James Drife MD FRCOG FRCPEd FRCSEd Hon FCOGSA

• Professor, Department of Obstetrics and Gynaecology, General
• Infirmary, Leeds

Anismus weight loss exercise routine purchase cheap astralean, defined as the failure of the puborectalis to relax during defecation weight loss pills yellow astralean 40 mcg with mastercard, often responds to biofeedback and pelvic floor physical therapy weight loss clinics near me purchase cheap astralean online. In combined disorders weight loss tumblr order cheap astralean on-line, it is recommended that nonsurgical treatment for anismus or slowtransit constipation (most common disorder of motility) be treated before embarking on surgical intervention weight loss retreat order astralean 40 mcg without prescription. Sexual dysfunction weight loss pills uk 2015 buy astralean 40 mcg on line, if present, is thought to be secondary to dyspareunia, although decreased desire and anorgasmia may also be contributing factors (Handa et al. Several authors have sought to identify patient factors that would predict who may benefit most from rectocele repair (Murthy et al. These include sensation of vaginal mass or bulge, need for digitalization (splinting) to complete rectal evacuation, non-emptying or partial emptying on defecography, and presence of a large rectocele. Sensation of incomplete emptying and constipation are not specific to rectoceles and may be associated with other disorders, including irritable rectum and slow transit constipation. Patients should be counseled that surgical repair of the posterior compartment may likely reduce vaginal protrusion symptoms and decrease or eliminate the need for vaginal splinting. However, some patients may have persistence of constipation, because motility disorders and anismus can independently coexist with prolapse and persist after a seemingly successful repair. Both approaches resulted in a high rate of symptom resolution (93% for the vaginal approach vs. However, the vaginal approach had better objective findings and a lower rate of prolapse recurrence (7% vs. The traditional posterior colporrhaphy was devised in the 19th century to treat perineal tears, which occurred during vaginal delivery. The original description involved plicating the pubococcygeus muscles and the posterior vaginal wall with reconstruction of the perineal body, which was termed posterior colpoperineorrhaphy (Cundiff and Fenner, 2004). This resulted in a rigid inferior shelf, reduced the herniation of the posterior wall, and aided in preventing descensus of the vaginal vault or uterus. In 1961 Francis and Jeffcoate reported a high incidence of dyspareunia after colporrhaphy with levator plication. In addition, there is evidence to suggest that traditional posterior colporrhaphy with levator plication may worsen defecatory symptoms. Kahn and Stanton (1997) reported increased symptoms of fecal incontinence, constipation, incomplete evacuation, and dyspareunia postoperatively. Because of the increase in dyspareunia postoperatively, plication of the levator ani muscles has largely been abandoned. Site-specific repairs and midline fascial plication without levator ani plication have emerged as the predominant surgical treatments of a rectocele. Level 1 and Level 2 evidence support the superior objective outcomes of midline posterior plication without levatorplasty compared with site-specific repairs. However, if a patient requires an anterior or middle compartment repair, it should be performed first (Rovner and Ginsberg, 2001). The anterior wall can be retracted with a Heaney or Lone Star retractor with hooks to improve visualization. Hydrodissection may be accomplished by injecting saline or a local anesthetic with or without epinephrine. For a high rectocele the incision may be as high as the vaginal apex (cuff); for smaller rectoceles the incision is started at the most caudal position. The rectovaginal fascia (muscularis) is separated from the vaginal epithelium with Metzenbaum scissors. Native tissue sacrospinous hysteropexy with the posterior cervix attached to the right sacrospinous ligament and anterior colporrhaphy. The dissection proceeds laterally until the pararectal attachments to the pelvic sidewall are visualized. In cases of large posterior defects, a purse-string suture of 2-0 or 3-0 absorbable suture may be placed at the base of the rectal herniation to reduce it; however, care should be taken to avoid foreshortening the posterior wall cephalad to caudad. In addition, this acts to bring the attenuated rectovaginal fascia together to aid in its re-approximation. The rectovaginal fascia is then plicated in the midline with either interrupted or continuous 2-0 absorbable sutures. Care should be taken to avoid excessive lateral placement or wide spacing of these sutures; this may result in overtightening or painful ridges along the posterior vaginal wall. Suture placement is continued distally and incorporated into the perineal body re-approximation. The excess vaginal epithelium is judiciously trimmed and closed with a running absorbable 2-0 suture. A perineorrhaphy may also be performed before the vaginal epithelium is closed if the introital laxity dictates and care is taken to avoid overtightening. To minimize complications associated with posterior colporrhaphy, a site-specific defect repair was described. Richardson (1993) described discrete defects in the rectovaginal fascia found in patients undergoing posterior colporrhaphy and cadaveric dissections. This essentially results in a separation of the rectovaginal fascia from the perineal body. The goal of the site-specific repair is to restore the anatomy by closing these discrete defects. For a high rectocele the incision may be as high as the vaginal apex; for smaller rectoceles the incision is started at the most caudal position. The rectovaginal fascia (muscularis) is separated through a virtually bloodless plane from