abdomen can be seen during entry with the trocar. This is useful when the port is inserted in the Palmer’s point; however, the layers of the abdominal wall are not so well defined at the umbilicus and training and experience is needed to perform this technique. Several studies do not show an increased risk of major complications with this technique and some minor complications may be prevented by this method (Ahmad et al. 2007).

Once inside the abdomen a thorough 360°Check should be performed to check for any inadvertent injuries. Additional ports under vision are usually placed in either iliac fossae lateral to the inferior epigastric vessels and the suprapubic area (Fig. 15.7.4).

In patients with laparotomy incisions, alternative sites like the Palmer’s point (3 cm below the left costal margin in the midclavicular line in the left upper quadrant) should be used. There is a high rate of adhesions to the umbilicus with midline scars (50%) and with transverse scars (23%) (Audebert and Gomel 2000).

Fig. 15.7.3 Anatomy of umbilicus (courtesy of Karl Storz and reproduced with permission).

In such cases the Palmer’s point should be chosen for entry with the Veress needle and primary trocar insertion. Other sites like the suprapubic and posterior vaginal fornix have been tried; however, they are associated with more complications and failures and hence not used very commonly. Common types of gynaecological procedures carried out through laparoscopy

• Sterilization

• Salpingectomy

• Salpingostomy

• Ovarian cyst aspiration

• Ovarian cystectomy

• Oophorectomy

• Ovarian drilling in polycystic ovaries

• Adhesiolysis

• Myomectomy

• Hysterectomy

• Resection of endometriosis

• Ablation of endometriosis

• Pelvic lymphadenopathy

• Colposuspension for stress urinary incontinence

• Sacrocoplopexy for vault prolapse

• Tubal reconstructive surgery

• Oocyte retrieval in assisted conception techniques

• Misplaced intrauterine device retrieval.

Fig. 15.7.4 Position of instruments at laparoscopy (courtesy of Karl Storz and reproduced with permission). Complications of laparoscopy

The risks associated with laparoscopy can be divided into serious or frequently occurring risks (RCOG 2004).

Serious risks

• Damage to bowel

• Injury to blood vessels: inferior epigastric, iliac, aorta, inferior vena cava, mesenteric

• Injury to the bladder and ureter

• Failure to gain entry to the abdominal cavity

• Uterine perforation

• Overall risk with diagnostic laparoscopy is around 2 in 1000

• In advanced laparoscopic procedures the risk of major complications can be as high as 12.5 per 1000 (Chapron et al. 1998).

• The mortality rate is between is 3 and 8 per 100 000.

Frequent risks

• Shoulder tip pain

• Bruising

• Wound infection

• Failure to identify disease

• Surgical emphysema

• Incisional hernia

During the consent procedure, these risk should be discussed with patients; the risks will vary according to the type of procedure being carried out. It is important for patients to consent for open surgery/laparotomy in case there is a complication. It is also important to remember that some patients may present with delayed complications, as thermal injuries and missed injuries can present several days later with serious consequences. Advantages of laparoscopy

• Less analgesic requirement

• Shorter hospital stay

• Earlier mobilization

• Earlier resumption of normal activities

• Return to work earlier

• Cosmetic

• Cost saving Training in laparoscopic surgery

Surgeons undertaking laparoscopic procedures should make themselves familiar with the equipment that is used for the procedures. They should attend courses, lectures, and have hands-on training on pelvic trainers. Laparoscopic surgery requires good hand, foot, and eye coordination, which needs to be developed. Laparoscopic surgery requires a three-dimensional approach compared with the two dimensional views obtained at open surgery. The understanding of the different energy sources is of paramount importance and trainees need to familiarize themselves with this. Having the knowledge and using good and simple surgical principles will make laparoscopic surgery safer with good outcomes.

Training for diagnostic and minor operative laparoscopic procedures can be attained during the Basic and Intermediate training as outlined by the Royal College of Obstetricians and Gynaecologists. For further advanced training Advanced Training Skills Module (ATSM): ‘Benign Gynaecological Surgery: Laparoscopy’ needs to be completed. Further reading

Consensus document concerning laparoscopic entry technique: Middlesbrough, March 19-20 1999. Gynaecol Endosc 1999;8:403–6.

Ahmad G, Duffy J, Phillips K, Watson A. Laparoscopic entry techniques (protocol). Cochrane Database Syst Rev 2007; 3: CD006583.

Audebert A J, Gomel V. Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion. Fertil Steril 2000;73:631–5.

Chapron C, Quwerleu, Bruhat MA, et al. Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29966 cases. Hum Reproduction 1998;13:867–72.

