Fascial repair Douglas Tincello Professor of Urogynaecology and Consultant Gynaecologist.

Fascial repair

Douglas TincelloProfessor of Urogynaecology and Consultant Gynaecologist

Outline

I didn’t!

Tincello DG Kuwait Feb 16th -18th 2013

What are the relevant fascial structures?Delancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am.J.Obstet.Gynecol. 1992;166:1717-24.

Level 1

Level 2

Level 3

Do we know what fascial repair is?


Do we know how to repair fascia? “Traditional” surgery

Midline plication of fascia during anterior repair Midline plication ± levator plication during

posterior repair

“Site specific” surgery Lateral paravaginal defects Fascial defect rectocele repair Sacrocolpopexy or sacrospinous fixation


Anterior compartment surgery Three anatomical types of cystocele

(Nichols DH. Cystocele. In Nichols DH, Clarke-Pearson DL, eds: Gynecologic, Obstetric & Related Surgery, 2nd Edition, Missouri, 2000, Mosby Inc.)

“Anterior cystocele” (pseudocystocele) Rotation of urethra due to separation of pubourethral

ligament Distal to the inter-ureteric ridge

“Posterior cystocele” (true cystocele) Stretch of vaginal wall/fascia without loss of lateral supports Proximal to inter-ureteric bar Loss of vaginal rugae Persistence of lateral vaginal sulci “Distension cystocele”


Anterior compartment surgery

Anterior cystocele Posterior cystocele

Nichols DH. Cystocele. In Nichols DH, Clarke-Pearson DL, eds: Gynecologic, Obstetric & Related Surgery, 2nd Edition, Missouri, 2000, Mosby Inc.Tincello DG Kuwait Feb 16th -18th 2013

Anterior compartment surgery Paravaginal defects

(Richardson AC et al Am J Obstet Gynecol 1976;126:568-71) Traumatic damage to lateral fascial supports of

anterior vagina Loss of one or both lateral vaginal sulci Persistence of vaginal rugae Anterior vaginal wall relaxed and does not move with

pelvic floor contraction(Baden WF & Walker T. Evaluation of uterovaginal support. In Baden WF, Walker T, eds: Surgical repair of vaginal defects. Philadelphia 1992, JB Lippincott)

“Displacement cystocele”


Paravaginal defects- prevalence “Much less common” than midline defects

(Nichols DH. Cystocele. In Nichols DH, Clarke-Pearson DL, eds: Gynecologic, Obstetric & Related Surgery, 2nd Edition, Missouri, 2000, Mosby Inc.)

85-90% of cases of urethrovaginal prolapse(Richardson AC et al Am J Obstet Gynecol 1976;126:568-71)

(Grady Bruce R et al Urol 1999;54:647-51)

Often coexist with central defects(Shull BL et al Am J Obstet Gynecol 1994;171:1429-39)

Uncommon finding in my practice Uncommon finding in UK colleagues’ practice


Grady Bruce R et al Urol 1999;54:647-51

Paravaginal defect repair Abdominal or vaginal approach Re-attach lateral vaginal edge/fascia to arcus

tendineus Ischial spine anteriorly towards Cooper’s

ligament


Paravaginal defect repair Abstract only reviewed

60 women (Richardson AC et al Am J Obstet Gynecol 1976;126:568-71)

223 women (Richardson AC et al Obstet Gynecol 1981;57:357-62)

Full papers reviewed 52 women (Grady Bruce R et al Urol1999;54;647-51) 149 women (Shull BL & Baden WF Am J Obstet Gynecol

1989;160:1432-9) 66 women (Viana R et al Int Urogynecol J 2006;17;621-3) 100 women (Young SB et al Am J Obstet Gynecol 2001;185:1360-6) 62 women (Shull BL et al Am J Obstet Gynecol 1994;171:1429-39)

bilateral defects


Retrospective series-abstract only (Richardson AC et al Am J Obstet Gynecol

1976;126:568-71) 60 women

92% cure at follow up (3 – 48 months)

(Richardson AC et al Obstet Gynecol 1981;57:357-62)

223 women, surgery for stress incontinence

“Functionally satisfactory results in over 95%... 2 to 8 years follow up”


Abdominal approach (Grady Bruce R et al Urol1999;54;647-51)

52 women (27 also had fascial sling for ISD) Surgery for cystocele and incontinence Follow up 17 months

Incontinence cure 79%Cystocele cure 92%

(Shull BL & Baden WF Am J Obstet Gynecol 1989;160:1432-9) 149 women; cystocele and incontinence Follow up 18 months

Incontinence cure 97%Cystocele cure 95%


Abdominal approach Shull BL et al Am J Obstet Gynecol

1994;171:1429-39 100 women with bilateral defects and midline

repair Median follow up 2 years Anatomic cure 79% (does not specify

site)


Vaginal approach Young SB et al Am J Obstet Gynecol

2001;185:1360-6 100 women; midline and paravaginal repair done

vaginally 84 women 6 week follow up; 55 one year

Paravaginal cure 98%

Midline cure 78%

(Viana R et al Int Urogynecol J 2006;17;621-3) 57 of 66 women; vaginal approach for cystocele only Follow up 18 months 47 unilateral defects; 5 central defect; 5 bilateral

