Surgical Techniques

Watch 5 video clips illustrating robotic sacrocolpopexy

• Promontory dissection and creation of the retroperitoneal tunnel
• Dissection of the rectovaginal and vesicovaginal spaces
• Attachment of y-mesh to vagina: Start anteriorly
• Posterior y-mesh attachment
• Attachment of mesh to sacral promontory

These videos were provided by Catherine A. Matthews, MD.

Recent years have seen growing recognition that adequate support of the vaginal apex is an essential component of durable surgical repair of pelvic organ prolapse.^1,2 Sacrocolpopexy is now considered the gold standard for repair of Level-1 defects of pelvic support, providing excellent long-term results.^3-5

A recent randomized, controlled trial demonstrated the superior efficacy of laparoscopic sacrocolpopexy to a total vaginal mesh procedure in women who have vaginal vault prolapse—further evidence that sacrocolpopexy is the procedure of choice for these patients.⁶

The advantages of sacrocolpopexy include:

• reduced risk of mesh exposure, compared to insertion of vaginal mesh
• preservation of vaginal length
• reduced risk of re-operation for symptomatic recurrent prolapse
• reduced risk of de novo dyspareunia secondary to contraction of mesh.

Obstacles. Although a small number of surgeons are able to accomplish sacrocolpopexy using standard laparoscopic techniques, most of these procedures are still performed by laparotomy because the extensive suturing and knot-tying present a surgical challenge. Open sacrocolpopexy has disadvantages, too, including more pain, longer recovery, and longer length of stay.^7-9

With the introduction of the da Vinci robot (Intuitive Surgical), the feasibility of having more surgeons perform this operation using a reproducible, minimally-invasive technique is much greater. The steep learning curve associated with standard laparoscopy in regard to mastering intracorporeal knot-tying and suturing is greatly diminished by articulating instruments. This makes robotic sacrocolpopexy an accessible option for all gynecologic surgeons who treat women with pelvic organ prolapse.

In this article, I detail the steps—with tips and tricks from my experience—to completing an efficient robotic-assisted sacrocolpopexy—modeled exactly after the open technique—that utilizes a y-shaped polypropylene mesh graft. Included is capsule advice from OBG Management’s coding consultant on obtaining reimbursement for robotic procedures (see “ Coding tips for robotic sacrocolpopexy”).

Details of the procedure

1. Surgical preparation, set-up

The patient completes a bowel prep using two bottles of magnesium citrate and taking only clear liquids 1 day before surgery. Although mechanical bowel cleansing has not been shown to decrease operative morbidity, manipulation and retraction of the sigmoid colon may be easier with the bowel empty.

Perioperative antibiotics are administered 30 minutes prior to the procedure. Heparin, 5,000 U, is injected subcutaneously for thromboprophylaxis as the patient is en route to the operating suite.

The patient is placed in the dorsal lithotomy position, buttocks extending one inch over the end of the operating table. The table should be covered with egg-crate foam to avoid having her slip down while in steep Trendelenburg position.

After the patient is prepped and draped, a Foley catheter is placed into the bladder. EEA sizers (Covidien) are inserted into the vagina and rectum.

Two experienced surgical assistants are necessary:

• One on the patient’s right side to assist with tissue retraction and introduction of suture material
• Another seated between the patient’s legs to provide adequate vaginal and rectal manipulation during surgery.

2. Port placement, docking, and instrumentation

Pneumoperitoneum is obtained with a Veress needle. Five trocars are then placed (FIGURE 1).

Careful port placement is integral to the success of this procedure because:

• Inadequate distance between robotic arms and the camera results in arm collisions and interference
• Visualization and access to the sacral promontory may be compromised if the camera is inserted too low on the anterior abdominal wall
• Bowel retraction may be compromised if the fourth arm of the robot isn’t at least 3 cm above the anterior superior iliac crest.

My experience evaluating the abdomen before trocar insertion is that at least 15 cm is required between the pubic bone and the umbilicus to rely on this landmark for locating the 12-mm camera port.¹⁰ If this distance is shorter (as it is in many obese women), insertion above the umbilicus is necessary.

An accessory 12-mm port, used to introduce sutures and the mesh graft, is placed approximately 10 cm lateral and 4 cm cephalad to the camera in the right-upper quadrant.

An 8-mm robotic port is placed in the right lower quadrant, 10 cm lateral to the accessory port and approximately 3 cm above the anterior superior iliac crest.

The third and fourth robotic arms are placed 10 cm apart in the left lower quadrant, with the fourth arm typically as far lateral as possible.

Docking. After the patient has been placed in steep Trendelenburg position and the table is locked, the robot is docked from the patient’s left side at a 45° angle to the table. Side-docking permits easy access to the vagina to 1) evaluate graft tension and 2) complete cystoscopy to ensure ureteral and bladder integrity.

TIP Take care to ensure that the spine of the robot is positioned right next to the bed at the level of the patient’s hip; driving it up too high in relation to the abdomen can compromise the mobility of the fourth arm. In addition, if the robot is not close enough to the bed, the reach of the first (right) arm may be limited.

Next, introduce monopolar scissors through the right arm; a bipolar PK Dissector (Intuitive Surgical) through the left arm; and an atraumatic bowel grasper, such as Cadiere Forceps (Intuitive Surgical), through the fourth arm.

FIGURE 1 Placement of 5 ports for robotic sacrocolpopexy
Key: C, camera; A, accessory port; 1, right arm (monopolar shears); 2, left arm (PK Dissector); 3, fourth arm (Cadiere Forceps).

3. Dissect the sacral promontory and create a retroperitoneal tunnel

With the use of a 0° scope or 30° down-scope, retract the sigmoid colon laterally using Cadiere forceps and identify the right ureter.

TIP When you attempt robotic sacrocolpopexy for the first time, it may help to identify the sacral promontory, using a standard laparoscopic instrument with haptic feedback, before you dock the robot.

Elevate the peritoneum overlying the sacral promontory and open it using monopolar cautery. Expose the fat pad that overlays the anterior longitudinal ligament and gently dissect it away (FIGURE 2; VIDEO 1). Often, the middle sacral artery is visualized; it can be coagulated using the PK Dissector if necessary.

TIP In a case in which the promontory is difficult to find, dissecting the retrorectal space is a simple way to mobilize the bowel away from the sacrum, thus exposing the promontory.

TRICK Instead of opening the peritoneum from the sacrum to the cul-de-sac, I create a retroperitoneal tunnel along that right paracolic gutter, from the promontory to just medial to the right uterosacral ligament (VIDEO 1). Doing so has three benefits:

• It is quicker and less bloody
• It allows the mesh to lay flat in the hollow of the sacrum when you bring the sacral arm up to the promontory
• There is much less peritoneum to close over the mesh at the end of the procedure.

FIGURE 2 Entering the peritoneum
Open the peritoneum at the sacral promontory and dissect the fat pad. This reveals the anterior longitudinal ligament.

4. Dissect the vesicovaginal and rectovaginal spaces

Effective vaginal and rectal manipulation is critical to complete this part of the procedure safely. To gain access to the rectovaginal space, the vaginal assistant needs to push the vagina all the way in and up toward the anterior abdominal wall (the handle of the EEA sizer will be pushing hard up against the perineum) while simultaneously pushing the rectal probe downward (effectively scissoring the two apart).

From the exit point of the retroperitoneal tunnel that was created at the beginning of the case, then extend the peritoneal incision transversely in the shape of a “T” to expose the posterior vaginal wall (FIGURE 3, VIDEO 2). If indicated, dissect the rectovaginal space all the way down to the perineal body.

Deviate the vagina posteriorly to facilitate dissection of the bladder from the anterior vaginal wall. Use sharp dissection with scissors and short bursts of energy with monopolar cautery.

TIP If you encounter significant scarring between the bladder and vagina, retrograde-fill the bladder with 300 mL of saline mixed with methylene blue dye to identify the surgical plane.

Expose approximately 4 to 6 cm of anterior vaginal wall, depending on the degree of anterior vaginal wall prolapse. Try to leave the peritoneum intact at the apex of the vagina to reduce the chance that mesh will erode.

FIGURE 3 The peritoneal incision
Extend the peritoneal incision along the cul-de-sac to the posterior vaginal wall in a T-shaped configuration to gain access the rectovaginal space. When perorming cervicosacropexy, it is easiest to develop this surgical plane before amputating the cervix.

5. Attach the y-mesh to the vagina

Several mesh options exist: IntePro (American Medical Systems), Alyte (Bard Medical), and Restorelle Y (Mpathy Medical) are preformed Type-1 polypropylene mesh products. A correctly sized mesh can easily be fashioned by suturing together two strips of Gynemesh (Ethicon) that are approximately 3 cm wide.

Because there can be significant variability in the relative dimensions of the anterior and posterior segments of mesh, I recommend fashioning the graft after dissection is complete: When posterior wall prolapse is extensive, for example, preformed y-mesh strips may not be long enough to reach all the way down to the perineal body. After having assessed the differences in graft placement and manipulation when the two arms are sutured together 1) before the grafts are placed intracorporeally and 2) after they are placed, I’ve concluded that the first method—suturing before placement—is far easier.

Introduce the mesh graft through the accessory port after exchanging the scissors and PK dissector for a suture cutter and a large needle driver. Retract the bladder using the fourth arm, and place the anterior mesh arm over the anterior vaginal wall; suture it in place using 2-0 Gore-Tex sutures on CT-2 needles that are each cut to 6 inches long.

For greatest efficiency, anchor the two distal corners first (FIGURE 4; VIDEO 3), then place a series of interrupted stitches towards the vaginal apex. Tie the knots using 2 surgeon’s knots, followed by 2 half-hitches. Attempt to achieve healthy bites through the vaginal muscularis without perforating the epithelium.

FIGURE 4 Suturing the mesh graft to the vaginal wall
Left and right: Suture the y-shaped polypropylene mesh graft to the anterior vaginal wall first, starting at the distal corners. The bladder is retracted cephalad using the fourth arm.After you’ve adequately secured the anterior mesh arm, deviate the vagina anteriorly and drape the posterior mesh arm over the posterior vaginal wall with the assistance of the fourth robotic arm that can hold upward traction on the sacral end of the mesh graft. Starting at the vaginal apex, place 6 to 8 interrupted sutures to secure the mesh to the posterior vaginal wall (FIGURE 5; VIDEO 4). If necessary, exchange the 0° scope for a 30° up-scope so that you can fully visualize the rectovaginal space.

FIGURE 5 Attachment of the posterior arm of the mesh
The fourth arm of the robot provides upward traction on the sacral portion of the mesh graft.

6. Attach the graft to the sacrum

Again retract the sigmoid laterally to expose the promontory dissection. Retrieve the sacral arm of the mesh through the retroperitoneal tunnel and pull it up toward the promontory. Deviate the vagina toward the sacrum and, ensuring that there is no excessive tension, suture the sacral portion of the mesh graft to the anterior longitudinal ligament at the promontory, using 2 or 3 interrupted sutures (FIGURE 6, VIDEO 5).

When placing the needle during this critical juncture, it is important to rotate through the ligament along the curvature of the needle—as opposed to driving the needle forward and risking exiting farther laterally than expected.

TIP Because of the slight traction that exists on the mesh, a slip-knot is preferred instead of a surgeon’s knot when suturing the sacral portion of the mesh graft to the anterior longitudinal ligament. Take care to visualize the middle sacral artery and either suture around it or cauterize it.

FIGURE 6 Suture the mesh directly to the anterior longitudinal ligament
Use two or three stitches, secured with slip-knots. Take care not to create excessive tension on the mesh graft.

7. Extraperitonealize the mesh

I no longer routinely close the peritoneum over the mesh at the vaginal apex because I have not had a single case of small-bowel obstruction since I began performing this procedure laparoscopically. You should close the peritoneal window at the promontory, however, if the mesh is tented up at all, because tenting creates the potential for bowel to get caught beneath the mesh. Perform this closure using 2-0 monofilament suture or 2-0 Vicryl suture (Ethicon) cut to 8 inches (FIGURE 7). It is always easiest to start distally and suture towards the camera and operative instruments.

FIGURE 7 Extraperitonealize the mesh
Close the peritoneum from the apex of the vagina with a purse-string—like stitch, continuing it to the promontory in running fashion.

8. Ensure that mesh is not in the bladder or rectum

Perform cystoscopy and a rectal examination at the end of each case to confirm that no sutures or mesh material are within either viscus. It is much easier to remove these before leaving the operating room.

Modifying the procedure for uterovaginal prolapse

If the patient has an intact uterus and benign cervical cytology, perform supracervical hysterectomy before proceeding with Steps 1–8 above.

TIP Leaving the cervix in situ may reduce the chance of mesh erosion and provides an excellent platform for mesh attachment.

TRICK I find it most helpful to fully dissect the anterior and posterior vaginal walls before cervical amputation because upward traction on the corpus improves visualization of the surgical planes.

Once the cervix is amputated, however, effective vaginal manipulation can present a surgical challenge. Some surgeons use a tenaculum attached to the fourth arm of the robot to apply traction on the cervix, but this eliminates this arm from performing other necessary tasks. Malleable or Breisky-Navratil retractors can be used to delineate the anterior and posterior vaginal fornices, but are not always satisfactory—especially if an assistant isn’t seated between the legs.

TIP A useful and inexpensive instrument is the Colpo-Probe vaginal fornix delineator (Cooper Surgical) (FIGURE 8), which not only assists in dissecting the vagina from the bladder and rectum but also provides a stable surface during attachment of mesh.

FIGURE 8 Colpo-Probe
This device delineates the anterior and posterior vaginal fornices. It provides a stable platform against which to suture the mesh graft.

Tips and tricks for managing hemorrhage during sacrocolpopexy

Four potential areas of bleeding danger exist:

• In trying to find the sacral promontory, you risk entering the right common iliac vein if dissection is too far cephalad and lateral.
  TIP I strongly advise novice robotic surgeons to try to identify the site of the promontory with a standard laparoscopic instrument with haptic feedback before moving to the surgical console.
  TRICK Another trick that can help with safe identification of the promontory is mobilization of the sigmoid colon away from the sacrum by developing the retrorectal space.
• During dissection of the fat pad from the promontory, you can encounter the middle sacral artery.
  TRICK Spreading carefully in a caudal–cephalad direction until the level of the ligament is reached, instead of spreading in a lateral dimension, can decrease the chances of lacerating of this vessel.
• A dangerous plexus of veins traverses the hollow of the sacrum. If you are trying to affix mesh at the level of S2-3, therefore, you may encounter significant bleeding.
  TIP Work above the level of S1 to avoid these veins completely.
• In securing the mesh to the sacral promontory, you can puncture the left common iliac vein if you are not aware of the exit point of the needle and it traverses too far medially.

TIP If you encounter bleeding, introduce a RAY-TEC sponge (Johnson & Johnson) through the accessory port. Apply manual compression for at least 5 minutes. If bleeding persists, I recommend Floseal Hemostatic Matrix (Baxter) to control hemorrhage that arises from arterial and venous sources.

TRICK As last resort, perform emergency undocking in rapid fashion while the bedside assistant maintains pressure through the accessory port.

Conclusion

The da Vinci robotic surgical system facilitates completion of sacrocolpopexy and cervicosacropexy, in a manner identical to the open technique, by surgeons who may not possess advanced laparoscopic skills. Full knowledge of the relevant anatomy is critical; there is the potential for significant morbidity during the procedure if surgical planes are created incorrectly.

We want to hear from you! Tell us what you think.

Watch 5 video clips illustrating robotic sacrocolpopexy

• Promontory dissection and creation of the retroperitoneal tunnel
• Dissection of the rectovaginal and vesicovaginal spaces
• Attachment of y-mesh to vagina: Start anteriorly
• Posterior y-mesh attachment
• Attachment of mesh to sacral promontory

These videos were provided by Catherine A. Matthews, MD.

Recent years have seen growing recognition that adequate support of the vaginal apex is an essential component of durable surgical repair of pelvic organ prolapse.^1,2 Sacrocolpopexy is now considered the gold standard for repair of Level-1 defects of pelvic support, providing excellent long-term results.^3-5

A recent randomized, controlled trial demonstrated the superior efficacy of laparoscopic sacrocolpopexy to a total vaginal mesh procedure in women who have vaginal vault prolapse—further evidence that sacrocolpopexy is the procedure of choice for these patients.⁶

The advantages of sacrocolpopexy include:

• reduced risk of mesh exposure, compared to insertion of vaginal mesh
• preservation of vaginal length
• reduced risk of re-operation for symptomatic recurrent prolapse
• reduced risk of de novo dyspareunia secondary to contraction of mesh.

Obstacles. Although a small number of surgeons are able to accomplish sacrocolpopexy using standard laparoscopic techniques, most of these procedures are still performed by laparotomy because the extensive suturing and knot-tying present a surgical challenge. Open sacrocolpopexy has disadvantages, too, including more pain, longer recovery, and longer length of stay.^7-9

With the introduction of the da Vinci robot (Intuitive Surgical), the feasibility of having more surgeons perform this operation using a reproducible, minimally-invasive technique is much greater. The steep learning curve associated with standard laparoscopy in regard to mastering intracorporeal knot-tying and suturing is greatly diminished by articulating instruments. This makes robotic sacrocolpopexy an accessible option for all gynecologic surgeons who treat women with pelvic organ prolapse.

In this article, I detail the steps—with tips and tricks from my experience—to completing an efficient robotic-assisted sacrocolpopexy—modeled exactly after the open technique—that utilizes a y-shaped polypropylene mesh graft. Included is capsule advice from OBG Management’s coding consultant on obtaining reimbursement for robotic procedures (see “ Coding tips for robotic sacrocolpopexy”).

Details of the procedure

1. Surgical preparation, set-up

The patient completes a bowel prep using two bottles of magnesium citrate and taking only clear liquids 1 day before surgery. Although mechanical bowel cleansing has not been shown to decrease operative morbidity, manipulation and retraction of the sigmoid colon may be easier with the bowel empty.

Perioperative antibiotics are administered 30 minutes prior to the procedure. Heparin, 5,000 U, is injected subcutaneously for thromboprophylaxis as the patient is en route to the operating suite.

The patient is placed in the dorsal lithotomy position, buttocks extending one inch over the end of the operating table. The table should be covered with egg-crate foam to avoid having her slip down while in steep Trendelenburg position.

After the patient is prepped and draped, a Foley catheter is placed into the bladder. EEA sizers (Covidien) are inserted into the vagina and rectum.

Two experienced surgical assistants are necessary:

• One on the patient’s right side to assist with tissue retraction and introduction of suture material
• Another seated between the patient’s legs to provide adequate vaginal and rectal manipulation during surgery.

2. Port placement, docking, and instrumentation

Pneumoperitoneum is obtained with a Veress needle. Five trocars are then placed (FIGURE 1).

Careful port placement is integral to the success of this procedure because:

• Inadequate distance between robotic arms and the camera results in arm collisions and interference
• Visualization and access to the sacral promontory may be compromised if the camera is inserted too low on the anterior abdominal wall
• Bowel retraction may be compromised if the fourth arm of the robot isn’t at least 3 cm above the anterior superior iliac crest.

My experience evaluating the abdomen before trocar insertion is that at least 15 cm is required between the pubic bone and the umbilicus to rely on this landmark for locating the 12-mm camera port.¹⁰ If this distance is shorter (as it is in many obese women), insertion above the umbilicus is necessary.

An accessory 12-mm port, used to introduce sutures and the mesh graft, is placed approximately 10 cm lateral and 4 cm cephalad to the camera in the right-upper quadrant.

An 8-mm robotic port is placed in the right lower quadrant, 10 cm lateral to the accessory port and approximately 3 cm above the anterior superior iliac crest.

The third and fourth robotic arms are placed 10 cm apart in the left lower quadrant, with the fourth arm typically as far lateral as possible.

Docking. After the patient has been placed in steep Trendelenburg position and the table is locked, the robot is docked from the patient’s left side at a 45° angle to the table. Side-docking permits easy access to the vagina to 1) evaluate graft tension and 2) complete cystoscopy to ensure ureteral and bladder integrity.

TIP Take care to ensure that the spine of the robot is positioned right next to the bed at the level of the patient’s hip; driving it up too high in relation to the abdomen can compromise the mobility of the fourth arm. In addition, if the robot is not close enough to the bed, the reach of the first (right) arm may be limited.

Next, introduce monopolar scissors through the right arm; a bipolar PK Dissector (Intuitive Surgical) through the left arm; and an atraumatic bowel grasper, such as Cadiere Forceps (Intuitive Surgical), through the fourth arm.

FIGURE 1 Placement of 5 ports for robotic sacrocolpopexy
Key: C, camera; A, accessory port; 1, right arm (monopolar shears); 2, left arm (PK Dissector); 3, fourth arm (Cadiere Forceps).

3. Dissect the sacral promontory and create a retroperitoneal tunnel

With the use of a 0° scope or 30° down-scope, retract the sigmoid colon laterally using Cadiere forceps and identify the right ureter.

TIP When you attempt robotic sacrocolpopexy for the first time, it may help to identify the sacral promontory, using a standard laparoscopic instrument with haptic feedback, before you dock the robot.

Elevate the peritoneum overlying the sacral promontory and open it using monopolar cautery. Expose the fat pad that overlays the anterior longitudinal ligament and gently dissect it away (FIGURE 2; VIDEO 1). Often, the middle sacral artery is visualized; it can be coagulated using the PK Dissector if necessary.

TIP In a case in which the promontory is difficult to find, dissecting the retrorectal space is a simple way to mobilize the bowel away from the sacrum, thus exposing the promontory.

TRICK Instead of opening the peritoneum from the sacrum to the cul-de-sac, I create a retroperitoneal tunnel along that right paracolic gutter, from the promontory to just medial to the right uterosacral ligament (VIDEO 1). Doing so has three benefits:

• It is quicker and less bloody
• It allows the mesh to lay flat in the hollow of the sacrum when you bring the sacral arm up to the promontory
• There is much less peritoneum to close over the mesh at the end of the procedure.

FIGURE 2 Entering the peritoneum
Open the peritoneum at the sacral promontory and dissect the fat pad. This reveals the anterior longitudinal ligament.

4. Dissect the vesicovaginal and rectovaginal spaces

Effective vaginal and rectal manipulation is critical to complete this part of the procedure safely. To gain access to the rectovaginal space, the vaginal assistant needs to push the vagina all the way in and up toward the anterior abdominal wall (the handle of the EEA sizer will be pushing hard up against the perineum) while simultaneously pushing the rectal probe downward (effectively scissoring the two apart).

From the exit point of the retroperitoneal tunnel that was created at the beginning of the case, then extend the peritoneal incision transversely in the shape of a “T” to expose the posterior vaginal wall (FIGURE 3, VIDEO 2). If indicated, dissect the rectovaginal space all the way down to the perineal body.

Deviate the vagina posteriorly to facilitate dissection of the bladder from the anterior vaginal wall. Use sharp dissection with scissors and short bursts of energy with monopolar cautery.

TIP If you encounter significant scarring between the bladder and vagina, retrograde-fill the bladder with 300 mL of saline mixed with methylene blue dye to identify the surgical plane.

Expose approximately 4 to 6 cm of anterior vaginal wall, depending on the degree of anterior vaginal wall prolapse. Try to leave the peritoneum intact at the apex of the vagina to reduce the chance that mesh will erode.

FIGURE 3 The peritoneal incision
Extend the peritoneal incision along the cul-de-sac to the posterior vaginal wall in a T-shaped configuration to gain access the rectovaginal space. When perorming cervicosacropexy, it is easiest to develop this surgical plane before amputating the cervix.

5. Attach the y-mesh to the vagina

Several mesh options exist: IntePro (American Medical Systems), Alyte (Bard Medical), and Restorelle Y (Mpathy Medical) are preformed Type-1 polypropylene mesh products. A correctly sized mesh can easily be fashioned by suturing together two strips of Gynemesh (Ethicon) that are approximately 3 cm wide.

Because there can be significant variability in the relative dimensions of the anterior and posterior segments of mesh, I recommend fashioning the graft after dissection is complete: When posterior wall prolapse is extensive, for example, preformed y-mesh strips may not be long enough to reach all the way down to the perineal body. After having assessed the differences in graft placement and manipulation when the two arms are sutured together 1) before the grafts are placed intracorporeally and 2) after they are placed, I’ve concluded that the first method—suturing before placement—is far easier.

Introduce the mesh graft through the accessory port after exchanging the scissors and PK dissector for a suture cutter and a large needle driver. Retract the bladder using the fourth arm, and place the anterior mesh arm over the anterior vaginal wall; suture it in place using 2-0 Gore-Tex sutures on CT-2 needles that are each cut to 6 inches long.

For greatest efficiency, anchor the two distal corners first (FIGURE 4; VIDEO 3), then place a series of interrupted stitches towards the vaginal apex. Tie the knots using 2 surgeon’s knots, followed by 2 half-hitches. Attempt to achieve healthy bites through the vaginal muscularis without perforating the epithelium.

FIGURE 4 Suturing the mesh graft to the vaginal wall
Left and right: Suture the y-shaped polypropylene mesh graft to the anterior vaginal wall first, starting at the distal corners. The bladder is retracted cephalad using the fourth arm.After you’ve adequately secured the anterior mesh arm, deviate the vagina anteriorly and drape the posterior mesh arm over the posterior vaginal wall with the assistance of the fourth robotic arm that can hold upward traction on the sacral end of the mesh graft. Starting at the vaginal apex, place 6 to 8 interrupted sutures to secure the mesh to the posterior vaginal wall (FIGURE 5; VIDEO 4). If necessary, exchange the 0° scope for a 30° up-scope so that you can fully visualize the rectovaginal space.

FIGURE 5 Attachment of the posterior arm of the mesh
The fourth arm of the robot provides upward traction on the sacral portion of the mesh graft.

6. Attach the graft to the sacrum

Again retract the sigmoid laterally to expose the promontory dissection. Retrieve the sacral arm of the mesh through the retroperitoneal tunnel and pull it up toward the promontory. Deviate the vagina toward the sacrum and, ensuring that there is no excessive tension, suture the sacral portion of the mesh graft to the anterior longitudinal ligament at the promontory, using 2 or 3 interrupted sutures (FIGURE 6, VIDEO 5).

When placing the needle during this critical juncture, it is important to rotate through the ligament along the curvature of the needle—as opposed to driving the needle forward and risking exiting farther laterally than expected.

TIP Because of the slight traction that exists on the mesh, a slip-knot is preferred instead of a surgeon’s knot when suturing the sacral portion of the mesh graft to the anterior longitudinal ligament. Take care to visualize the middle sacral artery and either suture around it or cauterize it.

FIGURE 6 Suture the mesh directly to the anterior longitudinal ligament
Use two or three stitches, secured with slip-knots. Take care not to create excessive tension on the mesh graft.

7. Extraperitonealize the mesh

I no longer routinely close the peritoneum over the mesh at the vaginal apex because I have not had a single case of small-bowel obstruction since I began performing this procedure laparoscopically. You should close the peritoneal window at the promontory, however, if the mesh is tented up at all, because tenting creates the potential for bowel to get caught beneath the mesh. Perform this closure using 2-0 monofilament suture or 2-0 Vicryl suture (Ethicon) cut to 8 inches (FIGURE 7). It is always easiest to start distally and suture towards the camera and operative instruments.

FIGURE 7 Extraperitonealize the mesh
Close the peritoneum from the apex of the vagina with a purse-string—like stitch, continuing it to the promontory in running fashion.

8. Ensure that mesh is not in the bladder or rectum

Perform cystoscopy and a rectal examination at the end of each case to confirm that no sutures or mesh material are within either viscus. It is much easier to remove these before leaving the operating room.

Modifying the procedure for uterovaginal prolapse

If the patient has an intact uterus and benign cervical cytology, perform supracervical hysterectomy before proceeding with Steps 1–8 above.

TIP Leaving the cervix in situ may reduce the chance of mesh erosion and provides an excellent platform for mesh attachment.

TRICK I find it most helpful to fully dissect the anterior and posterior vaginal walls before cervical amputation because upward traction on the corpus improves visualization of the surgical planes.