the vaginal epithelium. They are secured with the posterior mesh to the anterior longitudinal ligament of the sacrum. The excess vaginal epithelium is judicially trimmed, and the vaginal epithelium is closed with a running absorbable suture. A triangular incision at the mucocutaneous junction is removed (Rovner and Ginsberg, 2001). The triangular island of posterior vaginal wall is sharply removed from the pre-rectal levator fascia. Horizontal mattress sutures are used to approximate the attenuated perineal body fibromuscular tissue. Once these are brought together, the muscles of the urogenital diaphragm are reconstituted, and support is restored to the central tendon. It is important that a smooth contour be created along the suture line, because ridges may cause dyspareunia. A vaginal packing moistened with saline, antibiotic solution, cream, or gel may then then placed if warranted. Kahn and Stanton (1997) reported on the anatomic and functional results of posterior repair using levator plication. Both reported anatomic success; however, many patients complained of bowel symptoms and dyspareunia postoperatively (Kahn and Stanton, 1997). Because of the adverse events associated with levator plication, the technique has been abandoned by many surgeons. They found that posterior colporrhaphy and site-specific rectocele repair had similar functional and anatomic outcomes. In a follow-up study of these same patients specifically looking at bowel symptoms, GustiloAshby et al. They found that bowel symptoms, including feeling of incomplete emptying, straining to defecate, splinting to defecate, and fecal incontinence improved significantly after rectocele repair. They found that the recurrence of posterior defects was higher in the site-specific group compared with the midline plication of the rectovaginal fascia: 33% versus 14% for second degree and 11% versus 4% for third degree. In addition, recurrence of symptomatic rectocele was greater in the site-specific group (11% vs. Rates of de novo dyspareunia and postoperative bowel symptoms were the same in both groups. They found that improved anatomic outcome correlated with improved functional outcomes. Eighty-seven percent no longer experienced obstructive defecation postoperatively. Significant improvements were seen in awareness of prolapse, obstructive defecation, straining to defecate, hard stools, dyspareunia, and digitations. At 18 months, they estimated the relief of vaginal symptoms to be between 73% and 92%. Sixty-five percent had improvement of the defecatory symptoms, and 38% had improvement of sexual discomfort. In contrast to the generalized repair of midline plication of the rectovaginal fascia, several authors have reported their experience with site-specific repair. Glavind and Madsen (2000) prospectively studied 67 patients who underwent a discrete repair. Of the 67 patients 64 were found to have a discrete defect, which was repaired, and in 3 there was an attenuation of the tissue. At 3-month follow-up, 85% of those who reported bowel symptoms preoperatively reported resolution of symptoms. Improvement or cure was noted for pain or pressure, vaginal mass, splinting, and difficulty with defecation. Emotional health also improved, specifically thoughts of embarrassment and frustration. Statistically significant symptom relief was noted in the realms of protrusion, manual evacuation, difficult defecation, and dyspareunia. At 1 year, 7 of 11 patients who used manual evacuation preoperatively returned to doing so. The authors commented that this may be due to a functional decompensation of the rectum, which is not corrected surgically. Splinting was eliminated in 63% of patients who reported this symptom preoperatively. The mean improvement did not correlate to the anatomic correction but did correlate with alleviation of defecatory symptoms, stressing the importance of symptom relief being of priority to the patient over anatomic correction. The Fifth International Collaboration on Incontinence offered a grade B recommendation that Level 1 and 2 evidence suggest that midline plication posterior repair without levatorplasty may have superior objective outcomes compared with site-specific posterior repair, concluding that midline fascial plication without levatorplasty is the procedure of choice for posterior compartment prolapse (Karram and Maher, 2013). However, a 2018 Cochrane review concluded that because of the paucity of data and lack of good trials, the evidence was insufficient to draw conclusions about the relative effectiveness of these two procedures for posterior compartment prolapse (Mowat et al. Interposition Graft Repairs of the Posterior Compartment Synthetic mesh and biologic grafts have been used in posterior repairs, although data are lacking regarding routine use. Also, several authors caution against the use of synthetic materials in the posterior compartment because of the potential for dyspareunia and visceral erosion, favoring the use of biologic grafts (Chen et al. Kohli and Miklos (2003) reported anatomic outcomes on 43 patients who underwent a site-specific repair with cadaveric dermis; 30 were available for evaluation at an average of 12. The graft was fixed proximally to the vaginal apex, laterally to the levator ani muscles and distally to the perineal body. Ninety percent of those examined had a grade 0 rectocele by the Baden-Walker classification. Twenty-three were available at 3-year follow-up; 41% had recurrence of stage 2 or greater, and 12 of 23 patients reported incomplete rectal evacuation. They advocated further study before recommending the routine use of graft augmented tissue repair. Although not advocated by the authors of this chapter, we will review some of the salient, albeit limited, results. The use of mesh in the posterior compartment was reviewed by the Fifth International Collaboration on Incontinence after a thorough literature