Markus Huebner

The use of graft materials in vaginal pelvic floor surgery

To review recent literature on graft materials used in vaginal pelvic floor surgery.

Heterogeneity in anatomic outcome of sacrospinous ligament fixation for prolapse: a systematic review.

OBJECTIVE: To explore why failure rates vary so much between published reports of sacrospinous ligament fixation to correct pelvic organ prolapse and what the potential sources of heterogeneity may be. DATA SOURCES: MEDLINE was queried for studies between 1966 and 2005 that included the term “sacrospinous.” METHODS OF STUDY SELECTION: One-hundred eighty-seven studies were reviewed. Studies were selected if they 1) involved a surgical procedure performed unilaterally with a posterior or apical vaginal incision and approach to the ligament; 2) reported objective outcomes with a classification system (Baden-Walker, pelvic organ prolapse quantification) over a defined follow-up period; and 3) were published in English, French, or German. Random effects meta-analyses were conducted for both objective and subjective measures of failure. TABULATION, INTEGRATION, AND RESULTS: Seventeen cohorts met the selection criteria, and the Baden-Walker vaginal profile or a close variation suitable for meta-analysis was used in 10 of them. Variability in failure rates was observed depending on site of and grade of vaginal support (P<.05). The anterior compartment was the most common site of failure for any given grade. This was most striking when the criterion for failure was grade 1 (40.1% anterior, 11.0% apical, 18.2% posterior) or grade 2 prolapse (21.3% anterior, 7.2% apical, 6.3% posterior). Areas of vaginal support were more equally affected when the criterion for failure was grade 3 prolapse (3.7% anterior, 2.7% apical, 2.3% posterior). Among cohorts using grade 2 prolapse as the criterion for objective failure, the pooled measure of failure to relieve symptoms was 10.3% (95% confidence interval 4.4–16.2%) and to provide patient satisfaction was 13.0% (95% confidence interval 7.4–18.6%). CONCLUSION: The variation in published failure rates after sacrospinous ligament fixation is, in part, accounted for by differences in how anatomical outcomes are evaluated and which compartment of vaginal support is being considered. Failure rates are highest in the anterior compartment. LEVEL OF EVIDENCE: III

Pelvic architectural distortion is associated with pelvic organ prolapse

The aim of this study was to determine whether there is an association between architectural distortion seen on magnetic resonance (MR) scans (lateral “spill” of the vagina and posterior extension of the space of Retzius) and pelvic organ prolapse. Secondary analysis of MR imaging scans from a case-control study of women with prolapse (maximum point ≥+1cm; N = 144) and normal controls (maximum point ≤−1cm; N = 126) was done. Two independent investigators, blinded to prolapse status and previously established levator-defect scores, determined the presence of architectural distortion on axial MR scans. Women were categorized into three groups based on levator defects and architectural distortion. Among the three groups, women with levator defects and architectural distortion have the highest proportion of prolapse (78%; p < 0.001). Among women with levator defects, those with prolapse had an odds ratio of 2.2 for the presence of architectural distortion (95% CI = 1.1–4.6). Pelvic organ prolapse is associated with the presence of visible architectural distortion on MR scans.

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.

The impact of pregnancy and vaginal delivery on urinary incontinence

To identify women who had urinary incontinence (UI) before, during, and after pregnancy, and to determine whether women with symptoms of UI during pregnancy were the same women who had urinary incontinence postpartum.

Quantification of Levator Ani Cross-Sectional Area Differences Between Women With and Those Without Prolapse

OBJECTIVE: Compare levator ani cross-sectional area as a function of prolapse and muscle defect status. METHODS: Thirty women with prolapse and 30 women with normal pelvic support were selected from an ongoing case-control study of prolapse. For each of the two groups, 10 women were selected from three categories of levator defect severity: none, minor, and major identified on supine magnetic resonance scans. Using those scans, three-dimensional (3D) models of the levator ani muscles were made using a modeling program (3D Slicer), and cross-sections of the pubic portion were calculated perpendicular to the muscle fiber direction using another program, I-DEAS. An analysis of variance was performed. RESULTS: The ventral component of the levator muscle of women with major defects had a 36% smaller cross-sectional area, and women with minor defects had a 29% smaller cross-sectional area compared with the women with no defects (P<.001). In the dorsal component, there were significant differences in cross-sectional area according to defect status (P=.03); women with major levator defects had the largest cross-sectional area compared with the other defect groups. For each defect severity category (none, minor, major), there were no significant differences in cross-sectional area between women with and those without prolapse. CONCLUSION: Women with visible levator ani defects on magnetic resonance imaging had significantly smaller cross-sectional areas in the ventral component of the pubic portion of the muscle compared with women with intact muscles. Women with major levator ani defects had larger cross-sectional areas in the dorsal component than women with minor or no defects. LEVEL OF EVIDENCE: II-2

Fecal incontinence after obstetric anal sphincter injuries

To determine obstetric variables associated with the long‐term prevalence of flatal and/or fecal incontinence among women who sustained obstetric anal sphincter injuries (OASIS).

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.

Laparoscopic Transection and Immediate Repair of Obturator Nerve during Pelvic Lymphadenectomy

Radical pelvic surgery including pelvic lymphadenectomy in the obturator fossa has become a routine endoscopically performed procedure in patients with gynecologic cancer. Nerve injury during these procedures is rare. However, to choose the best surgical procedure, the surgeon must be aware of the anatomical landmarks of the obturator fossa and of various injury mechanisms. Herein is presented the case of obturator nerve transection during laparoscopic pelvic lymph node dissection, radical vulvectomy, and inguinal lymphadenectomy and its immediate laparoscopic repair in a 56-year-old patient.

Abdominal Sacrocolpopexy – Standardized Surgical Technique, Perioperative Management and Outcome in Women with Posthysterectomy Vaginal Vault Prolapse

Aims: To provide a detailed description of abdominal sacrocolpopexy and to present a retrospective evaluation of the outcomes. Methods: 78 patients underwent sacrocolpopexy between January 2004 and July 2006; 72% had concomitant procedures; 53 patients participated in the follow-up. Anatomical success was defined as any leading point of the vaginal wall remaining >1 cm above the hymen. Failures were split into 3 groups: (1) asymptomatic, no further treatment; (2) symptomatic, conservative treatment; (3) symptomatic, requiring repeat surgery. The key points of the surgical technique were standardized mesh shape, reasonable choice of fixation of the mesh to the anterior and posterior vaginal walls as well as to the longitudinal ligament at S2, and short operating time. Results: Standardization kept the mean operating time short (72.7 ± 14.5 min for sacrocolpopexy only, 86.4 ± 21.0 min if combined with the Burch procedure; p = 0.03). At the follow-up, none of the 53 patients (100%) presented with a recurrent apical prolapse; 17% (n = 9) had stage II anterior wall prolapse, and 69.8% (n = 37) did not show symptoms specific to anterior wall prolapse. Regarding the posterior compartment, 38% (n = 20) had stage II and 1 stage III posterior wall prolapse; 86.8% (n = 46) did not show symptoms specific to posterior wall prolapse. Questionnaire items showed improvement of quality of life. Nine patients required reinterventions: suburethral sling (3), excision due to erosion (2), anterior (1) and posterior (1) repair, stapled transanal rectal resection (1), botulinum toxin injection (1). Every fourth woman presented with symptoms requiring further treatment. Conclusions: Sacrocolpopexy is a valid technique to treat apical and anterior vaginal wall prolapse.