Once the cervix is amputated, however, effective vaginal manipulation can present a surgical challenge. Some surgeons use a tenaculum attached to the fourth arm of the robot to apply traction on the cervix, but this eliminates this arm from performing other necessary tasks. Malleable or Breisky-Navratil retractors can be used to delineate the anterior and posterior vaginal fornices, but are not always satisfactory—especially if an assistant isn’t seated between the legs.

TIP A useful and inexpensive instrument is the Colpo-Probe vaginal fornix delineator (Cooper Surgical) (FIGURE 8), which not only assists in dissecting the vagina from the bladder and rectum but also provides a stable surface during attachment of mesh.

FIGURE 8 Colpo-Probe
This device delineates the anterior and posterior vaginal fornices. It provides a stable platform against which to suture the mesh graft.

Tips and tricks for managing hemorrhage during sacrocolpopexy

Four potential areas of bleeding danger exist:

• In trying to find the sacral promontory, you risk entering the right common iliac vein if dissection is too far cephalad and lateral.
  TIP I strongly advise novice robotic surgeons to try to identify the site of the promontory with a standard laparoscopic instrument with haptic feedback before moving to the surgical console.
  TRICK Another trick that can help with safe identification of the promontory is mobilization of the sigmoid colon away from the sacrum by developing the retrorectal space.
• During dissection of the fat pad from the promontory, you can encounter the middle sacral artery.
  TRICK Spreading carefully in a caudal–cephalad direction until the level of the ligament is reached, instead of spreading in a lateral dimension, can decrease the chances of lacerating of this vessel.
• A dangerous plexus of veins traverses the hollow of the sacrum. If you are trying to affix mesh at the level of S2-3, therefore, you may encounter significant bleeding.
  TIP Work above the level of S1 to avoid these veins completely.
• In securing the mesh to the sacral promontory, you can puncture the left common iliac vein if you are not aware of the exit point of the needle and it traverses too far medially.

TIP If you encounter bleeding, introduce a RAY-TEC sponge (Johnson & Johnson) through the accessory port. Apply manual compression for at least 5 minutes. If bleeding persists, I recommend Floseal Hemostatic Matrix (Baxter) to control hemorrhage that arises from arterial and venous sources.

TRICK As last resort, perform emergency undocking in rapid fashion while the bedside assistant maintains pressure through the accessory port.

Conclusion

The da Vinci robotic surgical system facilitates completion of sacrocolpopexy and cervicosacropexy, in a manner identical to the open technique, by surgeons who may not possess advanced laparoscopic skills. Full knowledge of the relevant anatomy is critical; there is the potential for significant morbidity during the procedure if surgical planes are created incorrectly.

We want to hear from you! Tell us what you think.

Watch 5 video clips illustrating robotic sacrocolpopexy

• Promontory dissection and creation of the retroperitoneal tunnel
• Dissection of the rectovaginal and vesicovaginal spaces
• Attachment of y-mesh to vagina: Start anteriorly
• Posterior y-mesh attachment
• Attachment of mesh to sacral promontory

These videos were provided by Catherine A. Matthews, MD.

Recent years have seen growing recognition that adequate support of the vaginal apex is an essential component of durable surgical repair of pelvic organ prolapse.^1,2 Sacrocolpopexy is now considered the gold standard for repair of Level-1 defects of pelvic support, providing excellent long-term results.^3-5

A recent randomized, controlled trial demonstrated the superior efficacy of laparoscopic sacrocolpopexy to a total vaginal mesh procedure in women who have vaginal vault prolapse—further evidence that sacrocolpopexy is the procedure of choice for these patients.⁶

The advantages of sacrocolpopexy include:

• reduced risk of mesh exposure, compared to insertion of vaginal mesh
• preservation of vaginal length
• reduced risk of re-operation for symptomatic recurrent prolapse
• reduced risk of de novo dyspareunia secondary to contraction of mesh.

Obstacles. Although a small number of surgeons are able to accomplish sacrocolpopexy using standard laparoscopic techniques, most of these procedures are still performed by laparotomy because the extensive suturing and knot-tying present a surgical challenge. Open sacrocolpopexy has disadvantages, too, including more pain, longer recovery, and longer length of stay.^7-9

With the introduction of the da Vinci robot (Intuitive Surgical), the feasibility of having more surgeons perform this operation using a reproducible, minimally-invasive technique is much greater. The steep learning curve associated with standard laparoscopy in regard to mastering intracorporeal knot-tying and suturing is greatly diminished by articulating instruments. This makes robotic sacrocolpopexy an accessible option for all gynecologic surgeons who treat women with pelvic organ prolapse.

In this article, I detail the steps—with tips and tricks from my experience—to completing an efficient robotic-assisted sacrocolpopexy—modeled exactly after the open technique—that utilizes a y-shaped polypropylene mesh graft. Included is capsule advice from OBG Management’s coding consultant on obtaining reimbursement for robotic procedures (see “ Coding tips for robotic sacrocolpopexy”).

Details of the procedure

1. Surgical preparation, set-up

The patient completes a bowel prep using two bottles of magnesium citrate and taking only clear liquids 1 day before surgery. Although mechanical bowel cleansing has not been shown to decrease operative morbidity, manipulation and retraction of the sigmoid colon may be easier with the bowel empty.

Perioperative antibiotics are administered 30 minutes prior to the procedure. Heparin, 5,000 U, is injected subcutaneously for thromboprophylaxis as the patient is en route to the operating suite.

The patient is placed in the dorsal lithotomy position, buttocks extending one inch over the end of the operating table. The table should be covered with egg-crate foam to avoid having her slip down while in steep Trendelenburg position.

After the patient is prepped and draped, a Foley catheter is placed into the bladder. EEA sizers (Covidien) are inserted into the vagina and rectum.

Two experienced surgical assistants are necessary:

• One on the patient’s right side to assist with tissue retraction and introduction of suture material
• Another seated between the patient’s legs to provide adequate vaginal and rectal manipulation during surgery.

2. Port placement, docking, and instrumentation

Pneumoperitoneum is obtained with a Veress needle. Five trocars are then placed (FIGURE 1).

Careful port placement is integral to the success of this procedure because:

• Inadequate distance between robotic arms and the camera results in arm collisions and interference
• Visualization and access to the sacral promontory may be compromised if the camera is inserted too low on the anterior abdominal wall
• Bowel retraction may be compromised if the fourth arm of the robot isn’t at least 3 cm above the anterior superior iliac crest.

My experience evaluating the abdomen before trocar insertion is that at least 15 cm is required between the pubic bone and the umbilicus to rely on this landmark for locating the 12-mm camera port.¹⁰ If this distance is shorter (as it is in many obese women), insertion above the umbilicus is necessary.

An accessory 12-mm port, used to introduce sutures and the mesh graft, is placed approximately 10 cm lateral and 4 cm cephalad to the camera in the right-upper quadrant.

An 8-mm robotic port is placed in the right lower quadrant, 10 cm lateral to the accessory port and approximately 3 cm above the anterior superior iliac crest.

The third and fourth robotic arms are placed 10 cm apart in the left lower quadrant, with the fourth arm typically as far lateral as possible.

Docking. After the patient has been placed in steep Trendelenburg position and the table is locked, the robot is docked from the patient’s left side at a 45° angle to the table. Side-docking permits easy access to the vagina to 1) evaluate graft tension and 2) complete cystoscopy to ensure ureteral and bladder integrity.

TIP Take care to ensure that the spine of the robot is positioned right next to the bed at the level of the patient’s hip; driving it up too high in relation to the abdomen can compromise the mobility of the fourth arm. In addition, if the robot is not close enough to the bed, the reach of the first (right) arm may be limited.

Next, introduce monopolar scissors through the right arm; a bipolar PK Dissector (Intuitive Surgical) through the left arm; and an atraumatic bowel grasper, such as Cadiere Forceps (Intuitive Surgical), through the fourth arm.

FIGURE 1 Placement of 5 ports for robotic sacrocolpopexy
Key: C, camera; A, accessory port; 1, right arm (monopolar shears); 2, left arm (PK Dissector); 3, fourth arm (Cadiere Forceps).

3. Dissect the sacral promontory and create a retroperitoneal tunnel

With the use of a 0° scope or 30° down-scope, retract the sigmoid colon laterally using Cadiere forceps and identify the right ureter.

TIP When you attempt robotic sacrocolpopexy for the first time, it may help to identify the sacral promontory, using a standard laparoscopic instrument with haptic feedback, before you dock the robot.

Elevate the peritoneum overlying the sacral promontory and open it using monopolar cautery. Expose the fat pad that overlays the anterior longitudinal ligament and gently dissect it away (FIGURE 2; VIDEO 1). Often, the middle sacral artery is visualized; it can be coagulated using the PK Dissector if necessary.

TIP In a case in which the promontory is difficult to find, dissecting the retrorectal space is a simple way to mobilize the bowel away from the sacrum, thus exposing the promontory.

TRICK Instead of opening the peritoneum from the sacrum to the cul-de-sac, I create a retroperitoneal tunnel along that right paracolic gutter, from the promontory to just medial to the right uterosacral ligament (VIDEO 1). Doing so has three benefits:

• It is quicker and less bloody
• It allows the mesh to lay flat in the hollow of the sacrum when you bring the sacral arm up to the promontory
• There is much less peritoneum to close over the mesh at the end of the procedure.

FIGURE 2 Entering the peritoneum
Open the peritoneum at the sacral promontory and dissect the fat pad. This reveals the anterior longitudinal ligament.

4. Dissect the vesicovaginal and rectovaginal spaces

Effective vaginal and rectal manipulation is critical to complete this part of the procedure safely. To gain access to the rectovaginal space, the vaginal assistant needs to push the vagina all the way in and up toward the anterior abdominal wall (the handle of the EEA sizer will be pushing hard up against the perineum) while simultaneously pushing the rectal probe downward (effectively scissoring the two apart).

From the exit point of the retroperitoneal tunnel that was created at the beginning of the case, then extend the peritoneal incision transversely in the shape of a “T” to expose the posterior vaginal wall (FIGURE 3, VIDEO 2). If indicated, dissect the rectovaginal space all the way down to the perineal body.

Deviate the vagina posteriorly to facilitate dissection of the bladder from the anterior vaginal wall. Use sharp dissection with scissors and short bursts of energy with monopolar cautery.

TIP If you encounter significant scarring between the bladder and vagina, retrograde-fill the bladder with 300 mL of saline mixed with methylene blue dye to identify the surgical plane.

Expose approximately 4 to 6 cm of anterior vaginal wall, depending on the degree of anterior vaginal wall prolapse. Try to leave the peritoneum intact at the apex of the vagina to reduce the chance that mesh will erode.

FIGURE 3 The peritoneal incision
Extend the peritoneal incision along the cul-de-sac to the posterior vaginal wall in a T-shaped configuration to gain access the rectovaginal space. When perorming cervicosacropexy, it is easiest to develop this surgical plane before amputating the cervix.

5. Attach the y-mesh to the vagina

Several mesh options exist: IntePro (American Medical Systems), Alyte (Bard Medical), and Restorelle Y (Mpathy Medical) are preformed Type-1 polypropylene mesh products. A correctly sized mesh can easily be fashioned by suturing together two strips of Gynemesh (Ethicon) that are approximately 3 cm wide.

Because there can be significant variability in the relative dimensions of the anterior and posterior segments of mesh, I recommend fashioning the graft after dissection is complete: When posterior wall prolapse is extensive, for example, preformed y-mesh strips may not be long enough to reach all the way down to the perineal body. After having assessed the differences in graft placement and manipulation when the two arms are sutured together 1) before the grafts are placed intracorporeally and 2) after they are placed, I’ve concluded that the first method—suturing before placement—is far easier.

Introduce the mesh graft through the accessory port after exchanging the scissors and PK dissector for a suture cutter and a large needle driver. Retract the bladder using the fourth arm, and place the anterior mesh arm over the anterior vaginal wall; suture it in place using 2-0 Gore-Tex sutures on CT-2 needles that are each cut to 6 inches long.

For greatest efficiency, anchor the two distal corners first (FIGURE 4; VIDEO 3), then place a series of interrupted stitches towards the vaginal apex. Tie the knots using 2 surgeon’s knots, followed by 2 half-hitches. Attempt to achieve healthy bites through the vaginal muscularis without perforating the epithelium.

FIGURE 4 Suturing the mesh graft to the vaginal wall
Left and right: Suture the y-shaped polypropylene mesh graft to the anterior vaginal wall first, starting at the distal corners. The bladder is retracted cephalad using the fourth arm.After you’ve adequately secured the anterior mesh arm, deviate the vagina anteriorly and drape the posterior mesh arm over the posterior vaginal wall with the assistance of the fourth robotic arm that can hold upward traction on the sacral end of the mesh graft. Starting at the vaginal apex, place 6 to 8 interrupted sutures to secure the mesh to the posterior vaginal wall (FIGURE 5; VIDEO 4). If necessary, exchange the 0° scope for a 30° up-scope so that you can fully visualize the rectovaginal space.

FIGURE 5 Attachment of the posterior arm of the mesh
The fourth arm of the robot provides upward traction on the sacral portion of the mesh graft.

6. Attach the graft to the sacrum

Again retract the sigmoid laterally to expose the promontory dissection. Retrieve the sacral arm of the mesh through the retroperitoneal tunnel and pull it up toward the promontory. Deviate the vagina toward the sacrum and, ensuring that there is no excessive tension, suture the sacral portion of the mesh graft to the anterior longitudinal ligament at the promontory, using 2 or 3 interrupted sutures (FIGURE 6, VIDEO 5).

When placing the needle during this critical juncture, it is important to rotate through the ligament along the curvature of the needle—as opposed to driving the needle forward and risking exiting farther laterally than expected.

TIP Because of the slight traction that exists on the mesh, a slip-knot is preferred instead of a surgeon’s knot when suturing the sacral portion of the mesh graft to the anterior longitudinal ligament. Take care to visualize the middle sacral artery and either suture around it or cauterize it.

FIGURE 6 Suture the mesh directly to the anterior longitudinal ligament
Use two or three stitches, secured with slip-knots. Take care not to create excessive tension on the mesh graft.

7. Extraperitonealize the mesh

I no longer routinely close the peritoneum over the mesh at the vaginal apex because I have not had a single case of small-bowel obstruction since I began performing this procedure laparoscopically. You should close the peritoneal window at the promontory, however, if the mesh is tented up at all, because tenting creates the potential for bowel to get caught beneath the mesh. Perform this closure using 2-0 monofilament suture or 2-0 Vicryl suture (Ethicon) cut to 8 inches (FIGURE 7). It is always easiest to start distally and suture towards the camera and operative instruments.

FIGURE 7 Extraperitonealize the mesh
Close the peritoneum from the apex of the vagina with a purse-string—like stitch, continuing it to the promontory in running fashion.

8. Ensure that mesh is not in the bladder or rectum

Perform cystoscopy and a rectal examination at the end of each case to confirm that no sutures or mesh material are within either viscus. It is much easier to remove these before leaving the operating room.

Modifying the procedure for uterovaginal prolapse

If the patient has an intact uterus and benign cervical cytology, perform supracervical hysterectomy before proceeding with Steps 1–8 above.

TIP Leaving the cervix in situ may reduce the chance of mesh erosion and provides an excellent platform for mesh attachment.

TRICK I find it most helpful to fully dissect the anterior and posterior vaginal walls before cervical amputation because upward traction on the corpus improves visualization of the surgical planes.

Once the cervix is amputated, however, effective vaginal manipulation can present a surgical challenge. Some surgeons use a tenaculum attached to the fourth arm of the robot to apply traction on the cervix, but this eliminates this arm from performing other necessary tasks. Malleable or Breisky-Navratil retractors can be used to delineate the anterior and posterior vaginal fornices, but are not always satisfactory—especially if an assistant isn’t seated between the legs.

TIP A useful and inexpensive instrument is the Colpo-Probe vaginal fornix delineator (Cooper Surgical) (FIGURE 8), which not only assists in dissecting the vagina from the bladder and rectum but also provides a stable surface during attachment of mesh.

FIGURE 8 Colpo-Probe
This device delineates the anterior and posterior vaginal fornices. It provides a stable platform against which to suture the mesh graft.

Tips and tricks for managing hemorrhage during sacrocolpopexy

Four potential areas of bleeding danger exist:

• In trying to find the sacral promontory, you risk entering the right common iliac vein if dissection is too far cephalad and lateral.
  TIP I strongly advise novice robotic surgeons to try to identify the site of the promontory with a standard laparoscopic instrument with haptic feedback before moving to the surgical console.
  TRICK Another trick that can help with safe identification of the promontory is mobilization of the sigmoid colon away from the sacrum by developing the retrorectal space.
• During dissection of the fat pad from the promontory, you can encounter the middle sacral artery.
  TRICK Spreading carefully in a caudal–cephalad direction until the level of the ligament is reached, instead of spreading in a lateral dimension, can decrease the chances of lacerating of this vessel.
• A dangerous plexus of veins traverses the hollow of the sacrum. If you are trying to affix mesh at the level of S2-3, therefore, you may encounter significant bleeding.
  TIP Work above the level of S1 to avoid these veins completely.
• In securing the mesh to the sacral promontory, you can puncture the left common iliac vein if you are not aware of the exit point of the needle and it traverses too far medially.

TIP If you encounter bleeding, introduce a RAY-TEC sponge (Johnson & Johnson) through the accessory port. Apply manual compression for at least 5 minutes. If bleeding persists, I recommend Floseal Hemostatic Matrix (Baxter) to control hemorrhage that arises from arterial and venous sources.

TRICK As last resort, perform emergency undocking in rapid fashion while the bedside assistant maintains pressure through the accessory port.

Conclusion

The da Vinci robotic surgical system facilitates completion of sacrocolpopexy and cervicosacropexy, in a manner identical to the open technique, by surgeons who may not possess advanced laparoscopic skills. Full knowledge of the relevant anatomy is critical; there is the potential for significant morbidity during the procedure if surgical planes are created incorrectly.

We want to hear from you! Tell us what you think.

CASE: Pain during intercourse, well after mesh implantation

Your patient, 61 years old, para 3, has come to your office by referral with a complaint of dyspareunia. The history includes placement of a synthetic vaginal mesh kit 14 months earlier for prolapse.

The medical record shows that the referring physician performed a “mesh excision” 1 year after the original procedure.

The woman reports that she is “very frustrated” that she is still dealing with this problem so long after the original procedure.

On examination, you note a 2.5-cm diameter area of exposed mesh in the anterior vagina, with healthy surrounding tissue and without inflammation or purulence (FIGURE 1). You are unable to reproduce her complaint of pain on vaginal examination.

What options can you offer to this woman? And will those options meet her therapeutic expectations?

FIGURE 1 Examination of your referred patient: Mesh is noticeably exposedThe recent increase in the use of mesh grafts to reconstruct pelvic anatomy has been directed mainly at improving surgical outcomes. Yet, at the same time, gynecologic surgeons find themselves facing a rise in associated complications of such surgery that they did not see previously.

Among the most troublesome and concerning of those complications are 1) exposure of mesh through the vaginal epithelium and 2) contraction or hardening of mesh (or both) that can result in dyspareunia and chronic pelvic pain. Other, rare complications include infection and fistula.

Our goal in this article is to address the management of graft-healing abnormalities in which a segment of the mesh is palpable or visible, or both, within the vaginal canal. Our focus is on simple abnormalities that can be managed by most generalist gynecologists; to be clear, more complex abnormalities, and those that provoke more serious or lasting symptoms, belong under the care of a specialist.

A recent shift in terminology is significant

Early on, this complication was called “erosion” as understanding of the mechanism of its development grew, however, terminology applied to the problem has changed.

In fact, mesh itself very rarely erodes into the vagina or an underlying viscus. Instead, the complication occurs most commonly as a result of disruption of a suture line—most likely the result of a hematoma or localized inflammation that develops postoperatively.

“Exposure” (our preference here) and “extrusion” are now the recommended terms, based on a consensus terminology document published this year jointly by the International Urogynecological Association and the International Continence Society.¹

Exposure of implanted mesh is considered a “simple” healing abnormality because it typically

• occurs along the suture line and early in the course of healing
• is not associated with infection of the graft.²

The typical physical appearance is one of visible mesh along an open suture line without granulation tissue or purulence—again, see FIGURE 1. The mesh is firmly adherent to the vaginal epithelial edges and underlying fascia.

The reported incidence of mesh exposures—in regard to currently used meshes, which are all Type-1, monofilament, macroporous polypropylene grafts—is approximately 10% but as high as 15% to 20% in some reported series.^3,4 The higher rates of exposure are usually seen in series in which some patients have had a synthetic graft implanted as an overlay to fascial midline plication. When the graft is implanted in the subfascial layer of the vaginal wall (i.e., without midline plication), however, the reported rate of exposure falls—to 5% to 10%.^5-7

Recommendations for management

Most common problem: Exposure

Initially, recommendations for “erosion” management were based on concerns about underlying mesh infection or rejection, and included a need to remove the entire graft. That recommendation still applies to multifilament, microporous grafts that present with inflammatory infiltrates, granulation tissue, and purulence. Although these kinds of grafts (known as “Type-2/3 grafts”—e.g., GoreTex, IVS) have not been marketed for pelvic reconstruction over the past 3 to 5 years, their behavior post-implantation is less predictable—and patients who have delayed healing abnormalities are, therefore, still being seen. It’s fortunate that development of an overlying biofilm prevents tissue incorporation into these types of graft, allowing them to be removed easily.

Exposures related to Type-1 mesh—currently used in pelvic reconstruction—that occur without surrounding infection do not require extensive removal. Rather, they can be managed conservatively or, when necessary, with outpatient surgery. In patients who are not sexually active, exposures are usually asymptomatic; they might only be observed by the physician on vaginal examination and are amenable to simple monitoring. In sexually active patients, exposure of Type-1 mesh usually results in dyspareunia or a complaint that the partner “can feel the mesh.” Depending on the size and the nature of symptoms and the extent of the defect, these commonly seen exposures can be managed by following a simple algorithm.

Palpable or visible mesh fibrils can be trimmed in the office; they might even respond to local estrogen alone. Consider these options if the patient displays vaginal atrophy.

Typically, vaginal estrogen is prescribed as 1 g nightly for 2 weeks and then 1 g two or three nights a week. Re-examine the patient in 3 months; if symptoms of mesh exposure persist, it’s unlikely that continued conservative therapy will be successful, and outpatient surgery is recommended.

When exposure is asymptomatic, you can simply monitor the condition for 3 to 6 months; if complaints or findings arise, consider intervention.

Small (<0.5 cm in diameter) exposures can also be managed in the office, including excision of exposed mesh and local estrogen. If the exposure is easily reachable, we recommend grasping the exposed area with pick-ups or a hemostat and with gentle traction, using Metzenbaum scissors to trim exposed mesh as close to the vaginal epithelium as possible. Local topical or injected anesthesia may be needed. Bleeding should be minimal because no dissection is necessary. Silver nitrate can be applied for any minor bleeding. Larger (0.5–4.0 cm) exposures are unlikely to heal on their own. They require outpatient excision in the operating room.

Preoperative tissue preparation with local estrogen is key to successful repair of these exposures. Vaginal estrogen increases blood flow to the epithelium; as tissue becomes well-estrogenized, risk of recurrence diminishes.

The technique we employ includes:

• circumferential infiltration of vaginal epithelium surrounding the exposed mesh with 1% lidocaine with epinephrine
• sharp circumscription of the area of exposure, using a scalpel, with a 0.5-cm margin of vaginal epithelium (FIGURE 2)
• wide dissection, with undermining and mobilization of surrounding healthy vaginal epithelium around the exposure (FIGURE 3)
• excision of the exposed mesh and attached vaginal mucosa, with careful dissection of the mesh off underlying tissues with Metzenbaum scissors—being careful to avoid injury to underlying bladder or rectum (FIGURE 4)
• reapproximation of mesh edges, using 2-0 polypropylene suture to close the resulting defect so that prolapse does not recur (FIGURE 5)
• closing of the previously mobilized vaginal epithelium with 2-0 Vicryl suture, without tension, to cover the reapproximated mesh edges—after irrigation and assurance of adequate hemostasis (FIGURE 6).

FIGURE 2 Incision of vaginal epithelium
Allow for a 0.5-cm margin.

FIGURE 3 Undermining and mobilization of epithelium
Perform wide dissection.

FIGURE 4 Dissection of mesh from underlying tissue
Keep clear of underlying bladder and rectum!

FIGURE 5 Reapproximation of edges to re-establish support
Our choice of suture is 2-0 polypropylene.

FIGURE 6 Irrigation of vaginal epithelium, followed by closure
Before you close, ensure that hemostasis is adequate.The choice of closure—vertical or horizontal—depends on the nature of the original defect.

You can watch a video of this technique that we’ve provided.

Several cautions should be taken with this technique, including:

• avoiding narrowing the vaginal canal
• minimizing trauma to healthy vaginal epithelium that will be used for closure
• maintaining hemostasis to avoid formation of hematomas.

Largest (>4 cm) exposures are likely the result of devascularized sloughing of vaginal epithelium. They are, fortunately, uncommon.

It’s unlikely that, after excision of exposed mesh, the vaginal epithelial edges can be approximated without significantly narrowing or shortening the vaginal canal. Proposed techniques for managing these large exposures include covering the defect with a biologic graft, such as small intestinal submucosa, to allow epithelium to re-grow. Regrettably, prolapse is likely to recur in the unprotected area that results.

Contraction and localized pain

Hardening and contraction typically occur along the fixation arms of the mesh. These complications might result from mesh shrinkage or from mesh being placed too tight, so to speak, at implantation. Rarely does the entire implanted mesh contract.

Severe mesh contraction can result in localized pain and de novo dyspareunia. Symptoms usually resolve after identification of the painful area and removal of the involved mesh segment.⁸

Diagnostic maneuver. In-office trigger-point injection of bupivacaine with triamcinolone is useful to accurately identify the location of pain that is causing dyspareunia. After injection, the patient is asked to return home and resume sexual intercourse; if dyspareunia diminishes significantly, surgical removal of the involved mesh segment is likely to ameliorate symptoms.

If dyspareunia persists after injection, however, the problem either 1) originates in a different location along the graft or 2) may not be related to the mesh—that is, it may be introital pain or preexisting vaginal pain.

The findings of trigger-point injection and a subsequent trial of sexual intercourse are useful for counseling the patient and developing realistic expectations that surgery will be successful.

Management note: Mesh contraction should be managed by a surgeon who is experienced in extensive deep pelvic dissection, which is necessary to remove the mesh arms.

Chronic pain

Diffuse vaginal pain after mesh implantation is unusual; typically, the patient’s report of pain has been preceded by recognition of another, underlying pelvic pain syndrome. Management of such pain is controversial, and many patients will not be satisfied until the entire graft is removed. Whether such drastic intervention actually resolves the pain is unclear; again, work with the patient to create realistic expectations before surgery—including the risk that prolapse will recur and that reoperation will be necessary.

Management note: An existing pelvic pain syndrome should be considered a relative contraindication to implantation of mesh.

Infection of the graft

Rarely, infection has been reported after implantation of Type-1 mesh—the result of either multi-microbial colonization or isolated infection by Bacteriodes melaninogenicus, Actinomyces spp, or Staphylococcus aureus. Untreated preoperative bacterial vaginitis is likely the underlying cause, and should be considered a contraindication to mesh implantation.

Typically, these patients complain of vaginal discharge and bleeding early postoperatively. Vaginal exposure of the mesh results from local inflammation and necrosis of tissue.

Management note: In these cases, it is necessary to 1) prescribe antimicrobial therapy that covers gram-negative and anaerobic bacteria and 2) undertake surgical removal of the exposed mesh, as we outlined above.⁹

Visceral erosion or fistula

Many experts believe that what is recorded as “erosion” of synthetic mesh into bladder or rectum is, in fact, a result of unrecognized visceral perforation at original implantation. This is a rare complication of mesh implantation.

Patients who experience mesh erosion into the bladder may have lower urinary-tract symptoms (LUTS) of urgency, frequency, dysuria, and hematuria. Any patient who reports de novo LUTS in the early postoperative period after a vaginal mesh procedure should receive office cystourethroscopy to ensure that no foreign body is present in the bladder or urethra.

