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Vaginal Cerclage: Pelvic Organ Prolapse Option

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Vaginal Cerclage: Pelvic Organ Prolapse Option 30 GYNECOLOGY OCTOBER 2010 • OB.GYN. NEWS Vaginal Cerclage: Pelvic Organ Prolapse Option This novel surgical procedure is proving effective in bulge, pressure, discharge, defecation to have severe prolapse during a pelvic dysfunction, and abdominal pain; she exam prior to surgery. Vaginal cerclage select patients with severe, refractory prolapse. was diagnosed with stage IV vaginal was used as a rescue procedure so that vault prolapse. As in the first patient, she could undergo the transplant surgery. BY SHARON WORCESTER recurrent urinary tract infections. vaginectomy was performed and The prolapse was reduced, the cerclage A decision was made to perform augmented by vaginal cerclage. The was placed, and the transplant was EXPERT ANALYSIS FROM AN INTERNATIONAL PELVIC vaginectomy augmented by the place- patient’s vagina was obliterated, and her successful, he said. RECONSTRUCTIVE AND VAGINAL ment of a simple introital cerclage. prolapse reduced with no change in Vaginal cerclage is a simple and SURGERY CONFERENCE Dr. Kovac adequately infiltrated the urethral angle. “clever” procedure that can be accom- introitus with 0.5% Marcaine with Both patients were doing well at 8 plished in about 5 minutes, is reimbursed ST. LOUIS – Vaginal cerclage, a novel epinephrine, then used nonabsorbable months’ follow-up, Dr. Kovac said. as a colpocleisis, and vastly improves surgical procedure for pelvic organ pro- braided sterile Dr. Kovac, patient comfort, Dr. Kovac said. lapse, is proving effective as a treatment polyester suture Vaginal cerclage is a simple who argued that “It has great advantages, and we’re do- option for severe and refractory prolapse beginning at the vaginal cerclage ing it routinely today on select patients in select patients. 12 o’clock posi- and ‘clever’ procedure that can is superior to the who come in with recurrent prolapse af- Also known as introital cerclage, the tion. The suture be accomplished in about 5 “very outdated” ter multiple attempts at correctional procedure involves permanent suturing was placed away LeFort colpoclei- surgery – with excellent results.” of the introitus, and is often performed from the mid- minutes, is reimbursed as sis procedure The availability of such a technique is in conjunction with vaginectomy. This urethra and clos- colpocleisis, and vastly that’s used in important because, typically, the repair obliterative approach is suitable only in er to the bladder patients with used for a failed colpocleisis is a repeat those who are certain they no longer de- neck to decrease improves patient comfort. severe prolapse colpocleisis. sire coital function, but on its own, vagi- the risk of de who still have Also, an increase in patients who seek nal cerclage also can serve as a bridge to novo stress urinary incontinence. their uterus, noted that the new tech- treatment is anticipated, given that U.S. nonobliterative repair, Dr. S. Robert Suture placement continued in a cir- nique also can be used as an intermedi- Census data indicate that the number of Kovac and Dr. Carl W. Zimmerman said cumferential manner toward the 6 ate procedure in certain patients await- adults older than age 65 is expected to at the conference, which was sponsored o’clock position in several steps, ending ing nonobliterative prolapse repair. reach 90 million by 2050, and that 30%- by the Society of Pelvic Reconstructive at the 7 o’clock position to minimize dis- For example, he described a patient 50% of women experience prolapse in Surgeons. comfort. The suture ends were cut and with a significant prolapse who was their lifetime, 11% undergo surgery for Dr. Kovac, the John D. Thompson tied down to obliterate the vagina and re- unable to undergo surgery because of prolapse, and a third of prolapse and in- Distinguished Professor of Gynecologic duce the prolapse, and the ends were elevated creatinine. Vaginal cerclage continence surgeries are for recurrent Surgery and director of the Emory buried under the skin to decrease dis- allowed for temporary relief over the 8- prolapse. Center for Reconstructive Pelvic Surgery comfort. 