search of all English-language literature through January 2012. Their conclusion with a grade B recommendation (mostly level 2 and 3 evidence) was that no studies have shown any benefit of mesh overlay or augmentation over a suture repair for posterior vaginal wall prolapse (Karram and Maher, 2013). Using permanent materials, multi-compartmental repairs are more commonly performed, extending from the sacrospinous ligament to the perineal body. Fifty patients underwent posterior repair, 17 of which had anterior and posterior repair. In this descriptive study, 90 patients underwent loose placement of an interposition graft in the posterior compartment with no primary repair. Five patients with recurrence of the rectocele did not have prolapse in other compartments (Lim et al. When deciding on treatment options for the posterior compartment, the surgeon and the patient should be aware that graft extrusion rates of 1. Chapter 124 Vaginal and Abdominal Reconstructive Surgery for Pelvic Organ Prolapse 2829.

The overall proportion of node-positive patients in the extended versus limited cohorts was 26% and 13% weight loss pills images order discount astralean on line, respectively weight loss medication cheap astralean 40 mcg free shipping. The 5-year recurrence-free survival of patients with node-positive disease was 7% for limited node dissection and 35% for extended node dissection weight loss lunch discount astralean 40 mcg overnight delivery. The 5-year recurrence-free survival for pT2pN0 cases was 67% and 77% for limited and extended dissections weight loss jewelry buy generic astralean 40 mcg line, respectively weight loss pills do they work trusted astralean 40 mcg, and 23% and 57% for pT3N0 cases weight loss hacks buy astralean on line amex, respectively. The 5-year recurrence-free survival for pT2pN0-2 cases was 63% and 71%, respectively, for limited and extended lymph node dissections and 19% and 49%, respectively, for pT3pN0-2 patients. This study, in a large cohort of patients, confirms the value of an extended pelvic lymph node dissection with regard to staging accuracy and prognosis. Based on anatomic mapping studies, it is recommended that a standard pelvic lymph node dissection at the time of radical cystectomy include the lymph node packets from the external iliac lymph vessels up to the level of the common iliac bifurcation cephalad and the genitofemoral nerve laterally to the ureter medially. An extended template dissection should include the tissue extending above the common iliac bifurcation to the aortic bifurcation and presacral region. Finally, with a superextended lymph node dissection, the tissue up to the level of the inferior mesenteric artery should be included (Sanli et al. The exact anatomic extent of dissection remains debatable; however, clinical recent and ongoing clinical trials will ultimately answer this question. A plot describing the relationship between the number of lymph nodes removed and the probability of detecting lymph node metastasis. Assessing the minimum number of lymph nodes needed at radical cystectomy in patients with bladder cancer. Although controversy remains regarding the actual number of nodes that constitutes an adequate dissection, the absolute number of nodes removed has been shown to provide important prognostic information and staging accuracy both in node-positive and node-negative patients. As one would expect, increasing nodal yield at the time of pelvic lymph node dissection improves the sensitivity of detecting nodal metastasis. In addition to staging, lymph node count has been reported to improve therapeutic efficacy; however, prospective data to substantiate such a benefit are currently lacking. Using a 16-node threshold, there were significant differences in cancer-specific and disease-free survival among patients with 16 or more lymph nodes removed compared with those who had fewer nodes removed. For their survival analysis, a 16-node threshold was used because the correlation between the total number of lymph nodes removed and the percentage of positive nodes was strongest at this count. There is no general consensus in the literature regarding the exact threshold of nodes at which a survival benefit can be predicted, with most studies reporting numbers in the 9 to 16 range (Herr, 2003; Herr et al. The study included 1121 patients who underwent radical cystectomy during a 14-year period. The authors were unable to find a plateau in the dose-response curve with an increasing number of nodes up to 23; however, few patients had more than 24 nodes removed. Limitations of this study include the fact that 13% of patients had no nodes identified on the pathology report, and the percent of patients who underwent an extended node dissection was not reported. The number of lymph nodes identified has also been showed to be consistently associated with risk for pelvic failure, with Chapter 137 Management of Muscle-Invasive and Metastatic Bladder Cancer 3117 10 lymph nodes being the most common threshold in studies of locoregional failure endpoint (Christodouleas et al. Although the studies in the last two sections have demonstrated the prognostic and therapeutic value of a thorough pelvic lymph node dissection at the time of radical cystectomy, it must be remembered that they are all either retrospective or nonrandomized reports. There are inherent biases that need to be accounted for when considering the actual value and extent of a pelvic lymph node dissection when one considers it from a nonprospective, nonrandomized approach. Surgical and nonsurgical factors, including anatomic extent of the template and pathologic processing, including the number of packets submitted to pathology, can greatly influence nodal counts (Ather et al. More definitive studies are currently underway to better address this issue, including randomized controlled trials, with the goal of determining