Management note: Operative cystourethroscopy, with removal of exposed mesh, is the management of choice when mesh is found in the bladder or urethra.

Patients who have constant urinary or fecal incontinence immediately after surgery should be evaluated for vesicovaginal or rectovaginal fistula.

The presence of any of these complications necessitates removal of the involved mesh in its entirety, with concomitant repair of fistula. Typically, the procedures are performed by a specialist.

Our experience with correcting simple mesh exposures

During the past year at our tertiary referral center, 26 patients have undergone mesh revision because of exposure, using the technique we described above (FIGURE 2-6). The problem resolved in all; none had persistent dyspareunia. Many of these patients had already undergone attempts at correction of the exposure elsewhere—mostly, in the office, using techniques appropriate for that setting. Prolapse has not recurred in the 10 patients who required reapproximation of mesh edges because of a defect >2.5 cm.

CASE RESOLVED: Treatment, improvement

Under your care, the patient undergoes simplified outpatient excision of the exposed area of mesh. Mesh edges are reapproximated to support the resulting 3-cm defect.

At a 12-week postop visit, you note complete resolution of the exposure and normal vaginal caliber. The patient continues to apply estrogen cream and reports sustained improvement in sexual function.

For simple presentations, success is within reach

Simple mesh exposure can (as in the case we described) be managed by most gynecologists, utilizing the simple stepwise approach that we outlined above (for additional tips based on our experience, see “Pearls for avoiding mesh exposures”). In the case of more significant symptoms, de novo dyspareunia, visceral erosion, or fistula, however, referral to a specialist is warranted.

We want to hear from you! Tell us what you think.

CASE: Pain during intercourse, well after mesh implantation

Your patient, 61 years old, para 3, has come to your office by referral with a complaint of dyspareunia. The history includes placement of a synthetic vaginal mesh kit 14 months earlier for prolapse.

The medical record shows that the referring physician performed a “mesh excision” 1 year after the original procedure.

The woman reports that she is “very frustrated” that she is still dealing with this problem so long after the original procedure.

On examination, you note a 2.5-cm diameter area of exposed mesh in the anterior vagina, with healthy surrounding tissue and without inflammation or purulence (FIGURE 1). You are unable to reproduce her complaint of pain on vaginal examination.

What options can you offer to this woman? And will those options meet her therapeutic expectations?

FIGURE 1 Examination of your referred patient: Mesh is noticeably exposedThe recent increase in the use of mesh grafts to reconstruct pelvic anatomy has been directed mainly at improving surgical outcomes. Yet, at the same time, gynecologic surgeons find themselves facing a rise in associated complications of such surgery that they did not see previously.

Among the most troublesome and concerning of those complications are 1) exposure of mesh through the vaginal epithelium and 2) contraction or hardening of mesh (or both) that can result in dyspareunia and chronic pelvic pain. Other, rare complications include infection and fistula.

Our goal in this article is to address the management of graft-healing abnormalities in which a segment of the mesh is palpable or visible, or both, within the vaginal canal. Our focus is on simple abnormalities that can be managed by most generalist gynecologists; to be clear, more complex abnormalities, and those that provoke more serious or lasting symptoms, belong under the care of a specialist.

A recent shift in terminology is significant

Early on, this complication was called “erosion” as understanding of the mechanism of its development grew, however, terminology applied to the problem has changed.

In fact, mesh itself very rarely erodes into the vagina or an underlying viscus. Instead, the complication occurs most commonly as a result of disruption of a suture line—most likely the result of a hematoma or localized inflammation that develops postoperatively.

“Exposure” (our preference here) and “extrusion” are now the recommended terms, based on a consensus terminology document published this year jointly by the International Urogynecological Association and the International Continence Society.¹

Exposure of implanted mesh is considered a “simple” healing abnormality because it typically

• occurs along the suture line and early in the course of healing
• is not associated with infection of the graft.²

The typical physical appearance is one of visible mesh along an open suture line without granulation tissue or purulence—again, see FIGURE 1. The mesh is firmly adherent to the vaginal epithelial edges and underlying fascia.

The reported incidence of mesh exposures—in regard to currently used meshes, which are all Type-1, monofilament, macroporous polypropylene grafts—is approximately 10% but as high as 15% to 20% in some reported series.^3,4 The higher rates of exposure are usually seen in series in which some patients have had a synthetic graft implanted as an overlay to fascial midline plication. When the graft is implanted in the subfascial layer of the vaginal wall (i.e., without midline plication), however, the reported rate of exposure falls—to 5% to 10%.^5-7

Recommendations for management

Most common problem: Exposure

Initially, recommendations for “erosion” management were based on concerns about underlying mesh infection or rejection, and included a need to remove the entire graft. That recommendation still applies to multifilament, microporous grafts that present with inflammatory infiltrates, granulation tissue, and purulence. Although these kinds of grafts (known as “Type-2/3 grafts”—e.g., GoreTex, IVS) have not been marketed for pelvic reconstruction over the past 3 to 5 years, their behavior post-implantation is less predictable—and patients who have delayed healing abnormalities are, therefore, still being seen. It’s fortunate that development of an overlying biofilm prevents tissue incorporation into these types of graft, allowing them to be removed easily.

Exposures related to Type-1 mesh—currently used in pelvic reconstruction—that occur without surrounding infection do not require extensive removal. Rather, they can be managed conservatively or, when necessary, with outpatient surgery. In patients who are not sexually active, exposures are usually asymptomatic; they might only be observed by the physician on vaginal examination and are amenable to simple monitoring. In sexually active patients, exposure of Type-1 mesh usually results in dyspareunia or a complaint that the partner “can feel the mesh.” Depending on the size and the nature of symptoms and the extent of the defect, these commonly seen exposures can be managed by following a simple algorithm.

Palpable or visible mesh fibrils can be trimmed in the office; they might even respond to local estrogen alone. Consider these options if the patient displays vaginal atrophy.

Typically, vaginal estrogen is prescribed as 1 g nightly for 2 weeks and then 1 g two or three nights a week. Re-examine the patient in 3 months; if symptoms of mesh exposure persist, it’s unlikely that continued conservative therapy will be successful, and outpatient surgery is recommended.

When exposure is asymptomatic, you can simply monitor the condition for 3 to 6 months; if complaints or findings arise, consider intervention.

Small (<0.5 cm in diameter) exposures can also be managed in the office, including excision of exposed mesh and local estrogen. If the exposure is easily reachable, we recommend grasping the exposed area with pick-ups or a hemostat and with gentle traction, using Metzenbaum scissors to trim exposed mesh as close to the vaginal epithelium as possible. Local topical or injected anesthesia may be needed. Bleeding should be minimal because no dissection is necessary. Silver nitrate can be applied for any minor bleeding. Larger (0.5–4.0 cm) exposures are unlikely to heal on their own. They require outpatient excision in the operating room.

Preoperative tissue preparation with local estrogen is key to successful repair of these exposures. Vaginal estrogen increases blood flow to the epithelium; as tissue becomes well-estrogenized, risk of recurrence diminishes.

The technique we employ includes:

• circumferential infiltration of vaginal epithelium surrounding the exposed mesh with 1% lidocaine with epinephrine
• sharp circumscription of the area of exposure, using a scalpel, with a 0.5-cm margin of vaginal epithelium (FIGURE 2)
• wide dissection, with undermining and mobilization of surrounding healthy vaginal epithelium around the exposure (FIGURE 3)
• excision of the exposed mesh and attached vaginal mucosa, with careful dissection of the mesh off underlying tissues with Metzenbaum scissors—being careful to avoid injury to underlying bladder or rectum (FIGURE 4)
• reapproximation of mesh edges, using 2-0 polypropylene suture to close the resulting defect so that prolapse does not recur (FIGURE 5)
• closing of the previously mobilized vaginal epithelium with 2-0 Vicryl suture, without tension, to cover the reapproximated mesh edges—after irrigation and assurance of adequate hemostasis (FIGURE 6).

FIGURE 2 Incision of vaginal epithelium
Allow for a 0.5-cm margin.

FIGURE 3 Undermining and mobilization of epithelium
Perform wide dissection.

FIGURE 4 Dissection of mesh from underlying tissue
Keep clear of underlying bladder and rectum!

FIGURE 5 Reapproximation of edges to re-establish support
Our choice of suture is 2-0 polypropylene.

FIGURE 6 Irrigation of vaginal epithelium, followed by closure
Before you close, ensure that hemostasis is adequate.The choice of closure—vertical or horizontal—depends on the nature of the original defect.

You can watch a video of this technique that we’ve provided.

Several cautions should be taken with this technique, including:

• avoiding narrowing the vaginal canal
• minimizing trauma to healthy vaginal epithelium that will be used for closure
• maintaining hemostasis to avoid formation of hematomas.

Largest (>4 cm) exposures are likely the result of devascularized sloughing of vaginal epithelium. They are, fortunately, uncommon.

It’s unlikely that, after excision of exposed mesh, the vaginal epithelial edges can be approximated without significantly narrowing or shortening the vaginal canal. Proposed techniques for managing these large exposures include covering the defect with a biologic graft, such as small intestinal submucosa, to allow epithelium to re-grow. Regrettably, prolapse is likely to recur in the unprotected area that results.

Contraction and localized pain

Hardening and contraction typically occur along the fixation arms of the mesh. These complications might result from mesh shrinkage or from mesh being placed too tight, so to speak, at implantation. Rarely does the entire implanted mesh contract.

Severe mesh contraction can result in localized pain and de novo dyspareunia. Symptoms usually resolve after identification of the painful area and removal of the involved mesh segment.⁸

Diagnostic maneuver. In-office trigger-point injection of bupivacaine with triamcinolone is useful to accurately identify the location of pain that is causing dyspareunia. After injection, the patient is asked to return home and resume sexual intercourse; if dyspareunia diminishes significantly, surgical removal of the involved mesh segment is likely to ameliorate symptoms.

If dyspareunia persists after injection, however, the problem either 1) originates in a different location along the graft or 2) may not be related to the mesh—that is, it may be introital pain or preexisting vaginal pain.

The findings of trigger-point injection and a subsequent trial of sexual intercourse are useful for counseling the patient and developing realistic expectations that surgery will be successful.

Management note: Mesh contraction should be managed by a surgeon who is experienced in extensive deep pelvic dissection, which is necessary to remove the mesh arms.

Chronic pain

Diffuse vaginal pain after mesh implantation is unusual; typically, the patient’s report of pain has been preceded by recognition of another, underlying pelvic pain syndrome. Management of such pain is controversial, and many patients will not be satisfied until the entire graft is removed. Whether such drastic intervention actually resolves the pain is unclear; again, work with the patient to create realistic expectations before surgery—including the risk that prolapse will recur and that reoperation will be necessary.

Management note: An existing pelvic pain syndrome should be considered a relative contraindication to implantation of mesh.

Infection of the graft

Rarely, infection has been reported after implantation of Type-1 mesh—the result of either multi-microbial colonization or isolated infection by Bacteriodes melaninogenicus, Actinomyces spp, or Staphylococcus aureus. Untreated preoperative bacterial vaginitis is likely the underlying cause, and should be considered a contraindication to mesh implantation.

Typically, these patients complain of vaginal discharge and bleeding early postoperatively. Vaginal exposure of the mesh results from local inflammation and necrosis of tissue.

Management note: In these cases, it is necessary to 1) prescribe antimicrobial therapy that covers gram-negative and anaerobic bacteria and 2) undertake surgical removal of the exposed mesh, as we outlined above.⁹

Visceral erosion or fistula

Many experts believe that what is recorded as “erosion” of synthetic mesh into bladder or rectum is, in fact, a result of unrecognized visceral perforation at original implantation. This is a rare complication of mesh implantation.

Patients who experience mesh erosion into the bladder may have lower urinary-tract symptoms (LUTS) of urgency, frequency, dysuria, and hematuria. Any patient who reports de novo LUTS in the early postoperative period after a vaginal mesh procedure should receive office cystourethroscopy to ensure that no foreign body is present in the bladder or urethra.

Management note: Operative cystourethroscopy, with removal of exposed mesh, is the management of choice when mesh is found in the bladder or urethra.

Patients who have constant urinary or fecal incontinence immediately after surgery should be evaluated for vesicovaginal or rectovaginal fistula.

The presence of any of these complications necessitates removal of the involved mesh in its entirety, with concomitant repair of fistula. Typically, the procedures are performed by a specialist.

Our experience with correcting simple mesh exposures

During the past year at our tertiary referral center, 26 patients have undergone mesh revision because of exposure, using the technique we described above (FIGURE 2-6). The problem resolved in all; none had persistent dyspareunia. Many of these patients had already undergone attempts at correction of the exposure elsewhere—mostly, in the office, using techniques appropriate for that setting. Prolapse has not recurred in the 10 patients who required reapproximation of mesh edges because of a defect >2.5 cm.

CASE RESOLVED: Treatment, improvement

Under your care, the patient undergoes simplified outpatient excision of the exposed area of mesh. Mesh edges are reapproximated to support the resulting 3-cm defect.

At a 12-week postop visit, you note complete resolution of the exposure and normal vaginal caliber. The patient continues to apply estrogen cream and reports sustained improvement in sexual function.

For simple presentations, success is within reach

Simple mesh exposure can (as in the case we described) be managed by most gynecologists, utilizing the simple stepwise approach that we outlined above (for additional tips based on our experience, see “Pearls for avoiding mesh exposures”). In the case of more significant symptoms, de novo dyspareunia, visceral erosion, or fistula, however, referral to a specialist is warranted.

We want to hear from you! Tell us what you think.

CASE: Pain during intercourse, well after mesh implantation

Your patient, 61 years old, para 3, has come to your office by referral with a complaint of dyspareunia. The history includes placement of a synthetic vaginal mesh kit 14 months earlier for prolapse.

The medical record shows that the referring physician performed a “mesh excision” 1 year after the original procedure.

The woman reports that she is “very frustrated” that she is still dealing with this problem so long after the original procedure.

On examination, you note a 2.5-cm diameter area of exposed mesh in the anterior vagina, with healthy surrounding tissue and without inflammation or purulence (FIGURE 1). You are unable to reproduce her complaint of pain on vaginal examination.

What options can you offer to this woman? And will those options meet her therapeutic expectations?

FIGURE 1 Examination of your referred patient: Mesh is noticeably exposedThe recent increase in the use of mesh grafts to reconstruct pelvic anatomy has been directed mainly at improving surgical outcomes. Yet, at the same time, gynecologic surgeons find themselves facing a rise in associated complications of such surgery that they did not see previously.

Among the most troublesome and concerning of those complications are 1) exposure of mesh through the vaginal epithelium and 2) contraction or hardening of mesh (or both) that can result in dyspareunia and chronic pelvic pain. Other, rare complications include infection and fistula.

Our goal in this article is to address the management of graft-healing abnormalities in which a segment of the mesh is palpable or visible, or both, within the vaginal canal. Our focus is on simple abnormalities that can be managed by most generalist gynecologists; to be clear, more complex abnormalities, and those that provoke more serious or lasting symptoms, belong under the care of a specialist.

A recent shift in terminology is significant

Early on, this complication was called “erosion” as understanding of the mechanism of its development grew, however, terminology applied to the problem has changed.

In fact, mesh itself very rarely erodes into the vagina or an underlying viscus. Instead, the complication occurs most commonly as a result of disruption of a suture line—most likely the result of a hematoma or localized inflammation that develops postoperatively.

“Exposure” (our preference here) and “extrusion” are now the recommended terms, based on a consensus terminology document published this year jointly by the International Urogynecological Association and the International Continence Society.¹

Exposure of implanted mesh is considered a “simple” healing abnormality because it typically

• occurs along the suture line and early in the course of healing
• is not associated with infection of the graft.²

The typical physical appearance is one of visible mesh along an open suture line without granulation tissue or purulence—again, see FIGURE 1. The mesh is firmly adherent to the vaginal epithelial edges and underlying fascia.

The reported incidence of mesh exposures—in regard to currently used meshes, which are all Type-1, monofilament, macroporous polypropylene grafts—is approximately 10% but as high as 15% to 20% in some reported series.^3,4 The higher rates of exposure are usually seen in series in which some patients have had a synthetic graft implanted as an overlay to fascial midline plication. When the graft is implanted in the subfascial layer of the vaginal wall (i.e., without midline plication), however, the reported rate of exposure falls—to 5% to 10%.^5-7

Recommendations for management

Most common problem: Exposure

Initially, recommendations for “erosion” management were based on concerns about underlying mesh infection or rejection, and included a need to remove the entire graft. That recommendation still applies to multifilament, microporous grafts that present with inflammatory infiltrates, granulation tissue, and purulence. Although these kinds of grafts (known as “Type-2/3 grafts”—e.g., GoreTex, IVS) have not been marketed for pelvic reconstruction over the past 3 to 5 years, their behavior post-implantation is less predictable—and patients who have delayed healing abnormalities are, therefore, still being seen. It’s fortunate that development of an overlying biofilm prevents tissue incorporation into these types of graft, allowing them to be removed easily.

Exposures related to Type-1 mesh—currently used in pelvic reconstruction—that occur without surrounding infection do not require extensive removal. Rather, they can be managed conservatively or, when necessary, with outpatient surgery. In patients who are not sexually active, exposures are usually asymptomatic; they might only be observed by the physician on vaginal examination and are amenable to simple monitoring. In sexually active patients, exposure of Type-1 mesh usually results in dyspareunia or a complaint that the partner “can feel the mesh.” Depending on the size and the nature of symptoms and the extent of the defect, these commonly seen exposures can be managed by following a simple algorithm.

Palpable or visible mesh fibrils can be trimmed in the office; they might even respond to local estrogen alone. Consider these options if the patient displays vaginal atrophy.

Typically, vaginal estrogen is prescribed as 1 g nightly for 2 weeks and then 1 g two or three nights a week. Re-examine the patient in 3 months; if symptoms of mesh exposure persist, it’s unlikely that continued conservative therapy will be successful, and outpatient surgery is recommended.

When exposure is asymptomatic, you can simply monitor the condition for 3 to 6 months; if complaints or findings arise, consider intervention.

Small (<0.5 cm in diameter) exposures can also be managed in the office, including excision of exposed mesh and local estrogen. If the exposure is easily reachable, we recommend grasping the exposed area with pick-ups or a hemostat and with gentle traction, using Metzenbaum scissors to trim exposed mesh as close to the vaginal epithelium as possible. Local topical or injected anesthesia may be needed. Bleeding should be minimal because no dissection is necessary. Silver nitrate can be applied for any minor bleeding. Larger (0.5–4.0 cm) exposures are unlikely to heal on their own. They require outpatient excision in the operating room.

Preoperative tissue preparation with local estrogen is key to successful repair of these exposures. Vaginal estrogen increases blood flow to the epithelium; as tissue becomes well-estrogenized, risk of recurrence diminishes.

The technique we employ includes:

• circumferential infiltration of vaginal epithelium surrounding the exposed mesh with 1% lidocaine with epinephrine
• sharp circumscription of the area of exposure, using a scalpel, with a 0.5-cm margin of vaginal epithelium (FIGURE 2)
• wide dissection, with undermining and mobilization of surrounding healthy vaginal epithelium around the exposure (FIGURE 3)
• excision of the exposed mesh and attached vaginal mucosa, with careful dissection of the mesh off underlying tissues with Metzenbaum scissors—being careful to avoid injury to underlying bladder or rectum (FIGURE 4)
• reapproximation of mesh edges, using 2-0 polypropylene suture to close the resulting defect so that prolapse does not recur (FIGURE 5)
• closing of the previously mobilized vaginal epithelium with 2-0 Vicryl suture, without tension, to cover the reapproximated mesh edges—after irrigation and assurance of adequate hemostasis (FIGURE 6).

FIGURE 2 Incision of vaginal epithelium
Allow for a 0.5-cm margin.

FIGURE 3 Undermining and mobilization of epithelium
Perform wide dissection.

FIGURE 4 Dissection of mesh from underlying tissue
Keep clear of underlying bladder and rectum!

FIGURE 5 Reapproximation of edges to re-establish support
Our choice of suture is 2-0 polypropylene.

FIGURE 6 Irrigation of vaginal epithelium, followed by closure
Before you close, ensure that hemostasis is adequate.The choice of closure—vertical or horizontal—depends on the nature of the original defect.

You can watch a video of this technique that we’ve provided.

Several cautions should be taken with this technique, including:

• avoiding narrowing the vaginal canal
• minimizing trauma to healthy vaginal epithelium that will be used for closure
• maintaining hemostasis to avoid formation of hematomas.

Largest (>4 cm) exposures are likely the result of devascularized sloughing of vaginal epithelium. They are, fortunately, uncommon.

It’s unlikely that, after excision of exposed mesh, the vaginal epithelial edges can be approximated without significantly narrowing or shortening the vaginal canal. Proposed techniques for managing these large exposures include covering the defect with a biologic graft, such as small intestinal submucosa, to allow epithelium to re-grow. Regrettably, prolapse is likely to recur in the unprotected area that results.

Contraction and localized pain

Hardening and contraction typically occur along the fixation arms of the mesh. These complications might result from mesh shrinkage or from mesh being placed too tight, so to speak, at implantation. Rarely does the entire implanted mesh contract.

Severe mesh contraction can result in localized pain and de novo dyspareunia. Symptoms usually resolve after identification of the painful area and removal of the involved mesh segment.⁸

Diagnostic maneuver. In-office trigger-point injection of bupivacaine with triamcinolone is useful to accurately identify the location of pain that is causing dyspareunia. After injection, the patient is asked to return home and resume sexual intercourse; if dyspareunia diminishes significantly, surgical removal of the involved mesh segment is likely to ameliorate symptoms.

If dyspareunia persists after injection, however, the problem either 1) originates in a different location along the graft or 2) may not be related to the mesh—that is, it may be introital pain or preexisting vaginal pain.

The findings of trigger-point injection and a subsequent trial of sexual intercourse are useful for counseling the patient and developing realistic expectations that surgery will be successful.

Management note: Mesh contraction should be managed by a surgeon who is experienced in extensive deep pelvic dissection, which is necessary to remove the mesh arms.

Chronic pain

Diffuse vaginal pain after mesh implantation is unusual; typically, the patient’s report of pain has been preceded by recognition of another, underlying pelvic pain syndrome. Management of such pain is controversial, and many patients will not be satisfied until the entire graft is removed. Whether such drastic intervention actually resolves the pain is unclear; again, work with the patient to create realistic expectations before surgery—including the risk that prolapse will recur and that reoperation will be necessary.

Management note: An existing pelvic pain syndrome should be considered a relative contraindication to implantation of mesh.

Infection of the graft

Rarely, infection has been reported after implantation of Type-1 mesh—the result of either multi-microbial colonization or isolated infection by Bacteriodes melaninogenicus, Actinomyces spp, or Staphylococcus aureus. Untreated preoperative bacterial vaginitis is likely the underlying cause, and should be considered a contraindication to mesh implantation.

Typically, these patients complain of vaginal discharge and bleeding early postoperatively. Vaginal exposure of the mesh results from local inflammation and necrosis of tissue.

Management note: In these cases, it is necessary to 1) prescribe antimicrobial therapy that covers gram-negative and anaerobic bacteria and 2) undertake surgical removal of the exposed mesh, as we outlined above.⁹

Visceral erosion or fistula

Many experts believe that what is recorded as “erosion” of synthetic mesh into bladder or rectum is, in fact, a result of unrecognized visceral perforation at original implantation. This is a rare complication of mesh implantation.

Patients who experience mesh erosion into the bladder may have lower urinary-tract symptoms (LUTS) of urgency, frequency, dysuria, and hematuria. Any patient who reports de novo LUTS in the early postoperative period after a vaginal mesh procedure should receive office cystourethroscopy to ensure that no foreign body is present in the bladder or urethra.

Management note: Operative cystourethroscopy, with removal of exposed mesh, is the management of choice when mesh is found in the bladder or urethra.

Patients who have constant urinary or fecal incontinence immediately after surgery should be evaluated for vesicovaginal or rectovaginal fistula.

The presence of any of these complications necessitates removal of the involved mesh in its entirety, with concomitant repair of fistula. Typically, the procedures are performed by a specialist.

Our experience with correcting simple mesh exposures

During the past year at our tertiary referral center, 26 patients have undergone mesh revision because of exposure, using the technique we described above (FIGURE 2-6). The problem resolved in all; none had persistent dyspareunia. Many of these patients had already undergone attempts at correction of the exposure elsewhere—mostly, in the office, using techniques appropriate for that setting. Prolapse has not recurred in the 10 patients who required reapproximation of mesh edges because of a defect >2.5 cm.

CASE RESOLVED: Treatment, improvement

Under your care, the patient undergoes simplified outpatient excision of the exposed area of mesh. Mesh edges are reapproximated to support the resulting 3-cm defect.

At a 12-week postop visit, you note complete resolution of the exposure and normal vaginal caliber. The patient continues to apply estrogen cream and reports sustained improvement in sexual function.

For simple presentations, success is within reach

Simple mesh exposure can (as in the case we described) be managed by most gynecologists, utilizing the simple stepwise approach that we outlined above (for additional tips based on our experience, see “Pearls for avoiding mesh exposures”). In the case of more significant symptoms, de novo dyspareunia, visceral erosion, or fistula, however, referral to a specialist is warranted.

We want to hear from you! Tell us what you think.

This article, with accompanying video footage, is presented with the support of the International Academy of Pelvic Surgery.

The concept of utilizing the uterosacral ligaments to support the vaginal cuff and correct an enterocele is nothing new: As early as 1957, Milton McCall described what became known as the McCall culdoplasty, in which sutures incorporated the uterosacral ligaments into the posterior vaginal vault to obliterate the cul-de-sac and suspend or support the vaginal apex at the time of vaginal hysterectomy.¹

Later, in the 1990s, Richardson promoted the concept that, in patients who have pelvic organ prolapse, the uterosacral ligaments do not become attenuated, instead, they break at specific points.

Shull and colleagues took this idea and described how utilizing uterosacral ligaments to support the vaginal cuff can be performed vaginally—by passing sutures bilaterally through the uterosacral ligaments near the level of the ischial spine.²

Since Shull described this procedure, numerous published studies have demonstrated outcomes similar to other vaginal suspension procedures, such as sacrospinous ligament suspension.^3-5

Potential advantages of a high uterosacral vaginal vault suspension are that:

• it provides good apical support without significantly distorting the vaginal axis, making it applicable to all types of vaginal prolapse
• intraperitoneal passage of sutures can be a lot cleaner and simpler than passing sutures, or anchors, through retroperitoneal structures, such as the sacrospinous ligament (FIGURE 1).

FIGURE 1 Locating intraperitoneal sutures during uterosacral suspension

Cross-section of the pelvic floor shows where sutures are placed as part of McCall culdoplasty (1), traditional uterosacral suspension (2), and modified high uterosacral suspension (3). Note: High uterosacral suspension may involve passing the suture through the sacrospinous ligament–coccygeus (SSL-C) muscle complex (dashed oval) because a segment of the uterosacral ligament inserts into that structure.

A disadvantage of the procedure is that the uterosacral ligament may, at times, lie in close proximity to the ureter. Studies have shown that the ureter can become kinked when sutures in this procedure are passed too far laterally.^2-5

High uterosacral suspension has been our operation of choice for 11 years for patients who have pelvic organ prolapse in which the peritoneum is accessible (see “How this procedure evolved in our hands”). In this article, we provide a step-by-step description of the procedure. Four accompanying videos that further illuminate those steps are noted in the text here at appropriate places.(For example, Video #1, immediately below, sets the stage for the step-by-step discussion by reviewing pertinent pelvic anatomy.)

Details of the procedure

1. Enter the peritoneum

It’s our opinion that, even though extraperitoneal uterosacral suspension procedures have been described, the pertinent anatomic structures (again, see Video #1) are not easily identifiable unless suspension is undertaken intraperitoneally. Entering the peritoneum is, obviously, not a concern if the patient is undergoing vaginal hysterectomy. If the patient has post-hysterectomy prolapse, however, you must be able to isolate an enterocele and enter the peritoneum (follow FIGURE 2, beginning here and through subsequent steps of the procedure).

