Christl Reisenauer

Nerve-preserving sacrocolpopexy: anatomical study and surgical approach

OBJECTIVE The aim of our study is to describe the course of the autonomic nerves in the presacral space and to find the best nerve-preserving approach for sacrocolpopexy. STUDY DESIGN The autonomic nerves of the presacral space were dissected on six specially preserved female cadavers. RESULTS The superior hypogastric plexus is located in front of the abdominal aorta and its bifurcation and deviates to the left of the midsagittal plane. At the level of the promontory, or just below, the superior hypogastric plexus branches into two hypogastric nerves that run in front of the sacrum. In the presacral space the parasympathetic pelvic splanchnic nerves from the ventral rami of the sacral spinal nerves (S2-S3) join the hypogastric nerves, forming the inferior hypogastric plexus on both sides. From the inferior hypogastric plexus, nerve fibres spread out bilaterally to the pelvic organs. In two of the six cadavers sacral splanchnic nerves could be identified leading from the sacral sympathetic ganglion S1 of the sympathetic trunk to the inferior hypogastric plexus. CONCLUSION Longitudinal incision of the peritoneum along the right common iliac artery and above the promontory allows for a safe approach for sacrocolpopexy. After exposing the vascular structure (e.g. medial sacral vessels) above the promontory, the anterior longitudinal ligament becomes visible and can be prepared for the fixation of the mesh for vaginal suspension. By protecting the superior hypogastric plexus and the part of the presacral area below the promontory we can preserve the hypogastric nerves, the sacral and pelvic splanchnic nerves and thus the autonomic innervation of the pelvic organs. Awareness of the course of the autonomic nerves in the presacral space will significantly improve the functional outcome of sacrocolpopexy and reduce bowel, urinary and sexual dysfunctions.

Dynamic magnetic resonance imaging for assessment of minimally invasive pelvic floor reconstruction with polypropylene implant

INTRODUCTION The purpose of the study was to assess the usefulness of dynamic MRI in patients with pelvic organ prolapse after pelvic floor repair with polypropylene mesh. MATERIALS AND METHODS Fifteen consecutive patients (mean age 66.5 years) who were scheduled for either anterior (n=9) or posterior (n=6) pelvic floor repair were prospectively evaluated by clinical assessment and dynamic MRI 1 day before and 3 months after surgery. MRI diagnoses and MRI measurements of relevant anatomical points at rest and on straining were analysed before and after surgery. RESULTS At follow-up assessment 93.3% of all patients were clinically cured. Dynamic MRI showed newly developed (n=6) or increased (n=6) pelvic organ prolapse in 80% (n=12) of all patients 3 months after pelvic floor repair. Most of them (n=11; 91.7%) affected the untreated pelvic floor compartment. On straining anatomical points of reference in the anterior pelvic floor compartment were significantly (p<0.05) elevated after anterior repair and rectal bulging was significantly (p=0.036) reduced after posterior pelvic floor repair. CONCLUSIONS In this study dynamic MRI could verify the effective support of anterior and posterior pelvic floor structures by anterior and posterior polypropylene implant respectively. But dynamic MRI demonstrates if one compartment of the pelvic floor is repaired another compartment frequently (73.3%) develops dysfunction. These results did not correspond to clinical symptoms on short-term follow-up (3 months). Studies with long-term follow-up are necessary to prove if dynamic MRI can reliably identify clinically significant pelvic organ prolapse after pelvic floor repair before the onset of symptoms.

Urethrovaginal fistula—a rare complication after the placement of a suburethral sling (IVS)

A sixty-year-old woman with stress urinary incontinence had undergone a placement of an IVS (Tyco Health Care UK) in another hospital in February 2003. Seventeen months after the procedure, she complained about a suppurative discharge from the vagina and a recurrent severe stress urinary incontinence. The gynecological examination revealed an erosion of the sling into the vagina and a large urethrovaginal fistula bordered by granuloma. After removal of the sling, the urethrovaginal fistula was closed using a vaginal flap. A subsequent conservative treatment regime with duloxetine and pelvic floor training improved the stress urinary incontinence to the patient’s satisfaction.

Anatomic study of prolapse surgery with nonanchored mesh and a vaginal support device

OBJECTIVE The purpose of this study was to evaluate the anatomic position and relations to neighboring neurovascular structures of polypropylene implants after vaginal repair with nonanchored mesh and a vaginal support device in a cadaver model. STUDY DESIGN We undertook anatomic dissection of 6 cadavers, with and without prolapse after surgery. RESULTS All polypropylene implants were positioned in accordance with the prescribed surgical technique. This surgery reconstructed the entire anterior and posterior pelvic floor compartments without extension beyond the pelvic cavity. A safe distance between the implants and their neighboring neurovascular structures (obturator nerve and vessels, 2.8-3.3 cm; pudendal nerve and internal pudendal vessels, 1.8-2.2 cm; sacral plexus, 2-2.2 cm) was observed. CONCLUSION Anatomic cadaver dissection confirmed the accurate and safe placement of the polypropylene implants with the use of the prescribed surgical technique.

