This document discusses surgical techniques for reconstructive pelvic surgery involving the central compartment. It compares surgery for primary pelvic organ prolapse (POP) grade 2 or higher to surgery for apical prolapse. Different techniques are described for vaginal vault repair involving the uterus versus repair after hysterectomy. Variations of sacrospinous hysteropexy and iliococcygeus fixation are outlined. Studies comparing outcomes of abdominal sacral colpopexy to vaginal repairs are summarized. The document advocates following principles of regenerative surgery using native tissues to repair defects and avoid excessive tension.

1. Chirurgia ricostruttiva pelvica fasciale :
Il compartimento centrale
P.S. Anastasio
3° Congr Naz
GLUP
2-10-2015 Treviso
Direttore Dipartimento Donna Maternità
Infanzia ASL Matera

2. Chirurgia fasciale :compartimento
centrale
2 contesti
Chirurgia primaria di POP ≥ 2
Chirurgia del prolasso di cupola
DIFFERENTI ?

3. Bladder DescentBladder Descent
Cervical(Apical)DescentCervical(Apical)Descent
Bladder Prolapse versus Uterine ProlapseBladder Prolapse versus Uterine Prolapse
Summers et al, Obstet Gynecol 2006Summers et al, Obstet Gynecol 2006
60% of bladder descent explained by apical descent*60% of bladder descent explained by apical descent*
r = 0.73r = 0.73

4. Principi di chirurgia ricostruttiva pelvica
Per assicurare un supporto apicalePer assicurare un supporto apicale
duraturo occorre ristabilire laduraturo occorre ristabilire la
continuità della fascia vaginalecontinuità della fascia vaginale
anteriore e posteriore a livello dellaanteriore e posteriore a livello della
cupola o della cervice.cupola o della cervice.
Se il tetto della tenda sprofonda, le pareti seguirannoSe il tetto della tenda sprofonda, le pareti seguiranno
““ il primo step di qualunqueil primo step di qualunque
riparazione anteriore o posterioreriparazione anteriore o posteriore
consiste nel garantire un supportoconsiste nel garantire un supporto
grado 0 al segmento apicale ”grado 0 al segmento apicale ”
Baden WF, Walker TBaden WF, Walker T
Surgical repair of vaginal defects,1992Surgical repair of vaginal defects,1992

5. Obstet Gynecol. 2013 Nov;122(5):981-7.
Outcomes of vaginal prolapse surgery among
female Medicare beneficiaries: the role of apical
support
Eilber KS1
, Alperin M, Khan A, Wu N, Pashos CL, Clemens JQ, Anger JT.
1999 : 3244 / 21245 donne con diagnosi di prolasso
sottoposte a chirurgia per POP con o senza sospensione
dell’apice
tassi di re- intervento dopo 10 aa
senza supporto apicale 20.2 % con supporto apicale 11.6 %
P <.0.03
“This analysis of a national cohort suggests that the
appropriate use of a vaginal apical support procedure at the
time of surgical treatment of POP might reduce the long-term
risk of prolapse recurrence.”

6. Am J Obstet Gynecol. 2015 Apr;212(4):463.e1-8..
Trends in management of pelvic organ prolapse
among female Medicare beneficiaries
Khan AA1
, Eilber KS2
, Clemens JQ3
, Wu N4
, Pashos CL4
, Anger JT5
.
• Patterns and rates of prolapse repairs remained relatively
unchanged from 1999 through 2009, with an exception of a
rapid rise in mesh use.
• The majority of mesh techniques were used for
augmentation purposes only, but did not result in an
increase in apical repairs performed in the United States.
• There remains a disappointingly low rate of vault
suspension repairs concomitantly at time of hysterectomy
for POP

7. Sacral colpopexy has superior outcomes to a
variety of vaginal procedures including
• Sacrospinous colpopexy
• Uterosacral colpopexy
• Transvaginal mesh
PERCHÈ CONTINUARE A
DISCUTERE ?
Maher C, Feiner B, Baessler K, Glazener C : Surgical management of POP in
women
Cochrane Database Syst Rev 4 , 2013

8. Int Urogynecol J. 2013 Nov;24(11):1815-33. doi: 10.1007/s00192-013-2172-1.
Apical prolapse
•Barber MD, Maher C.
• Sacral colpopexy is an effective procedure for vault
prolapse and further data are required on the route of
performance and efficacy of this surgery for uterine
prolapse.
• Vaginal procedures for vault prolapse are well described
and are suitable alternatives for those not suitable for
sacral colpopexy.

10. Int Urogynecol J. 2015 Jul;26(7):937-9. Epub 2015 May 12.
Systematic reviews of apical prolapse
surgery: are we being misled down a
dangerous path?
Moen M1
, Gebhart J, Tamussino K.

