Saturday, September 11, 2010

THE USE OF MESH IN PELVIC ORGAN PROLAPSE SURGERY

THE USE OF MESH IN PELVIC ORGAN PROLAPSE SURGERY - TO USE OR NOT TO USE - THAT IS THE QUESTION.

Dr Christopher Chong
Obstetrician, Gynaecologist, Urogynaecologist
Chris Chong Women and Urogynae Centre, Gleneagles Hospital
Past International Board of Directors, IUGA
Urogynae Committee, AOFOG
Visiting Consultant, KK Women's and Children's Hospital
Chairman, O & G Committee, Medical Advisory Board, Mt. Alvernia Hospital
Singapore

The lifetime risk of pelvic organ prolapse has been assessed to be 11%, with a recurrence rate of 30% for moderate to severe prolapses. Anterior compartment and apical vaginal prolapses are the most difficult to treat. Pelvic organ prolapse is a problem of the aging population. Singapore is the fastest aging population in Asia. Life expectancy has gone up to 81 - 83 for women in Singapore. The incidence of pelvic organ prolapse, being associated more with the elderly, is thus expected to rise.

Surgical treatment for pelvic organ prolapse is aimed at restoring anatomy and preserving functions, including sexual function. This can be done via the abdominal ( open or laparoscopic ) or vaginal route. When pelvic organ prolapse is severe, the existing tissues of the patient are expected to be very weak. Re-using these weak tissues for support is likely to result in a high recurrence rate. It is with this in mind that meshes are developed to try to reduce recurrence rates without compromising on restoring anatomy or function.

There are many types of meshes developed, both synthetic and non-synthetic. Non-synthetic meshes such as fasia lata from autograft or allograft are difficult to come by and to harvest. Latest studies have ventured into injecting stem cells into meshes. Synthetic meshes have the problems of rejection, infection and erosion. The advancement is then to find the best synthetic mesh to use. These meshes are classified into different grades, grade 1 being those with the least infection, rejection and erosion rates.

It is also important that we reduce complication rates other than proper selection of the mesh. Gentamicin wash of the mesh and the operative site, and antibiotics during and after surgery have been used to reduce infection rates. The mesh should be laid loose. Vaginal skin should not be cut. The use of a vaginal pack for a day after surgery should be considered. Oestrogens before and after surgery, when the wound has healed, especially in severely atrophic vaginal epithelium has helped me to prevent erosions.

The question is whether meshes should be used. In Singapore, meshes are not used as a first line of treatment - they are reserved for severe prolapses and recurrent prolapses. Only Grade 1 meshes should be used. The success rate of the modified mesh Anterior Repair with prolene mesh, and more recently the Anterior Prolift procedure is about 94%, with low complication rates ( most commonly mesh erosion and voiding problems ).

Gone are the days when women should suffer pelvic organ prolapse in silence. We are working towards improving our success rates for severe prolapses, including using meshes for selected cases. Patients need to be educated, and doctors to be vigilant to prevent pelvic organ prolapse, failing which, it is very important to seek treatment early for better success rates.

Pelvic Floor Disorders

Pelvic floor disorders are common gynaecological problems that affect the quality of life of thousands of women and many of them are suffering uncomfortably in embarrassment and silence. Although this condition is not considered a life-threatening condition, it may cause a great deal of discomfort and distress.
Pelvic floor disorders are caused by weakening support of the muscles, ligaments and connective tissue in the pelvic area. Pelvic organ prolapse (POP) and incontinence are two problems women face as a result of pelvic floor dysfunction.
What is Pelvic Organ Prolapse (POP)?
Pelvic Organ Prolapse (POP) occurs when the pelvic floor muscles become weak or damaged and can no longer support the pelvic organs - the uterus (womb), vagina, bladder, rectum and the surrounding muscles. POP is the descent or sagging of the uterus or other pelvic organ into the vagina. There are several different types of pelvic organ prolapsed.

Uterine (womb) Prolapse
The uterus can prolapse (drops) into and even outside the vagina. This condition may cause discomfort and problems with difficulty having bowel movements.

Cystocele and urethrocele
When the top (‘roof’) of the vagina is affected, the bladder and urethra (water-pipe) prolapse into or outside the vagina causing a cystocoele and urethrocoele respectively.

Rectocele and Enterocele
Similarly, the rectum (lower end of the large intestines/bowels) and small intestines can protrude into the bottom (‘floor’) of the vagina causing a rectocoele and enterocoele respectively.

Procidentia
This is the most serious form of prolapse of the uterus and vagina, whereby the whole uterus is situated outside the vagina, pulling/dragging the bladder and rectum along with it. This usually results in a large cystocoele outside the vagina and a large rectocoele just inside the vagina.