FIGURE 2 Step by step: High uterosacral vaginal vault suspension

A The most prominent portion of the prolapsed vaginal vault is grasped with two Allis clamps. B The vaginal wall is opened up and the enterocele sac is identified and entered. C The bowel is packed high into the pelvis using large laparotomy sponges. The retractor lifts the sponges out of the lower pelvis, thus completely exposing the cul-de-sac. When appropriate traction is placed downward on the uterosacral ligaments with an Allis clamp, the uterosacral ligaments are easily palpated bilaterally. D Delayed absorbable sutures have been passed through the uppermost portion of the uterosacral ligaments on each side, and have been individually tagged.
E Each end of the previously passed sutures is brought out through the posterior peritoneum and the posterior vaginal wall. (A free needle is used to pass both ends of these delayed absorbable sutures through the full thickness of the vaginal wall.) F Anterior colporrhaphy is begun by initiating dissection between the prolapsed bladder and the anterior vaginal wall. G Anterior colporrhaphy is complete. H The vagina has been appropriately trimmed and closed with interrupted or continuous delayed absorbable sutures. Delayed absorbable sutures that were previously brought out through the full thickness of the posterior vaginal wall are then tied; doing so elevates the prolapsed vaginal vault high up into the hollow of the sacrum.Once you have entered the peritoneum, the cul-de-sac must be relatively free of adhesive disease if you are to be able to continue with this procedure. (See “5 surgical pearls for high ureterosacral vaginal vault suspension”)

2. Pack the bowel; expose the uterosacral ligaments

Next, pack the small bowel out of the cul-de-sac to allow easy access and visualization of the uppermost portions of the uterosacral ligament. This is best accomplished by passing large, moistened laparotomy sponges intraperitoneally and elevating them with a large retractor (e.g., Deaver, Breisky-Navrital, Sweetheart).

When the bowel is appropriately packed, the retractor lifts the intestinal contents out of the pelvis, usually allowing easy access to the proximal or uppermost portion of the uterosacral ligaments (see Video #3, which focuses on the anatomy of the uterosacral ligament).

When performing high uterosacral suspension, it is possible to pass sutures through the coccygeus muscle-sacrospinous ligament complex (arrow) because a segment of the uterosacral ligament inserts into that structure.

3. Palpate the ischial spines bilaterally

It’s important that you palpate the ischial spines. Often, the ureter can be palpated against the pelvic sidewall. If you palpate the ischial spines and continue to palpate medially and cephalad, you can usually palpate the coccygeus muscle-sacrospinous ligament complex transperitoneally because a portion of the uterosacral ligament inserts into the sacrospinous ligament.⁶

If sutures can be passed at this level, the result will (usually) be a vagina that is, at minimum, approximately 9 cm long.

FIGURE 3 Access to the sacrospinous ligament

The sacrospinous ligament can be palpated and exposed along any one of three approaches: anterior paravaginally (A), transperitoneally (B), and posterior pararectally (C).

4. Pass the sutures

We prefer to pass two or three sutures on each side, utilizing a long, straight needle holder. Because we eventually pass the sutures through the full thickness of the posterior vaginal wall, we’ve opted for a delayed absorbable suture—preferably, 0 Vicryl on a CT-2 needle.

A Breisky-Navrital retractor is utilized to retract the sigmoid colon in the opposite direction of the ligament in which the sutures are being passed. At times, attaching a light to a suction device or a retractor is also helpful to visualize this area.

Use an Allis clamp to elevate and apply traction on the distal uterosacral ligament; this facilitates palpation and visualization of the appropriate site for placement of the sutures. The exact area of suture passage is best identified by palpation.

(Note: In early descriptions of this procedure, permanent sutures were utilized; again, we use delayed absorbable sutures because all sutures are brought out through the full thickness of the posterior vaginal wall. Permanent suture in our approach would be unacceptable because the sutures are tied in the lumen of the vagina. In some other modifications of this procedure, sutures are passed through the muscular layer of the vagina to exclude epithelium; under those circumstances, permanent sutures can be utilized.)

Once the sutures are brought through the full thickness of the posterior vaginal wall—including the peritoneum, if possible—tag them individually. If the anterior segment is well-supported, close the vaginal incision with a continuous delayed absorbable suture.

Tie the suspension sutures, elevating the apex into the hollow of the sacrum.

If anterior colporrhaphy is needed, perform that repair. Close the anterior vaginal wall as well as the vaginal cuff before tying off the suspension sutures.

5. Ensure that the ureters are patent

After the sutures are tied, instruct the anesthesiologist to administer 5 cc of indigo carmine dye intravenously. Assuming no renal compromise, you should see dye in the bladder 5 to 10 minutes later. If the patient is elderly or if you want to expedite this step, furosemide, 5 to 10 mg, can be given by IV push.

Next, perform cystoscopy to ensure ureteral patency. You should observe a spill of dye-colored urine out of both ureteral orifices. If dye does not spill from either orifice after a reasonable wait (usually, 20 minutes), assume that the ureter on that side is obstructed.

FIGURE 4 Providing support for the posterior vaginal wall

A View of a posterior vaginal wall defect secondary to an enterocele and rectocele. B After entry into the enterocele sac, intraperitoneal suspension sutures are brought out through the full thickness of the vaginal wall at the level of the apex. C Tying these sutures after the vaginal incision is closed at the apex not only results in greater vaginal length but also contributes to overall support of the entire posterior vaginal wall.

6. Completely reconstruct the vagina

The remainder of steps required to complete the procedure usually involve posterior colporrhaphy and perineoplasty. We also reserve placement of a synthetic midurethral sling (if one is needed) until after the vault procedure is complete.

Refer to FIGURE 2 for a step-by step guide to how best to perform high uterosacral vaginal vault suspension.

Questions often asked about this procedure

What do I do if I can’t isolate an enterocele sac and enter it?

Perform a unilateral or bilateral sacrospinous ligament colpopexy.

Is it always possible to identify a usable uterosacral ligament in patients who have advanced prolapse?

We’ve found it extremely rare not to be able identify a usable and durable structure.

The trick to identifying the ligament is to pass an Allis clamp so that one end is positioned intraperitoneally, as high up as possible, and the other end is on the vaginal mucosa side. Elevating the clamp puts the ligament on tension. These clamps are usually placed between 4 and 5 o’clock on the left side and between 7 and 8 o’clock on the right side.

With appropriate traction, the ligament can usually be easily palpated.

If I don’t see indigo carmine dye spilling from one side during cystoscopy, what sequence of events should I undertake?

If the only sutures placed on that side were the uterosacral ligament sutures, cut them individually. If the ureter spills dye after a suture is cut, decide whether you think it is appropriate to replace that suture. Sometimes, unilateral suspension or a suspension with one remaining suture on the side where you cut a suture or two is sufficient.

If you do want to replace a cut suture, ureteral patency must be confirmed again after it is replaced.

No further management of the ureter is required—that is, it isn’t necessary to catheterize the ureter or perform postoperative imaging studies. If anterior colporrhaphy has also been performed, however, apply your highest index of suspicion to determine the source of the offending suture: the uterosacral suspension or the anterior repair.*

If the patient has severe hip or leg pain postoperatively, what should I suspect is wrong? How should I manage this complication?

The nerve to the levator ani runs within the coccygeus muscle. In a thin patient, in whom deep bites are taken, the nerve is often injured or trapped. Such trauma can cause hip pain that is fairly severe but that is almost always self-limiting and requires only nonsteroidal anti-inflammatory medication. Usually, this complication resolves within 2 weeks after surgery.

Significant postoperative pain that radiates down the back of the thigh or down the leg all the way to the foot is of greater concern because one of the sacral nerve segments has most likely been injured or stretched. Obtain a neurology consult; rarely, it becomes necessary to take the patient back to surgery to cut the offending suture.

*For detailed discussion of this subject, see the International Academy of Pelvic Surgery’s August 2010 “Case of the month” at www.academyofpelvicsurgery.com.

We want to hear from you! Tell us what you think.

This article, with accompanying video footage, is presented with the support of the International Academy of Pelvic Surgery.

The concept of utilizing the uterosacral ligaments to support the vaginal cuff and correct an enterocele is nothing new: As early as 1957, Milton McCall described what became known as the McCall culdoplasty, in which sutures incorporated the uterosacral ligaments into the posterior vaginal vault to obliterate the cul-de-sac and suspend or support the vaginal apex at the time of vaginal hysterectomy.¹

Later, in the 1990s, Richardson promoted the concept that, in patients who have pelvic organ prolapse, the uterosacral ligaments do not become attenuated, instead, they break at specific points.

Shull and colleagues took this idea and described how utilizing uterosacral ligaments to support the vaginal cuff can be performed vaginally—by passing sutures bilaterally through the uterosacral ligaments near the level of the ischial spine.²

Since Shull described this procedure, numerous published studies have demonstrated outcomes similar to other vaginal suspension procedures, such as sacrospinous ligament suspension.^3-5

Potential advantages of a high uterosacral vaginal vault suspension are that:

• it provides good apical support without significantly distorting the vaginal axis, making it applicable to all types of vaginal prolapse
• intraperitoneal passage of sutures can be a lot cleaner and simpler than passing sutures, or anchors, through retroperitoneal structures, such as the sacrospinous ligament (FIGURE 1).

FIGURE 1 Locating intraperitoneal sutures during uterosacral suspension

Cross-section of the pelvic floor shows where sutures are placed as part of McCall culdoplasty (1), traditional uterosacral suspension (2), and modified high uterosacral suspension (3). Note: High uterosacral suspension may involve passing the suture through the sacrospinous ligament–coccygeus (SSL-C) muscle complex (dashed oval) because a segment of the uterosacral ligament inserts into that structure.

A disadvantage of the procedure is that the uterosacral ligament may, at times, lie in close proximity to the ureter. Studies have shown that the ureter can become kinked when sutures in this procedure are passed too far laterally.^2-5

High uterosacral suspension has been our operation of choice for 11 years for patients who have pelvic organ prolapse in which the peritoneum is accessible (see “How this procedure evolved in our hands”). In this article, we provide a step-by-step description of the procedure. Four accompanying videos that further illuminate those steps are noted in the text here at appropriate places.(For example, Video #1, immediately below, sets the stage for the step-by-step discussion by reviewing pertinent pelvic anatomy.)

Details of the procedure

1. Enter the peritoneum

It’s our opinion that, even though extraperitoneal uterosacral suspension procedures have been described, the pertinent anatomic structures (again, see Video #1) are not easily identifiable unless suspension is undertaken intraperitoneally. Entering the peritoneum is, obviously, not a concern if the patient is undergoing vaginal hysterectomy. If the patient has post-hysterectomy prolapse, however, you must be able to isolate an enterocele and enter the peritoneum (follow FIGURE 2, beginning here and through subsequent steps of the procedure).

FIGURE 2 Step by step: High uterosacral vaginal vault suspension

A The most prominent portion of the prolapsed vaginal vault is grasped with two Allis clamps. B The vaginal wall is opened up and the enterocele sac is identified and entered. C The bowel is packed high into the pelvis using large laparotomy sponges. The retractor lifts the sponges out of the lower pelvis, thus completely exposing the cul-de-sac. When appropriate traction is placed downward on the uterosacral ligaments with an Allis clamp, the uterosacral ligaments are easily palpated bilaterally. D Delayed absorbable sutures have been passed through the uppermost portion of the uterosacral ligaments on each side, and have been individually tagged.
E Each end of the previously passed sutures is brought out through the posterior peritoneum and the posterior vaginal wall. (A free needle is used to pass both ends of these delayed absorbable sutures through the full thickness of the vaginal wall.) F Anterior colporrhaphy is begun by initiating dissection between the prolapsed bladder and the anterior vaginal wall. G Anterior colporrhaphy is complete. H The vagina has been appropriately trimmed and closed with interrupted or continuous delayed absorbable sutures. Delayed absorbable sutures that were previously brought out through the full thickness of the posterior vaginal wall are then tied; doing so elevates the prolapsed vaginal vault high up into the hollow of the sacrum.Once you have entered the peritoneum, the cul-de-sac must be relatively free of adhesive disease if you are to be able to continue with this procedure. (See “5 surgical pearls for high ureterosacral vaginal vault suspension”)

2. Pack the bowel; expose the uterosacral ligaments

Next, pack the small bowel out of the cul-de-sac to allow easy access and visualization of the uppermost portions of the uterosacral ligament. This is best accomplished by passing large, moistened laparotomy sponges intraperitoneally and elevating them with a large retractor (e.g., Deaver, Breisky-Navrital, Sweetheart).

When the bowel is appropriately packed, the retractor lifts the intestinal contents out of the pelvis, usually allowing easy access to the proximal or uppermost portion of the uterosacral ligaments (see Video #3, which focuses on the anatomy of the uterosacral ligament).

When performing high uterosacral suspension, it is possible to pass sutures through the coccygeus muscle-sacrospinous ligament complex (arrow) because a segment of the uterosacral ligament inserts into that structure.

3. Palpate the ischial spines bilaterally

It’s important that you palpate the ischial spines. Often, the ureter can be palpated against the pelvic sidewall. If you palpate the ischial spines and continue to palpate medially and cephalad, you can usually palpate the coccygeus muscle-sacrospinous ligament complex transperitoneally because a portion of the uterosacral ligament inserts into the sacrospinous ligament.⁶

If sutures can be passed at this level, the result will (usually) be a vagina that is, at minimum, approximately 9 cm long.

FIGURE 3 Access to the sacrospinous ligament

The sacrospinous ligament can be palpated and exposed along any one of three approaches: anterior paravaginally (A), transperitoneally (B), and posterior pararectally (C).

4. Pass the sutures

We prefer to pass two or three sutures on each side, utilizing a long, straight needle holder. Because we eventually pass the sutures through the full thickness of the posterior vaginal wall, we’ve opted for a delayed absorbable suture—preferably, 0 Vicryl on a CT-2 needle.

A Breisky-Navrital retractor is utilized to retract the sigmoid colon in the opposite direction of the ligament in which the sutures are being passed. At times, attaching a light to a suction device or a retractor is also helpful to visualize this area.

Use an Allis clamp to elevate and apply traction on the distal uterosacral ligament; this facilitates palpation and visualization of the appropriate site for placement of the sutures. The exact area of suture passage is best identified by palpation.

(Note: In early descriptions of this procedure, permanent sutures were utilized; again, we use delayed absorbable sutures because all sutures are brought out through the full thickness of the posterior vaginal wall. Permanent suture in our approach would be unacceptable because the sutures are tied in the lumen of the vagina. In some other modifications of this procedure, sutures are passed through the muscular layer of the vagina to exclude epithelium; under those circumstances, permanent sutures can be utilized.)

Once the sutures are brought through the full thickness of the posterior vaginal wall—including the peritoneum, if possible—tag them individually. If the anterior segment is well-supported, close the vaginal incision with a continuous delayed absorbable suture.

Tie the suspension sutures, elevating the apex into the hollow of the sacrum.

If anterior colporrhaphy is needed, perform that repair. Close the anterior vaginal wall as well as the vaginal cuff before tying off the suspension sutures.

5. Ensure that the ureters are patent

After the sutures are tied, instruct the anesthesiologist to administer 5 cc of indigo carmine dye intravenously. Assuming no renal compromise, you should see dye in the bladder 5 to 10 minutes later. If the patient is elderly or if you want to expedite this step, furosemide, 5 to 10 mg, can be given by IV push.

Next, perform cystoscopy to ensure ureteral patency. You should observe a spill of dye-colored urine out of both ureteral orifices. If dye does not spill from either orifice after a reasonable wait (usually, 20 minutes), assume that the ureter on that side is obstructed.

FIGURE 4 Providing support for the posterior vaginal wall

A View of a posterior vaginal wall defect secondary to an enterocele and rectocele. B After entry into the enterocele sac, intraperitoneal suspension sutures are brought out through the full thickness of the vaginal wall at the level of the apex. C Tying these sutures after the vaginal incision is closed at the apex not only results in greater vaginal length but also contributes to overall support of the entire posterior vaginal wall.

6. Completely reconstruct the vagina

The remainder of steps required to complete the procedure usually involve posterior colporrhaphy and perineoplasty. We also reserve placement of a synthetic midurethral sling (if one is needed) until after the vault procedure is complete.

Refer to FIGURE 2 for a step-by step guide to how best to perform high uterosacral vaginal vault suspension.

Questions often asked about this procedure

What do I do if I can’t isolate an enterocele sac and enter it?

Perform a unilateral or bilateral sacrospinous ligament colpopexy.

Is it always possible to identify a usable uterosacral ligament in patients who have advanced prolapse?

We’ve found it extremely rare not to be able identify a usable and durable structure.

The trick to identifying the ligament is to pass an Allis clamp so that one end is positioned intraperitoneally, as high up as possible, and the other end is on the vaginal mucosa side. Elevating the clamp puts the ligament on tension. These clamps are usually placed between 4 and 5 o’clock on the left side and between 7 and 8 o’clock on the right side.

With appropriate traction, the ligament can usually be easily palpated.

If I don’t see indigo carmine dye spilling from one side during cystoscopy, what sequence of events should I undertake?

If the only sutures placed on that side were the uterosacral ligament sutures, cut them individually. If the ureter spills dye after a suture is cut, decide whether you think it is appropriate to replace that suture. Sometimes, unilateral suspension or a suspension with one remaining suture on the side where you cut a suture or two is sufficient.

If you do want to replace a cut suture, ureteral patency must be confirmed again after it is replaced.

No further management of the ureter is required—that is, it isn’t necessary to catheterize the ureter or perform postoperative imaging studies. If anterior colporrhaphy has also been performed, however, apply your highest index of suspicion to determine the source of the offending suture: the uterosacral suspension or the anterior repair.*

If the patient has severe hip or leg pain postoperatively, what should I suspect is wrong? How should I manage this complication?

The nerve to the levator ani runs within the coccygeus muscle. In a thin patient, in whom deep bites are taken, the nerve is often injured or trapped. Such trauma can cause hip pain that is fairly severe but that is almost always self-limiting and requires only nonsteroidal anti-inflammatory medication. Usually, this complication resolves within 2 weeks after surgery.

Significant postoperative pain that radiates down the back of the thigh or down the leg all the way to the foot is of greater concern because one of the sacral nerve segments has most likely been injured or stretched. Obtain a neurology consult; rarely, it becomes necessary to take the patient back to surgery to cut the offending suture.

*For detailed discussion of this subject, see the International Academy of Pelvic Surgery’s August 2010 “Case of the month” at www.academyofpelvicsurgery.com.

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This article, with accompanying video footage, is presented with the support of the International Academy of Pelvic Surgery.

The concept of utilizing the uterosacral ligaments to support the vaginal cuff and correct an enterocele is nothing new: As early as 1957, Milton McCall described what became known as the McCall culdoplasty, in which sutures incorporated the uterosacral ligaments into the posterior vaginal vault to obliterate the cul-de-sac and suspend or support the vaginal apex at the time of vaginal hysterectomy.¹

Later, in the 1990s, Richardson promoted the concept that, in patients who have pelvic organ prolapse, the uterosacral ligaments do not become attenuated, instead, they break at specific points.

Shull and colleagues took this idea and described how utilizing uterosacral ligaments to support the vaginal cuff can be performed vaginally—by passing sutures bilaterally through the uterosacral ligaments near the level of the ischial spine.²

Since Shull described this procedure, numerous published studies have demonstrated outcomes similar to other vaginal suspension procedures, such as sacrospinous ligament suspension.^3-5

Potential advantages of a high uterosacral vaginal vault suspension are that:

• it provides good apical support without significantly distorting the vaginal axis, making it applicable to all types of vaginal prolapse
• intraperitoneal passage of sutures can be a lot cleaner and simpler than passing sutures, or anchors, through retroperitoneal structures, such as the sacrospinous ligament (FIGURE 1).

FIGURE 1 Locating intraperitoneal sutures during uterosacral suspension

Cross-section of the pelvic floor shows where sutures are placed as part of McCall culdoplasty (1), traditional uterosacral suspension (2), and modified high uterosacral suspension (3). Note: High uterosacral suspension may involve passing the suture through the sacrospinous ligament–coccygeus (SSL-C) muscle complex (dashed oval) because a segment of the uterosacral ligament inserts into that structure.

A disadvantage of the procedure is that the uterosacral ligament may, at times, lie in close proximity to the ureter. Studies have shown that the ureter can become kinked when sutures in this procedure are passed too far laterally.^2-5

High uterosacral suspension has been our operation of choice for 11 years for patients who have pelvic organ prolapse in which the peritoneum is accessible (see “How this procedure evolved in our hands”). In this article, we provide a step-by-step description of the procedure. Four accompanying videos that further illuminate those steps are noted in the text here at appropriate places.(For example, Video #1, immediately below, sets the stage for the step-by-step discussion by reviewing pertinent pelvic anatomy.)

Details of the procedure

1. Enter the peritoneum

It’s our opinion that, even though extraperitoneal uterosacral suspension procedures have been described, the pertinent anatomic structures (again, see Video #1) are not easily identifiable unless suspension is undertaken intraperitoneally. Entering the peritoneum is, obviously, not a concern if the patient is undergoing vaginal hysterectomy. If the patient has post-hysterectomy prolapse, however, you must be able to isolate an enterocele and enter the peritoneum (follow FIGURE 2, beginning here and through subsequent steps of the procedure).

FIGURE 2 Step by step: High uterosacral vaginal vault suspension

A The most prominent portion of the prolapsed vaginal vault is grasped with two Allis clamps. B The vaginal wall is opened up and the enterocele sac is identified and entered. C The bowel is packed high into the pelvis using large laparotomy sponges. The retractor lifts the sponges out of the lower pelvis, thus completely exposing the cul-de-sac. When appropriate traction is placed downward on the uterosacral ligaments with an Allis clamp, the uterosacral ligaments are easily palpated bilaterally. D Delayed absorbable sutures have been passed through the uppermost portion of the uterosacral ligaments on each side, and have been individually tagged.
E Each end of the previously passed sutures is brought out through the posterior peritoneum and the posterior vaginal wall. (A free needle is used to pass both ends of these delayed absorbable sutures through the full thickness of the vaginal wall.) F Anterior colporrhaphy is begun by initiating dissection between the prolapsed bladder and the anterior vaginal wall. G Anterior colporrhaphy is complete. H The vagina has been appropriately trimmed and closed with interrupted or continuous delayed absorbable sutures. Delayed absorbable sutures that were previously brought out through the full thickness of the posterior vaginal wall are then tied; doing so elevates the prolapsed vaginal vault high up into the hollow of the sacrum.Once you have entered the peritoneum, the cul-de-sac must be relatively free of adhesive disease if you are to be able to continue with this procedure. (See “5 surgical pearls for high ureterosacral vaginal vault suspension”)

2. Pack the bowel; expose the uterosacral ligaments

Next, pack the small bowel out of the cul-de-sac to allow easy access and visualization of the uppermost portions of the uterosacral ligament. This is best accomplished by passing large, moistened laparotomy sponges intraperitoneally and elevating them with a large retractor (e.g., Deaver, Breisky-Navrital, Sweetheart).

When the bowel is appropriately packed, the retractor lifts the intestinal contents out of the pelvis, usually allowing easy access to the proximal or uppermost portion of the uterosacral ligaments (see Video #3, which focuses on the anatomy of the uterosacral ligament).

When performing high uterosacral suspension, it is possible to pass sutures through the coccygeus muscle-sacrospinous ligament complex (arrow) because a segment of the uterosacral ligament inserts into that structure.

3. Palpate the ischial spines bilaterally

It’s important that you palpate the ischial spines. Often, the ureter can be palpated against the pelvic sidewall. If you palpate the ischial spines and continue to palpate medially and cephalad, you can usually palpate the coccygeus muscle-sacrospinous ligament complex transperitoneally because a portion of the uterosacral ligament inserts into the sacrospinous ligament.⁶

If sutures can be passed at this level, the result will (usually) be a vagina that is, at minimum, approximately 9 cm long.

FIGURE 3 Access to the sacrospinous ligament

The sacrospinous ligament can be palpated and exposed along any one of three approaches: anterior paravaginally (A), transperitoneally (B), and posterior pararectally (C).

4. Pass the sutures

We prefer to pass two or three sutures on each side, utilizing a long, straight needle holder. Because we eventually pass the sutures through the full thickness of the posterior vaginal wall, we’ve opted for a delayed absorbable suture—preferably, 0 Vicryl on a CT-2 needle.

A Breisky-Navrital retractor is utilized to retract the sigmoid colon in the opposite direction of the ligament in which the sutures are being passed. At times, attaching a light to a suction device or a retractor is also helpful to visualize this area.

Use an Allis clamp to elevate and apply traction on the distal uterosacral ligament; this facilitates palpation and visualization of the appropriate site for placement of the sutures. The exact area of suture passage is best identified by palpation.

(Note: In early descriptions of this procedure, permanent sutures were utilized; again, we use delayed absorbable sutures because all sutures are brought out through the full thickness of the posterior vaginal wall. Permanent suture in our approach would be unacceptable because the sutures are tied in the lumen of the vagina. In some other modifications of this procedure, sutures are passed through the muscular layer of the vagina to exclude epithelium; under those circumstances, permanent sutures can be utilized.)

Once the sutures are brought through the full thickness of the posterior vaginal wall—including the peritoneum, if possible—tag them individually. If the anterior segment is well-supported, close the vaginal incision with a continuous delayed absorbable suture.

Tie the suspension sutures, elevating the apex into the hollow of the sacrum.

If anterior colporrhaphy is needed, perform that repair. Close the anterior vaginal wall as well as the vaginal cuff before tying off the suspension sutures.

5. Ensure that the ureters are patent

After the sutures are tied, instruct the anesthesiologist to administer 5 cc of indigo carmine dye intravenously. Assuming no renal compromise, you should see dye in the bladder 5 to 10 minutes later. If the patient is elderly or if you want to expedite this step, furosemide, 5 to 10 mg, can be given by IV push.

Next, perform cystoscopy to ensure ureteral patency. You should observe a spill of dye-colored urine out of both ureteral orifices. If dye does not spill from either orifice after a reasonable wait (usually, 20 minutes), assume that the ureter on that side is obstructed.

FIGURE 4 Providing support for the posterior vaginal wall

A View of a posterior vaginal wall defect secondary to an enterocele and rectocele. B After entry into the enterocele sac, intraperitoneal suspension sutures are brought out through the full thickness of the vaginal wall at the level of the apex. C Tying these sutures after the vaginal incision is closed at the apex not only results in greater vaginal length but also contributes to overall support of the entire posterior vaginal wall.

6. Completely reconstruct the vagina

The remainder of steps required to complete the procedure usually involve posterior colporrhaphy and perineoplasty. We also reserve placement of a synthetic midurethral sling (if one is needed) until after the vault procedure is complete.

Refer to FIGURE 2 for a step-by step guide to how best to perform high uterosacral vaginal vault suspension.

Questions often asked about this procedure

What do I do if I can’t isolate an enterocele sac and enter it?

Perform a unilateral or bilateral sacrospinous ligament colpopexy.

Is it always possible to identify a usable uterosacral ligament in patients who have advanced prolapse?

We’ve found it extremely rare not to be able identify a usable and durable structure.

The trick to identifying the ligament is to pass an Allis clamp so that one end is positioned intraperitoneally, as high up as possible, and the other end is on the vaginal mucosa side. Elevating the clamp puts the ligament on tension. These clamps are usually placed between 4 and 5 o’clock on the left side and between 7 and 8 o’clock on the right side.

With appropriate traction, the ligament can usually be easily palpated.

If I don’t see indigo carmine dye spilling from one side during cystoscopy, what sequence of events should I undertake?

If the only sutures placed on that side were the uterosacral ligament sutures, cut them individually. If the ureter spills dye after a suture is cut, decide whether you think it is appropriate to replace that suture. Sometimes, unilateral suspension or a suspension with one remaining suture on the side where you cut a suture or two is sufficient.

If you do want to replace a cut suture, ureteral patency must be confirmed again after it is replaced.

No further management of the ureter is required—that is, it isn’t necessary to catheterize the ureter or perform postoperative imaging studies. If anterior colporrhaphy has also been performed, however, apply your highest index of suspicion to determine the source of the offending suture: the uterosacral suspension or the anterior repair.*

If the patient has severe hip or leg pain postoperatively, what should I suspect is wrong? How should I manage this complication?