the importance and extent of lymph node dissection at the time of radical cystectomy. Lymph Node Density and Extracapsular Nodal Extension Lymph node density refers to the percentage of positive nodes relative to the total number of nodes removed (Kassouf et al. In their study of node-positive bladder cancer patients, they identified a lymph node density of 20% to carry prognostic value. Herr (2003) also demonstrated the 20% lymph node density value to confer prognostic value. The current lymph node density studies reported in the literature are retrospective surgical series, and they report varying lymph node counts and templates of dissection, in turn limiting comparisons among studies. Several small retrospective series have reported the potential prognostic significance of extranodal extension. Using a multivariable model, including pT stage, tumor grade, age, gender, lymphovascular invasion, surgical margin status, lymph node density, total lymph nodes, number of positive nodes, and adjuvant therapy, extranodal extension was significantly associated with both disease recurrence and cancerspecific mortality. Patients who do achieve a complete response appear to have a significant survival advantage with 5-year cancer-specific survival rates of 63% (Meiger et al. Herr also reported that the overwhelming majority of patients who initially respond to chemotherapy but do not have surgery are destined to recur (Herr, 2001), and therefore consolidative cystectomy should be strongly considered in appropriate surgical candidates who respond to systemic therapy. If adenopathy is encountered at the time of cystectomy, a frozen section should be taken to confirm metastasis, and an extended lymph node dissection and radical cystectomy should be completed when feasible. Cystectomy is not performed when lymph node metastases are unresectable because of bulk, when there is evidence of extensive periureteral disease, when the bladder is fixed to the pelvic sidewall, or when the tumor is invading the rectosigmoid colon. The Johns Hopkins group published their outcomes of 35 patients who had an aborted cystectomy because of intraoperative findings of metastatic disease (Guzzo et al. Sixty percent of patients in the study cohort died from disease progression at a median time of 26 months. Intraoperative Frozen Sections of the Ureter the incidence of involvement of the distal ureter with tumor on final pathology at the time of radical cystectomy was 6% to 8% (Gakis et al. There is no definitive recommendation for the precise length of the distal ureter that should be removed at the time of surgery. Final ureteral margin status has proven to be an independent predictor of upper tract recurrence following cystectomy (Tran et al. However, the overall incidence of upper tract recurrence following cystectomy is a relatively rare event ranging from 2% to 8% (Gakis et al. Upper tract recurrences have been reported to occur most commonly between 2 and 4 years postcystectomy (Meissner et al. Unfortunately, when upper tract recurrences do occur, they are often locally advanced and can be associated with poorer outcomes than de novo upper tract disease (Balaji et al. The risk for upper urinary tract recurrence appears to be a stable event with time (Tran et al. The role of intraoperative frozen-section analysis of the ureters at the time of cystectomy remains somewhat controversial. Although it would seem intuitive that achieving a negative ureteral margin is necessary, the literature has not always demonstrated improved outcomes with this approach (Lee et al. Contemporary studies report frozen-section analysis of the distal ureteral margins to have a 74% to 75% sensitivity, a 98% to 99% specificity, and a positive predictive value of 98% (Gakis et al. Whether or not sequential resection for positive frozen ureteral margins confers an absolute benefit remains questionable. An analysis of 1397 cystectomy patients who underwent frozen-section analysis of the distal ureters demonstrated an initial positive margin rate of 12. In those with initial positive margins, 83% were subsequently converted to a negative margin with further resection. These findings suggest that patients with ureteral disease at the time of cystectomy experience an increased risk for upper tract recurrence regardless of margin Intraoperative Decision Making Grossly Positive Nodes and T4b Disease For patients with clinically positive lymph nodes, the standard of care is cisplatin-based systemic chemotherapy. Patients who have a radiographic complete or partial response to systemic therapy are candidates for and should be evaluated for cystectomy. Those undergoing cystectomy have been noted to have a complete pathologic response typically in the 14% to 25% range (Meiger et al. Of note, several retrospective surgical series have reported a decreased risk for urethral recurrence in patients with orthotopic urinary diversions (Hassan et al. Whereas some have hypothesized that this decrease may be related to a protective effect of exposing the urethra to urine, it is more likely a result of selection bias. In their series, 25% of patients had an intraoperative positive margin that was ultimately converted to a negative margin in 48% of cases. Ureteral margins that were not converted to negative intraoperatively were associated with poorer cancer-specific mortality, but only in patients with negative soft tissue margins and without nodal metastasis. Ureteric skip lesions (negative distal frozen, positive proximal permanent margin) were identified in 4. Given the findings outlined earlier, it appears logical to attempt to clear the distal ureter when feasible at the time of radical cystectomy. In patients who are at high risk for an upper tract recurrence, ureteropyeloscopy, when feasible, is the most sensitive means for detecting upper tract recurrences. Managing the Female Urethra Before female