12. La dichiarata superiorità di SC nella riparazione del
prolasso apicale basata :
• Numero limitato studi di livello 1
• Studi focalizzati su esiti anatomici a breve
termine
• Mancata valutazione del rischio di reintervento
mesh related
• Mancato confronto dei dati di RCT con “ real
life “ (registri e database)
PERCHÈ CONTINUARE A
DISCUTERE ?

13. JAMA. 2013 May 15;309(19):2016-24.
Long-term outcomes following abdominal
sacrocolpopexy for pelvic organ prolapse
Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, Fine P, Menefee S,
Ridgeway B, Visco A, Warren LK, Zhang M, Meikle S.
Abdominal sacrocolpopexy is considered the
most durable POP surgery, but little is known
about safety and long-term effectiveness
treatment failure for
anatomic POP 0.27 and 0.22 symptomatic POP
0.29 and 0.24
SUI 0.268 to 0.33 overall UI 0.75 and 0.81
Mesh erosion probability at 7 years was 10.5%
(95% CI, 6.8%to 16.1%).

14. JAMA. 2013 May 15;309(19):2016-24.
Long-term outcomes following abdominal
sacrocolpopexy for pelvic organ prolapse
Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, Fine P, Menefee S,
Ridgeway B, Visco A, Warren LK, Zhang M, Meikle S.
CONCLUSIONS AND RELEVANCE:
•During 7 years of follow-up, abdominal sacrocolpopexy
failure rates increased in both groups.
•Urethropexy prevented SUI longer than no urethropexy.
•Abdominal sacrocolpopexy effectiveness should be
balanced with long-term risks of mesh or suture erosion

15. Standardization and Terminology Committees IUGA* & ICS#,
Joint IUGA / ICS Working Group on Female POP Terminology^
AN INTERNATIONAL UROGYNECOLOGICAL
ASSOCIATION (IUGA) / INTERNATIONAL
CONTINENCE
SOCIETY (ICS) JOINT REPORT ON THE
TERMINOLOGY
FOR FEMALE PELVIC ORGAN PROLAPSE (POP)
Bernard T. Haylen *^, Christopher F. Maher*^, Matthew D. Barber^,
Sérgio Camargo^, Vani Dandolu^, Alex Digesu^,
Howard B. Goldman^, Martin Huser^, Alfredo L. Milani^,
Paul A. Moran*^, Gabriel. N. Schaer *^, Mariëlla I.J. Withagen^

16. VAGINAL VAULT REPAIR
INVOLVING UTERUS
VAGINAL VAULT REPAIR
(POST-HYSTERECTOMY)

17. • Vaginal hysterectomy
• Vaginal hysterectomy with adjunctive McCall
culdoplasty (culdoplasty sutures incorporate
the uterosacral ligaments into the posterior
vaginal vault to obliterate the cul-de-sac and
support and suspend the vaginal apex )
• Sacrospinous hysteropexy
VAGINAL VAULT REPAIR
INVOLVING UTERUS

18. • Unilaterale o bilaterale
• Approccio anteriore o posteriore
• Numero di prese del ligamento
• Suture assorbibili o non riassorbibili
• Device utilizzati
VARIANTI ISTEROPESSI
SACROSPINOSO

19. • Colpopessi al sacrospinoso (varianti come
isteropessi + Michigan 4 wall
suspension(pfrg.smugmug.com)
• Sospensione ai ligamenti uterosacrali
a) Approccio intraperitoneale (variante laparoscopica)
b) Approccio extraperitoneale
• Sospensione ai mm. ilio-coccigei
VAGINAL VAULT REPAIR
(post-hysterectomy)

23. Standardization and Terminology Committees IUGA* & ICS#,
Joint IUGA / ICS Working Group on Female POP Terminology^
AN INTERNATIONAL UROGYNECOLOGICAL
ASSOCIATION (IUGA) / INTERNATIONAL
CONTINENCE
SOCIETY (ICS) JOINT REPORT ON THE
TERMINOLOGY
FOR FEMALE PELVIC ORGAN PROLAPSE (POP)
Bernard T. Haylen *^, Christopher F. Maher*^, Matthew D. Barber^,
Sérgio Camargo^, Vani Dandolu^, Alex Digesu^,
Howard B. Goldman^, Martin Huser^, Alfredo L. Milani^,
Paul A. Moran*^, Gabriel. N. Schaer *^, Mariëlla I.J. Withagen^

25. Obstet Gynecol. 2001 Jul;98(1):40-4.
ILIOCOCCYGEUS OR SACROSPINOUS
FIXATION FOR VAGINAL VAULT PROLAPSE.
•Maher CF1, Murray CJ, Carey MP, Dwyer PL, Ugoni AM.
Sacrospinous and iliococcygeus fixation are
•Equally effective procedures for vaginal vault prolapse
• Have similar rates of postoperative cystocele, buttock
pain, and hemorrhage requiring transfusion.
Sacrospinous ligament fixation should not be discarded in
favor of the iliococcygeus fixation in the management of
vaginal vault prolapse.