The nerve to the levator ani runs within the coccygeus muscle. In a thin patient, in whom deep bites are taken, the nerve is often injured or trapped. Such trauma can cause hip pain that is fairly severe but that is almost always self-limiting and requires only nonsteroidal anti-inflammatory medication. Usually, this complication resolves within 2 weeks after surgery.

Significant postoperative pain that radiates down the back of the thigh or down the leg all the way to the foot is of greater concern because one of the sacral nerve segments has most likely been injured or stretched. Obtain a neurology consult; rarely, it becomes necessary to take the patient back to surgery to cut the offending suture.

*For detailed discussion of this subject, see the International Academy of Pelvic Surgery’s August 2010 “Case of the month” at www.academyofpelvicsurgery.com.

We want to hear from you! Tell us what you think.

The benefits of minimally invasive surgery—including less pain, faster recovery, and improved cosmesis—are well known.^1,2 Standard laparotomy has been replaced by multiple-port operative laparoscopy for a great array of procedures, and advances in medical technology allow for a minimally invasive surgical approach even when a surgeon is faced with complex pathology.

Single-port laparoscopic surgery (SPLS) represents the latest advance in minimally invasive surgery. Using flexible endoscopes and articulating instruments, the surgeon can complete complex procedures through a single 2-cm incision in the abdomen. The incision is usually placed in the umbilicus, where it is easily hidden.^3-8

Since the first laparoscopic hysterectomy through a single incision was performed 20 years ago, SPLS has been used successfully to perform nephrectomy, prostatectomy, hemicolectomy, cholecystectomy, splenectomy, intussusception reduction, gastrostomy tube placement, thoracoscopic lung biopsy, thoracoscopic decortication, and appendectomy.^4-7

In gynecology, SPLS has been used to perform oophorectomy, salpingectomy, bilateral tubal ligation, ovarian cystectomy, surgical treatment of ectopic pregnancy, and both total and partial hysterectomy.^7-11 At least two recent studies have concluded that SPLS is an acceptable way to treat many benign and malignant gynecologic conditions that are currently treated using multiport laparoscopy.^3,11

This article outlines our approach to SPLS in the gynecologic patient and provides an overview of instrumentation, with the aim of allowing you to consider whether this approach might be feasible in your surgical practice, at your institution.

Unique setup required

When SPLS is performed through the umbilicus, the instruments must be held closer to the midline and more cephalad than during conventional laparoscopy to permit adequate visualization and manipulation. For this reason, the surgeon needs to assume a position higher over the torso and thorax of the patient, and both of the patient’s arms need to be tucked. Place the patient in a dorsal lithotomy position with a uterine manipulator in place to facilitate surgery—even when the uterus will be preserved and surgery involves only the adnexae.

With appropriate equipment and positioning, visualization and manipulation of anatomy are comparable to those of standard multiport laparoscopy.

New instruments simplify SPLS

Innovative surgical instruments allow for appropriate hand positioning outside the abdomen and minimize the internal collision of instruments brought through a single midline incision (FIGURE 1). A variety of single-port options are available, each with a unique patented design and method of insertion. In fact, the development of ports with multiple instrument channels has revolutionized SPLS.

FIGURE 1 Setup
Desired triangulation of instruments in SPLS setup.Before true single ports became available, it was necessary to place three 5-mm low-profile trocars in the fascia at three separate sites through a single skin incision. Pneumoperitoneum was established with a Veress needle, but the fascial incisions gradually merged with repeated cannula manipulation, producing air leaks.

Today, multiple-channel ports are placed using an open technique into a single skin and fascial incision. Trocars and instruments of varying size can be exchanged with ease without jeopardizing pneumoperitoneum.

Among the options:

• the SILS Port (Covidien) – a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm (FIGURE 2)
• the TriPort (Olympus America) – two flexible rings joined by a sleeve and multiple-channel port (FIGURE 3)
• GelPOINT Advanced Access Platform (Applied Medical) – a system constructed of synthetic gel material and consisting of a “GelSeal” cap, cannulas, and seals to accommodate 5-mm to 10-mm instrumentation (FIGURE 4).

We have found that all three devices allow for good range of motion while maintaining pneumoperitoneum.

(A recent article from Korea reports an inventive technique to perform single-incision laparoscopy using standard instrumentation: The authors fitted a self-retaining ring retractor with a surgical glove that had three of the fingers cut off and replaced by trocars.¹²)

FIGURE 2 SILS Port
The SILS Port is a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm.

FIGURE 3 TriPort
The TriPort system comprises two flexible rings joined by a sleeve and multiple-channel port.

FIGURE 4 GelPOINT
The GelPOINT Advanced Access Platform is constructed of synthetic gel material and accommodates 5-mm to 10-mm instrumentation.

A flexible laparoscope improves visualization

The ability to visualize the operative field is vital to any surgery, including SPLS. Use of a flexible laparoscope facilitates uncompromised visualization of the entire pelvis (FIGURE 5). Outside the abdomen, the flexible camera can be held laterally and away from the midline to help reduce the clashing of instruments and hands.

FIGURE 5 Flexible-tip laparoscope
A flexible-tip laparoscope ensures good visualization of the surgical field.If a flexible laparoscope is not available, a rigid 30-degree or 45-degree angled scope can be used, although visualization may be limited and adequate triangulation of instruments may be difficult to achieve.

When using a rigid laparoscope, a light cord that inserts into the back of the camera is necessary; otherwise, a 90-degree light cord adapter can be purchased.

Design enhancements facilitate coordination of instruments

One of the disadvantages of SPLS has been the restriction of movement that arises because of the close proximity of instruments and instrument handles. The latest designs have made articulation possible for tissue graspers, scissors, vessel sealers, and scopes.^9,10 The value of articulation is apparent inside the abdomen, where it allows perfect positioning of the area of dissection. Outside the abdomen, the handles can be arranged in an angled pattern to allow the surgeon and assistant to operate comfortably (FIGURE 1).

In a four-handed procedure, one hand is on the camera, one on the uterine manipulator, and the remaining two hands operate the articulating grasper, vessel sealer, or needle driver, depending on the task.

Standard straight instruments can also be used for portions of the procedure.

Dissection and hemostasis are achieved in a manner similar to that of conventional laparoscopy. Our instrument of choice is an enhanced bipolar instrument, although harmonic and traditional biopolar energy can be used as well, depending on the preference of the surgeon.

The latest instruments are designed to dissect, cauterize, and cut, thereby decreasing the number of instrument exchanges necessary.

With the right aids, suturing can be simplified

Suturing through a single port can be a challenge. When possible, closure of the vaginal cuff following a total laparoscopic or laparoscopic-assisted vaginal hysterectomy should be performed from below. When endoscopic suturing is required, standard suturing using both intracorporeal and extracorporeal methods is possible.

Suturing aids such as the Endo Stitch (Covidien) or Lapra-Ty (Ethicon) are helpful. One author recommends Quill bidirectional, self-retaining suture with barbs (Angiotech) to avoid the need for knot-tying.⁶ (For more on self-retaining suture, see “Barbed suture, now in the toolbox of minimally invasive gyn surgery,” by Jon I. Einarsson, MD, MPH, and James A. Greenberg, MD, in the September 2009 issue at obgmanagement.com.)

The MiniLap (Stryker) is a 2.3-mm grasper that is inserted percutaneously directly through the abdominal wall without an incision. It can be used to set the needle on the needle driver or manipulate tissue while suturing. The resulting skin incision is barely visible and does not require closure.

Options are varied for specimen removal

Small specimens can be removed directly through a single-port system that has been opened, or they can be extracted after the system is removed, with rapid desufflation (FIGURE 6).

FIGURE 6 Single-incision oophorectomy
An ovary and tube removed through a single incision using the A) TriPort and B) SILS Port systems.Compared with conventional laparoscopy, the larger incision associated with single-port surgery facilitates specimen removal. Larger or potentially malignant specimens can be placed into an EndoCatch bag (Covidien) inserted through the single-incision 10-mm cannula (FIGURE 7).

FIGURE 7 Specimen removal
In this case, the specimen was placed in a 10-mm EndoCatch bag and removed through the 10-mm cannula of the SILS Port.In total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina. In supracervical hysterectomy, a small uterus can be removed through the cul-de-sac or directly through the single incision after placement in a bag.

When morcellation is required, the instrument can be placed through the cul-desac, cervix, or a single port. The morcellator can be placed directly through the SPLS port while utilizing the flexible scope in an angled direction (looking back toward the morcellator) for complete visualization (note: Covidien does not recommend this usage).

Transcervical tissue morcellation has also been described. In this approach, the cervix is dilated once the uterine body has been amputated, and the tissue morcellator is inserted through the cervix while the surgeon maintains visualization from above.^6,13

How to master the technique

Many patients desire SPLS for its superior cosmetic outcome, but the approach may not always be appropriate. Depending on the procedure and characteristics of the patient (TABLE), multiple-port laparoscopy may be a better option. When a surgeon first attempts SPLS, we recommend that it be limited to the treatment of adnexal pathology only.

In your early SPlS cases, look for these patient characteristics

By using the techniques described in this article and selecting patients carefully, the surgeon can develop expertise in SPLS.^11,14 During the learning process, the use of additional ports or Mini-Lap instruments (Stryker) can reduce the challenges of more difficult procedures and should be considered without reservation, as should the use of articulating accessory instruments and flexible or angled laparoscopes.

Although the clinical benefits of SPLS have yet to be determined, the cosmetic advantage of a single, hidden, umbilical incision likely increases patient satisfaction.

Clearly, the goal of SPLS is to use technology in a way that offers all of the benefits of traditional multiport laparoscopy without any of the limitations. Further study is required to determine whether SPLS meets this standard and, more important, whether it has any advantages over conventional techniques.

We want to hear from you! Tell us what you think.

The benefits of minimally invasive surgery—including less pain, faster recovery, and improved cosmesis—are well known.^1,2 Standard laparotomy has been replaced by multiple-port operative laparoscopy for a great array of procedures, and advances in medical technology allow for a minimally invasive surgical approach even when a surgeon is faced with complex pathology.

Single-port laparoscopic surgery (SPLS) represents the latest advance in minimally invasive surgery. Using flexible endoscopes and articulating instruments, the surgeon can complete complex procedures through a single 2-cm incision in the abdomen. The incision is usually placed in the umbilicus, where it is easily hidden.^3-8

Since the first laparoscopic hysterectomy through a single incision was performed 20 years ago, SPLS has been used successfully to perform nephrectomy, prostatectomy, hemicolectomy, cholecystectomy, splenectomy, intussusception reduction, gastrostomy tube placement, thoracoscopic lung biopsy, thoracoscopic decortication, and appendectomy.^4-7

In gynecology, SPLS has been used to perform oophorectomy, salpingectomy, bilateral tubal ligation, ovarian cystectomy, surgical treatment of ectopic pregnancy, and both total and partial hysterectomy.^7-11 At least two recent studies have concluded that SPLS is an acceptable way to treat many benign and malignant gynecologic conditions that are currently treated using multiport laparoscopy.^3,11

This article outlines our approach to SPLS in the gynecologic patient and provides an overview of instrumentation, with the aim of allowing you to consider whether this approach might be feasible in your surgical practice, at your institution.

Unique setup required

When SPLS is performed through the umbilicus, the instruments must be held closer to the midline and more cephalad than during conventional laparoscopy to permit adequate visualization and manipulation. For this reason, the surgeon needs to assume a position higher over the torso and thorax of the patient, and both of the patient’s arms need to be tucked. Place the patient in a dorsal lithotomy position with a uterine manipulator in place to facilitate surgery—even when the uterus will be preserved and surgery involves only the adnexae.

With appropriate equipment and positioning, visualization and manipulation of anatomy are comparable to those of standard multiport laparoscopy.

New instruments simplify SPLS

Innovative surgical instruments allow for appropriate hand positioning outside the abdomen and minimize the internal collision of instruments brought through a single midline incision (FIGURE 1). A variety of single-port options are available, each with a unique patented design and method of insertion. In fact, the development of ports with multiple instrument channels has revolutionized SPLS.

FIGURE 1 Setup
Desired triangulation of instruments in SPLS setup.Before true single ports became available, it was necessary to place three 5-mm low-profile trocars in the fascia at three separate sites through a single skin incision. Pneumoperitoneum was established with a Veress needle, but the fascial incisions gradually merged with repeated cannula manipulation, producing air leaks.

Today, multiple-channel ports are placed using an open technique into a single skin and fascial incision. Trocars and instruments of varying size can be exchanged with ease without jeopardizing pneumoperitoneum.

Among the options:

• the SILS Port (Covidien) – a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm (FIGURE 2)
• the TriPort (Olympus America) – two flexible rings joined by a sleeve and multiple-channel port (FIGURE 3)
• GelPOINT Advanced Access Platform (Applied Medical) – a system constructed of synthetic gel material and consisting of a “GelSeal” cap, cannulas, and seals to accommodate 5-mm to 10-mm instrumentation (FIGURE 4).

We have found that all three devices allow for good range of motion while maintaining pneumoperitoneum.

(A recent article from Korea reports an inventive technique to perform single-incision laparoscopy using standard instrumentation: The authors fitted a self-retaining ring retractor with a surgical glove that had three of the fingers cut off and replaced by trocars.¹²)

FIGURE 2 SILS Port
The SILS Port is a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm.

FIGURE 3 TriPort
The TriPort system comprises two flexible rings joined by a sleeve and multiple-channel port.

FIGURE 4 GelPOINT
The GelPOINT Advanced Access Platform is constructed of synthetic gel material and accommodates 5-mm to 10-mm instrumentation.

A flexible laparoscope improves visualization

The ability to visualize the operative field is vital to any surgery, including SPLS. Use of a flexible laparoscope facilitates uncompromised visualization of the entire pelvis (FIGURE 5). Outside the abdomen, the flexible camera can be held laterally and away from the midline to help reduce the clashing of instruments and hands.

FIGURE 5 Flexible-tip laparoscope
A flexible-tip laparoscope ensures good visualization of the surgical field.If a flexible laparoscope is not available, a rigid 30-degree or 45-degree angled scope can be used, although visualization may be limited and adequate triangulation of instruments may be difficult to achieve.

When using a rigid laparoscope, a light cord that inserts into the back of the camera is necessary; otherwise, a 90-degree light cord adapter can be purchased.

Design enhancements facilitate coordination of instruments

One of the disadvantages of SPLS has been the restriction of movement that arises because of the close proximity of instruments and instrument handles. The latest designs have made articulation possible for tissue graspers, scissors, vessel sealers, and scopes.^9,10 The value of articulation is apparent inside the abdomen, where it allows perfect positioning of the area of dissection. Outside the abdomen, the handles can be arranged in an angled pattern to allow the surgeon and assistant to operate comfortably (FIGURE 1).

In a four-handed procedure, one hand is on the camera, one on the uterine manipulator, and the remaining two hands operate the articulating grasper, vessel sealer, or needle driver, depending on the task.

Standard straight instruments can also be used for portions of the procedure.

Dissection and hemostasis are achieved in a manner similar to that of conventional laparoscopy. Our instrument of choice is an enhanced bipolar instrument, although harmonic and traditional biopolar energy can be used as well, depending on the preference of the surgeon.

The latest instruments are designed to dissect, cauterize, and cut, thereby decreasing the number of instrument exchanges necessary.

With the right aids, suturing can be simplified

Suturing through a single port can be a challenge. When possible, closure of the vaginal cuff following a total laparoscopic or laparoscopic-assisted vaginal hysterectomy should be performed from below. When endoscopic suturing is required, standard suturing using both intracorporeal and extracorporeal methods is possible.

Suturing aids such as the Endo Stitch (Covidien) or Lapra-Ty (Ethicon) are helpful. One author recommends Quill bidirectional, self-retaining suture with barbs (Angiotech) to avoid the need for knot-tying.⁶ (For more on self-retaining suture, see “Barbed suture, now in the toolbox of minimally invasive gyn surgery,” by Jon I. Einarsson, MD, MPH, and James A. Greenberg, MD, in the September 2009 issue at obgmanagement.com.)

The MiniLap (Stryker) is a 2.3-mm grasper that is inserted percutaneously directly through the abdominal wall without an incision. It can be used to set the needle on the needle driver or manipulate tissue while suturing. The resulting skin incision is barely visible and does not require closure.

Options are varied for specimen removal

Small specimens can be removed directly through a single-port system that has been opened, or they can be extracted after the system is removed, with rapid desufflation (FIGURE 6).

FIGURE 6 Single-incision oophorectomy
An ovary and tube removed through a single incision using the A) TriPort and B) SILS Port systems.Compared with conventional laparoscopy, the larger incision associated with single-port surgery facilitates specimen removal. Larger or potentially malignant specimens can be placed into an EndoCatch bag (Covidien) inserted through the single-incision 10-mm cannula (FIGURE 7).

FIGURE 7 Specimen removal
In this case, the specimen was placed in a 10-mm EndoCatch bag and removed through the 10-mm cannula of the SILS Port.In total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina. In supracervical hysterectomy, a small uterus can be removed through the cul-de-sac or directly through the single incision after placement in a bag.

When morcellation is required, the instrument can be placed through the cul-desac, cervix, or a single port. The morcellator can be placed directly through the SPLS port while utilizing the flexible scope in an angled direction (looking back toward the morcellator) for complete visualization (note: Covidien does not recommend this usage).

Transcervical tissue morcellation has also been described. In this approach, the cervix is dilated once the uterine body has been amputated, and the tissue morcellator is inserted through the cervix while the surgeon maintains visualization from above.^6,13

How to master the technique

Many patients desire SPLS for its superior cosmetic outcome, but the approach may not always be appropriate. Depending on the procedure and characteristics of the patient (TABLE), multiple-port laparoscopy may be a better option. When a surgeon first attempts SPLS, we recommend that it be limited to the treatment of adnexal pathology only.

In your early SPlS cases, look for these patient characteristics

By using the techniques described in this article and selecting patients carefully, the surgeon can develop expertise in SPLS.^11,14 During the learning process, the use of additional ports or Mini-Lap instruments (Stryker) can reduce the challenges of more difficult procedures and should be considered without reservation, as should the use of articulating accessory instruments and flexible or angled laparoscopes.

Although the clinical benefits of SPLS have yet to be determined, the cosmetic advantage of a single, hidden, umbilical incision likely increases patient satisfaction.

Clearly, the goal of SPLS is to use technology in a way that offers all of the benefits of traditional multiport laparoscopy without any of the limitations. Further study is required to determine whether SPLS meets this standard and, more important, whether it has any advantages over conventional techniques.

We want to hear from you! Tell us what you think.

The benefits of minimally invasive surgery—including less pain, faster recovery, and improved cosmesis—are well known.^1,2 Standard laparotomy has been replaced by multiple-port operative laparoscopy for a great array of procedures, and advances in medical technology allow for a minimally invasive surgical approach even when a surgeon is faced with complex pathology.

Single-port laparoscopic surgery (SPLS) represents the latest advance in minimally invasive surgery. Using flexible endoscopes and articulating instruments, the surgeon can complete complex procedures through a single 2-cm incision in the abdomen. The incision is usually placed in the umbilicus, where it is easily hidden.^3-8

Since the first laparoscopic hysterectomy through a single incision was performed 20 years ago, SPLS has been used successfully to perform nephrectomy, prostatectomy, hemicolectomy, cholecystectomy, splenectomy, intussusception reduction, gastrostomy tube placement, thoracoscopic lung biopsy, thoracoscopic decortication, and appendectomy.^4-7

In gynecology, SPLS has been used to perform oophorectomy, salpingectomy, bilateral tubal ligation, ovarian cystectomy, surgical treatment of ectopic pregnancy, and both total and partial hysterectomy.^7-11 At least two recent studies have concluded that SPLS is an acceptable way to treat many benign and malignant gynecologic conditions that are currently treated using multiport laparoscopy.^3,11

This article outlines our approach to SPLS in the gynecologic patient and provides an overview of instrumentation, with the aim of allowing you to consider whether this approach might be feasible in your surgical practice, at your institution.

Unique setup required

When SPLS is performed through the umbilicus, the instruments must be held closer to the midline and more cephalad than during conventional laparoscopy to permit adequate visualization and manipulation. For this reason, the surgeon needs to assume a position higher over the torso and thorax of the patient, and both of the patient’s arms need to be tucked. Place the patient in a dorsal lithotomy position with a uterine manipulator in place to facilitate surgery—even when the uterus will be preserved and surgery involves only the adnexae.

With appropriate equipment and positioning, visualization and manipulation of anatomy are comparable to those of standard multiport laparoscopy.

New instruments simplify SPLS

Innovative surgical instruments allow for appropriate hand positioning outside the abdomen and minimize the internal collision of instruments brought through a single midline incision (FIGURE 1). A variety of single-port options are available, each with a unique patented design and method of insertion. In fact, the development of ports with multiple instrument channels has revolutionized SPLS.

FIGURE 1 Setup
Desired triangulation of instruments in SPLS setup.Before true single ports became available, it was necessary to place three 5-mm low-profile trocars in the fascia at three separate sites through a single skin incision. Pneumoperitoneum was established with a Veress needle, but the fascial incisions gradually merged with repeated cannula manipulation, producing air leaks.

Today, multiple-channel ports are placed using an open technique into a single skin and fascial incision. Trocars and instruments of varying size can be exchanged with ease without jeopardizing pneumoperitoneum.

Among the options:

• the SILS Port (Covidien) – a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm (FIGURE 2)
• the TriPort (Olympus America) – two flexible rings joined by a sleeve and multiple-channel port (FIGURE 3)
• GelPOINT Advanced Access Platform (Applied Medical) – a system constructed of synthetic gel material and consisting of a “GelSeal” cap, cannulas, and seals to accommodate 5-mm to 10-mm instrumentation (FIGURE 4).

We have found that all three devices allow for good range of motion while maintaining pneumoperitoneum.

(A recent article from Korea reports an inventive technique to perform single-incision laparoscopy using standard instrumentation: The authors fitted a self-retaining ring retractor with a surgical glove that had three of the fingers cut off and replaced by trocars.¹²)

FIGURE 2 SILS Port
The SILS Port is a soft, flexible, three-channel port that allows for placement of blunt trocars ranging in size from 5 mm to 12 mm.

FIGURE 3 TriPort
The TriPort system comprises two flexible rings joined by a sleeve and multiple-channel port.

FIGURE 4 GelPOINT
The GelPOINT Advanced Access Platform is constructed of synthetic gel material and accommodates 5-mm to 10-mm instrumentation.

A flexible laparoscope improves visualization

The ability to visualize the operative field is vital to any surgery, including SPLS. Use of a flexible laparoscope facilitates uncompromised visualization of the entire pelvis (FIGURE 5). Outside the abdomen, the flexible camera can be held laterally and away from the midline to help reduce the clashing of instruments and hands.

FIGURE 5 Flexible-tip laparoscope
A flexible-tip laparoscope ensures good visualization of the surgical field.If a flexible laparoscope is not available, a rigid 30-degree or 45-degree angled scope can be used, although visualization may be limited and adequate triangulation of instruments may be difficult to achieve.

When using a rigid laparoscope, a light cord that inserts into the back of the camera is necessary; otherwise, a 90-degree light cord adapter can be purchased.

Design enhancements facilitate coordination of instruments

One of the disadvantages of SPLS has been the restriction of movement that arises because of the close proximity of instruments and instrument handles. The latest designs have made articulation possible for tissue graspers, scissors, vessel sealers, and scopes.^9,10 The value of articulation is apparent inside the abdomen, where it allows perfect positioning of the area of dissection. Outside the abdomen, the handles can be arranged in an angled pattern to allow the surgeon and assistant to operate comfortably (FIGURE 1).

In a four-handed procedure, one hand is on the camera, one on the uterine manipulator, and the remaining two hands operate the articulating grasper, vessel sealer, or needle driver, depending on the task.

Standard straight instruments can also be used for portions of the procedure.

Dissection and hemostasis are achieved in a manner similar to that of conventional laparoscopy. Our instrument of choice is an enhanced bipolar instrument, although harmonic and traditional biopolar energy can be used as well, depending on the preference of the surgeon.

The latest instruments are designed to dissect, cauterize, and cut, thereby decreasing the number of instrument exchanges necessary.

With the right aids, suturing can be simplified

Suturing through a single port can be a challenge. When possible, closure of the vaginal cuff following a total laparoscopic or laparoscopic-assisted vaginal hysterectomy should be performed from below. When endoscopic suturing is required, standard suturing using both intracorporeal and extracorporeal methods is possible.

Suturing aids such as the Endo Stitch (Covidien) or Lapra-Ty (Ethicon) are helpful. One author recommends Quill bidirectional, self-retaining suture with barbs (Angiotech) to avoid the need for knot-tying.⁶ (For more on self-retaining suture, see “Barbed suture, now in the toolbox of minimally invasive gyn surgery,” by Jon I. Einarsson, MD, MPH, and James A. Greenberg, MD, in the September 2009 issue at obgmanagement.com.)

The MiniLap (Stryker) is a 2.3-mm grasper that is inserted percutaneously directly through the abdominal wall without an incision. It can be used to set the needle on the needle driver or manipulate tissue while suturing. The resulting skin incision is barely visible and does not require closure.

Options are varied for specimen removal

Small specimens can be removed directly through a single-port system that has been opened, or they can be extracted after the system is removed, with rapid desufflation (FIGURE 6).

FIGURE 6 Single-incision oophorectomy
An ovary and tube removed through a single incision using the A) TriPort and B) SILS Port systems.Compared with conventional laparoscopy, the larger incision associated with single-port surgery facilitates specimen removal. Larger or potentially malignant specimens can be placed into an EndoCatch bag (Covidien) inserted through the single-incision 10-mm cannula (FIGURE 7).

FIGURE 7 Specimen removal
In this case, the specimen was placed in a 10-mm EndoCatch bag and removed through the 10-mm cannula of the SILS Port.In total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy, the uterus is removed through the vagina. In supracervical hysterectomy, a small uterus can be removed through the cul-de-sac or directly through the single incision after placement in a bag.

When morcellation is required, the instrument can be placed through the cul-desac, cervix, or a single port. The morcellator can be placed directly through the SPLS port while utilizing the flexible scope in an angled direction (looking back toward the morcellator) for complete visualization (note: Covidien does not recommend this usage).

Transcervical tissue morcellation has also been described. In this approach, the cervix is dilated once the uterine body has been amputated, and the tissue morcellator is inserted through the cervix while the surgeon maintains visualization from above.^6,13

How to master the technique

Many patients desire SPLS for its superior cosmetic outcome, but the approach may not always be appropriate. Depending on the procedure and characteristics of the patient (TABLE), multiple-port laparoscopy may be a better option. When a surgeon first attempts SPLS, we recommend that it be limited to the treatment of adnexal pathology only.

In your early SPlS cases, look for these patient characteristics

By using the techniques described in this article and selecting patients carefully, the surgeon can develop expertise in SPLS.^11,14 During the learning process, the use of additional ports or Mini-Lap instruments (Stryker) can reduce the challenges of more difficult procedures and should be considered without reservation, as should the use of articulating accessory instruments and flexible or angled laparoscopes.

Although the clinical benefits of SPLS have yet to be determined, the cosmetic advantage of a single, hidden, umbilical incision likely increases patient satisfaction.

Clearly, the goal of SPLS is to use technology in a way that offers all of the benefits of traditional multiport laparoscopy without any of the limitations. Further study is required to determine whether SPLS meets this standard and, more important, whether it has any advantages over conventional techniques.

We want to hear from you! Tell us what you think.

CASE 1: Problematic prolapse, but no incontinence

An 81-year-old multiparous woman, who has a history of recurrent stage-III pelvic organ prolapse (POP), reports worsening discomfort that makes it difficult for her to care for her ailing husband. She also has “trouble” with bladder emptying and constipation, but denies any loss of urine. She has not had vaginal intercourse in more than a decade because of her husband’s medical condition.

Aside from health issues—she suffers from obesity, coronary artery disease, hypertension, and diabetes—the patient is content with her marriage of 58 years.

