Pelvic Floor Surgery in the Older Woman

Geriatric gynecology: promoting health and avoiding harm

Age increases vulnerability, commonly accompanied by greater reliance on others and susceptibility to maltreatment. Physiologic processes become less resilient; the potential for harm from medical care increases. Awareness of frailty, functional, social, and potential maltreatment issues enables early referrals to help the patient maintain her independence. Health issues that may impede both gynecologic care and self-sufficiency include sensory deficits, physical disability, and cognitive impairment. Speaking slowly and providing contextual information enhance patient comprehension. Cancer screening depends on life expectancy. Osteoporosis treatment requires managing fall risk. Gynecologic symptoms more likely have multiple contributing factors than one etiology. Incontinence is a particularly complex issue, but invariably includes bladder diary assessment and pelvic floor muscle training. Function and frailty measures best predict perioperative morbidity. Communication with the patient, her family, other providers, and health care organizations is an important frontier in avoiding errors and adverse outcomes.

Dynamic evaluation of pelvic floor reconstructive surgery using radiopaque meshes and three-dimensional helical CT

PURPOSE

This prospective study was performed to achieve visualization of the reestablishment of anatomy after reconstructive surgery in the different pelvic compartments with non-absorbable radiopaque meshes, providing valuable anatomic information for surgeons implanting meshes.

MATERIALS AND METHODS

A total of 30 female patients with stress urinary incontinence (SUI), anterior and posterior vaginal wall prolapse, or both underwent surgical repair using radiopaque meshes after written informed consent. Patients with SUI underwent five different surgeries. Patients with anterior vaginal prolapse underwent a procedure using a combined pre-pubic and transobturator mesh, and those with posterior vaginal prolapse underwent posterior slingplasty. Three-dimensional reconstruction using helical CT was performed four weeks postoperatively.

RESULTS

In all cases, the mesh was clearly visualized. Transobturator slings were shown at the midurethra, and the anchoring tails perforated the obturator foramen at the safety region. Mini-slings were in the proper place, and computed angiography revealed that the anchoring system was away from the obturator vessels. In patients undergoing procedure for anterior vaginal prolapse, both pre-pubic armpit and obturator slings were clearly seen and the mesh was in the proper position, supporting the bladder base and occluding the distal part of the urogenital hiatus. Transcoccygeal sacropexy revealed indirectly a well-supported "neo rectovaginal fascia" and the anchoring tails at the level of ischial spines.

CONCLUSION

Three-dimensional helical tomography images of the female pelvis using radiopaque meshes have a potential role in improving our understanding of pelvic floor reconstructive surgeries. These radiopaque meshes might be the basis of a new investigative methodology.

[Transcoccigeal colpopexy with polyprolylene mesh with helper orifices for the treatment of posterior vaginal wall prolapse: anatomical and functional results]

OBJECTIVE

The creation of neo utero-sacral neoligaments, decribed by Petros, evolved into a new procedure allowing for the anatomical reconstruction of the three levels proposed by DeLancey. The aim of this study is evaluate the anatomical and functional outcomes of this minimally invasive procedure.

PATIENTS AND METHOD

From December 2004 to March 2007, a total of 34 patients with posterior defect grade III or higher underwent this procedure. The minimum follow up was 13 months Mean age was 63 years. The site of fixation was the Sacrospinous ligament.

SURGICAL TECHNIQUE

The ischiorectal fossa is dissected. Next two small skin incisions are made 3 cm lateral and inferior to the center of the anus. A proper needle is introduced, vertically towards the sacrospinal ligament at the level of the ischial spine, guided by the surgeon index finger, 2 cm medially avoiding the Alcok canal. The armpit of the mesh is connected to the tip of the needle and brought to the perineal region. No site specific correction is made.

RESULTS

The cure rate was 94,7% and recurrence rate was 5,3%. No visceral, nerurovascular injuries were observed. The mesh exposure rate (less than 1 cm2) was (14.7%) and all patients were treated conservatively with no impact on the outcome. There were transient dyspareunia in 2 (11.8%) of the 17 sexually active patient and persistent in 1 case (5.9%).

CONCLUSIONS

This procedure is an attractive minimally invasive alternative for the anatomical and functional reconstruction of the posterior and apical defects.