Hasson HM. A modified instrument and method for laparoscopy. Am J Obstet Gynaecol 1971;110:886–7.

Hasson HM. Open laparoscopy as a method of access in laparoscopic surgery. Gynaecological Endoscopy 1999;8:353–62.

RCOG. Consent Advice 2. October 2004

RCOG. Preventing entry related gynaecological laparoscopic injuries. Green Top Guideline 49. May 2008.

Pelvic floor surgery

The management of pelvic organ prolapse is broadly divided into surgical or conservative treatment.

Conservative management includes

• lifestyle intervention such as weight loss, reducing heavy lifting and treating conditions like chronic coughing

• physical therapy, such as pelvic floor muscle training

• pessaries have been shown to be effective in the control of symptoms associated with prolapse. Anterior vaginal prolapse

Anterior vaginal wall prolapse is thought to result from tears in or detachment of the pubocervical fascia. Lateral or paravaginal defects, midline defect or transverse defect in the pubocervical fascia are described (Karram 2001). Symptoms

Anterior vaginal wall prolapse presents with symptoms such as vaginal bulge or mass, low back pain, pelvic pressure, or sexual difficulty. It may also be associated with stress urinary incontinence. Surgical repair technique

The commonest method of repair of anterior vaginal wall prolapse is plication of the pubocervical fascia (anterior colporrhapy). It is carried out by making a midline longitudinal incision on the anterior vagina after infiltration with haemostatic solution containing 1% xylocaine with 1:200 000 adrenaline. The vaginal flap is dissected using the Metzenbaum scissor towards the inferior pubis ramus. This dissection is done bilaterally, thus exposing the anterior vaginal fascia. Interrupted 2-0 polyglactin stitches are used to plicate the exposed paravaginal connective tissue. The vaginal flap is trimmed and closed with absorbable inter-locking stitches. Other authors use longer term absorbable sutures. This procedure can be used for recurrences; some surgeons use support meshes to enhance the repair. There appear to be complications associated with this, and further research is required.

Other methods for repair of anterior vaginal wall prolapse include carrying out a paravaginal repair; this can be done by the vaginal or abdominal route. More recently the use of synthetic material to provide support in the anterior vaginal wall has been introduced. The safety and efficacy of this latter technique is awaited. Complications

Complications include bleeding, vaginal haematoma formation, inadvertent damage to bladder and urethra. Urinary tract infection is a common complication. Other complications include voiding difficulty and sexual dysfunction. Posterior vaginal wall prolapse

Posterior vaginal wall prolapse commonly known as rectocele is a defect in the rectovaginal fascia. It is an out-pocketing of the anterior rectal wall and the posterior vaginal wall into the lumen of the vagina (Mellgren et al. 1995) Symptoms

These include feeling of something falling down in the vagina, a mass in the vagina, lower abdominal or backache, difficulty passing stool, faecal incontinence, constipation. Some rectoceles are asymptomatic. Management

Conservative measures in the management of rectocele include living an active lifestyle, eating adequate dietary fibre, adopting proper bowel training. Vaginal pessaries are also used in the non-surgical treatment of rectocele. Surgical repair technique

The gynaecologist uses the transvaginal route for rectocele repair, whereas colorectal surgeons favour the transrectal route.

The repair of rectocele is carried out under general or local anaesthesia. An initial rectal examination is performed to assess the extent of the rectocele. Infiltration of the posterior vaginal wall using xylocaine with 1:200 000 adrenaline is performed. A longitudinal midline incision on the posterior vaginal wall is made. The vaginal flap is dissected off bilaterally exposing the rectovaginal fascia. The defect in the rectovaginal is plicated using 2-0 ployglactin suture. Excess vaginal tissue is trimmed off and the vaginal skin closed with 2-0 polyglactin suture. Perineorrhapy is carried if indicated.

Synthetic meshes or grafts are also used for repair of rectocele. Complications

Dyspareunia is a complication that may occur after a posterior colporrhaphy. Vaginal apical prolapse

Prolapse of the vaginal apex may occur in the presence or absence of the uterus. Traditionally, the management of uterovaginal prolapse is vaginal hysterectomy together with posterior and/or anterior compartment repair. Hysterectomy is not always considered necessary as the presence of the uterus does not affect the effectiveness of the procedure (Langer et al. 1988). This uterus-sparing approach is desirable when fertility consideration is an issue. Symptoms

The patients with vaginal apex prolapse typically presents with symptoms such as a feeling of something coming down, vaginal pressure, sexual difficulty, difficulty emptying the bowel, urinary symptoms, such as urgency, frequency, incontinence, and voiding difficulty. Some patients are asymptomatic. Surgical management of vaginal apical prolapse

The surgical management of vaginal apical prolapse can be carried out either by the vaginal or abdominal approach. The approach used is guided by the patient’s age, presence of medical comorbidities, weight, desire for coital activity, previous abdominal surgery, and history of previous failed surgery.