Urodynamic testing fails to demonstrate detrusor overactivity, stress urinary incontinence, or intrinsic sphincteric deficiency. A cough stress test is repeated after reduction of her prolapse using a large cotton swab, and confirms the findings of the urodynamic tests.

Is reconstructive surgery appropriate for this patient?

Traditional reconstructive surgical procedures for treating POP fail in as many as 30% of patients, and new approaches—some involving grafts—are proposed every day, often without much data behind them.¹

Regardless of the approach, reconstructive surgery is a lengthy procedure that subjects patients who are already medically compromised to significant risk, including bleeding, infection, and fluid shifts. Delayed return to normal activity may be especially costly among elderly women because of the risk of venous thromboembolism.

Because of the high failure rate, slow recovery, and risk of complications, reconstructive surgery may not be as appropriate as colpocleisis for the woman described above. Colpocleisis—suturing the inside walls of the vagina together—has an efficacy rate exceeding 90%.² This relatively simple operation has been around for almost two centuries and has a good track record, but is often overlooked when counseling a patient about her options.

Any frail, elderly woman who has stage-III or -IV POP who does not desire to preserve coital ability is a candidate for colpocleisis (TABLE). Advantages include:

• a short operating time
• few complications
• amenability of local anesthesia
• short hospitalization
• speedy recovery
• high success rate
• low rate of regret.^2-5

Because it precludes coital activity, however, colpocleisis may cause problems with self-image. It also may lead to de novo or worsening urinary incontinence and complicate or delay the diagnosis of cervical and endometrial pathology.

This article explores these issues through a case-based discussion of colpocleisis, including a detailed description of surgical technique.

TABLE

Requirements for colpocleisis

Why colpocleisis?

Colpocleisis, as noted, entails suturing the inside walls of the vagina together. It is controversial because of its impact on coital activity. With careful patient selection, however, colpocleisis is considered a valid option for frail and elderly women who have POP and do not desire or foresee the possibility of future vaginal intercourse. Such women may represent a surprising percentage of the elderly population. A community-based survey found that 78% of married women 70 to 79 years old are not sexually active,⁶ and a study from The Netherlands found a prevalence of symptomatic POP of 11.4% among white women 45 to 85 years old.⁷

The fundamental reason for choosing an obliterative procedure such as colpocleisis over total pelvic reconstruction is to treat the prolapse with the least invasive technique in the shortest time. Hysterectomy, which often adds 30 to 80 minutes to the procedure, should therefore be performed only in patients who have a suspicious finding upon initial evaluation. For the same reason, partial colpocleisis—performed using the LeFort technique with limited dissection—has become the most popular obliterative approach. We try to avoid a total colpocleisis procedure—also known as colpectomy—in which the entire vaginal epithelium is stripped, because it is feasible only when the uterus is already absent or scheduled to be removed concomitantly.

(Note: The term vaginectomy should be reserved for gynecologic oncology procedures performed to remove vaginal cancer. Vaginectomy entails full-thickness excision of the vaginal walls, including the fibromuscular layer, as opposed to excision of the epithelial layer only, as in colpocleisis. In this article, we present the LeFort method, a partial colpocleisis technique, because we believe it is more easily adapted by the general gynecologist.⁸)

CASE 1 RESOLVED

After detailed counseling, which includes family members, the patient opts to undergo colpocleisis. The procedure takes 45 minutes. She is discharged on postoperative Day 1, and reports substantially improved quality of life.

CASE 2: Recurrent prolapse and problems with a pessary

A 72-year-old multiparous, widowed woman experiences recurrent stage-III isolated apical prolapse. She has already undergone two reconstructive procedures, and was discouraged from undergoing a third because of her chronic obstructive lung disease. She tried to use a Gellhorn-type pessary, which required a doctor’s intervention to insert and remove. Frustrated by the many office visits involved in having the pessary checked, she now demands surgical therapy. Another gynecologist has offered to repair the prolapse using mesh, but the patient has concerns about the safety and efficacy of the procedure because it is a relatively new approach.

In addition to the recurrent prolapse, she loses urine with stress and urge. She often has a postvoid residual volume >100 cc; urodynamic assessment confirms mixed urinary incontinence. The patient does not foresee any change in her social status (unmarried, sexually inactive).

Is colpocleisis a reasonable option?

Although the pessary is a helpful conservative alternative for women who are either unable or unwilling to undergo complex surgical pelvic repair and is considered first-line treatment by a majority of urogynecologists, it sometimes becomes more difficult to maintain than the patient is willing to tolerate.⁹ When a woman cannot remove and reinsert the device herself, the pessary requires a lifelong commitment to doctor’s visits every 2 or 3 months. This commitment is especially problematic for patients who become unable to drive or who lack social support.

Maintenance of the pessary becomes more frustrating as the patient becomes more dependent. Many gynecologists have seen a patient who developed a serious complication such as vesicovaginal or rectovaginal fistula because of a neglected pessary.¹⁰

In Case 2, the patient appears to be a potential candidate for colpocleisis, given her age and single status. Although pelvic floor repair appears to be safe in older women, any perioperative complication in a patient 70 years of age or older doubles the risk of discharge to a care facility.^11,12 Women who have already undergone several surgeries or who have advanced medical problems such as coronary artery disease or cancer should be counseled thoroughly about the safety and efficacy of colpocleisis.

As for self-image, colpocleisis eliminates prolapse and reduces the genital hiatus. If the patient understands that colpocleisis is obliterative for the vagina but may improve the external appearance of the genital area, she may be more accepting of the procedure. One recent prospective, multicenter study found that only 2% of women thought their body looked worse 1 year after colpocleisis; 60% thought their body looked better.⁵

When reviewing treatment options, inform the patient that the pessary is a palliative option, whereas surgical therapy aims to be definitive.

CASE 2 RESOLVED

After comprehensive counseling, the patient elects to undergo colpocleisis, along with placement of a midurethral sling. She is discharged 1 day after surgery, and reports substantially improved urinary function, including bladder emptying, and quality of life. She says she would recommend the procedure to any woman who has a similar condition.

CASE 3: Pessary-related complications, incontinence, and underlying medical conditions

A 92-year-old multiparous widow, whose stage-IV uterovaginal prolapse has been managed by a pessary, develops vaginal ulcers in both anterior and posterior walls. After removal of the pessary and 4 weeks of treatment with vaginal estrogen, a smaller pessary is inserted, but she again develops ulcers and bleeding.

The patient’s medical condition is complicated by hypertension and generalized arthritis. She has urodynamically confirmed mixed urinary incontinence. She lives with her daughter and does not want to be placed in a nursing home.

What treatment options should you offer to her?

Because of this patient’s advanced age, poor health, and pessary-related problems, she is an ideal candidate for colpocleisis, provided she consents to the procedure after thorough counseling about its benefits and limitations.

Preoperative concerns

A thorough history, physical examination, and normal Pap test are necessary. If a suspicious pelvic mass or uterine bleeding is present, transvaginal ultrasonography (US) is crucial. In-office endometrial sampling also is necessary in any woman who has unexplained vaginal bleeding. More invasive procedures such as dilatation and curettage and hysteroscopy are needed only when the biopsy is inadequate or endometrial thickness exceeds 4 mm on transvaginal US.¹³

All elderly women who have high-risk medical problems must be cleared for surgery, with the necessary cardiac and pulmonary workup completed before the procedure.

Because colpocleisis is an extraperitoneal procedure, we have adapted use of over-the-counter enema products on the day before surgery in lieu of mechanical bowel preparation, which may lead to dehydration in very elderly women.

Coordinated consultation between the surgeon and anesthesiologist is necessary to determine the type of anesthesia to be used. Sedation and local anesthesia can be adequate for extremely high-risk women.^14,15 Antibiotic prophylaxis is conventional for all patients.

Surgical technique

The LeFort method involves denudation and approximation of the midportions of the anterior and posterior vaginal walls.⁸ This operation creates a longitudinal vaginal septum with bilateral channels on each side, which serve as conduits for any secretion or bleeding from the apical vagina (FIGURE 1A AND B). Aggressive perineorraphy is also needed to shorten the genital hiatus. The following description incorporates perineorraphy into the LeFort technique.

FIGURE 1 Principles of LeFort colpocleisis

The depiction here is not anatomically precise: The vagina is illustrated as a rectangular prism to clarify the relationship between tissues.

Patient positioning

Place the patient in the dorsal lithotomy position, using stirrups to support the entire leg up to the knee. Let the patient’s buttocks overhang the edge of the table by 1 to 2 inches. A slight Trendelenburg position is imperative, especially when operating on the anterior compartment of the vagina. The bladder should be only partially emptied because the leakage of urine from the bladder makes it easier to identify inadvertent cystotomy. Infiltration of local anesthetic solution to develop the surgical planes is acceptable.

Initiating the procedure

Remove a rectangular piece of vaginal epithelium from the anterior vaginal wall, beginning 2 to 3 cm distal to the vaginal apex (or cervix, if the uterus is present) and ending immediately proximal to the urethrovesical junction to leave space for midurethral sling placement. Remove a similarly sized piece of epithelium from the posterior vaginal wall. This posterior rectangle is an almost geometric projection of the anterior rectangle, but is somewhat longer (2 to 3 cm) (FIGURE 1).

When removing the vaginal epithelium, it may be helpful to use the skills developed for anterior and posterior colporraphy. Our operation begins with a 5- to 6-cm transverse incision at the anterior vaginal apex, which creates the proximal side of the anterior rectangle described above (FIGURE 2A).

As you develop the plane between the epithelium and fibromuscular layer, make a midline sagittal incision and extend it to the urethrovesical junction (FIGURE 2B). Dissect the epithelium off the fibromuscular layer approximately 3 cm bilaterally, then make a transverse incision at the urethrovesical junction. Finally, remove the anterior rectangle in two pieces by cutting along the lateral sides (FIGURE 2C AND D). Remove the posterior rectangle using the same technique, but also excise a triangular piece of skin from the posterior fourchette for the perineorraphy portion of the procedure (FIGURE 2E).

FIGURE 2 LeFort technique, step by step

Begin with a 5–6 cm transverse incision at the anterior vaginal apex.

Dissect the epithelium off the fibromuscular layer, with a midline sagittal incision extending to the urethrovesical junction.

After dissection is completed, make a transverse incision at the urethrovesical junction, and remove the anterior rectangle in two pieces by cutting along the lateral sides.

Denude the posterior rectangle using the same technique. In addition, excise a triangular piece of skin from the perineum.

The posterior rectangle is ready for removal.

Suturing

Suture the apical sides of the anterior and posterior rectangles together using a continuous running technique (FIGURE 2F). Then approximate the lateral sides bilaterally using continuous sutures.

To ensure adherence of the anterior and posterior rectangles, stitch the raw surfaces together in three rows (FIGURE 2G). Do not include the distal 2 cm of the posterior vagina because you will need to leave room for perineorraphy.

Using several sutures, reapproximate the torn perineal fibromuscular structures in the midline to perform perineorraphy (FIGURE 2H). Close the distal vagina, beginning at the midpoint of the anterior transverse side, which lies at the urethrovesical junction (FIGURE 2I). Continue this suture on the posterior vagina and then the perineal body, sagittally, creating a small invagination in the distal vagina (FIGURE 2J).

FIGURE 2 LeFort technique, step by step

Suture all but the distal sides of the rectangles between the anterior and posterior vaginal walls.

Also stitch together the raw surfaces in three rows in an imbricating fashion.

Perform perineorraphy.

Close the distal vagina, starting at the midpoint of the anterior transverse side. If indicated, place a midurethral sling.

Final appearance.

Sling procedure

We place a midurethral sling as part of most colpocleisis operations. It is best to do this after the colpocleisis but before the perineorraphy.

In our cases, cystoscopy with simultaneous intravenous indigo carmine injection is standard before perineorraphy, even when a sling procedure is not planned. This safeguard ensures ureteral patency, which can be compromised (although rarely) in these procedures. Cutting and replacement of one of the sutures that approximate the raw tissues typically resolve the problem.¹⁶

Special considerations

Here are additional key points about colpocleisis, based on our experience:

• If an ulcer lies within the area designated to be denuded, some debridement to freshen up the surface will suffice. An ulcer is not an indication to deviate from the standard procedure.
• A modification developed by Goodall and Power may allow coitus by removing only a triangular piece of epithelium from each wall, leaving more room for the channels.¹⁷
• We have been unable to find any report of uterine or cervical cancer after colpocleisis, despite a MEDLINE search of the literature in English. Even so, the lateral channels created by the LeFort procedure allow any bleeding to escape the vagina, and may therefore enable recognition of malignancy. When noninvasive imaging techniques such as US or magnetic resonance are inadequate, vaginoscopy and hysteroscopy may be accomplished via these channels.
• When colpocleisis is performed in a hysterectomized woman, no lateral channel is necessary. Therefore, it is appropriate to do total colpocleisis.^18,19
• When a patient with POP has a rectovaginal or vesicovaginal fistula caused by a neglected pessary, the addition of LeFort colpocleisis to the fistula repair may provide an effective treatment for both problems.¹⁰

Surgical outcomes

Success rate

Evidence concerning colpocleisis comes from case series, some of which are more than 30 years old. Although the definition of success is not clear in some series, the reported success rate has always exceeded 90% over the past three decades.^2,18-22 Moreover, some of these reports involve as many as 30 years of follow-up.

Perioperative complication

In a recent review of the literature, the procedure-related mortality rate was 0.025%.² When the authors focused only on studies published since 1980, major complications due to the patient’s underlying cardiovascular and pulmonary condition were seen in 2% of cases. Major surgical complications such as pyelonephritis and bleeding requiring transfusion occurred in 4% of cases, and less severe complications occurred in 15%.

In a study that included women who underwent concomitant vaginal hysterectomy, hysterectomy prolonged the surgery by 52 minutes, with a 5% rate of laparotomy as a result of intraoperative bleeding.²²

Quality of life

In our series of 40 colpocleisis cases, we noted no instance in which a patient regretted the procedure.¹⁸ Others have also reported a low rate of regret—the highest being 9%.^3-5,19-21

Using validated questionnaires, FitzGerald and colleagues found significant improvement in mental and physical quality of life, as well as urinary, colorectal, and bulge-related pelvic floor symptoms, 1 year after colpocleisis.⁵

De novo or worsening urinary incontinence is one of the drawbacks of colpocleisis. However, the same risk is present in approximately 40% of women who undergo surgical reconstructive procedures for POP without a continence operation.²³ Because preoperative urinary retention is common in women who have POP, the decision to add a potentially harmful continence procedure is complicated in colpocleisis candidates. A small case series reported that the success rate ranged from 90% to 94% in women who underwent a midurethral tension-free sling procedure for the treatment of urinary incontinence at the time of colpocleisis.⁵

Preoperative urodynamic studies to detect urethral intrinsic deficiency and detrusor dysfunction are prudent, and detailed counseling of the patient about urinary control is vital. We perform a midurethral sling procedure in most of our colpocleisis cases, and have had pleasing results.

CASE 3 RESOLVED

The patient decides to undergo partial colpocleisis using the LeFort procedure, along with placement of a midurethral sling, for a total operative time of 75 minutes. She is discharged 1 day later and reports substantial improvement in urinary function and quality of life.

CASE 1: Problematic prolapse, but no incontinence

An 81-year-old multiparous woman, who has a history of recurrent stage-III pelvic organ prolapse (POP), reports worsening discomfort that makes it difficult for her to care for her ailing husband. She also has “trouble” with bladder emptying and constipation, but denies any loss of urine. She has not had vaginal intercourse in more than a decade because of her husband’s medical condition.

Aside from health issues—she suffers from obesity, coronary artery disease, hypertension, and diabetes—the patient is content with her marriage of 58 years.

Urodynamic testing fails to demonstrate detrusor overactivity, stress urinary incontinence, or intrinsic sphincteric deficiency. A cough stress test is repeated after reduction of her prolapse using a large cotton swab, and confirms the findings of the urodynamic tests.

Is reconstructive surgery appropriate for this patient?

Traditional reconstructive surgical procedures for treating POP fail in as many as 30% of patients, and new approaches—some involving grafts—are proposed every day, often without much data behind them.¹

Regardless of the approach, reconstructive surgery is a lengthy procedure that subjects patients who are already medically compromised to significant risk, including bleeding, infection, and fluid shifts. Delayed return to normal activity may be especially costly among elderly women because of the risk of venous thromboembolism.

Because of the high failure rate, slow recovery, and risk of complications, reconstructive surgery may not be as appropriate as colpocleisis for the woman described above. Colpocleisis—suturing the inside walls of the vagina together—has an efficacy rate exceeding 90%.² This relatively simple operation has been around for almost two centuries and has a good track record, but is often overlooked when counseling a patient about her options.

Any frail, elderly woman who has stage-III or -IV POP who does not desire to preserve coital ability is a candidate for colpocleisis (TABLE). Advantages include:

• a short operating time
• few complications
• amenability of local anesthesia
• short hospitalization
• speedy recovery
• high success rate
• low rate of regret.^2-5

Because it precludes coital activity, however, colpocleisis may cause problems with self-image. It also may lead to de novo or worsening urinary incontinence and complicate or delay the diagnosis of cervical and endometrial pathology.

This article explores these issues through a case-based discussion of colpocleisis, including a detailed description of surgical technique.

TABLE

Requirements for colpocleisis

Why colpocleisis?

Colpocleisis, as noted, entails suturing the inside walls of the vagina together. It is controversial because of its impact on coital activity. With careful patient selection, however, colpocleisis is considered a valid option for frail and elderly women who have POP and do not desire or foresee the possibility of future vaginal intercourse. Such women may represent a surprising percentage of the elderly population. A community-based survey found that 78% of married women 70 to 79 years old are not sexually active,⁶ and a study from The Netherlands found a prevalence of symptomatic POP of 11.4% among white women 45 to 85 years old.⁷

The fundamental reason for choosing an obliterative procedure such as colpocleisis over total pelvic reconstruction is to treat the prolapse with the least invasive technique in the shortest time. Hysterectomy, which often adds 30 to 80 minutes to the procedure, should therefore be performed only in patients who have a suspicious finding upon initial evaluation. For the same reason, partial colpocleisis—performed using the LeFort technique with limited dissection—has become the most popular obliterative approach. We try to avoid a total colpocleisis procedure—also known as colpectomy—in which the entire vaginal epithelium is stripped, because it is feasible only when the uterus is already absent or scheduled to be removed concomitantly.

(Note: The term vaginectomy should be reserved for gynecologic oncology procedures performed to remove vaginal cancer. Vaginectomy entails full-thickness excision of the vaginal walls, including the fibromuscular layer, as opposed to excision of the epithelial layer only, as in colpocleisis. In this article, we present the LeFort method, a partial colpocleisis technique, because we believe it is more easily adapted by the general gynecologist.⁸)

CASE 1 RESOLVED

After detailed counseling, which includes family members, the patient opts to undergo colpocleisis. The procedure takes 45 minutes. She is discharged on postoperative Day 1, and reports substantially improved quality of life.

CASE 2: Recurrent prolapse and problems with a pessary

A 72-year-old multiparous, widowed woman experiences recurrent stage-III isolated apical prolapse. She has already undergone two reconstructive procedures, and was discouraged from undergoing a third because of her chronic obstructive lung disease. She tried to use a Gellhorn-type pessary, which required a doctor’s intervention to insert and remove. Frustrated by the many office visits involved in having the pessary checked, she now demands surgical therapy. Another gynecologist has offered to repair the prolapse using mesh, but the patient has concerns about the safety and efficacy of the procedure because it is a relatively new approach.

In addition to the recurrent prolapse, she loses urine with stress and urge. She often has a postvoid residual volume >100 cc; urodynamic assessment confirms mixed urinary incontinence. The patient does not foresee any change in her social status (unmarried, sexually inactive).

Is colpocleisis a reasonable option?

Although the pessary is a helpful conservative alternative for women who are either unable or unwilling to undergo complex surgical pelvic repair and is considered first-line treatment by a majority of urogynecologists, it sometimes becomes more difficult to maintain than the patient is willing to tolerate.⁹ When a woman cannot remove and reinsert the device herself, the pessary requires a lifelong commitment to doctor’s visits every 2 or 3 months. This commitment is especially problematic for patients who become unable to drive or who lack social support.

Maintenance of the pessary becomes more frustrating as the patient becomes more dependent. Many gynecologists have seen a patient who developed a serious complication such as vesicovaginal or rectovaginal fistula because of a neglected pessary.¹⁰

In Case 2, the patient appears to be a potential candidate for colpocleisis, given her age and single status. Although pelvic floor repair appears to be safe in older women, any perioperative complication in a patient 70 years of age or older doubles the risk of discharge to a care facility.^11,12 Women who have already undergone several surgeries or who have advanced medical problems such as coronary artery disease or cancer should be counseled thoroughly about the safety and efficacy of colpocleisis.

As for self-image, colpocleisis eliminates prolapse and reduces the genital hiatus. If the patient understands that colpocleisis is obliterative for the vagina but may improve the external appearance of the genital area, she may be more accepting of the procedure. One recent prospective, multicenter study found that only 2% of women thought their body looked worse 1 year after colpocleisis; 60% thought their body looked better.⁵

When reviewing treatment options, inform the patient that the pessary is a palliative option, whereas surgical therapy aims to be definitive.

CASE 2 RESOLVED

After comprehensive counseling, the patient elects to undergo colpocleisis, along with placement of a midurethral sling. She is discharged 1 day after surgery, and reports substantially improved urinary function, including bladder emptying, and quality of life. She says she would recommend the procedure to any woman who has a similar condition.

CASE 3: Pessary-related complications, incontinence, and underlying medical conditions

A 92-year-old multiparous widow, whose stage-IV uterovaginal prolapse has been managed by a pessary, develops vaginal ulcers in both anterior and posterior walls. After removal of the pessary and 4 weeks of treatment with vaginal estrogen, a smaller pessary is inserted, but she again develops ulcers and bleeding.

The patient’s medical condition is complicated by hypertension and generalized arthritis. She has urodynamically confirmed mixed urinary incontinence. She lives with her daughter and does not want to be placed in a nursing home.

What treatment options should you offer to her?

Because of this patient’s advanced age, poor health, and pessary-related problems, she is an ideal candidate for colpocleisis, provided she consents to the procedure after thorough counseling about its benefits and limitations.

Preoperative concerns

A thorough history, physical examination, and normal Pap test are necessary. If a suspicious pelvic mass or uterine bleeding is present, transvaginal ultrasonography (US) is crucial. In-office endometrial sampling also is necessary in any woman who has unexplained vaginal bleeding. More invasive procedures such as dilatation and curettage and hysteroscopy are needed only when the biopsy is inadequate or endometrial thickness exceeds 4 mm on transvaginal US.¹³

All elderly women who have high-risk medical problems must be cleared for surgery, with the necessary cardiac and pulmonary workup completed before the procedure.

Because colpocleisis is an extraperitoneal procedure, we have adapted use of over-the-counter enema products on the day before surgery in lieu of mechanical bowel preparation, which may lead to dehydration in very elderly women.

Coordinated consultation between the surgeon and anesthesiologist is necessary to determine the type of anesthesia to be used. Sedation and local anesthesia can be adequate for extremely high-risk women.^14,15 Antibiotic prophylaxis is conventional for all patients.

Surgical technique

The LeFort method involves denudation and approximation of the midportions of the anterior and posterior vaginal walls.⁸ This operation creates a longitudinal vaginal septum with bilateral channels on each side, which serve as conduits for any secretion or bleeding from the apical vagina (FIGURE 1A AND B). Aggressive perineorraphy is also needed to shorten the genital hiatus. The following description incorporates perineorraphy into the LeFort technique.

FIGURE 1 Principles of LeFort colpocleisis

The depiction here is not anatomically precise: The vagina is illustrated as a rectangular prism to clarify the relationship between tissues.

Patient positioning

Place the patient in the dorsal lithotomy position, using stirrups to support the entire leg up to the knee. Let the patient’s buttocks overhang the edge of the table by 1 to 2 inches. A slight Trendelenburg position is imperative, especially when operating on the anterior compartment of the vagina. The bladder should be only partially emptied because the leakage of urine from the bladder makes it easier to identify inadvertent cystotomy. Infiltration of local anesthetic solution to develop the surgical planes is acceptable.

Initiating the procedure

Remove a rectangular piece of vaginal epithelium from the anterior vaginal wall, beginning 2 to 3 cm distal to the vaginal apex (or cervix, if the uterus is present) and ending immediately proximal to the urethrovesical junction to leave space for midurethral sling placement. Remove a similarly sized piece of epithelium from the posterior vaginal wall. This posterior rectangle is an almost geometric projection of the anterior rectangle, but is somewhat longer (2 to 3 cm) (FIGURE 1).

When removing the vaginal epithelium, it may be helpful to use the skills developed for anterior and posterior colporraphy. Our operation begins with a 5- to 6-cm transverse incision at the anterior vaginal apex, which creates the proximal side of the anterior rectangle described above (FIGURE 2A).

As you develop the plane between the epithelium and fibromuscular layer, make a midline sagittal incision and extend it to the urethrovesical junction (FIGURE 2B). Dissect the epithelium off the fibromuscular layer approximately 3 cm bilaterally, then make a transverse incision at the urethrovesical junction. Finally, remove the anterior rectangle in two pieces by cutting along the lateral sides (FIGURE 2C AND D). Remove the posterior rectangle using the same technique, but also excise a triangular piece of skin from the posterior fourchette for the perineorraphy portion of the procedure (FIGURE 2E).

FIGURE 2 LeFort technique, step by step

Begin with a 5–6 cm transverse incision at the anterior vaginal apex.

Dissect the epithelium off the fibromuscular layer, with a midline sagittal incision extending to the urethrovesical junction.

After dissection is completed, make a transverse incision at the urethrovesical junction, and remove the anterior rectangle in two pieces by cutting along the lateral sides.

Denude the posterior rectangle using the same technique. In addition, excise a triangular piece of skin from the perineum.

The posterior rectangle is ready for removal.

Suturing

Suture the apical sides of the anterior and posterior rectangles together using a continuous running technique (FIGURE 2F). Then approximate the lateral sides bilaterally using continuous sutures.

To ensure adherence of the anterior and posterior rectangles, stitch the raw surfaces together in three rows (FIGURE 2G). Do not include the distal 2 cm of the posterior vagina because you will need to leave room for perineorraphy.

Using several sutures, reapproximate the torn perineal fibromuscular structures in the midline to perform perineorraphy (FIGURE 2H). Close the distal vagina, beginning at the midpoint of the anterior transverse side, which lies at the urethrovesical junction (FIGURE 2I). Continue this suture on the posterior vagina and then the perineal body, sagittally, creating a small invagination in the distal vagina (FIGURE 2J).

FIGURE 2 LeFort technique, step by step

Suture all but the distal sides of the rectangles between the anterior and posterior vaginal walls.

Also stitch together the raw surfaces in three rows in an imbricating fashion.

Perform perineorraphy.

Close the distal vagina, starting at the midpoint of the anterior transverse side. If indicated, place a midurethral sling.

Final appearance.

Sling procedure

We place a midurethral sling as part of most colpocleisis operations. It is best to do this after the colpocleisis but before the perineorraphy.

In our cases, cystoscopy with simultaneous intravenous indigo carmine injection is standard before perineorraphy, even when a sling procedure is not planned. This safeguard ensures ureteral patency, which can be compromised (although rarely) in these procedures. Cutting and replacement of one of the sutures that approximate the raw tissues typically resolve the problem.¹⁶

Special considerations

Here are additional key points about colpocleisis, based on our experience:

• If an ulcer lies within the area designated to be denuded, some debridement to freshen up the surface will suffice. An ulcer is not an indication to deviate from the standard procedure.
• A modification developed by Goodall and Power may allow coitus by removing only a triangular piece of epithelium from each wall, leaving more room for the channels.¹⁷
• We have been unable to find any report of uterine or cervical cancer after colpocleisis, despite a MEDLINE search of the literature in English. Even so, the lateral channels created by the LeFort procedure allow any bleeding to escape the vagina, and may therefore enable recognition of malignancy. When noninvasive imaging techniques such as US or magnetic resonance are inadequate, vaginoscopy and hysteroscopy may be accomplished via these channels.
• When colpocleisis is performed in a hysterectomized woman, no lateral channel is necessary. Therefore, it is appropriate to do total colpocleisis.^18,19
• When a patient with POP has a rectovaginal or vesicovaginal fistula caused by a neglected pessary, the addition of LeFort colpocleisis to the fistula repair may provide an effective treatment for both problems.¹⁰

Surgical outcomes

Success rate

Evidence concerning colpocleisis comes from case series, some of which are more than 30 years old. Although the definition of success is not clear in some series, the reported success rate has always exceeded 90% over the past three decades.^2,18-22 Moreover, some of these reports involve as many as 30 years of follow-up.