26. Pelviperineology 2010 29: 11-14
BILATERAL ILIOCOCCYGEUS FIXATION
TECHNICQUE FOR ENTEROCELE
AND VAGINAL VAULT PROLAPSE REPAIR
HAIM KRISSI 1,2*, STUART L STANTON1**
1 Pelvic Reconstruction & Urogynaecology Unit, Department of Obstetrics and
Gynecology, St. George’s Hospital, London, UK.
2 Department of Obstetrics and Gynecology, Beilinson Hospital, Petah-Tiqva, and
Sackler Faculty Of Medicine, Tel-Aviv University, Israel.
*Clinical and Research Fellow in Pelvic Reconstruction and Urogynaecology
** Professor of Pelvic Reconstruction and Urogynaecology

27. Int Urogynecol J. 2014 Feb;25(2):279-84. doi: 10.1007/s00192-013-2216-6. Epub 2013
Sep 13.
ILIOCOCCYGEUS FIXATION OR ABDOMINAL
SACRAL COLPOPEXY FOR THE TREATMENT OF
VAGINAL VAULT PROLAPSE: A RETROSPECTIVE
COHORT STUDY.
•Milani R1, Cesana MC, Spelzini F, Sicuri M, Manodoro S, Fruscio R.
Prolasso di cupola : 41 SCP versus 36 ICG fixation
ICG : più breve , maggiore perdita ematica , recidiva 22%
vs 15%

28. Int Urogynecol J. 2014 Feb;25(2):279-84. doi: 10.1007/s00192-013-2216-6. Epub 2013
Sep 13.
ILIOCOCCYGEUS FIXATION OR ABDOMINAL
SACRAL COLPOPEXY FOR THE TREATMENT OF
VAGINAL VAULT PROLAPSE: A RETROSPECTIVE
COHORT STUDY.
•Milani R1, Cesana MC, Spelzini F, Sicuri M, Manodoro S, Fruscio R.
• Both ICG fixation and SCP are effective in restoring
normal anatomy in patients with vaginal vault prolapse
and in relieving associated symptoms.
• Owing to its lower morbidity and to the advantage of not
using a synthetic device, ICG might be an excellent
option for the treatment of recurrent vaginal vault
prolapse following hysterectomy

29. Int Urogynecol J (2015) 26:1007-1012 DOI 10,1907/s00 192-015-2629- 5
Iliococcygeus fixation for the treatment of
apical vaginal prolapse:
efficacy and safety at 5 years of follow-up
Maurizio Serati • Andrea Braga • Giorgio Bogani • Umberto Leone Roberti
Maggiore • Paola Sorice • Fabio Ghezzi • Stefano Salvatore

30. • Studio prospettico di 44 pz seguite per 5 aa
• Valutazione operata da # dagli operatori
• Nessuna perdita al follow-up
• Valutazione outcomes soggettivi ed
oggettivi con strumenti validati

31. Sospensione ai mm. ilio-coccigei
• Incisione longitudinale parete vaginale posteriore
• Dissezione bilaterale degli spazi pararettali
• Identificazione del muscolo elevatore dell’ano
• Trasfissione distalmente alla spina ischiatica
del muscolo e della fascia con 3 suture
riassorbibili
• Sospensione dell’apice alle suture passate
trasversalmente
• Tensionamento successivo alla colporaffia

32. • POP stage 4 13.6%
• POP recidivo 16%
• No complicanze intraoperatorie
• Correlazione tra stadio del prolasso e
recidiva

34. OPTIMAL RANDOMIZED TRIAL (JAMA 2014)
S LSS VERSUS S USL A 2 AA
Nessuna differenza per :
•Successo chirurgico
•Sintomi di bulge fastidioso
•Descensus anteriore o posteriore all’imene
•Necessità di re-trattamento per POP
S LSS : dolore neurologico. 12.4% vs 6.9%
S USL : ostruzione ureterale 3.2% vs 0%
S USL : ileo < 0.5%

36. Non chiedetevi quanto grande è il prolasso
Chiedetevi perché è avvenuto
La capacità di riparare il difetto che ha generato il
prolasso determinerà l’esito chirurgico
Gli impianti devono essere utilizzati come un aiuto al
processo di guarigione dei tessuti
Ciò avviene solo seguendo i principi della chirurgia
rigenerativa nel maneggiamento dei tessuti
Nieuwoudt : Native tissue and pelvic floor ( editorial ) .
Pelviperineology ,2014;4.99

37. Chirurgia vaginale rigenerativa
Ricostruzione anatomo-morfo-funzionale con cicatrice minima
Tessuto nativo + processo di guarigione
•Dissezione in piani anatomici
•Approssimare i bordi lacerati dei tessuti lacerati
•Eliminare tensione
•Utilizzare materiali che non aumentano la risposta
infiammatoria
•Supportare il rimodellamento da parte della matrice
extracellulare con scaffolds biodegradabili
A, Nieuwoudt : Native tissue and pelvic floor ( editorial ) .
Pelviperineology ,2014;4.99