54 O B .GYN. NEWS • March 1, 2005 T HE M ASTER C LASS Surgeons Respond to Pelvic Reconstruction Column ather than repudiating Dr. Grody’s opin- lthough I have the utmost respect for s editor of the Master Class columns on gynecology, Rion about laparoscopic surgery, I will Aboth Dr. Grody and Dr. Liu and I believe AI was very proud to have C.Y. Liu, M.D., present an only respond to his point about the impor- that everyone is entitled to his or her own excellent two-part discourse on pelvic floor prolapse in the tance of the perineal membrane and PB to opinion, Dr Liu’s article is certainly not wor- October 1, 2004, and November 1, 2004, issues of OB.GYN. pelvic organ support. thy of such admonishment. NEWS. All defects should be repaired at the time of Dr. Liu not only correctly addresses nor- I subsequently received a letter to the editor from Mar- pelvic floor reconstructive surgery. Any tear or mal vaginal anatomy, clinical assessment, vin H. Terry Grody, M.D. In my mind, Dr. Grody has defect in the area of the perineal membrane and one surgeon’s approach to the anatom- raised compelling issues, especially in regard to the im- or PB should be repaired concurrently with ical correction of symptomatic prolapse, he portance of the perineal body in pelvic floor prolapse. Be- pelvic floor reconstruction. This point was does so in a concise, informative manner. cause of this, I have asked Dr. Liu and a panel of experts emphasized in the final step outlined in Part Dr. Grody’s belief that the perineal mem- to discuss Dr. Grody’s concerns. CHARLES E. 2 of my series: “Repair the rectocele and per- brane and PB are crucial for pelvic organ sup- I trust you will find this discussion both interesting and MILLER, M.D. form perineorrhaphy vaginally if necessary.” port is indeed just that: his belief. Using the informative. Based upon my understanding of the func- PubMed search term “perineal body tional pelvic support anatomy as well as clin- surgery,” I found no scientific literature writ- CHARLES E. MILLER, M.D., a reproductive endocrinologist in private practice in Arlington ical observation, I maintain my position that ten in the past 40 years that supports the con- Heights, Ill., and Naperville, Ill., is the medical editor of this column. “the perineal membrane and perineal body cept that either the perineal membrane or are not very crucial for pelvic organ support.” the PB is crucial in the support of any organs The perineal membrane is a single layer of the pelvis. I have yet to read or find an ar- Dear Editors: The PB is a key element in the struc- of fibromuscular tissue that spans the ante- ticle that suggests that the cure rates of In the Oct. 1, 2004, issue of Ob.Gyn. tural composition of the normal vaginal rior triangle of the pelvic outlet. Laterally, it sacrospinous ligament suspension; sacral News, there appeared Part 1 of a two- axis. If significant defects in the PB are ig- attaches to the ischiopubic ramus; medially, colpopexy; paravaginal repair; uterosacral part series entitled “Laparoscopic Pelvic nored and not completely repaired to nat- it fuses with the sidewalls of the vagina and ligament suspension; enterocele repair; or Reconstructive Surgery.” The author, C.Y. ural configuration in this commonly co- perineal body. The anterior portion of the Burch, sling, or any other prolapse corrective Liu, M.D., who is a well-reputed and existent lesion in pelvic floor anatomical perineal membrane is fused with the mus- surgery—including colpocleisis or Lefort pro- skilled laparoscopic surgeon, acceptably failure, then no matter how wonderful the cles of the distal urethra. Rather than form- cedures—are improved by repairing the PB. covered the issues of defects of the pelvic surgeon feels about his or her effort in cor- ing a supportive sheet as it does in the male, Furthermore, there is no scientific litera- supportive and suspensory mechanisms recting the other defects, the operation is the perineal membrane in the female—be- ture that supports the concept that poor per- and their effects on associated organs. But almost certainly doomed to fail in time. cause of the large opening of the vagina— ineal support increases the incidence of pro- from the viewpoint of a vaginal and Such inevitability relates to the interde- provides only lateral attachment for the PB lapse. If this were a fact, patients with pelvic reconstructive surgeon, he em- pendence of all the elements of the con- and some support for the lower urethra. traumatic or congenital cloaca would also bodied a major misconception in his nective tissue network running through The PB is an ill-defined, bordered mass of suffer a greater incidence of vaginal pro- statement, “The perineal membrane and the pelvis. An ignored, significantly de- dense connective tissue lying between the lapse. I have not seen or read of any scien- perineal body are not very crucial for fective PB can become the weak link that vagina and anus. Fused