Perioperative complication

In a recent review of the literature, the procedure-related mortality rate was 0.025%.² When the authors focused only on studies published since 1980, major complications due to the patient’s underlying cardiovascular and pulmonary condition were seen in 2% of cases. Major surgical complications such as pyelonephritis and bleeding requiring transfusion occurred in 4% of cases, and less severe complications occurred in 15%.

In a study that included women who underwent concomitant vaginal hysterectomy, hysterectomy prolonged the surgery by 52 minutes, with a 5% rate of laparotomy as a result of intraoperative bleeding.²²

Quality of life

In our series of 40 colpocleisis cases, we noted no instance in which a patient regretted the procedure.¹⁸ Others have also reported a low rate of regret—the highest being 9%.^3-5,19-21

Using validated questionnaires, FitzGerald and colleagues found significant improvement in mental and physical quality of life, as well as urinary, colorectal, and bulge-related pelvic floor symptoms, 1 year after colpocleisis.⁵

De novo or worsening urinary incontinence is one of the drawbacks of colpocleisis. However, the same risk is present in approximately 40% of women who undergo surgical reconstructive procedures for POP without a continence operation.²³ Because preoperative urinary retention is common in women who have POP, the decision to add a potentially harmful continence procedure is complicated in colpocleisis candidates. A small case series reported that the success rate ranged from 90% to 94% in women who underwent a midurethral tension-free sling procedure for the treatment of urinary incontinence at the time of colpocleisis.⁵

Preoperative urodynamic studies to detect urethral intrinsic deficiency and detrusor dysfunction are prudent, and detailed counseling of the patient about urinary control is vital. We perform a midurethral sling procedure in most of our colpocleisis cases, and have had pleasing results.

CASE 3 RESOLVED

The patient decides to undergo partial colpocleisis using the LeFort procedure, along with placement of a midurethral sling, for a total operative time of 75 minutes. She is discharged 1 day later and reports substantial improvement in urinary function and quality of life.

CASE 1: Problematic prolapse, but no incontinence

An 81-year-old multiparous woman, who has a history of recurrent stage-III pelvic organ prolapse (POP), reports worsening discomfort that makes it difficult for her to care for her ailing husband. She also has “trouble” with bladder emptying and constipation, but denies any loss of urine. She has not had vaginal intercourse in more than a decade because of her husband’s medical condition.

Aside from health issues—she suffers from obesity, coronary artery disease, hypertension, and diabetes—the patient is content with her marriage of 58 years.

Urodynamic testing fails to demonstrate detrusor overactivity, stress urinary incontinence, or intrinsic sphincteric deficiency. A cough stress test is repeated after reduction of her prolapse using a large cotton swab, and confirms the findings of the urodynamic tests.

Is reconstructive surgery appropriate for this patient?

Traditional reconstructive surgical procedures for treating POP fail in as many as 30% of patients, and new approaches—some involving grafts—are proposed every day, often without much data behind them.¹

Regardless of the approach, reconstructive surgery is a lengthy procedure that subjects patients who are already medically compromised to significant risk, including bleeding, infection, and fluid shifts. Delayed return to normal activity may be especially costly among elderly women because of the risk of venous thromboembolism.

Because of the high failure rate, slow recovery, and risk of complications, reconstructive surgery may not be as appropriate as colpocleisis for the woman described above. Colpocleisis—suturing the inside walls of the vagina together—has an efficacy rate exceeding 90%.² This relatively simple operation has been around for almost two centuries and has a good track record, but is often overlooked when counseling a patient about her options.

Any frail, elderly woman who has stage-III or -IV POP who does not desire to preserve coital ability is a candidate for colpocleisis (TABLE). Advantages include:

• a short operating time
• few complications
• amenability of local anesthesia
• short hospitalization
• speedy recovery
• high success rate
• low rate of regret.^2-5

Because it precludes coital activity, however, colpocleisis may cause problems with self-image. It also may lead to de novo or worsening urinary incontinence and complicate or delay the diagnosis of cervical and endometrial pathology.

This article explores these issues through a case-based discussion of colpocleisis, including a detailed description of surgical technique.

TABLE

Requirements for colpocleisis

Why colpocleisis?

Colpocleisis, as noted, entails suturing the inside walls of the vagina together. It is controversial because of its impact on coital activity. With careful patient selection, however, colpocleisis is considered a valid option for frail and elderly women who have POP and do not desire or foresee the possibility of future vaginal intercourse. Such women may represent a surprising percentage of the elderly population. A community-based survey found that 78% of married women 70 to 79 years old are not sexually active,⁶ and a study from The Netherlands found a prevalence of symptomatic POP of 11.4% among white women 45 to 85 years old.⁷

The fundamental reason for choosing an obliterative procedure such as colpocleisis over total pelvic reconstruction is to treat the prolapse with the least invasive technique in the shortest time. Hysterectomy, which often adds 30 to 80 minutes to the procedure, should therefore be performed only in patients who have a suspicious finding upon initial evaluation. For the same reason, partial colpocleisis—performed using the LeFort technique with limited dissection—has become the most popular obliterative approach. We try to avoid a total colpocleisis procedure—also known as colpectomy—in which the entire vaginal epithelium is stripped, because it is feasible only when the uterus is already absent or scheduled to be removed concomitantly.

(Note: The term vaginectomy should be reserved for gynecologic oncology procedures performed to remove vaginal cancer. Vaginectomy entails full-thickness excision of the vaginal walls, including the fibromuscular layer, as opposed to excision of the epithelial layer only, as in colpocleisis. In this article, we present the LeFort method, a partial colpocleisis technique, because we believe it is more easily adapted by the general gynecologist.⁸)

CASE 1 RESOLVED

After detailed counseling, which includes family members, the patient opts to undergo colpocleisis. The procedure takes 45 minutes. She is discharged on postoperative Day 1, and reports substantially improved quality of life.

CASE 2: Recurrent prolapse and problems with a pessary

A 72-year-old multiparous, widowed woman experiences recurrent stage-III isolated apical prolapse. She has already undergone two reconstructive procedures, and was discouraged from undergoing a third because of her chronic obstructive lung disease. She tried to use a Gellhorn-type pessary, which required a doctor’s intervention to insert and remove. Frustrated by the many office visits involved in having the pessary checked, she now demands surgical therapy. Another gynecologist has offered to repair the prolapse using mesh, but the patient has concerns about the safety and efficacy of the procedure because it is a relatively new approach.

In addition to the recurrent prolapse, she loses urine with stress and urge. She often has a postvoid residual volume >100 cc; urodynamic assessment confirms mixed urinary incontinence. The patient does not foresee any change in her social status (unmarried, sexually inactive).

Is colpocleisis a reasonable option?

Although the pessary is a helpful conservative alternative for women who are either unable or unwilling to undergo complex surgical pelvic repair and is considered first-line treatment by a majority of urogynecologists, it sometimes becomes more difficult to maintain than the patient is willing to tolerate.⁹ When a woman cannot remove and reinsert the device herself, the pessary requires a lifelong commitment to doctor’s visits every 2 or 3 months. This commitment is especially problematic for patients who become unable to drive or who lack social support.

Maintenance of the pessary becomes more frustrating as the patient becomes more dependent. Many gynecologists have seen a patient who developed a serious complication such as vesicovaginal or rectovaginal fistula because of a neglected pessary.¹⁰

In Case 2, the patient appears to be a potential candidate for colpocleisis, given her age and single status. Although pelvic floor repair appears to be safe in older women, any perioperative complication in a patient 70 years of age or older doubles the risk of discharge to a care facility.^11,12 Women who have already undergone several surgeries or who have advanced medical problems such as coronary artery disease or cancer should be counseled thoroughly about the safety and efficacy of colpocleisis.

As for self-image, colpocleisis eliminates prolapse and reduces the genital hiatus. If the patient understands that colpocleisis is obliterative for the vagina but may improve the external appearance of the genital area, she may be more accepting of the procedure. One recent prospective, multicenter study found that only 2% of women thought their body looked worse 1 year after colpocleisis; 60% thought their body looked better.⁵

When reviewing treatment options, inform the patient that the pessary is a palliative option, whereas surgical therapy aims to be definitive.

CASE 2 RESOLVED

After comprehensive counseling, the patient elects to undergo colpocleisis, along with placement of a midurethral sling. She is discharged 1 day after surgery, and reports substantially improved urinary function, including bladder emptying, and quality of life. She says she would recommend the procedure to any woman who has a similar condition.

CASE 3: Pessary-related complications, incontinence, and underlying medical conditions

A 92-year-old multiparous widow, whose stage-IV uterovaginal prolapse has been managed by a pessary, develops vaginal ulcers in both anterior and posterior walls. After removal of the pessary and 4 weeks of treatment with vaginal estrogen, a smaller pessary is inserted, but she again develops ulcers and bleeding.

The patient’s medical condition is complicated by hypertension and generalized arthritis. She has urodynamically confirmed mixed urinary incontinence. She lives with her daughter and does not want to be placed in a nursing home.

What treatment options should you offer to her?

Because of this patient’s advanced age, poor health, and pessary-related problems, she is an ideal candidate for colpocleisis, provided she consents to the procedure after thorough counseling about its benefits and limitations.

Preoperative concerns

A thorough history, physical examination, and normal Pap test are necessary. If a suspicious pelvic mass or uterine bleeding is present, transvaginal ultrasonography (US) is crucial. In-office endometrial sampling also is necessary in any woman who has unexplained vaginal bleeding. More invasive procedures such as dilatation and curettage and hysteroscopy are needed only when the biopsy is inadequate or endometrial thickness exceeds 4 mm on transvaginal US.¹³

All elderly women who have high-risk medical problems must be cleared for surgery, with the necessary cardiac and pulmonary workup completed before the procedure.

Because colpocleisis is an extraperitoneal procedure, we have adapted use of over-the-counter enema products on the day before surgery in lieu of mechanical bowel preparation, which may lead to dehydration in very elderly women.

Coordinated consultation between the surgeon and anesthesiologist is necessary to determine the type of anesthesia to be used. Sedation and local anesthesia can be adequate for extremely high-risk women.^14,15 Antibiotic prophylaxis is conventional for all patients.

Surgical technique

The LeFort method involves denudation and approximation of the midportions of the anterior and posterior vaginal walls.⁸ This operation creates a longitudinal vaginal septum with bilateral channels on each side, which serve as conduits for any secretion or bleeding from the apical vagina (FIGURE 1A AND B). Aggressive perineorraphy is also needed to shorten the genital hiatus. The following description incorporates perineorraphy into the LeFort technique.

FIGURE 1 Principles of LeFort colpocleisis

The depiction here is not anatomically precise: The vagina is illustrated as a rectangular prism to clarify the relationship between tissues.

Patient positioning

Place the patient in the dorsal lithotomy position, using stirrups to support the entire leg up to the knee. Let the patient’s buttocks overhang the edge of the table by 1 to 2 inches. A slight Trendelenburg position is imperative, especially when operating on the anterior compartment of the vagina. The bladder should be only partially emptied because the leakage of urine from the bladder makes it easier to identify inadvertent cystotomy. Infiltration of local anesthetic solution to develop the surgical planes is acceptable.

Initiating the procedure

Remove a rectangular piece of vaginal epithelium from the anterior vaginal wall, beginning 2 to 3 cm distal to the vaginal apex (or cervix, if the uterus is present) and ending immediately proximal to the urethrovesical junction to leave space for midurethral sling placement. Remove a similarly sized piece of epithelium from the posterior vaginal wall. This posterior rectangle is an almost geometric projection of the anterior rectangle, but is somewhat longer (2 to 3 cm) (FIGURE 1).

When removing the vaginal epithelium, it may be helpful to use the skills developed for anterior and posterior colporraphy. Our operation begins with a 5- to 6-cm transverse incision at the anterior vaginal apex, which creates the proximal side of the anterior rectangle described above (FIGURE 2A).

As you develop the plane between the epithelium and fibromuscular layer, make a midline sagittal incision and extend it to the urethrovesical junction (FIGURE 2B). Dissect the epithelium off the fibromuscular layer approximately 3 cm bilaterally, then make a transverse incision at the urethrovesical junction. Finally, remove the anterior rectangle in two pieces by cutting along the lateral sides (FIGURE 2C AND D). Remove the posterior rectangle using the same technique, but also excise a triangular piece of skin from the posterior fourchette for the perineorraphy portion of the procedure (FIGURE 2E).

FIGURE 2 LeFort technique, step by step

Begin with a 5–6 cm transverse incision at the anterior vaginal apex.

Dissect the epithelium off the fibromuscular layer, with a midline sagittal incision extending to the urethrovesical junction.

After dissection is completed, make a transverse incision at the urethrovesical junction, and remove the anterior rectangle in two pieces by cutting along the lateral sides.

Denude the posterior rectangle using the same technique. In addition, excise a triangular piece of skin from the perineum.

The posterior rectangle is ready for removal.

Suturing

Suture the apical sides of the anterior and posterior rectangles together using a continuous running technique (FIGURE 2F). Then approximate the lateral sides bilaterally using continuous sutures.

To ensure adherence of the anterior and posterior rectangles, stitch the raw surfaces together in three rows (FIGURE 2G). Do not include the distal 2 cm of the posterior vagina because you will need to leave room for perineorraphy.

Using several sutures, reapproximate the torn perineal fibromuscular structures in the midline to perform perineorraphy (FIGURE 2H). Close the distal vagina, beginning at the midpoint of the anterior transverse side, which lies at the urethrovesical junction (FIGURE 2I). Continue this suture on the posterior vagina and then the perineal body, sagittally, creating a small invagination in the distal vagina (FIGURE 2J).

FIGURE 2 LeFort technique, step by step

Suture all but the distal sides of the rectangles between the anterior and posterior vaginal walls.

Also stitch together the raw surfaces in three rows in an imbricating fashion.

Perform perineorraphy.

Close the distal vagina, starting at the midpoint of the anterior transverse side. If indicated, place a midurethral sling.

Final appearance.

Sling procedure

We place a midurethral sling as part of most colpocleisis operations. It is best to do this after the colpocleisis but before the perineorraphy.

In our cases, cystoscopy with simultaneous intravenous indigo carmine injection is standard before perineorraphy, even when a sling procedure is not planned. This safeguard ensures ureteral patency, which can be compromised (although rarely) in these procedures. Cutting and replacement of one of the sutures that approximate the raw tissues typically resolve the problem.¹⁶

Special considerations

Here are additional key points about colpocleisis, based on our experience:

• If an ulcer lies within the area designated to be denuded, some debridement to freshen up the surface will suffice. An ulcer is not an indication to deviate from the standard procedure.
• A modification developed by Goodall and Power may allow coitus by removing only a triangular piece of epithelium from each wall, leaving more room for the channels.¹⁷
• We have been unable to find any report of uterine or cervical cancer after colpocleisis, despite a MEDLINE search of the literature in English. Even so, the lateral channels created by the LeFort procedure allow any bleeding to escape the vagina, and may therefore enable recognition of malignancy. When noninvasive imaging techniques such as US or magnetic resonance are inadequate, vaginoscopy and hysteroscopy may be accomplished via these channels.
• When colpocleisis is performed in a hysterectomized woman, no lateral channel is necessary. Therefore, it is appropriate to do total colpocleisis.^18,19
• When a patient with POP has a rectovaginal or vesicovaginal fistula caused by a neglected pessary, the addition of LeFort colpocleisis to the fistula repair may provide an effective treatment for both problems.¹⁰

Surgical outcomes

Success rate

Evidence concerning colpocleisis comes from case series, some of which are more than 30 years old. Although the definition of success is not clear in some series, the reported success rate has always exceeded 90% over the past three decades.^2,18-22 Moreover, some of these reports involve as many as 30 years of follow-up.

Perioperative complication

In a recent review of the literature, the procedure-related mortality rate was 0.025%.² When the authors focused only on studies published since 1980, major complications due to the patient’s underlying cardiovascular and pulmonary condition were seen in 2% of cases. Major surgical complications such as pyelonephritis and bleeding requiring transfusion occurred in 4% of cases, and less severe complications occurred in 15%.

In a study that included women who underwent concomitant vaginal hysterectomy, hysterectomy prolonged the surgery by 52 minutes, with a 5% rate of laparotomy as a result of intraoperative bleeding.²²

Quality of life

In our series of 40 colpocleisis cases, we noted no instance in which a patient regretted the procedure.¹⁸ Others have also reported a low rate of regret—the highest being 9%.^3-5,19-21

Using validated questionnaires, FitzGerald and colleagues found significant improvement in mental and physical quality of life, as well as urinary, colorectal, and bulge-related pelvic floor symptoms, 1 year after colpocleisis.⁵

De novo or worsening urinary incontinence is one of the drawbacks of colpocleisis. However, the same risk is present in approximately 40% of women who undergo surgical reconstructive procedures for POP without a continence operation.²³ Because preoperative urinary retention is common in women who have POP, the decision to add a potentially harmful continence procedure is complicated in colpocleisis candidates. A small case series reported that the success rate ranged from 90% to 94% in women who underwent a midurethral tension-free sling procedure for the treatment of urinary incontinence at the time of colpocleisis.⁵

Preoperative urodynamic studies to detect urethral intrinsic deficiency and detrusor dysfunction are prudent, and detailed counseling of the patient about urinary control is vital. We perform a midurethral sling procedure in most of our colpocleisis cases, and have had pleasing results.

CASE 3 RESOLVED

The patient decides to undergo partial colpocleisis using the LeFort procedure, along with placement of a midurethral sling, for a total operative time of 75 minutes. She is discharged 1 day later and reports substantial improvement in urinary function and quality of life.

The author reports that he serves on the speaker’s bureau for Novogyne, TherRx, Warner-Chilcott, and Solvay, and on the advisory board for Upsher-Smith, Novogyne, QuatRx, and Wyeth.

CASE: History of dyspareunia

At her latest visit, a 56-year-old woman who is 7 years postmenopausal relates that she has been experiencing worsening pain with intercourse to the point that she now has very little sex drive at all. This problem began approximately 1 year after she discontinued hormone therapy in the wake of reports that it causes cancer and heart attack. She has been offered both local vaginal and systemic hormone therapy, but is too frightened to use any hormones at all. Sexual lubricants no longer seem to work.

How do you counsel her about these symptoms? And what therapy do you offer?

Physicians and other health-care practitioners are seeing a large and growing number of genitourinary and sexual-related complaints among menopausal women—so much so that it has reached epidemic proportions. Yet dyspareunia is underreported and undertreated, and quality of life suffers for these women.

In this article, I focus on two interrelated causes of this epidemic:

• vaginal dryness and vulvovaginal atrophy (VVA) and the impact of these conditions on women’s sexual function and psychosocial well-being
• barriers to optimal treatment.

I also explore how ObGyns’ role in this area of care is evolving—as a way to understand how you can better serve this expanding segment of our patient population.

Dyspareunia can have many causes, including endometriosis, interstitial cystitis, surgical scarring, injury that occurs during childbirth, and psychosocial origin (such as a history of sexual abuse). Our focus here is on dyspareunia due to VVA.

Just how sizable is the postmenopausal population?

About 32% of the female population is older than 50 years.¹ That means that around 48 million women are currently menopausal, or will become so over the next few years.

Because average life expectancy approaches 80 years in the United States and other countries of the industrialized world,² many women will live approximately 40 years beyond menopause or their final menstrual period. Their quality of life during the second half of their life is dependent on both physical and psychosocial health.

Postmenopausal dyspareunia isn’t new

Sexual issues arising from physical causes—dyspareunia among them—have long accounted for a large share of medical concerns reported by postmenopausal women. In a 1985 survey, for example, dyspareunia accounted for 42.5% of their complaints.³

But epidemiologic studies to determine the prevalence of female sexual dysfunction in postmenopausal women are difficult to carry out. Why? Because researchers would need to 1) address changes over time and 2) distinguish problems of sexual function from those brought on by aging.⁴

The techniques and methodology for researching female sexual dysfunction continue to evolve, creating new definitions of the stages of menopause and new diagnostic approaches to female sexual dysfunction.

However, based on available studies, Dennerstein and Hayes concluded that:

• postmenopausal women report a high rate of sexual dysfunction (higher than men)
• psychosocial factors can ameliorate a decline in sexual function
• “vaginal dryness and dyspareunia seem to be driven primarily by declining estradiol.”⁴

The WHI and its domino effect

Millions of postmenopausal women stopped taking estrogen-based therapy in the wake of widespread media coverage after 2002 publication of data from the estrogen–progestin arm of the Women’s Health Initiative (WHI), which purported to show, among other things, an increased risk of breast cancer.⁵

For decades, many postmenopausal women achieved medical management of VVA through long-term use of systemic hormone replacement therapy (HRT), which they used primarily to control other chronic symptoms of menopause, such as hot flashes.

After the WHI data were published (and misrepresented), reduced usage of estrogen-based HRT “unmasked” vaginal symptoms, including sexual pain, due to the effects of estrogen deficiency on the vaginal epithelium and vaginal blood flow. Since then, we have been forced to examine anew the natural history of menopause.

Within days or weeks of discontinuing HRT, women may reexperience the acute vasomotor symptoms that accompany estrogen withdrawal—most commonly hot flashes, night sweats, sleeplessness, palpitations, and headaches. Over time—anywhere from 6 months to several years—the body adjusts to the loss or withdrawal of estrogen, and these vasomotor symptoms eventually diminish or resolve. Not so for the longer-term physical effects of chronic low serum levels of estrogen, which worsen over time.

Approximately 6 months after discontinuing estrogen therapy, postmenopausal women may begin to experience vaginal dryness and VVA. As the years pass, other side effects of estrogen deficiency arise: bone loss, joint pain, mood alteration (including depression), change in skin tone, hair loss, and cardiac and central nervous system changes. These side effects do not resolve spontaneously; in fact, they grow worse as a woman ages. They may have deleterious psychosocial as well as physical impacts on her life—especially on the quality of her intimate relationship.

Is 60 the new 40?

Many women and men in the large cohort known as the Baby Boomer generation continue to be sexually active into their 60s, 70s, and 80s, as demonstrated by a 2007 study of sexuality and health in older adults.⁶ In the 57- to 64-year-old age group, 61.6% of women and 83.7% of men were sexually active (defined as sexual activity with a partner within the past 12 months). In the 65- to 74-year-old group, 39.5% of women and 67% of men were sexually active; and in the 75- to 85-year-old group, 16.7% of women and 38.5% of men were sexually active (TABLE).

These findings indicate that fewer women than men remain sexually active during their later years. One reason may be the epidemic of sexual-related symptoms among postmenopausal women. In the same survey, 34.3% of women 57 to 64 years old reported avoiding sex because of:

• pain during intercourse (17.8%)
• difficulty with lubrication (35.9%).

Across all groups, the most prevalent sexual problem was low desire (43%).⁶ Around 40% of postmenopausal women reported no sexual activity in the past 12 months, as well as lack of interest in sex. This number may include women who have ceased to have sex because of vaginal dryness and dyspareunia, thereby reducing the percentage reporting these symptoms (TABLE).

TABLE

Older adults are having sex—and experiencing sexual problems

Assessing menopause-related sexual function is a challenge

Although the transition phases of menopause have been well studied and reported for decades, few of these studies have included questions about the impact of menopause on sexual function.⁷ When longitudinal studies that included the classification of female sexual dysfunction began to appear, they provided evidence of the important role that VVA and psychosocial factors play in female sexual dysfunction.⁸

In the fourth year of the Melbourne Women’s Midlife Health Project longitudinal study, six variables related to sexual function were identified. Three were determinate of sexual function:

• feelings for the partner
• problems related to the partner
• vaginal dryness/dyspareunia.

The other three variables—sexual responsiveness, frequency of sexual activity, and libido—were dependent or outcome variables.

By the sixth year of this study, two variables had increased in significance: vaginal dryness/dyspareunia and partner problems.⁷

Sexual pain and relationship problems can create a vicious cycle

The interrelationship of vaginal dryness, sexual pain, flagging desire, and psychosocial parameters can produce a vicious cycle. A woman experiencing or anticipating pain may have diminished sexual desire or avoid sex altogether. During intercourse, the brain’s awareness of vaginal pain may trigger a physiologic response that can cause the muscles of the vagina to tighten and lubrication to decrease. The result? Greater vaginal pain.

This vicious cycle can contribute to relationship issues with the sexual partner and harm a woman’s psychosocial well-being. Resentment, anger, and misunderstanding may arise when a couple is dealing with problems of sexual function, and these stressors can damage many aspects of the relationship, further exacerbating sexual difficulties.

An additional and very important dimension of these issues is their potential impact on the family unit.

VVA can diminish overall well-being

In a 2007 survey reported at the North American Menopause Society (NAMS), one third to one half of 506 respondents said that VVA had a bad effect on their sexual interest, mood, self-esteem, and the intimate relationship (FIGURE 1).⁹ Reports from in-depth interviews were consistent with survey results and offered further insight into a woman’s emotional response to the condition of vaginal dryness and its impact on her life. Women found the condition “embarrassing,” something they had to endure but didn’t talk about, and felt that it had a major impact on their self-esteem and intimate relationship.

FIGURE 1 Dyspareunia affects more than interest in sex—relationships, mood, and self-esteem suffer

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

Clinicians often don’t ask about VVA, and patients are reluctant to talk

Among women of all ages, dyspareunia is underreported and undertreated. In the survey reported at NAMS, 40% of respondents said that their physician had never asked them about the problem of VVA (FIGURE 2).⁹

Women themselves may be reluctant to discuss the problem with physicians, nurse practitioners, or other health-care providers out of embarrassment or the assumption that there is nothing to be done about the problem. Nevertheless, more than 40% of respondents said they would be highly likely to seek treatment for VVA if they had a concern about urogenital complications of the condition (FIGURE 3).⁹

Another barrier may be the sense that asking the health-care provider about sex may embarrass him or her. As a result, sufferers do not anticipate help from their physician and other members of the health-care profession and fail to seek treatment or counseling for this chronic medical condition.^10,11

In a 1999 telephone survey of 500 adults 25 years of age or older, 71% said they thought that their doctor would dismiss concerns about sexual problems, but 85% said they would talk to their physician anyway if they had a problem, even though they might not get treatment.¹¹ In that survey, 91% of married men and 84% of married women rated a satisfying sex life as important to quality of life.¹¹

Another important and often overlooked limitation on this type of discussion is the time constraints that busy clinicians face, especially with the low reimbursement offered by managed care. Sexual problems can hardly be adequately discussed in 7 to 10 minutes.

FIGURE 2 Do physicians ask about dyspareunia? Most women surveyed said “rarely” or “never”

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

FIGURE 3 Are these women likely to seek treatment?

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

Women have performance anxiety, too

It is well known that men with even a mild degree of erectile dysfunction can suffer from performance anxiety, but the fact that women can also suffer from this phenomenon is not given as much attention. Such anxiety can be a factor in relationship difficulties. With both partners perhaps feeling anxious about sexual performance, a couple may avoid even simple acts of affection, such as holding hands, to avoid raising the other’s expectations.

Exacerbating the situation is the fact that many men use widely prescribed phosphodiesterase type 5 (PDE5) inhibitors, whereas women are contending with barriers to continued sexual activity as they age. It does not take a psychologist to understand that this imbalance often adds to emotional strain and tension between partners.

Popular media address the issue

Look beyond what our postmenopausal patients tell us directly—to the popular media and online forums—to appreciate the scope of sexual pain as a major issue among postmenopausal women. Evidence of psychosocial effects is found on numerous Web sites—some from organizations, others designed by women seeking help from each other.