orthotopic bladder substitution became more commonplace, complete removal of the female urethra at the time of radical cystectomy was routine. T4 tumors involving the urethra and/ or vagina mandate complete urethrectomy, and these patients should not be offered urethral preservation. Concomitant involvement of the urethra in women with bladder cancer ranges from 2% to 12% (Stein et al. Clinical features associated with an increased risk for distal urethral tumor involvement include primary tumor location at the bladder neck, vaginal involvement, or inguinal lymphadenopathy (Maralani et al. Although tumor presence at the bladder neck is significantly associated with urethral involvement, approximately 60% of patients with tumors in this location will not have a tumor in the urethra on final pathology; therefore controversy exists with regard to an absolute need for complete urethrectomy in this setting. Frozen-section analysis of the distal urethra has demonstrated high correlation with final urethral margin and should be performed in all women in which orthotopic bladder substitution is being considered (Akkad et al. Isolated urethral recurrence following orthotopic bladder substitution occurs in approximately 1% of cases (Ali-El-Dein et al. Prostatic Urothelial Carcinoma and Management of the Distal Urethra the absolute risk for urethral recurrence following cystectomy ranges from 4% to 8% in men (Cho et al. The majority of urethral recurrences are symptomatic, but in patients who are deemed at high risk for such events, periodic cytology can be useful for detection of recurrences (Clark et al. Preoperative evaluation of the prostatic urethra via biopsy can be performed to characterize further the risk for urethral recurrence and help dictate intraoperative management of the distal urethra and choice of urinary diversion. The sensitivity and specificity of transurethral prostatic urethral biopsy is moderate, with a relatively low positive predictive value compared with final cystoprostatectomy specimens (Donat et al. Given the modest value of preoperative urethral biopsy, some experts advocate for urethrectomy only in the setting of a positive apical urethral margin (Donat et al. Small low-grade papillary tumors of the urethra can be resected before cystectomy and the Oncologic Outcomes Following Radical Cystectomy Table 137. Pathologic tumor stage and presence of nodal metastasis are the strongest predictors of recurrence and survival following cystectomy (Frazier et al. Patients who are pT0 or who have residual noninvasive disease on final pathology have excellent outcomes with 5-year cancer-specific survival rates approaching 90% (Ghoneim et al. However, long-term survival has been reported in patients with low-volume lymph node metastasis (Bruins et al. Margin status is also an important predictor of recurrence and survival following radical cystectomy (Dotan et al. A multicenter, retrospective study of 4410 radical cystectomy patients reported an overall soft tissue positive margin rate of 6. Additional variables that were reported to possess prognostic value following radical cystectomy include the presence of lymphovascular invasion (Herrmann et al. Despite aggressive surgical therapy, approximately 50% of cystectomy patients will ultimately die of disease. Recurrence of disease often occurs within the first 2 years after surgery, with median recurrence times of 7 to 18 months reported in large series. Improved and more frequent postoperative imaging has demonstrated more substantial rates of isolated or co-synchronous pelvic failure than historically appreciated. This model consistently stratifies pelvic failure risk in geographically and temporally diverse radical cystectomy cohorts, with 5-year pelvic failure rates of approximately 8% for low-risk groups, 19% to 21% for intermediate-risk groups, and 41% to 46% for high-risk groups (Christodouleas et al. Clearly, surgery alone is not sufficient therapy in a large number of patients with invasive bladder cancer. Systemic therapy with cisplatin-based chemotherapy has been shown to provide response rates in multiple bladder cancer studies since the mid-1980s (Stenzl et al. Since the initial reports of its usefulness in muscle-invasive bladder cancer, there have been multiple randomized controlled studies undertaken to define further the effectiveness of neoadjuvant cisplatin-based chemotherapy in advance of cystectomy. Unfortunately, many of these studies have been hampered by inadequate power and a lack of standardization of surgical approaches to demonstrate clearly a survival advantage with neoadjuvant chemotherapy in most of these studies when they are evaluated individually. There are several arguments for cisplatin-based chemotherapy in the neoadjuvant setting for patients with muscle-invasive bladder cancer. First, systemic chemotherapy is often better tolerated before surgery, rather than after surgery when patients may experience a delay in chemotherapy administration because of complications or debilitation. Second, patients who present with micrometastatic disease will receive therapy in a timelier fashion when their burden of disease is potentially low. Third, neoadjuvant chemotherapy has the potential to downstage bulky and locally advanced tumors, allowing for a higher likelihood for negative surgical margins that are a known predictor of local recurrence following cystectomy. A disadvantage of neoadjuvant chemotherapy is a delay in definitive local therapy for patients who do not respond to chemotherapy and thus experience disease progression. This study evaluated the benefit of three cycles of neoadjuvant cisplatin, methotrexate, and vinblastine in 976 patients before radiation or cystectomy (International Collaboration of Trialists, 1999). The study was designed to detect an absolute improvement in survival of 10% with a power of 90% and a type 1 error of 5%.

