Saturday, October 27, 2012

Early Procedures in Pelvic Organ Prolapse Surgery

This article discusses the historical procedures in the treatment of pelvic organ prolapse surgery. Based on an article in Current Urology Reports titled Surgery for Pelvic Organ Prolapse: A Historical Perspective by Yanina Barbalat and Hari Tunuguntla (2012 13:256-261), it is clear that surgical treatments for this disorder have shown a radical evolution through the ages. In the United States alone, there are over 400,000 surgeries performed for pelvic organ prolapse on an annual basis. In fact, it is estimated that one in nine women will be at risk for requiring surgery for stress urinary incontinence or pelvic organ prolapse.

The figures regarding pelvic organ prolapse tend to be somewhat uncertain since research is limited to those women who seek treatment for the condition. The Beth Israel Medical Center website states that “While we do not know exactly how many women suffer from pelvic organ prolapse, mostly because many women do not seek treatment, we do know that it is a very common problem. Nearly half of all women between the ages of 50 and 79 have some form of prolapse.”

What Causes Pelvic Organ Prolapse?

Pelvic organ prolapse occurs when the connective tissues and muscles which normally support the vagina are stretched beyond their capacity and begin to lose their resilience. This loss of tissue resilience in turn causes the internal female organs to drop and, in more severe cases, the woman may actually feel a protrusion from the vaginal opening. There are a variety of risk factors which can predispose women to pelvic organ prolapse or increase its severity. Vaginal delivery, especially in multiple births, can weaken the pelvic floor as can obesity, smoking, chronic constipation or cough, heavy lifting, the natural aging process, menopause and certain muscle and nerve diseases. Over the decades surgical techniques have become much more sophisticated with robotic techniques becoming more and more popular.

Early “Remedies” for Pelvic Organ Prolapse

The Egyptians were among the first to actually describe pelvic organ prolapse and indicated treatment using a pessary—a mechanical device which bears little resemblance to the modern day version. Current Urology Reports details that Hippocrates “suggested the use of fruit such as pomegranate soaked in wine to hold the uterus in place.” Soranus, a Greek physician, also recommended fruit for the disorder—only soaked in vinegar rather than wine. Upside-down suspension from a ladder was another remedy Hippocrates believed in. Once the woman was in the upside down position, she was moved up and down vigorously for approximately five minutes in order to convince the uterus to return to its rightful position.

Cupping—placing glass “cups” on the body with the help of a flam to create a vacuum and draw out suspected pathogens—was used on the abdomen of women with pelvic organ prolapse in the belief it would suck the uterus back to its proper position. The Greek physician Soranus also believed in the use of foul-smelling substances which he thought would cause the uterus to retract in disgust. When these “natural” remedies failed to achieve the expected results, Soranus performed a hysterectomy of sorts. Other natural remedies for pelvic organ prolapse included the use of honey and petroleum jelly.

Early Hysterectomies

Giacomo Berengario da Carpi, an Italian physician and anatomist who was the first to accurately describe the heart valve, performed a hysterectomy—of sorts—on a woman with severe pelvic organ prolapse. He is said to have secured a rope to the descended uterus, tightening it until gangrene set in and the dead tissue fell away (Current Urology Reports 2012 13:256-261). As the female anatomy began to be more fully understood by surgeons and as anesthesia, antibiotics and suture materials evolved, surgery gradually took the place of the treatments advocated by Hippocrates and Soranus. In New Orleans in 1861 the first vaginal hysterectomy as a treatment for pelvic organ prolapse was performed. Similar surgeries remained the standard therapy for the disorder until the 20^th century.

The Contributions of George White

George White, a gynecologist in the early 1900’s developed a specific repair technique for pelvic organ prolapse after identifying the bladder supports however his advancements were largely ignored for the next half a century. Two procedures – the anterior colporrhaphy (frontal repair of a rupture in the vagina through suturing the tear edges) and the paravaginal repair for lateral defects came into use for repair of a relatively simple cystocele, or bladder herniation correction. George White utilized permanent sutures between the urinary bladder junction to the ischial spines (the bony protrusions which form the lower pelvic border).

Types of Mesh Used in Pelvic Organ Prolapse Surgery

Through the years various surgical techniques were used to repair pelvic organ prolapse, however the recurrence rates were high—from 30-70%. Mesh, already used in abdominal hernia surgery began to be popular in the repair of pelvic organ prolapse. The weakened and damaged pelvic floors were replaced with either synthetic or biologic materials. The biologic materials could come from the patient, a donor cadaver, or even an animal donor. The mesh types were comprised of polypropylene, polyester and combinations of synthetic materials. Those patients who underwent anterior colporrhaphy with some form of mesh could expect a 42-100% cure rate. Although these numbers represented great strides in the surgical treatment of pelvic organ prolapse, specific complications when using synthetic mesh resulted in an increased use of biological materials or even a return to older surgical techniques.

FDA Warnings Regarding the Use of Mesh

In 2008 the Food and Drug Administration issued a warning regarding mesh used in pelvic organ prolapse surgical procedures or incontinence surgeries. A subsequent FDA Safety Bulletin issued July 13, 2011 updated the warning stating “The FDA is issuing this update to inform you that serious complications associated with surgical mesh for transvaginal repair of POP are not rare. This is a change from what the FDA previously reported on Oct. 20, 2008. Furthermore, it is not clear that transvaginal POP repair with mesh is more effective than traditional non-mesh repair in all patients with POP and it may expose patients to greater risk.” Chronic pain, infection and bleeding, perforation of surrounding organs and erosion of the mesh through the walls of the vagina have been noted by women who underwent pelvic organ prolapse surgery using mesh.

Abdominal Incision Repair of Pelvic Organ Prolapse

Barbalat and Tunuguntla’s article (2012 13:256-261) details that in 1949, then later in 1951 and 1978 abdominal incision was first proposed for the repair of anterior vaginal prolapse. Women who underwent a procedure known as the Burch urethropexy seemed to have fewer recurrences of their prolapse than women who had both the Burch procedure and an anterior wedge resection done at the same time. Abdominal paravaginal defect repairs eventually gave way to a vaginal approach although this newer technique was considerably more technically demanding. This article details the historical perspective of pelvic organ prolapse treatments.

Author: Sullo & Sullo Attorneys

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