Thursday, October 25, 2012

Early Pelvic Organ Prolapse Surgical Procedures

This article will discuss the early history of surgical techniques for women who suffered pelvic organ prolapse. An article from Current Urology Reports titled Surgery for Pelvic Organ Prolapse: A Historical Perspective by Ynina Barbalat and Hari Tunuguntla (2012 13:256-261) details the history and surgical procedures involved in pelvic organ prolapse. Because the research surrounding pelvic organ prolapse is limited to those women who seek care for the condition it is difficult to get a good estimate of the number of women who suffer pelvic organ prolapse.

Interestingly, according to an article from Beth Israel Medical Center on pelvic organ prolapse, “It is important to note that the symptoms and size of the prolapse do not correlate; in other words, one person can have a ‘small’ prolapse, but be very bothered by it, whereas another person can have a ‘large’ prolapse and not be bothered by it at all.” It is believed, however, that some level of prolapse is experienced by as many as half of all women between the ages of 50 and 79. Although the lifetime risk for a woman in the United States to have prolapse or urinary incontinence surgery is approximately 11%, only roughly a third of those women will undergo repeated corrective surgery for pelvic organ prolapse.

Women who experience pelvic organ prolapse may feel a pressure or heavy sensation in the vaginal region which grows worse as the day progresses or they may have difficulty beginning urination. They may experience frequency of urination or have the sensation that their bladder has not fully emptied. Urine leakage during intercourse is common and some women liken the feeling to sitting on a ball. Women who have had multiple children, delivered vaginally are more likely to suffer from pelvic organ prolapse as are those who are obese, smoke, have a chronic cough or a lung disorder which leads to prolonged periods of coughing or those who have certain spinal cord conditions such as multiple sclerosis or muscular dystrophy. There have been many medical answers to the problem of pelvic organ prolapse through the ages, the most recent of which are robotic surgical procedures. Surgeries to correct pelvic organ prolapse are done vaginally or abdominally or through a combination of the two techniques.

Treatments for Pelvic Organ Prolapse in the 1500’s

Some five centuries ago the uterus was believed to be a separate entity from the body which was able to move independently within the body “the uterus was portrayed as an independent animal, capable of moving within its host.” (Barbalat and Tunuguntla, 2012) The report also states that Hippocrates believed the uterus went “wild” when deprived of semen and would simply prolapse from this particular deprivation. Among the non-surgical treatments advocated by Hippocrates during this time, perhaps one of the most bizarre was the soaking of half a pomegranate in wine, then using it as a sort of pessary which held the uterus in place. Women were also hung upside-down on a ladder and shaken up and down for several minutes until the uterus returned to its rightful position.

Soranus, a Greek physician, followed Hippocrates and his views on pelvic organ prolapse were just as outlandish. Soranus encouraged women with pelvic organ prolapse to smell substances which had incredibly foul odors in the belief the uterus would retract from the smell and return to its proper position. If the smelly substances failed to send the uterus back to where it belonged Soranus would next bind the legs which he believed would prevent further prolapse. Should none of these techniques work and the uterus continue to drop and even turn black, he would resort to performing a hysterectomy on the woman.

The Beginnings of the Hysterectomy

Prior to Soranus, Berengario da Carpi performed a very crude hysterectomy in which he secured a rope around the descended uterus, tightening it until gangrene would set in then the dead portion of the uterus would finally fall away. Prior to the 19^th century, however, pessaries were the primary treatments used for pelvic organ prolapse. The designs of these pessaries became very elaborate in an attempt to keep them in place. Throughout the years the female anatomy began to be more widely understood with physicians drawing pictures and diagrams to help others understand the particular female organs.

Anesthesia, antibiotics and suture materials were being discovered and soon surgical procedures took the place of the treatments recommended by Hippocrates and Soranus. The first proper vaginal hysterectomy occurred in New Orleans in 1861 and for many years to come these surgeries were considered the gold standard in the treatment of pelvic organ prolapse. In 1898 Thomas Watkins introduced a surgical procedure which essentially rested the bladder on the back wall of the uterus, making them into antagonistic forces and, according to the article in Current Urology Reports, “He believed that it was ill-advised to remove the uterus in any case of prolapse unless it was diseased.”

The Contributions of George White

In 1909 George White introduced a surgical repair procedure for pelvic organ prolapse after identifying the bladder supports however his research was largely ignored for the next sixty years. White described a paravaginal repair utilizing permanent sutures from the ureter junction to the ischial spines. In the repair of a cystocele surgeons will typically use the anterior colporrhaphy – a frontal repair of the vaginal rupture using sutures on the edges of the tear – for centrally located defects and paravaginal repair for defects of a lateral nature.

Pelvic Organ Prolapse Using Mesh

Unfortunately, surgical repairs of herniated bladders often required a second surgery as the prolapse would recur at a rate from 30-70%. Surgeons who had been using mesh to repair abdominal hernias since the 1950’s began to see the merits of using it in pelvic organ prolapse surgeries. Weakened or damaged pelvic floors were anchored with both biologic and synthetic materials. The synthetic mesh was made primarily from polypropylene and polyester. The biologic grafts came from the patient’s own skin, a cadaver donor or an animal donor. When anterior colporrhaphy was combined with synthetic mesh, the patient could expect a cure rate from 42-100%, depending on other factors including age, weight and overall health. Unfortunately, complications from the use of the synthetic mesh were reported, particularly the erosion of the mesh into neighboring organs or the walls of the vagina.

FDA Warnings Regarding Synthetic Mesh

In 2008 the Federal Drug Administration issued a warning regarding the use of synthetic mesh for the surgical repair of prolapse and incontinence. In 2011, the warning was updated, but the scope was narrowed to encompass only the synthetic mesh used in the correction of pelvic organ prolapse. The FDA stated that complications from the use of synthetic mesh were not rare and the use of such mesh added little value over more traditional surgical techniques. Repair of frontal vaginal prolapse was proposed via an abdominal incision first in the late 1940’s and early 1950’s then again in 1978. The Current Urology Reports article states that women who underwent simultaneous Burch urethropexy and anterior wedge resection seemed to have a greater number of prolapse recurrence than those who underwent the Burch procedure alone. By the mid-1980’s a paravaginal defect repair was done vaginally and while more technically demanding as far as the surgical procedure

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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