Less than half the studies in the pooled analysis reported postoperative prolapse symptoms weight loss nutritionist generic astralean 40 mcg without a prescription. Of 289 patients who followed up weight loss videos generic 40 mcg astralean with mastercard, a majority (87%) had no recurrence of support defect at any site on any postoperative examination weight loss pills for men order astralean online. The most common site was the anterior compartment in which 10 patients had grade 2 or 3 defects weight loss 08080 quality astralean 40 mcg. Patient-reported outcomes indicated improvement in irritative voiding weight loss 53 generic astralean 40 mcg otc, obstructive voiding weight loss pills for dogs order 40 mcg astralean fast delivery, stress incontinence, and overall urinary symptoms compared with preoperative scores. Concurrent procedures included anterior colporrhaphy (20%), anterior mesh reinforcement (49%), posteriorly colporrhaphy (56%), and sling (29%). The authors conclude that this procedure is effective at restoring apical support while avoiding the morbidity of an intraperitoneal operation. Sacrospinous Ligament Fixation the sacrospinous ligament fixation was first described by Richter in 1942 but was not widely used until Nichols (1982) reported on the technique. This technique is appealing because of its extraperitoneal approach and consistency as a strong structure on which to anchor the apex. Access to the spine was originally achieved from the posterior approach, although dissection from the anterior approach may also be performed via the paravaginal space (Cespedes, 2000; Winkler et al. The advantages of sacrospinous ligament suspension are the ability to repair concomitant pelvic floor defects, absence of a laparotomy (Morley and DeLancey 1988), shorter hospital stay (Brown et al. The structures at risk with this technique include the pudendal or inferior gluteal vessels and the sciatic or pudendal nerves. Pudendal nerve entrapment results in posterior buttocks pain, which may radiate down the back of the thigh. A disadvantage of this approach is the alteration in vaginal axis, which results in apical displacement posteriorly and to the right side when unilateral fixation is used. This posterior displacement can result in anterior compartment recurrence, even when an anterior repair is performed (Morley and DeLancey, 1988; Sauer and Klutke, 1995; Shull et al. In younger, more active women, contemporary data suggest favoring abdominal repairs. Sacrospinous fixation may be performed unilaterally or bilaterally (Pohl and Frattarelli, 1997). Technically, it is easier to place the sutures on the right ligament for a right-handed surgeon (Sauer and Klutke, 1995). Cespedes reported success using the bilateral anterior support and noted the advantage of more midline location of the vaginal apex (Cespedes, 2000). Although bilateral placement has been advocated (Nichols, 1982), there is little to support the advantage of bilateral fixation over unilateral fixation when examining outcomes (Morley and DeLancey, 1988). The sacrospinous ligament is approximately 7 to 8 cm in length (Morley and DeLancey, 1988) and extends from the ischial spine laterally, coursing medially under the coccygeus muscle and inserts into the sacrum. In addition, the hypogastric plexus of veins are located superiorly, and the hemorrhoidal vessels are located medially to the sacrospinous ligament (Morley and DeLancey, 1988), thus retraction should be carried out carefully in these respective areas. To avoid the gluteal vessels, the suture should be placed into the ligament and not behind it (Kettel and Hebertson, 1989). Pudendal nerve entrapment may result in pain, which localizes to the buttocks or perineum. Branches from the S3 and S4 nerve roots are more likely to cause postoperative gluteal pain. Precise suture placement on the ligament, limiting the depth of needle penetration into the ligament, and avoiding needle entry or exit above the upper extent of the sacrospinous ligament may avoid nerve entrapment and postoperative gluteal pain (Florian-Rodriguez et al. Note the close proximity of the pudendal vessels, hypogastric plexus, inferior gluteal vessels, and sciatic nerve. Placing it too far medially may risk failure of the repair as the sacrospinous ligament fans and thins as it inserts into the sacrum (Sauer and Klutke, 1995). In addition, there is a higher concentration of sacral nerves in this medial location. Barksdale performed a cadaveric study to assess the histology of the sacrospinous ligament, taking segments near the ischial spine, middle and sacral portions of the ligament (Barksdale et al. The vaginal apex is then reduced to the sacrospinous ligament(s) intended to be used. A standard midline vaginal incision is made in the vaginal epithelium, which is separated from the rectovaginal septum posteriorly or pubocervical fascia anteriorly. Alternatively, if the posterior approach is used, the surgeon must enter the perirectal space by bluntly mobilizing the rectum