Department of Gynecology and Obstetrics, Metro Hospital, 06520 Adana, Turkey
Received Date: February 06, 2017; Accepted Date: March 20, 2017; Published Date: March 27, 2017
Citation: Sukgen G (2017) Laparoscopic Hysterectomy with Anterior Four-Arm Mesh Implant Technique in the Surgical Treatment of a Woman with Pelvic Organ Prolapse and Urinary Incontinence: A Case Report and Review of the Literature. J Cytol Histol 8: 446. doi: 10.4172/2157-7099.1000446
Copyright: © 2017 Sukgen G. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract Purpose: A woman with Pelvic Organ Prolapse (POP) and Stres Urinary İncontinence (SUI) who was treated with a technique utilizing laparoscopic hysterectomy followed by the placement of a 4-arm polypropylene mesh. Methods: Patient who applied to the clinic due to recurrent postmenopausal bleeding, urinary incontinence and vaginal swelling was performed alternative laparoscopic hysterectomy due to such factors as previous recurrent pelvic surgery, lack of isolated uterine descensus, and difficulty of vaginal hysterectomy. In the same session, the patient was treated with anterior 4-arms POP mesh implant. Results: Post-operative 6 months follow ups, both functional and anatomical improvement were observed as the patient’s SUI became continence, and there was an improvement in POP. Conclusion: The combination of laparoscopic hysterectomy, POP 4-arm mesh implant and anti-incontinence surgery in the hysterectomy plan is functional and effective for bbenign reasons in patients with POP and SUI. Future studies are needed to evaluate the utility of this technique
Laparoscopic hysterectomy; Pelvic organ prolapse; Urinary incontinence; 4-arm mesh implant
Postmenopausal bleeding is the bleeding that occurs a year after menstrual periods have stopped due to menopause. Endometrium is expected to be atrophic in postmenopausal period. Therefore, uterine bleeding that occurs during this period should be regarded as an abnormal symptom .
Pelvic Organ Prolapse (POP) is defined as the prolapse of the pelvic organs toward or through the vaginal opening as a result of the weakening of the combination of nerves, muscles and fascia which normally protects and supports the physical position of pelvic organs [2,3].
The purpose of this case report is to provide laparoscopic hysterectomy in cases where hysterectomy is planned due to recurrent postmenopausal bleeding but pelvic surgery is difficult due to previous pelvic surgical vaginal hysterectomy and also to provide anatomical and functional improvement in the surgical treatment of urinary incontinence together with current anterior pelvic organ prolapse.
For this purpose, synthetic, polypropylene mesh was used in order to compensate for the vesico-vaginal facial defect on the basis of POP. Besides, this method also enables tension free midurethral sling with the purpose of treating urinary incontinence. It also aims to prevent long term recurrence in post-operative apical prolapse and in anteriorposterior POP and to provide anatomic and functional improvement. We think that this case report will make a minimal invasive surgical contribution. However, future studies are needed to evaluate the utility of this technique.
A 65 years old patient with gravida: 9, parity: 7, abortion: 2, number of living children: 7 with no chronic illness history nor chronic drug use and had previous repeated pelvic surgery history (ovarian cyst) was referred to our clinic with recurrent postmenopausal bleeding, urinary incontinence and vaginal prolapse complaints. In her examination anterior POP (cystocele, paravaginal defect grade III-IV) and stress urinary incontinence, recurrent postmenopausal bleeding were detected. Her ultrasonographic endometrium thickness was 11 mm, uterus was a little larger than normal, and adnexal atrophy was consistent with age. Preoperative probe curettage report was atrophic endometrium. Laparoscopic hysterectomy+anterior 4-arm mesh implant+Posterior POP repair operations were performed.
CO2 infusion was performed in the lithotomy position under general anesthesia, with umbilicus’ Verres needle in a way to make intra-abdominal pressure 14 mm/Hg. After 10 mm optic trocar was inserted, 5 mm trocar and dissectors were inserted in both lower quadrants of abdomen (Figure 1A).
Pelvic adhesions were removed by sharp and blunt dissection (Figures 1B-1D). Ligamentum Rotundum bilateral electro cautery bipolar tissue dissection device (Ligasure*, Covidien*) was cauterized and cut. Arteria uterina, cardinal, sacrouterine ligaments were cauterized and cut. The uterine was removed from the vaginal cuff by dissecting from the cervix at the level of the uterine manipulator and the vaginal cuff was closed with 2/0 vicryl.
