Therapy for Pelvic Organ Prolapse (POP)
 

Pelvic organ prolapse (POP) may occur in up to 20% of parous women. It may cause a variety of urinary, bowel and sexual symptoms and, as reported, necessitates surgical correction in 11% of the female population. Previously reported surgical modalities such as colporrhaphy, plication of the uterosacral ligaments, sacrospineous and sacral colpopexies are associated with an to up 58% recurrence rate in terms of objective POPQ scoring and prolapse related subjective symptoms. For the last decade, various surgical modalities for curing POP through reconstruction of the pelvic floor have been advocated, mainly modification of the colpo-sacral and colpo-sacro-spinal fixations, using vaginal or abdominal approaches, via laparotomy or laparoscopy.

 

These operations where associated with well documented complications such as mesh erosion, dyspareunia, buttock pain, urinary and fecal incontinence, altered defecation and constipation, bladder injuries, urinary retention and infections, cystocele and rectocele formation and protrusion, and other disadvantages such as long operative time, slow return to normal living activities and great costs. Against this background, Petros was encouraged to develop the novel PIVS, entailing minimal invasiveness via a vaginal approach together with anatomical restoration of the uterosacral ligament suspension of the vaginal apex, performed in a daycare setting. This operation permits the restoration of the anatomical position of the vaginal apex, hence the conservation of the prolapsed uterus. Preservation of the uterus was lately shown to contribute positively to the patient's self-esteem, body image, confidence and sexuality.

The overall operative result with the PIVS patients demonstrates the safety and efficacy of the PIVS method for vaginal apex support. Replacement of the broken uterosacral ligaments applying PIVS provides adequate uterine re-suspension, hereby permitting uterine preservation while treating advanced uterine prolapse. Amputation of an elongated uterine cervix in order to prevent later bulging out might be appropriate. The differences between the hysterectomy and non-hysterectomy groups are insignificant except for the length of hospitalization. Bladder overactivity symptoms such as urgency, frequency, urge incontinence and nocturia, which had been troublesome for about three thirds of the patients preoperatively, were postoperatively reduced to about 10% of the patients in each group. The explanation for this major finding, the improvement of unstable bladder symptoms is unclear, as such symptoms are generally deemed to be incurable.

 

It has been previously explained with reference to the Integral Theory, using the trampoline analogy, whereby lax ligaments cannot support the bladder base stretch receptors, as a result of which these fire off prematurely. The PIVS restores the posterior ligamentous supports, hence contributing to the neural stability of the bladder and avoiding bladder overactivity symptoms. The PIVS therapeutic effectiveness does not appear to be inferior to previously reported operative techniques and uterine conservation does affect neither the cure nor the complication rates. This procedure seems easier and faster to perform and might be less associated with intra and post-operative procedure related morbidity than the above-reported operations.

 

Previously reported tape exposure rate of 10%, related to the mash nature, was successfully reduced since the tape is lately consisted with macro-porous mono-filament material. The Prolift, introduced by a 9 French surgeons group, is actually an improvement of the PIVS both - in terms of the mesh quality and mesh dimensions. Being a "type 1" mesh, manly macro porous and monofilament, is this mesh "bacteria unfriendly", hence are the field infection and mesh exposure rate reduced. Also is this a mesh rather then a tape, providing the possibility to reinforce the whole prolapse pelvic floor compartment rather than supporting the vaginal apex only. The long-term effectiveness of this type of uterine suspension as yet has to be demonstrated.


 

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