Treatment of recurrent vaginal eversion after previous Le Fort colpocleisis

Fig. 1. Anterior–posterior radiograph of needle placement and contrast spread for chemical neurolysis of the superior hypogastric plexus. On follow-up at 8 weeks, 6 months, 12 months, and 24 months after the procedure, the woman reported virtually complete pain relief. Her Oswestry Disability Index score decreased from 37 at her first hospital appointment in March 2006 to 5 at 12 and 24 months after neurolysis, there were no functional limitations, and she was able to resume her studies. Although endometriosis usually responds to a combination of medical and laparoscopic therapies, seemingly successful treatment sometimes fails to resolve the painful symptoms. In the present case, despite only mild endometriosis found at laparoscopy, the woman continued to experience severe pain after conventional methods were used. Although her response to the conventional local anesthetic blockswas not sustained, the temporary relief that occurred as a result indicated that chemical or surgical nerve-destructive therapy would be effective. Although the present case resulted in complete relief from a disabling condition and restoration of a normal quality of life, the use of nerve-destructive procedures should remain exceptional in patients with non-cancer pain. Superior hypogastric plexus neurolysis should be performed only by doctors familiar with interventional pain management techniques.

Mesh-related complications in urogynecology – a multidisciplinary challenge

Diagnoses of complications in women who underwent pelvic floor surgery using meshes and the multidisciplinary management of these cases at two national referral urogynecological centers between January and June 2011 are presented in a series of cases of mesh complications, which provide an indication of the wide range of symptoms and, at times, the long time span over which they may be encountered. Complications included infection, erosion (extrusion/exposure), fistulas, perforation into the surrounding organs (such as urethra, bladder and/or bowel), chronic pelvic pain (often radiating into buttocks, groins and/or thighs), dysuria, dyschezia, voiding difficulties, constipation, stool evacuation difficulties, de novo overactive bladder, urinary and fecal incontinence and prolapse recurrences. Although meshes have the ability to provide adequate anatomical support, the emergence of such a multitude of complications has resulted in restrictions for their use, as well as being a multidisciplinary challenge.

Laparoscopic Nerve-Preserving Colposacropexy for Surgical Management of Neovaginal Prolapse

BACKGROUND Neovaginal prolapse occurs rarely, and a standard treatment has not yet been defined. CASE We report 2 cases of patients with vaginal agenesis with a symptomatic neovaginal prolapse; one occurring 25 years after self-dilation and another occurring 24 years after sigmoid vaginoplasty. At 48 and 18 months after surgical treatment with laparoscopic nerve-preserving colposacropexy using 2 types of mesh and 2 kinds of sutures to anchor the mesh at the neovaginal wall, both women are asymptomatic and highly satisfied with the result, without prolapse recurrence or mesh/suture erosion. SUMMARY AND CONCLUSION For the surgical management of neovaginal prolapse after sigmoid vaginoplasty and vagina creation after self-dilation, we recommend the nerve-preserving sacrocolpopexy as a safe method to achieve durable functional outcomes and good anatomic vaginal level I and II support.

Management of device-related complications after sacral neuromodulation for lower urinary tract disorders in women: a single center experience

PurposeThis study is aimed at presenting and discussing the device-related complication management during a 5-year period, of the sacral nerve modulation (SNM), in a tertiary-care university unit.MethodsThis is a retrospective chart review of all women, who received SNM in our department between May 2011 and May 2016. All two-stage procedures were performed by the same experienced surgeon and according to our strict protocol of patients’ selection and follow-up. Data of perioperative and postoperative complications and their management were collected.ResultsThe test stimulation was positive in 59 out of 64 patients (92%), who then received the permanent implantation after a mean test phase duration of 9 days. Mean overall follow-up was 16.5 (±10.9) months. We recorded 20 complications (31%) in 15 patients, after a mean follow-up time of 160 days. These comprise: lead migration (13.8%), infection (8.6%), pain (5.2%), wound healing disorders (5.2%) and lead fibrosis (10%). The event/patient ratio was significantly reduced from 0.6 in the beginning of our experience with SNM to 0.2 at the second period of the study (p = 0.005). All complications could be successfully resolved after surgical intervention without influence on the treatment effect.ConclusionComplications after SNM are common and may require additional surgical intervention for full resolution but without affecting the treatment effect. Also, due to a learning curve, a lower events/patient ratio over time is to be expected.

Intrapartal pelvic floor protection: a pragmatic and interdisciplinary approach between obstetrics and urogynecology

Pelvic floor protection is an issue of increasing relevance. This article sought to summarize the session at last year’s annual meeting of the German Society of Gynecology and Obstetrics (DGGG) in Stuttgart (10/2016) called “Urogynecology 2020—what is the optimal rate of cesarean section—does urogynecology have to deal with Obstetrics?”. The main focus was set on the two important anatomical structures, the levator ani muscle and the anal sphincters. Operative vaginal delivery, epidural anesthesia, and episiotomy are subject to discussion.

Presence of relaxin‐2, oxytocin and their receptors in uterosacral ligaments of pre‐menopausal patients with and without pelvic organ prolapse

Pelvic organ prolapse (POP) is a major health concern for women. Its pathophysiology is yet not fully understood. We reported an impaired functional state of the smooth muscle compartment in uterosacral ligaments from patients with POP, which was cholinergic, stimulated by oxytocin and modulated by relaxin‐2. The current study investigated the presence of oxytocin and relaxin‐2 and their receptors in the uterosacral ligament from POP/non‐POP patients.