medially. Blunt dissection is continued to ensure that the rectum is retracted medially and the ligament is adequately exposed. At this point Heaney or Breisky-Navratil retractors are very useful to visualize the ligament and facilitate suture placement. The suture is placed approximately one to two fingerbreadths medial from the spine to avoid damage to the structures in Alcock canal. Several different methods have been used to fix the suture to the sacral spinous ligament. To create a pulley stitch, tying a knot onto the fibromuscular portion on the visceral side of the vagina creates a fixed point. Importantly, this resultant knot remains internal and is not within the vaginal canal. Closure of the vaginal wall halfway, before tying down the sutures, is useful, because the suspended apex may be difficult to reach. The sutures should be tied so that the vaginal apex is firmly attached to the coccygeal sacrospinous ligament complex with no intervening suture material bridging a gap (Morley and DeLancey, 1988; Sze and Karram, 1997). Palpation of the suture behind the vaginal cuff will ensure that the suture is tied securely. It is useful to leave the secured suture untrimmed until the cystoscopy is performed in case the suture must be removed. Once efflux is visualized bilaterally, the anchoring suture is trimmed, and the remainder of the vaginal incision is closed. Early data reported the feasibility and success associated with this approach to apical correction. This outcome was also observed in a study by Richter and Albrich (1981), who reported excellent patient satisfaction, although 8 patients were reluctant to resume sexual relations because of a perception of vaginal narrowing. They noted that the long-term results were acceptable with minimal adverse effects. Blood loss was minimal, and no transfusions were needed, but mild postoperative buttock pain was noted that resolved by 3 months. In 21 of 24 patients there was no recurrence of prolapse at the apex, but one patient underwent repeat operation for a significant cystocele. With a unilateral suspension, the vagina is deflected to the right side and caudally. The anterior compartment has been reported as a particularly vulnerable site for developing a defect after sacrospinous vaginal vault suspension. This is noted not only postoperatively but also intraoperatively, although many who develop anterior defects remain asymptomatic and do not undergo subsequent surgery to correct the anterior compartment defect (Paraiso et al. The Pelvic Floor Network Dyfunction Network evaluated anatomic anterior compartment prolapse recurrence and the effect of concomitant repair after vaginal apical procedures. Some of the theoretic advantages of the anterior approach include improved ability of the vagina to withstand increased intraabdominal pressures (Pohl and Frattarelli, 1997), and less likelihood of rectal injury (Sauer and Klutke, 1995). Again, a low incidence of anterior compartment recurrence was noted at 7% (Cespedes, 2000). Those who showed absence of any compartment defect at the 6-week follow-up had only a 3% likelihood of requiring additional reconstructive surgery within 2 to 5 years. Generally, this pain has shown spontaneous resolution within 2 to 3 months when delayed absorbable sutures were used (Maher et al. Postoperative mild to moderate neuropathic pain can be managed with observation, and patients should be counseled that duration may be as long as 3 months (Sauer and Klutke, 1995). Injection of the nerve with local anesthetic has been used for treatment (Lantzsch et al. In patients with severe or persistent radicular neuropathic type pain, suture removal may be considered. When a perforation was recognized at the time of surgery and repaired primarily, no sequelae were observed (Richter and Albrich, 1981; Sauer and Klutke, 1995). In addition, injury to the pudendal nerve and internal pudendal vessels may occur with sutures placed too near the ischial spine. As the fatty tissue is dissected free, the anterior surface of the sacral promontory is visualized, usually by identification of the anterior longitudinal ligament. Two to three interrupted, nonabsorbable monofilament sutures are placed in the anterior longitudinal ligament with care to avoid perforation of the midline sacral vessels. Generally, sutures are placed under the vessels and tied down over the top of the vessels. Alternatively, if vessels overlie the ligament, bipolar energy can be used on the vessels to prevent bleeding before placing the sutures. Alternatively, commercially available tacking devices may be used for securing the graft to the sacral promontory, although minimal data exist to confirm comparable efficacy. After placing an end-to-end anastomosis sizer or commercially available vaginal stent in the vagina, the surgeon identifies the enterocele sac, if present, and secures it with an Allis clamp. If the enterocele is large, a Halban culdoplasty can be performed by placing linear permanent or delayed absorbable sutures through