anteriorly to the pos- tific literature or text that can directly show pelvic organ support.” will blow the entire chain of support. terior vaginal wall and attached laterally to a cause-and-effect relationship between a He is not only dead wrong, but he is Even if we uncover the rare gyneco- the perineal membrane and bulbocaver- damaged PB and vaginal prolapse. giving misinformation that could be se- logic surgeon possessed of laparoscopic nosus and superficial transverse perineal Dr. Grody is a purist in his pursuit of vagi- riously destructive to surgery performed skill equivalent to that of Dr. Liu, if the muscles, a significant portion of what is nal anatomic correction, but this fine trait by a myriad of minimally experienced patient does not undergo a full perine- clinically called the perineal body is actual- does not constitute scientific proof for his al- young surgeons whom experts in the orrhaphy from the vaginal approach as ly the muscle of the external anal sphincter. legation. He has the right to theorize that the field are trying tenaciously to convince the last part of the total operation, then The strong upward traction of the levator anatomical correction is essential to improve otherwise. that surgeon must be considered stupid. ani muscles is much more important in long-term cure rates of prolapse surgery. But Before I go further into this matter, I Finally, I must question the wisdom of maintaining vaginal outlet support than are a theory is belief unsupported by substantial must first suppress my emotionally publishing this laparoscopy series that the bulbocavernosus and superficial trans- fact, and will thus remain just a theory. charged conviction (shared by many oth- focuses on a surgical approach that will verse perineal muscle. ers) that the average gynecologic surgeon unquestionably be within the province of Contrary to Dr. Grody’s assertion that the JOHN R. MIKLOS, M.D., is the director of the will not achieve anywhere near the de- only a highly-specialized, well-trained, PB makes a substantial contribution to pelvic Atlanta Center for Laparoscopic gree of success working through a tele- innately gifted few when other easier, support, in actuality the support is minimal. Urogynecology. scope that has been thrust through the safer, very effective, and far less costly and Rather, restoration of the PB is important for ❖ abdominal wall as she or he could attain time-consuming procedures can be ably sexual function and anal/fecal continence. I fter reading Dr. Liu's article on laparo- much more directly with less time and ex- pursued by a significantly larger segment have examined several patients with no PB as Ascopic pelvic reconstructive surgery and pense—and probably less risk—by using of qualified operating practitioners. the result of chronic unrepaired fourth-de- Dr. Grody's response, I found myself per- alternative approaches. Given today’s world of astounding gree obstetric lacerations, yet none of them plexed. How is it that two experienced and Contrary to Dr. Liu’s disregard of any technological feats, will such a truly per- had prolapse. Similarly, women who have respected surgeons can underappreciate contributive importance of the perineal verse printed exposure stimulate adven- had a radical resection of the anus and rec- each other’s perspective on pelvic recon- body (PB), pelvic reconstructive surgeons turous young gynecologic surgeons who tum for cancer, including the entire removal structive surgery? universally consider a disrupted PB to be think they are much better than they re- of the PB, suffered no significant prolapse. For the most part, I agree with most of a critical obstacle to the achievement of ally are into imprudent undertakings be- Because considerable descent (up to 1 inch) what each has stated but disagree on the fin- durably effective success in pelvic yond their true capabilities, leading to se- of the PB is possible during voluntary strain- er points. I must confess that being pre- anatomical and functional restoration. rious injury to their patients? Goodness ing, the perineal membrane and PB cannot be dominately a laparoscopic or minimally in- Over a period of 4 decades starting in the knows what difficulties we already find in the main supportive layer of the genital out- vasive surgeon, I too did not completely 1960s, David H. Nichols, M.D.—whom our cluttered residency programs in get- let. The fact that the PB can move backward comprehend the complexity and functional most of us view as one of the most ting basic maneuvers (like vaginal hys- 3-4 cm toward the sacrum when a weighted anatomy of the PB and membrane as an im- renowned vaginal surgeons—firmly and terectomy) across, let alone highly so- speculum is placed in the posterior vagina portant element in pelvic floor support un- repeatedly established the mandatory re- phisticated, industry-driven, potentially likewise indicates that the position of the PB til more recently.