9 days required for her creatinine levels Improved techniques are needed, at Emory University, Atlanta, used a The same approach was used in a 77- to normalize. particularly in light of the high rate of video demonstration to show the surgi- year-old patient who had undergone to- “This approach provided improved repeat repairs, Dr. Kovac said. ■ cal technique in an 82-year-old woman tal abdominal hysterectomy and bilater- comfort and quality of life, and reduced who had undergone two prior proce- al salpingo-oophorectomy, as well as her hydronephrosis, which was causing Disclosures: Dr. Kovac disclosed that he is dures for the treatment of prolapse, multiple prior prolapse repairs, including the elevated creatinine, thus enabling a consultant for Cook Medical Inc. and including a total abdominal hysterecto- transvaginal repair with graft augmen- her to undergo the full repair,” he said. Ethicon Endo-Surgery Inc. Dr. Zimmerman my followed by transvaginal repair with tation, a pubic bone sling, and trans- Similarly, Dr. Zimmerman, professor is a speaker/proctor for Cook Medical, graft augmentation. vaginal enterocele repair with graft aug- of obstetrics and gynecology at Vander- proctor for Boston Scientific Corp. and She presented with recurrent prolapse mentation and repeat enterocele repair bilt University in Nashville, Tenn., Covidien, and receives Royalties from and complaints of vaginal bulge and dis- with colpocleisis. described a patient who was preparing to Lumitex Inc. and Marina Medical comfort, difficulty with voiding, and The patient presented with vaginal undergo liver transplant and was found Instruments Inc. Pubic Bone Stabilization Slings Don’t Cause Osteomyelitis BY SHARON the conference, which was 1,228 patients who underwent comes of the various subu- Ǡ It is easy to learn and teach. WORCESTER sponsored by the Society of transvaginal bone anchor fixa- rethral slings currently used for Ǡ There is low or no pain. Pelvic Reconstructive Surgeons. tion in female pelvic recon- urinary incontinence, he said. Ǡ There is rapid return to nor- EXPERT ANALYSIS FROM AN INTERNATIONAL PELVIC Patients were treated for in- structive surgery, Dr. Kovac Currently, the procedure is mal voiding postoperatively. RECONSTRUCTIVE AND VAGINAL trinsic sphincter dysfunction noted (Urology 2004;64:669-74). performed transvaginally by Ǡ There is no need for blindly SURGERY CONFERENCE (ISD) and/or stress urinary in- By comparison, abdominal placing a suburethral sling of placed trocars. continence (SUI), and were fol- sacrocolpopexy is associated Biodesign Surgisis over the Ǡ Surgical time is less than 30 ST. LOUIS – Treatment of lowed for a mean of 13 years, with an osteomyelitis incidence midurethra, and securing it with minutes. urinary incontinence by means and up to 17 years at four dif- of 11%, according to reports in titanium bone screws to the Ǡ There is no need for mesh, so of a pubic bone stabilization ferent institutions, said Dr. the literature, Dr. Kovac said. posterior-inferior pubis to there are no mesh-related com- sling – a suburethral sling that is Kovac, the John D. Thompson “I think we got off on the restore proper anatomy for con- plications. anchored to the pubic bone Distinguished Professor of Gyn- wrong track,” he said of the tinence. Ǡ There is no voiding dysfunc- using titanium screws – is high- ecologic Surgery and director of unfounded fears regarding In addition to the high cure tion; it is truly tension free. ly effective and is not associated the center for pelvic reconstruc- osteomyelitis in patients under- rate and low complication rate, The procedure also has little with an increased risk of tive surgery and urogynecology going pubic bone stabilization the approach has several other reliance on cystoscopy, although osteomyelitis, according to find- at Emory University, Atlanta. (PBS) sling procedures. advantages, Dr. Kovac said, Dr. Kovac said that he recom- ings from the largest prospective His associates are Dr. P.D. Dietz, Dr. Kovac, who developed the including the following: mends cystoscoping all patients observational study to date. Dr. M. Muniz, and Dr. S.H. PBS sling procedure more than Ǡ It is a totally vaginal, unified to avoid potential bladder- Although concerns that the Cruikshank. 20 years ago, said that more approach; all defects can be related hazards. ■ procedure could cause osseous Follow-up was done by ex- than 350,000 have been per- treated during one procedure. complications have been circu- ams, questionnaires, and tele- formed worldwide, and that in Ǡ There is efficacy for both ure- Disclosures: Dr. Kovac disclosed lating for years and have dis- phone conversations. all that time he hasn’t seen a sin- thral hypermobility and ISD- that he is a consultant for Cook couraged some surgeons from The cure rate for those with gle case of osteomyelitis or os- related SUI. Medical Inc. and Ethicon-Endo using the pubic bone stabiliza- ISD and/or SUI who had total teitis pubis in any of his patients Ǡ It functions as a retropubic Surgery Inc., but he sold his tion sling, only 1 case occurred dryness was 92%. who underwent the procedure. procedure, a vaginal Marshall- patent on the PBS sling to in the 2,331 patients in the study, In a prospective study pub- Furthermore, the PBS sling Marchetti-Krantz (MMK) oper- American Medical Systems and for an incidence of 0.000043%, lished in 2004, the incidence of has the lowest complication rate ation without the need for an has no financial interest in the Dr. S. Robert Kovac reported at osteomyelitis was 0.08% in and the best long-term out- abdominal incision. procedure..
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