Causes and Symptoms
POP is caused by pregnancy, vaginal delivery, aging, menopause and congenital weakness of the pelvic floor muscles, ligaments and fascia. Obesity, chronic cough, constipation and occupations requiring heavy lifting are also contributory factors.
POP patients may experience the following symptoms:
 A bulge or lump on the outside of the vagina
 Feeling as though something is bulging inside or outside the vagina
 Difficulty in walking
 Stress incontinence
 Difficult or painful sexual intercourse
 Difficulty urinating or bowel movements
Patients often feel embarrassed and depressed by this condition, and because of this, it may even cause a strained marriage.
Dr Roy Ng, Gynaecologist at Mount Elizabeth Hospital cautions that one should consult their doctor or gynaecologist for treatment if they have any of the above symptoms as the outcome of conservative and surgical treatment for POP is excellent.
Treatments
There are a number of treatment options available, the choice of treatment depends on a variety of factors such as the type of prolapse, the severity of symptoms, patient’s age and other health issues, whether or not patient want to have children in the future, and patient’s personal preference.
Patient may be treated conservatively with insertion of vaginal pessary (a small plastic or silicone medical device) into the vagina to support the prolapsed. However, they must be changed every 2-3 months to prevent ulceration and infection of the vaginal skin leading to abnormal vaginal discharge and/or bleeding. Oestrogen (female hormone) cream and tablets can also be applied / inserted into the vagina to improve the thickness and blood supply of the vagina. However, if you’re experiencing major discomfort or inconvenience, surgery is the only definitive way to relieve symptoms and improve your quality of life
Surgery
The goal of surgery is to reposition the prolapsed organs and secure them to the surrounding tissues and ligaments. Surgery can be reconstructive, which corrects the prolapsed vagina while maintaining or improving sexual function and relieving symptoms, or obliterative, which moves the organs back into the pelvis and partially or totally closing off the vaginal canal. Surgery may also involve repairs to any pelvic organs.
Hysterectomy
In significant prolapse of the uterus, the uterus can be removed from the vaginal route; this operation is known as Vaginal Hysterectomy. After the uterus is removed vaginally the back of the vagina is then sutured to the ligaments of the pelvis to support it and also to prevent a vault prolapse (prolapse of the back of the vagina).
In Vaginal Hysterectomy, there are no incisions on the tummy. Hence, compared to an open or even laparoscopic (‘key-hole’) hysterectomy, post-operative pain is much less or negligible; recovery would be ‘smoother’ and faster. Dr Ng shares that patient can resume their daily activities like drinking, eating and walking faster. However, it is important that such patients do not exert physically, avoid constipation and abstain from sexual intercourse for at least 6 to 8 weeks to prevent any damage to the tissues repaired and suffering a recurrence of their uterovaginal prolapse.
Dr Ng says, “A vaginal hysterectomy is a relatively safe operation with a very low incidence of injury to the neighbouring organs.”
So, What Exactly is Stress Incontinence?
Stress Urinary Incontinence (SUI) is one of the most common types of urinary incontinence that affects women. It is the uncontrollable leakage of urine on exertion, such as running, jumping, sneezing, laughing and coughing – that puts pressure (stress) on your bladder. Associated causes include child-birth, menopause, obesity, chronic lifting of heavy loads, chronic cough and constipation. While for some women it may just be a few drops while coughing or running, others may experience a sudden and strong urge to urinate prior to eliminating a substantial amount of urine. The effects of urinary incontinence can range from being mildly bothersome to being completely debilitating.

A national survey on 3500 females in Singapore by Dr Christopher Chong, obstetrician, gynaecologist and urogynaecologist at Gleneagles Hospital revealed that 13.5% suffered from SUI and a shocking 35.6% in the above 50 age group; that is more than 1 out of 3 females above 50 years old suffer from SUI. This equates to about 190 000 females in Singapore. It is estimated that less than 30 000 have seeked treatment for this problem. Also from the survey, the reasons for this low treatment level were that majority of the females were too embarassed to talk about it (even with close friends or relatives), did not know that it is a problem, how it can be treated, and where to seek treatment. Many, sadly, accepted it as part of growing old.

How can Stress Incontinence be Treated?

Usually, the first line of treatment involves strengthening the muscles of the pelvic floor by doing pelvic floor exercises. In some cases, apart from the exercises, medication may also be advised. If these treatments do not provide the results and if the problem continues, then surgery may be required.

The surgical methods are used to support or tighten the structures and muscles under the bladder. There are many surgeries for SUI hence, it is very important to select the correct and best surgery for SUI. This is especially so as the success rate for SUI surgery falls with each subsequent surgery.

In Dr Chong’s practice, it is mandatory to perform a computer test of the bladder, called Urodynamics Studies, before any incontinence surgery in order to properly assess the bladder problem, select the best and correct surgery for the patient.
According to Dr Chong, the Tension-free Vaginal Tape (TVT) is now the accepted surgery of choice in the treatment of SUI. The latest technique using the same tape is called TVT_O (TVT-Obturator) and has been used in Singapore for more than 4 years. It uses a polypropylene mesh tape placed around the middle part of the baldder neck (" door" or outlet pipe of the bladder) without any tension or stitches. The exit point is not through the abdomen but through the inner thigh. When a person strains, the bladder neck pushes onto the tape and closes, thus preventing leakage of urine. This tape is left permanently in the body.

The new technique has advantages over the older techniques where there is less risk of bleeding and injury to the bladder, and cystoscopy to check for bladder damage and perforation need not be routinely done. This surgery can be done as a day procedure and the patient can be up and about the same day.


AD:
Don’t Suffer In Silence.
Pelvic floor disorders affect thousands of women and many of them suffering uncomfortably in embarrassment and silence. Today, treatment of female pelvic floor disorders is readily available and helping women of all ages regain their health, confidence and quality of life. If you think you are suffering from pelvic floor disorders, talk to your obstetrician/gynaecologist.

As one of Asia’s largest healthcare providers, ParkwayHealth has an international reputation for its high quality clinical outcomes, and service excellence in various multi-disciplinary specialties including Obstetrics & Gynaecology. We have more than 70 obstetricians and gynaecologists under one roof, specialised in obstetrics, gynaecological, Onco-gynaecological and Uro-gynaecological conditions.

Chinese Paper on Big Baby

Doctor in THE NEW PAPER