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Re: 4th posting: Dr. Ind: thanks and ~~Pelvic repairFrom: Thomas (anonymous@obgyn.net)Thu, 29 Apr 1999 12:53:03 -0500 (CDT)
Sorry about the need for a 4th re-post. A colleague has recently suffered a berievement and I'm spending most of my time at the hospital as a result.
>Just curious, why the 'wow' Lightheartedness only.
>&& Could you elaborate a little here please? Do you mean by type of prolapse the degree? It seems prolapse comes in groups of 3 at least since the whole cavity is interrelated. Yes we do grade prolapse by 3 grades. Grade 1 is prolapse but not to outside the vagina. Grade 2 is prolapse but only outside the vagina on exertion such as coughing and grade 3 is alwayds outside the vagina. Prolpase can be of the small bowel (an enterocele) the large bowel (rectocele) of the bladder (cystocele) or urethra (urethrocele).
>&& rough translation then would be that they had mild prolapse to begin with? Not specifically stated and I am not aware of a paper that says the more mild a degree of prolapse the more likely the success of an operation. However, theoretically, YES.
>If a woman can keep a pessary in, does that perhaps suggest that she's a better candidate for successful surgery? On one hand you could argue that if she can keep a pessary in then she is cured and there is no need for surgery. On the otherhand you can say that in an individuals case it is inconvenient and therefore the answer above applies.
>Are there any studies out of the comparison of resuspension with and without the uterus? And I've heard of a surgical procedure that includes mesh and basically reforms the apex of the vaginal cavity (hysterocolposacropexy with retaining the uterus). Have you heard much about this? Yes and have done a handfull. My personal experience is very good. However, they is no data in comparison and the operation is usually only performed on patient request. The usual and established operation is a vaginal hysterectomy. A sacrocolpoplexy is normally performed for a woman who has had a hysterectomy already and repairs the vault (top of the vagina) which is prolapsing down).
>In your opinion, do you think it makes a positive impact to have the surgery at a younger age while there is still adequate amounts of estrogen and collagen to aid in the healing process? Good question. We simply don't know. One argument we would give is that you have just proposed. The other argument is that surgery is so safe nowadays that we don't hesitate to anaesthetise 90 year old women. As there is no good evidence to support the first view then we should put women through a risk of more procedures. I don't know but I'm sure a paper will soon be published as it is a much investigated area at present.
>May I ask how old the patient who had that surgery? Probably should leave this one. But most of the above cases are in women with complete prolapse of there vault and usually over 40. However women over 40 are more likely to have had a hysterectomy.
> Any ideas of why these repairs don't last that long and what would you say is the average amount of time before the prolapse reoccurs. As further tissue gets older and further tissue weakens.
>Is it usually to a lesser degree? Often a recurring prolapse to a lesser degree is noticed by the doctor before the patient. A woman is likely to notice her prolapse at about the same degree she noticed it the first time.
>Have you done many resuspension or pelvic repair? I've heard that the old anterior and posterior repairs aren't used quite as much and that the Burch repair is used quite a bit when correcting a cystocele. There is good evidence that if a woman has genuine stress incontinence and a cystocele then a colposuspension is better than an anterior repair (unless she has an element of something called Detrussor instability which is uncontrolled bladder contractions). However, if a woman has a cystocele with no urodynamically proven genuine stress incontinence, many doctor believe that a quick and old fashioned anterior repair is best. There is a move for doing something called a paravaginal repair which is similar in some ways to a colposuspension. However, this has not been compared scientifically with an anterior repair.
-- Thomas Ind MB BS MD MRCOG London UK
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