In the same session, vesico-vaginal fascia was put back with linear incision performed 2, 5 cm underneath urethra until the bladder floor (Figures 2A and 2B) . Proximal part of the mesh was passed over ATFP (Arcus Tendinius Fascia Pelvis) with obturator fossa guide using 4-arms mesh, distal part was passed from obturator foramen, 4-atms anterior mesh implant was performed in a way it would pass from Midurethral and bladder body (Figures 2C and 2D).
Figure 2: and B. Urinary incontinence and vaginal prolapse complaints. In anterior POP cystocele, paravaginal defect grade III- IV and stress urinary incontinence. C and D. Distal part of mesh was passed from obturator foramen, 4-atms anterior mesh implant was performed in a way it would pass from Midurethral and bladder body. E. Bleeding controlled by placing two tampons in the vagina.
Posterior fringes of 4-arms mesh were fixed to sacrouterine and cardinal ligaments. Posterior mesh arms at skin level were fixed at the skin by performing traction, anterior side was not fixed at midurethral and skin level, tension free was performed. Vagina mucosa was sutured with no: 2/0 vicryl. In the same session, Fascia dissection was performed from Vagina posterior; fascia defect purse suture was done, and posterior repair was performed. Following the bleeding control, the operation was ended by placing two tampons in the vagina (Figure 2E).
Pelvic Organ Prolapse (POP) is defined as the prolapse of the pelvic organs toward or through the vaginal opening as a result of the weakening of the combination of nerves, muscles and fascia which normally protects and supports the physical position of pelvic organs [2,3]. Pelvic organ prolapsus and urinary incontinence are common complaints that might coexist in the same patient. The risk of having surgical operation because of POP is estimated 11% (4). On the other hand, almost 1/3 of these women need another surgery because of recurrance within the first four years [4,5]. These insufficient results are based on the results of traditional operations (Colporrhaphy Anterior, Kelly plication). Classical Colporrhaphy anterior operation, when applied alone, is reported to have recurrance in the proportion between 20% and 40% [5-7]. This high recurrance proportion indicates that classical plication (Colporrhaphy anterior) of the anterior wall fascia is insufficant alone.
Mesh practices were first used vaginally by Julian in 1996; and recurrance proportions and complications were found to be significantly lower . Succeeding studies have increased the place and importance of meshes in POP surgery [9-11].
According to ACOG (American College of Obstetricians and Gynecologists), decision for surgical procedure in hysterectomy surgery should be made according to the choice of the patient who was informed about the surgical indication, anatomic structure of the patient, all data about the surgical option and the approaches to be applied, and the experience and education of the surgeon . Other determinant factors for the vaginal approach include a sufficiently large subpubic arch and an adequate length of distance between ischial tuberocytes. Vaginal approach might be limited by especially in older cesarean section scar, previous pelvic surgeries, shortness of the anterior vaginal segment, narrow vaginal lumen, loss of vaginal flexibility, nulliparity, deep vagina, and menopause. Although being nulliparous is not considered to be an absolute contraindication to vaginal hysterectomy, vaginal approach can be applied in nullipars with no desensus in only 8% of all hysterectomies . When the indications of laparoscopic hysterectomy are investigated, it is possible to say that “today there is actually no absolute contraindication to laparoscopic hysterectomy” .
According to another view, beside the uterine size, perhaps the only indication of preferring vaginal approach is uterine prolapse . However, because no apical prolapse and uterine descensus were observed apart from significant anterior pelvic organ prolapse, laparoscopic approach was chosen in our case, due to the presence of a history of pelvic surgery. Nearly 30% of the surgical treatments for pelvic organ prolapse are performed due to recurrence . Although it is not a standard surgical method in approaching the patients, surgeons tend to use mesh practices with a view to increasing the positive outcomes. Besides, when compared to the existing conventional methods, it is predicted to be effective in the recurrence of pelvic organ prolapsus and urinary incontinence surgical treatment as well as anatomic and functional recovery. However, reports and literature information on the implementation and outcomes of this system are quite limited in number.
In this study we aimed to evaluate treatment results of 4-arms mesh implementation, which is a relatively new method for POP and urinary incontinence, applied to a patient who was planned to have laparoscopic hysterectomy.
In addition to POP recovery, this surgical technique showed a significant improvement in the stress incontinence table and parameters in the early postoperative period (6th month). It was predicted that both anatomical improvement and functional recovery would be provided by enabling midurethral sling application as it would reduce recurrence in comparison to the conventional colposcopy methods that do not repair vesicovaginal fascial defect on the basis of POP. However, there is no standard consensus as to which treatment method should be used in which patients. More comprehensive literature knowledge is needed on the issue. Evaluation and planning of patients’ long-term follow-up findings can shed more light on the issue to reach more comprehensive results.