the posterior peritoneum and on the outer surface of rectum up to the vaginal cuff (Geomini et al. Alternatively, if an aggressive posterior vaginal dissection to the perineum is to be performed (see later) for placement of an extended piece of posterior mesh with subsequent retroperitonealization of the mesh, the culdoplasty is usually not needed. Some pelvic surgeons perform minimal dissection of the peritoneum and bladder off the vagina, enough to fix the mesh for 4 to 5 cm on each side, whereas other techniques describe a more extensive dissection that involves lifting the posterior bladder wall and trigone off the underlying vagina, as well as dissecting all the way to the perineal body. With the advent of robotic techniques, it seems that more extensive dissections are being carried out with longer mesh segments attached to the bladder, although there are no controlled studies to identify the optimal technique of graft placement to the vagina. Care is taken to identify the border of the bladder to avoid suturing the graft to the bladder and to secure the lateralmost portions of the mesh to prevent folding. An obturator in the vagina is useful to facilitate suture placement and secure the mesh to the vagina. The graft is secured to the vagina by folding over the cuff of the vagina and allowing the long end of the graft to exit posteriorly and extend to the sacrum. The short arm of the this placed on the top of the vagina, and the long arm of the this secured to the lower end of the vagina. The posterior segment of the mesh is then attached to the posterior vaginal wall with 6 to 8 interrupted monofilament delayed absorbable or nonabsorbable sutures. At this step, the central sutures from the culdoplasty are placed through the long arm of the mesh if desired. Placing the obturator all the way into the vagina but not pushing the vagina upward establishes the proper length for the graft. The graft is placed along the right lateral aspect of the rectum in the space previously developed by extending the opening of the peritoneum from the sacrum. With this technique, the vaginal vault is attached to the fascia of the iliococcygeus muscle as the anchoring site in contrast to the uterosacral or sacrospinous ligaments. The fascia of the iliococcygeus muscle is identified lateral to the rectum and distal the ischial spine (Shull et al. It is recommended that bilateral suture fixation be performed to achieve optimal results. Special needle drivers and lighted retraction are useful to facilitate suture placement. In cases using permanent suture a pulley-stitch technique is applied, tying the knot internally. Eight patients experienced pelvic support loss postoperatively, 3 in the middle (apical) compartment, 2 in the posterior compartment, and 4 in the anterior compartment. Intraoperative complications included rectal and bladder laceration and hemorrhage requiring transfusion. Postoperative complications included vaginal cuff abscess, fever, and transient femoral neuropathy. Abdominal Sacrocolpopexy Abdominal sacrocolpopexy should be considered a treatment option in the following clinical scenarios: failed previous vaginal repair, isolated uterine prolapse and/or enterocele, younger women, women with a highly active lifestyle, women who are sexually active, and women who desire one of the consistently most durable repairs at the expense of a potentially more invasive approach. As discussed earlier, other pelvic floor defects and stress urinary incontinence can be addressed at the same time. In addition to open surgery, robotic-assisted laparoscopic and pure laparoscopic approaches have been described and are commonly used today (Daneshgari et al. The critical elements of the operation include the use of permanent mesh (polypropylene) or autologous fascia as graft material and secure fixation of the graft to the sacral promontory and vaginal cuff. The patient is positioned in the low lithotomy position, providing transvaginal and transabdominal access. Upon surgical entry into the peritoneal cavity, it is important to achieve exposure of true pelvis by careful packing of the small intestine and sigmoid colon. This is accomplished by releasing all adhesions in the pelvis and packing the bowel above the level of the sacral promontory and displacing the sigmoid to the left, exposing the sacral promontory and posterior peritoneum. An incision is made in the posterior peritoneum over the sacral promontory, extending inferiorly along the right lateral aspect of the rectum towards the cul-de-sac. Electrocautery is used when dividing the fatty tissue over the promontory to minimize bleeding and improve visualization. Abdominal sacrocolpopexy Synthetic graft material is sutured securely to vaginal cuff using multiple interrupted permanent sutures. The peritoneal cul-de-sac is closed using linearly placed sutures to obliterate this potential space. Tensioning in this fashion is not feasible with a robotic or laparoscopic approach.

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