Vaginal route

The advantage of the vaginal approach to management of vaginal apex prolapse include

• significant low postoperative morbidity

• can be performed either under local or regional anaesthesia

• allows for repair of other pelvic defects simultaneously

Various surgical techniques using the vaginal route have been described; these include sacrospinous vault suspension, uterosacral ligament fixation, iliococcygeus muscle fixation, McCall culdoplasty, and posterior intravaginal slingoplasty.

Sacrospinous fixation involves the attachment of the vaginal vault to the sacrospinous ligament without tension. It can be performed during vaginal hysterectomy as prophylaxis against future vaginal vault prolapse. Usually, unilateral fixation is performed when used to treat vault prolapse. Complications of the procedure include haemorrhage, nerve injury, injury to bladder and rectum, dyspareunia, postoperative stress incontinence, and voiding difficulty.

McCall culdoplasty involves suspension of the vaginal vault from the origin of the uterosacral ligament together with obliteration of the pouch of Douglas. This procedure is performed at vaginal hysterectomy to prevent occurrence of vault prolapse in the future.

The posterior intravaginal sling procedure involves the use of mesh to support the vault.

Uterus-sparing vaginal procedures are also utilized in the management of uterovaginal prolapse. These procedures include

• Manchester procedure

• sacrospinous hysteropexy

• uterosacral plication

• colpocleisis: this is carried out in elderly patients who are no longer sexually active.

Abdominal route

Sacrocolpopexy involve the using a suspensor bridge (mesh) to support the vaginal apex by attaching to the sacrum, and reperitonizing over the mesh to prevent erosion into bowel. The procedure can be done either as an open procedure or laparoscopically. Sacrocolpopexy has the advantage of allowing any concomitant intrabdominal pathology to be dealt with and it can be performed irrespective of the vaginal length.

Complications associated with sacrocolpopexy include bleeding, and injury to organs such as bowel, bladder, and ureter. Others include urinary tract infection, wound infection, postoperative ileus, and mesh erosion.

In randomized controlled trials (Benson et al. 1966; Maher et al. 2004) comparing abdominal sacrcolpopexy to vaginal sacrospinous fixation, there were more failures in the vaginal group.

Uterus-sparing abdominal procedures include

• sacrohysteropexy and sacrocervicopexy

• pectineal ligament suspension. Further reading

Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomised study with long-term outcome evaluation. Am J Obstet Gynecol 1966;175:1418–22.

Bump RC, Mattiasson A, Bo K, et al. The standardisation of terminology of female pelvic organ prolapse and pelvic organ dysfunction. Am J Obstet Gynecol 1996;175:10–7.

Karram MM. Vaginal operation for prolapse. In: Baggish MS, Karram MM (eds) Atlas of pelvic anatomy and Gynaecologic surgery. Philadelphia: Saunders 2001.

Langer R, Ron-El R, Neuman M, et al. The value of simultaneous hysterectomy during burch colposuspension for urinary stress incontinence. Obstet Gynecol 1988;72:866–9.

Maher CF, Qatawneh AM, Dwyer PL, et al. Abdominal sacrocolpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomised study. Am J Obstet Gynecol 2004;190:20–6.

Mellgren A, Anzen B, Nilsson BY, et al. Results of rectocoele repair. A prospective study. Dis Colon Rectum 1995;38:7–13.

Olsen AL, Smith VJ, Bergstrom VO, et al. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;89:501–6.

Price N, Slack A, Jwarah E, Jackson S. The incidence of reoperation for surgically treated pelvic organ prolapse: an 11-year experience. Menopause int. 2008;14:145–8.

Silva WA, Kleeman S, Segal J, et al. Effects of a full bladder and patient positioning on pelvic organ prolapse assessment. Obstet Gynecol 2004;104:37–41.

Sliskerten HMCP, Vierhout M, Bloembergen H, Schoenmaker G. Distribution of pelvic organ prolapse in the general population: prevalence, severity, aetiology and relation with function of the pelvic floor muscles. Abstract presented at the joint meeting of the ICS and IUGA, August 25–27, 2004, Paris, France.

Weber AM, Walters MD, Piedmonte MA, et al. Anterior Colporrhaphy: a randomised trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299–306