Tuesday, October 30, 2012

Pelvic Organ Prolapse Surgery: Early Procedures

This article will discuss the history of pelvic organ prolapse surgery which dates back to Hippocrates as detailed in an article from Current Urology Reports titled Surgery for Pelvic Organ Prolapse: a Historical Perspective by Yanina Barbalat and Hari Tunuguntla (2012 13: 256-261). The surgical treatments have evolved radically through the ages for pelvic organ prolapse which is a relatively common condition resulting in over 400,000 surgeries for the condition annually. The article noted above estimates that the lifetime risk of requiring surgery for either pelvic organ prolapse or urinary incontinence is as high as one in nine women.

The pelvic floor is often weakened or damaged through childbirth - particularly multiple vaginal deliveries – as well as obesity, smoking, lung disorders which lead to chronic coughing and spinal cord conditions such as muscular dystrophy and multiple sclerosis. When the tissues have been stretched and damaged beyond the point where they will bounce back, the organs can move out of their normal positions pressing against the inside vaginal walls. Surgical techniques have grown much more sophisticated through the years and today robotic techniques are becoming increasingly popular.

Hippocrates and Soranus

Hippocrates detailed numerous non-surgical treatments for pelvic organ prolapse but it is worth noting that he believed the injury was a result of the uterus going “wild” when deprived of male semen. His answer to such an infirmity was to soak a pomegranate in wine, then use it as a pessary to hold the uterus in place. The Global Library of Women’s Medicine noted that “Soranus likewise suggested the use of this fruit as a pessary and reported that Diocles was in the habit of supporting a prolapsed uterus by the introduction of half a pomegranate previously treated with vinegar.” Hippocrates also advocated upside-down suspension of the woman suffering from pelvic organ prolapse – using a ladder and aggressively moving her up and down for up to five minutes until the uterus “behaved” and returned to its proper position. Finally, as stated by Barbalat and Tunuguntla (2012 13: 256-261) “Hippocrates was also known to apply cupping to the buttocks and lower abdomen to suck the uterus back into place.”

While Hippocrates’ solutions to pelvic organ prolapse seem bizarre enough, the Greek physician Soranus who practiced and wrote about gynecology, introduced the use of foul-smelling substances which he believed would cause the uterus to retreat in disgust to its proper position. Soranus also practiced binding of the legs to prevent further prolapse but should those techniques fail, he performed hysterectomies on women whose prolapsed uterus became black—obviously those with severe pelvic organ prolapse. Honey and petroleum were also among the “cures” for pelvic organ prolapse during this time.

The First Hysterectomy

In 1507 Berengario da Carpi performed a hysterectomy of sorts on a woman in which he secured a rope to the descended uterus then tightened it until gangrene set in and the dropped portion of the uterus fell away. (Barbalat and Tunuguntla, 2012). Prior to the 19^th century the pessary was the primary treatment for pelvic organ prolapse and, in an attempt to keep them in place, the designs grew fairly intricate. As the female anatomy was better understood by surgeons and anesthesia, antibiotics and suture materials evolved, surgery for pelvic organ prolapse began to take the place of Hippocrates and Soranus’ treatments. In 1861 in New Orleans the first vaginal hysterectomy as a specific treatment for pelvic organ prolapse was performed and until the 20^th century such surgeries were the accepted therapy. Thomas Watkins introduced a novel approach to pelvic organ prolapse in 1898: he would remove the cervix in a surgical procedure, resting the bladder on the back wall of the uterus, causing the two to become antagonistic forces.

George White’s Contributions

Although George White identified the bladder supports and developed a specific repair technique for pelvic organ prolapse in 1909 his findings were largely ignored for the next six decades. For repair of a simple cystocele there are two common procedures including anterior colporrhaphy (frontal repair of a rupture of the vagina by suturing the edges of the tear) for central defects and paravaginal repair for lateral defects. The anterior colporrhaphy was first used in 1913 in the treatment of stress incontinence however is primarily performed today for cystocele (bladder herniation) correction. White “demonstrated the attachments of the vagina…and concluded that it was important to treat the pelvic organs as a unit.” (Barbalat and Tunuguntla, 2012).

Repairs Using Mesh

The surgical repair of herniated bladders has a 30-70% recurrence rate, causing the use of mesh to become increasingly popular. Surgeons began to realize that pelvic organ prolapse was simply another form of hernia thus began replacing the weak or damaged pelvic floor with biologic and synthetic materials. Biological grafts are taken from the patient, other human donors or animal donors while synthetic mesh types include polypropylene, polyester, Vypro and polyglactin. Barbalat and Tunuguntla noted that when combined with anterior colporrhaphy, patients whose surgeons used mesh could expect a 42-100% cure of their pelvic organ prolapse. Certain reported complications, however, led to an increase in biologic materials when performing the surgery or a return to older surgical techniques.
The FDA issued a warning in 2008 regarding the use of mesh for prolapse and incontinence surgical repair, updating that warning in 2011 but narrowing the scope to encompass only vaginal mesh used to correct pelvic organ prolapse. At this time the FDA noted that complications from the use of mesh are not rare and may add little value over the more traditional non-mesh repairs. The FDA safety bulletin noted that “…the FDA also recommends that health care providers: Recognize that in most cases, POP can be treated successfully without mesh thus avoiding the risk of mesh-related complications and Choose mesh surgery only after weighing the risks and benefits of surgery with mesh vs. all surgical and non-surgical alternatives.”

Pelvic Organ Prolapse Repair through Abdominal Incision

The repair of frontal vaginal prolapse was first proposed via an abdominal incision in 1949 and later in 1951 and 1978. It was noted that there were more prolapse recurrences in women who underwent a combined Burch urethropexy and anterior wedge resection than in those who underwent the Burch procedure alone. In 1976 there were reported results of an abdominal paravaginal defect repair; over a decade later the repair was described via a vaginal approach. The vaginal approach was believed to be more technically demanding, however, leaving the abdominal paravaginal defect repair the only accepted abdominal approach to cystocele correction. This article just discussed the history of pelvic organ prolapse repairs.

Author: Sullo & Sullo Attorneys

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