Fig. 22.1
Front (a) and lateral (b) view of the pelvic organ prolapse suspension procedure. A V-shaped mesh is fixed to the anterior and lateral vaginal fornix (a, b). The end of strips, the abdominal lateral subperitoneal tunnel, were pulled out through the lateral skin incisions above the iliac crest. A symmetrical traction on both strips reduce the genital prolapse, the cistocele and the rectal prolapse (A1+B1)
In patients who have had a hysterectomy, two separate meshes are used for each side (right and left), and these are then sutured at each side of the vagina, remaining below the perineum, thereby avoiding the possibility of contamination of the mesh due to the opening of the vagina and erosion of the mesh on the top of the stump.
In the event that the vaginal prolapse is prevalent posteriorly, the mesh is fixed on the posterior vaginal fornix; a uterine manipulator is useful because it offers appropriate exposure of the posterior vaginal fornix and the pouch of Douglas.
In patients with advanced cystocele with redundancy and dystrophy of the anterior vaginal wall, the space between the bladder and the vagina is opened and a 5-cm wide, 10-cm long V-shaped mesh is sutured and applied and fixed in the vesicovaginal space. Plication of round ligaments can be added to this basic procedure in order to avoid uterine retroversion.
Any sigmoid rectum intussusceptions are corrected by fixing the mesosigma distal to the left branch of the mesh.
At the end of the procedure, through the CAD, an evaluation of the rectal prolapse is performed. If a residual rectoanal prolapse and/or an anterior rectocele persists, then a STARR procedure is performed.
Indications for an approach by laparotomy are: previous Wertheim hysterectomy, or other complex operation in the pelvis performed via laparotomy; if hysterectomy for fibromatosis is planned; if a mesh for the reinforcement of the anterior vaginal wall and vaginoplasty is necessary.
The laparotomy technique is performed using the same steps as the laparoscopic approach, and the access to the pelvis is obtained by using a previous laparotomy incision (Pfannenstiel or umbilicus pubic incision).
The patient is discharged about 2-3 days after surgery.
22.4 Preliminary Results
From September 2001 to December 2010, we enrolled 486 consecutive women with symptomatic pelvic organ prolapse. The most frequent surgical complications were wound infections and postoperative rectal bleeding in 24 of 226 patients; these complications were associated with the STARR procedure. One patient developed acute postoperative bowel obstruction caused by twisting of the sigmoid colon on the fixing points. One patient developed left renal colic with ureteropyelodilatation caused by urethral kinking due to traction of the mesh on the overlying peritoneum. It was resolved by placing a transurethral catheter in the bladder for 30 days. The anatomotic STARR dehiscences were treated conservatively. The overall rate of surgical complications was 14.3%. Patients were discharged on average after 2.7 days (range 2–16). The mean catheterization time was 30 hours, and the incidence of urinary retention was 3.1%.
Of the 486 patients enrolled in the study, 482 were followed-up at 1 month, 426 at 3 months (of which 404 underwent a repeat dynamic pelvigraphy), 390 at 6 months, 304 at 1 year, 242 at 3 years, and 144 at 5 years. Defecation urgency (7.2%) was the main complication reported at 1 month, and this was resolved in all patients within 3 months. Postoperative pain was slight, on average. No cases of de novo dyspareunia were reported, and all 26 patients who reported this affliction preoperatively were cured or showed significant improvement.
When evaluated clinically, the anatomical results and pelvic organ prolapse stage were excellent. In particular, hysterocele was well corrected in 100% of patients. However, in 29 patients (5.97%) there was a residual grade I cystocele, and in 19 patients (3.9%) there was a grade I posterior colpocele. Pelvigraphy confirmed the excellent anatomical results: in 31.2%, a residual modest rectocele was observed; in 3.9%, a residual posterior colpocele grade I was evident; in 18 patients, a residual rectoanal intussusception was detected, and 10 of these patients also had a residual rectocele, and then underwent STARR for symptoms of ODS.
In 23.76% of patients, a deep pouch of Douglas was residual, but paradoxically in this subgroup the average postoperative ODS score was 1.4, while the same score was at least 3.03 for the group as a whole. In fact, the depth measurement of the pouch of Douglas was compared with the vaginal vault, which was often a little higher than the norm: the measurement of the distance of the pouch of Douglas to the pubococcygeal line was found to be normal in 93.5% of patients. There was a significant improvement in the descent of the perineum, especially in patients who underwent the STARR procedure.
We found six patients (1.23%) with vaginal prolapse relapse; five of these patients had previously undergone hysterectomy. All recurrences occurred within 6 months of surgery and we found that in all cases the cause was detachment of the vagina from the mesh. Four patients underwent reoperations to restore the suture between the vaginal vault and the mesh, using a prolene 0 continuous suture.
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