Cystocele cure (12/12) 92%Tincello DG Kuwait Feb 16th -18th 2013

Paravaginal defect repair-summary Retrospective series evidence

Anatomical correction – variable but generally good Cure of associated incontinence Many additional procedures done

Randomised trials? Long term follow up?(Maher C et al Int Urogynecol J 2011;22:1445-57)

(Cochrane Database of Systematic Reviews 2010, Issue 4. Art. No.: CD004014. DOI: 10.1002/14651858.CD004014.pub4)

Trials of anterior vaginal wall repair versus the abdominal paravaginal repair in the management of cystocele “No trials identified”


Rectovaginal fascia (Denonvillier’s fascia)

Attachments Uterosacral ligaments

above Arcus tendineus laterally Perineal body below

Function Support of posterior

vagina Vertically and

laterally Support of perineal

body Prevention of

descent

Richardson AC. Clin Obstet Gynecol 1993;36:976-83.


Rectovaginal fascial defects Discrete defects in cadavers and patients Repair of defect results in correction of

rectocele(Milley PS, Nichols DH. Anat Rec 1968;163:443-52.)

(Richardson AC. Clin Obstet Gynecol 1993;36:976-83.)


Fascial defect rectocele repair Retrospective series (100% cases)

69 women (Cundiff GW et al Am J Obstet Gynecol 1998;179:1451-6)

66 women (Kenton K et al Am J Obstet Gynecol 1999;181:1360-3)

125 women (Porter WE et al Am J Obstet Gynecol 1999;181;1353-8)

Prospective series 67 women; 96% specific defects

(Glavind K et al Acta Obstet Gyn Scand 2000;79:145-7) 42 women; 100% specific defects

(Singh K et al Am J Obstet Gynecol 2003;101:320-4)


Retrospective series Cundiff GW et al Am J Obstet Gynecol

1998;179:1451-6 Inferior or combined defects 86% 49 of 69 follow up at median 12 months

Anatomic cure 82%Constipation 84%Dyspareunia 66%

Kenton K et al Am J Obstet Gynecol 1999;181:1360-3 46 of 66 follow up at 12 months

Anatomic cure 77%Bulge 95%Constipation 62%Dyspareunia 72%Tincello DG Kuwait Feb 16th -18th 2013

Retrospective series Porter WE et al Am J Obstet Gynecol

1999;181;1353-8 114 of 125 follow up at median 12months

Anatomic cure 77%Bulge 90% Constipation 43%Dyspareunia 92%


Prospective series Glavind K et al Acta Obstet Gyn Scand

2000;79:145-7 3 month follow up (all women)

Anatomic cure 95%Constipation 85%Dyspareunia 75%

Singh K et al Am J Obstet Gynecol 2003;101:320-4 33 of 42 follow up at18 months

Anatomic cure 93%Bulge 87%“Bowel symptoms” 62%


Fascial defect rectocele repair-summary Retro/prospective series evidence

Anatomical correction Protrusion symptoms Evacuation difficulties Less good for constipation

Randomised trials? Long term follow up?(Maher C et al Neurourol Urodyn 2008;27:3-12)


Only four trials in total Paraiso MFR et al Am J Obstet Gynecol 2006;195:1762-

71


Fascial defect rectocele repair Paraiso MFR et al Am J Obstet Gynecol

2006;195:1762-71 Colporrhapy vs site specific repair vs SSR + porcine

dermis 96 women; 93% completed and followed 18 months

12 month data Anatomic cure Functional cureColporrhapy (28) 86% 85%Site-specific repair (27) 78% 85%SSR + graft (26) 54% 85%

Colporrhapy 83%

Site specific 60%

SSR+ graft 48%


Apical support surgery Must correct apical support

Cannot identify level II defects if you don’t Sacrocolpopexy, sacrospinous fixation, posterior IVS

etc Randomised trials

(Maher C et al Neurourol Urodyn 2008;27:3-12)


3 trials of abdominal sacral colpopexy versus vaginal sacrospinous colpopexy Less vault recurrence RR 0.23, 95% CI 0.07 to 0.77 Less dyspareunia RR 0.39, 95% CI 0.18 to 0.86 Fewer re-operations RR 0.46, 95% CI 0.19 to 1.11


Final conclusions Do we know what fascial repair is?

Paravaginal defect repair Fascial defect posterior repair

Is fascial repair effective? Appears to correct cystocele ± urinary incontinence Appears to correct anatomic and symptomatic

rectocele Not so good for constipation

Should I change what I do? Keep a look out; you’ll find some!

Interrupted PDS for rectovaginal septum repairs Enrol in any large RCTs being organised


Fascial repair Douglas Tincello Professor of Urogynaecology and Consultant Gynaecologist.

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Transcript of Fascial repair Douglas Tincello Professor of Urogynaecology and Consultant Gynaecologist.