Red Hot Mamas

(www.redhotmamas.org)

This organization aims to empower women through menopause education. Highlighted in the Winter 2007/2008 Red Hot Mamas Report is a survey done in conjunction with Harris Interactive exploring the impact of menopausal symptoms on a woman’s sex life, which found that 47% of women who have VVA have avoided or stopped sex completely because it was uncomfortable, compared with 23% of normal women.

Power Surge

(www.power-surge.com)

This Web site offers a list of strategies for dealing with sexual pain, including an overview of hormone-based prescription and nonprescription products, along with a variety of over-the-counter, natural, holistic, and herbal therapies for treating dyspareunia.

What is the physician’s role?

Given the epidemic of sexual pain, it is crucial that physicians and others who care for postmenopausal women increase their awareness of this issue and pay special attention to its psychosocial parameters.

Ask patients about sexual function in general and dyspareunia in particular as part of the routine annual visit. A simple opening “Yes/No” question, such as “Are you sexually active?” can lead to further questions appropriate to the patient. For example, if the answer is “No,” the follow-up question might be, “Does that bother you or your partner?” Further discussion may uncover whether the lack of sexual activity is a cause of distress and identify which variables are involved.

If, instead, the answer is “Yes,” follow-up questions can identify the presence of common postmenopausal physical issues, such as vaginal dryness and difficulty with lubrication. The visit then can turn to strategies to ameliorate those conditions.

When a patient reports dyspareunia, further diagnostic information such as precise location, degree of arousal, and reaction to pain can help determine the appropriate course of treatment. For an approach to this aspect of ascertaining patient history, see the list of sample questions above.¹²

During the physical, pay particular attention to any physical abnormalities or organic causes of sexual pain. Questions designed to characterize the location and nature of the pain can pinpoint the cause. Sexual pain arising from VVA is likely to 1) be localized at the introitus and 2) occur with penile entry.

Think female sexual function is linear? Think again

Since the mid-1990s, the availability of validated scales to measure female sexual function has increased rapidly and enabled researchers to better identify, quantify, and evaluate treatments for female sexual dysfunction.⁷ Over time, we have moved away from the somewhat mechanical sequence inherent in the linear progression of desire leading to genital stimulation followed by arousal and orgasm toward an appreciation of the multiple physical, emotional, and subjective factors that are at play in women’s sexual function.

By 1998, a classification scheme was developed to further the means to study and discuss disorders of desire, arousal, orgasm, and sexual pain.⁸ Further contextual definitions of sexual dysfunction are under consideration.¹³

Basson proposed one new model of female sexual function (see the diagram), and observed that

"…women identify many reasons they are sexual over and beyond inherent sexual drive or “hunger.” Women tell of wanting to increase emotional closeness, commitment, sharing, tenderness, and tolerance, and to show the partner that he or she has been missed (emotionally or physically). Such intimacy-based reasons motivate the woman to find a way to become sexually aroused. This arousal is not spontaneous but triggered by deliberately sought sexual stimuli."¹³

Intimacy-based model of female sexual response cycle

In this flow of physical and emotional variables involved in female sexual function, categories interact. For example, low desire can be and is frequently secondary to the anticipation of pain during sexual intercourse. Arousal can be hampered by lack of vaginal lubrication—perhaps inhibited by the anticipation of pain. Secondary orgasmic disorders can result from low desire, difficulty of arousal, and sexual pain.¹⁴ Sexual pain can affect sexual function at any point on this continuum.

Treatments in the pipeline

For decades, hormone-based treatments have been the predominant therapeutic option for vaginal dryness. Often they are a secondary benefit of hormone therapy for vasomotor symptoms and osteoporosis. Estrogen can be delivered in the form of oral tablet, transdermal patch, gel, spray, or vaginal ring for systemic use, or as vaginal cream, ring, or tablet for local use.

However, despite data to the contrary and our reassurances to the patient about overall safety, a large number of women, and many primary care providers, are no longer inclined to use short- or long-term HRT in any presentation.

Other women may have risk factors that contraindicate exogenous hormones.

Nonhormonal options for vaginal dryness and dyspareunia are limited, and there are no approved systemic or oral nonestrogen options. Over-the-counter topical lubricants can ease some of the symptoms of VVA temporarily and allow successful vaginal penetration in many cases. Some may cause vaginal warming and pleasant sensations, but overall they treat the symptom rather than the source of pain. Moreover, many patients consider local lubricants messy and inconvenient and claim they “ruin the mood.”

The use of vaginal dilators along with estrogen or lubricant therapy is an often-forgotten adjunct to therapy for dyspareunia caused by VVA (FIGURE 4).

FIGURE 4 Mechanical dilation of the vagina is a useful adjunct

Mechanical dilation is often needed to restore penetration capability in the vagina, even after hormonal treatment. The focus should be on the vaginal introitus, with the top 25% to 35% of the dilator inserted into the opening once a day for 15 minutes, increasing the dilator diameter over time.

New SERMs are in development

Preclinical and clinical research into the diverse class of selective estrogen receptor modulators (SERMs) to treat estrogen-mediated disease produced tamoxifen for breast cancer prevention and raloxifene for both vertebral osteoporosis and breast cancer prevention. Each SERM seems to have unique tissue selectivity. The antiestrogenic activity of tamoxifen and raloxifene extends to the vagina and can exacerbate vaginal dryness.

A new generation of orally active SERMs is under investigation specifically for the treatment of chronic vaginal symptoms. These new agents target the nonvaginal treatment of VVA and associated symptoms. The first oral SERM for long-term treatment of these symptoms, ospemifene (Ophena), may become available in the near future. It is a novel SERM that has both anti-estrogenic and estrogenic actions, depending on the tissue. It was shown to significantly improve both vaginal dryness and dyspareunia in a large placebo-controlled trial.¹⁵

The author reports that he serves on the speaker’s bureau for Novogyne, TherRx, Warner-Chilcott, and Solvay, and on the advisory board for Upsher-Smith, Novogyne, QuatRx, and Wyeth.

CASE: History of dyspareunia

At her latest visit, a 56-year-old woman who is 7 years postmenopausal relates that she has been experiencing worsening pain with intercourse to the point that she now has very little sex drive at all. This problem began approximately 1 year after she discontinued hormone therapy in the wake of reports that it causes cancer and heart attack. She has been offered both local vaginal and systemic hormone therapy, but is too frightened to use any hormones at all. Sexual lubricants no longer seem to work.

How do you counsel her about these symptoms? And what therapy do you offer?

Physicians and other health-care practitioners are seeing a large and growing number of genitourinary and sexual-related complaints among menopausal women—so much so that it has reached epidemic proportions. Yet dyspareunia is underreported and undertreated, and quality of life suffers for these women.

In this article, I focus on two interrelated causes of this epidemic:

• vaginal dryness and vulvovaginal atrophy (VVA) and the impact of these conditions on women’s sexual function and psychosocial well-being
• barriers to optimal treatment.

I also explore how ObGyns’ role in this area of care is evolving—as a way to understand how you can better serve this expanding segment of our patient population.

Dyspareunia can have many causes, including endometriosis, interstitial cystitis, surgical scarring, injury that occurs during childbirth, and psychosocial origin (such as a history of sexual abuse). Our focus here is on dyspareunia due to VVA.

Just how sizable is the postmenopausal population?

About 32% of the female population is older than 50 years.¹ That means that around 48 million women are currently menopausal, or will become so over the next few years.

Because average life expectancy approaches 80 years in the United States and other countries of the industrialized world,² many women will live approximately 40 years beyond menopause or their final menstrual period. Their quality of life during the second half of their life is dependent on both physical and psychosocial health.

Postmenopausal dyspareunia isn’t new

Sexual issues arising from physical causes—dyspareunia among them—have long accounted for a large share of medical concerns reported by postmenopausal women. In a 1985 survey, for example, dyspareunia accounted for 42.5% of their complaints.³

But epidemiologic studies to determine the prevalence of female sexual dysfunction in postmenopausal women are difficult to carry out. Why? Because researchers would need to 1) address changes over time and 2) distinguish problems of sexual function from those brought on by aging.⁴

The techniques and methodology for researching female sexual dysfunction continue to evolve, creating new definitions of the stages of menopause and new diagnostic approaches to female sexual dysfunction.

However, based on available studies, Dennerstein and Hayes concluded that:

• postmenopausal women report a high rate of sexual dysfunction (higher than men)
• psychosocial factors can ameliorate a decline in sexual function
• “vaginal dryness and dyspareunia seem to be driven primarily by declining estradiol.”⁴

The WHI and its domino effect

Millions of postmenopausal women stopped taking estrogen-based therapy in the wake of widespread media coverage after 2002 publication of data from the estrogen–progestin arm of the Women’s Health Initiative (WHI), which purported to show, among other things, an increased risk of breast cancer.⁵

For decades, many postmenopausal women achieved medical management of VVA through long-term use of systemic hormone replacement therapy (HRT), which they used primarily to control other chronic symptoms of menopause, such as hot flashes.

After the WHI data were published (and misrepresented), reduced usage of estrogen-based HRT “unmasked” vaginal symptoms, including sexual pain, due to the effects of estrogen deficiency on the vaginal epithelium and vaginal blood flow. Since then, we have been forced to examine anew the natural history of menopause.

Within days or weeks of discontinuing HRT, women may reexperience the acute vasomotor symptoms that accompany estrogen withdrawal—most commonly hot flashes, night sweats, sleeplessness, palpitations, and headaches. Over time—anywhere from 6 months to several years—the body adjusts to the loss or withdrawal of estrogen, and these vasomotor symptoms eventually diminish or resolve. Not so for the longer-term physical effects of chronic low serum levels of estrogen, which worsen over time.

Approximately 6 months after discontinuing estrogen therapy, postmenopausal women may begin to experience vaginal dryness and VVA. As the years pass, other side effects of estrogen deficiency arise: bone loss, joint pain, mood alteration (including depression), change in skin tone, hair loss, and cardiac and central nervous system changes. These side effects do not resolve spontaneously; in fact, they grow worse as a woman ages. They may have deleterious psychosocial as well as physical impacts on her life—especially on the quality of her intimate relationship.

Is 60 the new 40?

Many women and men in the large cohort known as the Baby Boomer generation continue to be sexually active into their 60s, 70s, and 80s, as demonstrated by a 2007 study of sexuality and health in older adults.⁶ In the 57- to 64-year-old age group, 61.6% of women and 83.7% of men were sexually active (defined as sexual activity with a partner within the past 12 months). In the 65- to 74-year-old group, 39.5% of women and 67% of men were sexually active; and in the 75- to 85-year-old group, 16.7% of women and 38.5% of men were sexually active (TABLE).

These findings indicate that fewer women than men remain sexually active during their later years. One reason may be the epidemic of sexual-related symptoms among postmenopausal women. In the same survey, 34.3% of women 57 to 64 years old reported avoiding sex because of:

• pain during intercourse (17.8%)
• difficulty with lubrication (35.9%).

Across all groups, the most prevalent sexual problem was low desire (43%).⁶ Around 40% of postmenopausal women reported no sexual activity in the past 12 months, as well as lack of interest in sex. This number may include women who have ceased to have sex because of vaginal dryness and dyspareunia, thereby reducing the percentage reporting these symptoms (TABLE).

TABLE

Older adults are having sex—and experiencing sexual problems

Assessing menopause-related sexual function is a challenge

Although the transition phases of menopause have been well studied and reported for decades, few of these studies have included questions about the impact of menopause on sexual function.⁷ When longitudinal studies that included the classification of female sexual dysfunction began to appear, they provided evidence of the important role that VVA and psychosocial factors play in female sexual dysfunction.⁸

In the fourth year of the Melbourne Women’s Midlife Health Project longitudinal study, six variables related to sexual function were identified. Three were determinate of sexual function:

• feelings for the partner
• problems related to the partner
• vaginal dryness/dyspareunia.

The other three variables—sexual responsiveness, frequency of sexual activity, and libido—were dependent or outcome variables.

By the sixth year of this study, two variables had increased in significance: vaginal dryness/dyspareunia and partner problems.⁷

Sexual pain and relationship problems can create a vicious cycle

The interrelationship of vaginal dryness, sexual pain, flagging desire, and psychosocial parameters can produce a vicious cycle. A woman experiencing or anticipating pain may have diminished sexual desire or avoid sex altogether. During intercourse, the brain’s awareness of vaginal pain may trigger a physiologic response that can cause the muscles of the vagina to tighten and lubrication to decrease. The result? Greater vaginal pain.

This vicious cycle can contribute to relationship issues with the sexual partner and harm a woman’s psychosocial well-being. Resentment, anger, and misunderstanding may arise when a couple is dealing with problems of sexual function, and these stressors can damage many aspects of the relationship, further exacerbating sexual difficulties.

An additional and very important dimension of these issues is their potential impact on the family unit.

VVA can diminish overall well-being

In a 2007 survey reported at the North American Menopause Society (NAMS), one third to one half of 506 respondents said that VVA had a bad effect on their sexual interest, mood, self-esteem, and the intimate relationship (FIGURE 1).⁹ Reports from in-depth interviews were consistent with survey results and offered further insight into a woman’s emotional response to the condition of vaginal dryness and its impact on her life. Women found the condition “embarrassing,” something they had to endure but didn’t talk about, and felt that it had a major impact on their self-esteem and intimate relationship.

FIGURE 1 Dyspareunia affects more than interest in sex—relationships, mood, and self-esteem suffer

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

Clinicians often don’t ask about VVA, and patients are reluctant to talk

Among women of all ages, dyspareunia is underreported and undertreated. In the survey reported at NAMS, 40% of respondents said that their physician had never asked them about the problem of VVA (FIGURE 2).⁹

Women themselves may be reluctant to discuss the problem with physicians, nurse practitioners, or other health-care providers out of embarrassment or the assumption that there is nothing to be done about the problem. Nevertheless, more than 40% of respondents said they would be highly likely to seek treatment for VVA if they had a concern about urogenital complications of the condition (FIGURE 3).⁹

Another barrier may be the sense that asking the health-care provider about sex may embarrass him or her. As a result, sufferers do not anticipate help from their physician and other members of the health-care profession and fail to seek treatment or counseling for this chronic medical condition.^10,11

In a 1999 telephone survey of 500 adults 25 years of age or older, 71% said they thought that their doctor would dismiss concerns about sexual problems, but 85% said they would talk to their physician anyway if they had a problem, even though they might not get treatment.¹¹ In that survey, 91% of married men and 84% of married women rated a satisfying sex life as important to quality of life.¹¹

Another important and often overlooked limitation on this type of discussion is the time constraints that busy clinicians face, especially with the low reimbursement offered by managed care. Sexual problems can hardly be adequately discussed in 7 to 10 minutes.

FIGURE 2 Do physicians ask about dyspareunia? Most women surveyed said “rarely” or “never”

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

FIGURE 3 Are these women likely to seek treatment?

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

Women have performance anxiety, too

It is well known that men with even a mild degree of erectile dysfunction can suffer from performance anxiety, but the fact that women can also suffer from this phenomenon is not given as much attention. Such anxiety can be a factor in relationship difficulties. With both partners perhaps feeling anxious about sexual performance, a couple may avoid even simple acts of affection, such as holding hands, to avoid raising the other’s expectations.

Exacerbating the situation is the fact that many men use widely prescribed phosphodiesterase type 5 (PDE5) inhibitors, whereas women are contending with barriers to continued sexual activity as they age. It does not take a psychologist to understand that this imbalance often adds to emotional strain and tension between partners.

Popular media address the issue

Look beyond what our postmenopausal patients tell us directly—to the popular media and online forums—to appreciate the scope of sexual pain as a major issue among postmenopausal women. Evidence of psychosocial effects is found on numerous Web sites—some from organizations, others designed by women seeking help from each other.

Red Hot Mamas

(www.redhotmamas.org)

This organization aims to empower women through menopause education. Highlighted in the Winter 2007/2008 Red Hot Mamas Report is a survey done in conjunction with Harris Interactive exploring the impact of menopausal symptoms on a woman’s sex life, which found that 47% of women who have VVA have avoided or stopped sex completely because it was uncomfortable, compared with 23% of normal women.

Power Surge

(www.power-surge.com)

This Web site offers a list of strategies for dealing with sexual pain, including an overview of hormone-based prescription and nonprescription products, along with a variety of over-the-counter, natural, holistic, and herbal therapies for treating dyspareunia.

What is the physician’s role?

Given the epidemic of sexual pain, it is crucial that physicians and others who care for postmenopausal women increase their awareness of this issue and pay special attention to its psychosocial parameters.

Ask patients about sexual function in general and dyspareunia in particular as part of the routine annual visit. A simple opening “Yes/No” question, such as “Are you sexually active?” can lead to further questions appropriate to the patient. For example, if the answer is “No,” the follow-up question might be, “Does that bother you or your partner?” Further discussion may uncover whether the lack of sexual activity is a cause of distress and identify which variables are involved.

If, instead, the answer is “Yes,” follow-up questions can identify the presence of common postmenopausal physical issues, such as vaginal dryness and difficulty with lubrication. The visit then can turn to strategies to ameliorate those conditions.

When a patient reports dyspareunia, further diagnostic information such as precise location, degree of arousal, and reaction to pain can help determine the appropriate course of treatment. For an approach to this aspect of ascertaining patient history, see the list of sample questions above.¹²

During the physical, pay particular attention to any physical abnormalities or organic causes of sexual pain. Questions designed to characterize the location and nature of the pain can pinpoint the cause. Sexual pain arising from VVA is likely to 1) be localized at the introitus and 2) occur with penile entry.

Think female sexual function is linear? Think again

Since the mid-1990s, the availability of validated scales to measure female sexual function has increased rapidly and enabled researchers to better identify, quantify, and evaluate treatments for female sexual dysfunction.⁷ Over time, we have moved away from the somewhat mechanical sequence inherent in the linear progression of desire leading to genital stimulation followed by arousal and orgasm toward an appreciation of the multiple physical, emotional, and subjective factors that are at play in women’s sexual function.

By 1998, a classification scheme was developed to further the means to study and discuss disorders of desire, arousal, orgasm, and sexual pain.⁸ Further contextual definitions of sexual dysfunction are under consideration.¹³

Basson proposed one new model of female sexual function (see the diagram), and observed that

"…women identify many reasons they are sexual over and beyond inherent sexual drive or “hunger.” Women tell of wanting to increase emotional closeness, commitment, sharing, tenderness, and tolerance, and to show the partner that he or she has been missed (emotionally or physically). Such intimacy-based reasons motivate the woman to find a way to become sexually aroused. This arousal is not spontaneous but triggered by deliberately sought sexual stimuli."¹³

Intimacy-based model of female sexual response cycle

In this flow of physical and emotional variables involved in female sexual function, categories interact. For example, low desire can be and is frequently secondary to the anticipation of pain during sexual intercourse. Arousal can be hampered by lack of vaginal lubrication—perhaps inhibited by the anticipation of pain. Secondary orgasmic disorders can result from low desire, difficulty of arousal, and sexual pain.¹⁴ Sexual pain can affect sexual function at any point on this continuum.

Treatments in the pipeline

For decades, hormone-based treatments have been the predominant therapeutic option for vaginal dryness. Often they are a secondary benefit of hormone therapy for vasomotor symptoms and osteoporosis. Estrogen can be delivered in the form of oral tablet, transdermal patch, gel, spray, or vaginal ring for systemic use, or as vaginal cream, ring, or tablet for local use.

However, despite data to the contrary and our reassurances to the patient about overall safety, a large number of women, and many primary care providers, are no longer inclined to use short- or long-term HRT in any presentation.

Other women may have risk factors that contraindicate exogenous hormones.

Nonhormonal options for vaginal dryness and dyspareunia are limited, and there are no approved systemic or oral nonestrogen options. Over-the-counter topical lubricants can ease some of the symptoms of VVA temporarily and allow successful vaginal penetration in many cases. Some may cause vaginal warming and pleasant sensations, but overall they treat the symptom rather than the source of pain. Moreover, many patients consider local lubricants messy and inconvenient and claim they “ruin the mood.”

The use of vaginal dilators along with estrogen or lubricant therapy is an often-forgotten adjunct to therapy for dyspareunia caused by VVA (FIGURE 4).

FIGURE 4 Mechanical dilation of the vagina is a useful adjunct

Mechanical dilation is often needed to restore penetration capability in the vagina, even after hormonal treatment. The focus should be on the vaginal introitus, with the top 25% to 35% of the dilator inserted into the opening once a day for 15 minutes, increasing the dilator diameter over time.

New SERMs are in development

Preclinical and clinical research into the diverse class of selective estrogen receptor modulators (SERMs) to treat estrogen-mediated disease produced tamoxifen for breast cancer prevention and raloxifene for both vertebral osteoporosis and breast cancer prevention. Each SERM seems to have unique tissue selectivity. The antiestrogenic activity of tamoxifen and raloxifene extends to the vagina and can exacerbate vaginal dryness.

A new generation of orally active SERMs is under investigation specifically for the treatment of chronic vaginal symptoms. These new agents target the nonvaginal treatment of VVA and associated symptoms. The first oral SERM for long-term treatment of these symptoms, ospemifene (Ophena), may become available in the near future. It is a novel SERM that has both anti-estrogenic and estrogenic actions, depending on the tissue. It was shown to significantly improve both vaginal dryness and dyspareunia in a large placebo-controlled trial.¹⁵

The author reports that he serves on the speaker’s bureau for Novogyne, TherRx, Warner-Chilcott, and Solvay, and on the advisory board for Upsher-Smith, Novogyne, QuatRx, and Wyeth.

CASE: History of dyspareunia

At her latest visit, a 56-year-old woman who is 7 years postmenopausal relates that she has been experiencing worsening pain with intercourse to the point that she now has very little sex drive at all. This problem began approximately 1 year after she discontinued hormone therapy in the wake of reports that it causes cancer and heart attack. She has been offered both local vaginal and systemic hormone therapy, but is too frightened to use any hormones at all. Sexual lubricants no longer seem to work.

How do you counsel her about these symptoms? And what therapy do you offer?

Physicians and other health-care practitioners are seeing a large and growing number of genitourinary and sexual-related complaints among menopausal women—so much so that it has reached epidemic proportions. Yet dyspareunia is underreported and undertreated, and quality of life suffers for these women.

In this article, I focus on two interrelated causes of this epidemic:

• vaginal dryness and vulvovaginal atrophy (VVA) and the impact of these conditions on women’s sexual function and psychosocial well-being
• barriers to optimal treatment.

I also explore how ObGyns’ role in this area of care is evolving—as a way to understand how you can better serve this expanding segment of our patient population.

Dyspareunia can have many causes, including endometriosis, interstitial cystitis, surgical scarring, injury that occurs during childbirth, and psychosocial origin (such as a history of sexual abuse). Our focus here is on dyspareunia due to VVA.

Just how sizable is the postmenopausal population?

About 32% of the female population is older than 50 years.¹ That means that around 48 million women are currently menopausal, or will become so over the next few years.

Because average life expectancy approaches 80 years in the United States and other countries of the industrialized world,² many women will live approximately 40 years beyond menopause or their final menstrual period. Their quality of life during the second half of their life is dependent on both physical and psychosocial health.

Postmenopausal dyspareunia isn’t new

Sexual issues arising from physical causes—dyspareunia among them—have long accounted for a large share of medical concerns reported by postmenopausal women. In a 1985 survey, for example, dyspareunia accounted for 42.5% of their complaints.³

But epidemiologic studies to determine the prevalence of female sexual dysfunction in postmenopausal women are difficult to carry out. Why? Because researchers would need to 1) address changes over time and 2) distinguish problems of sexual function from those brought on by aging.⁴

The techniques and methodology for researching female sexual dysfunction continue to evolve, creating new definitions of the stages of menopause and new diagnostic approaches to female sexual dysfunction.

However, based on available studies, Dennerstein and Hayes concluded that:

• postmenopausal women report a high rate of sexual dysfunction (higher than men)
• psychosocial factors can ameliorate a decline in sexual function
• “vaginal dryness and dyspareunia seem to be driven primarily by declining estradiol.”⁴

The WHI and its domino effect

Millions of postmenopausal women stopped taking estrogen-based therapy in the wake of widespread media coverage after 2002 publication of data from the estrogen–progestin arm of the Women’s Health Initiative (WHI), which purported to show, among other things, an increased risk of breast cancer.⁵

For decades, many postmenopausal women achieved medical management of VVA through long-term use of systemic hormone replacement therapy (HRT), which they used primarily to control other chronic symptoms of menopause, such as hot flashes.

After the WHI data were published (and misrepresented), reduced usage of estrogen-based HRT “unmasked” vaginal symptoms, including sexual pain, due to the effects of estrogen deficiency on the vaginal epithelium and vaginal blood flow. Since then, we have been forced to examine anew the natural history of menopause.

Within days or weeks of discontinuing HRT, women may reexperience the acute vasomotor symptoms that accompany estrogen withdrawal—most commonly hot flashes, night sweats, sleeplessness, palpitations, and headaches. Over time—anywhere from 6 months to several years—the body adjusts to the loss or withdrawal of estrogen, and these vasomotor symptoms eventually diminish or resolve. Not so for the longer-term physical effects of chronic low serum levels of estrogen, which worsen over time.

Approximately 6 months after discontinuing estrogen therapy, postmenopausal women may begin to experience vaginal dryness and VVA. As the years pass, other side effects of estrogen deficiency arise: bone loss, joint pain, mood alteration (including depression), change in skin tone, hair loss, and cardiac and central nervous system changes. These side effects do not resolve spontaneously; in fact, they grow worse as a woman ages. They may have deleterious psychosocial as well as physical impacts on her life—especially on the quality of her intimate relationship.

Is 60 the new 40?

Many women and men in the large cohort known as the Baby Boomer generation continue to be sexually active into their 60s, 70s, and 80s, as demonstrated by a 2007 study of sexuality and health in older adults.⁶ In the 57- to 64-year-old age group, 61.6% of women and 83.7% of men were sexually active (defined as sexual activity with a partner within the past 12 months). In the 65- to 74-year-old group, 39.5% of women and 67% of men were sexually active; and in the 75- to 85-year-old group, 16.7% of women and 38.5% of men were sexually active (TABLE).

These findings indicate that fewer women than men remain sexually active during their later years. One reason may be the epidemic of sexual-related symptoms among postmenopausal women. In the same survey, 34.3% of women 57 to 64 years old reported avoiding sex because of:

• pain during intercourse (17.8%)
• difficulty with lubrication (35.9%).

Across all groups, the most prevalent sexual problem was low desire (43%).⁶ Around 40% of postmenopausal women reported no sexual activity in the past 12 months, as well as lack of interest in sex. This number may include women who have ceased to have sex because of vaginal dryness and dyspareunia, thereby reducing the percentage reporting these symptoms (TABLE).

TABLE

Older adults are having sex—and experiencing sexual problems

Assessing menopause-related sexual function is a challenge

Although the transition phases of menopause have been well studied and reported for decades, few of these studies have included questions about the impact of menopause on sexual function.⁷ When longitudinal studies that included the classification of female sexual dysfunction began to appear, they provided evidence of the important role that VVA and psychosocial factors play in female sexual dysfunction.⁸

In the fourth year of the Melbourne Women’s Midlife Health Project longitudinal study, six variables related to sexual function were identified. Three were determinate of sexual function:

• feelings for the partner
• problems related to the partner
• vaginal dryness/dyspareunia.

The other three variables—sexual responsiveness, frequency of sexual activity, and libido—were dependent or outcome variables.

By the sixth year of this study, two variables had increased in significance: vaginal dryness/dyspareunia and partner problems.⁷

Sexual pain and relationship problems can create a vicious cycle

The interrelationship of vaginal dryness, sexual pain, flagging desire, and psychosocial parameters can produce a vicious cycle. A woman experiencing or anticipating pain may have diminished sexual desire or avoid sex altogether. During intercourse, the brain’s awareness of vaginal pain may trigger a physiologic response that can cause the muscles of the vagina to tighten and lubrication to decrease. The result? Greater vaginal pain.

This vicious cycle can contribute to relationship issues with the sexual partner and harm a woman’s psychosocial well-being. Resentment, anger, and misunderstanding may arise when a couple is dealing with problems of sexual function, and these stressors can damage many aspects of the relationship, further exacerbating sexual difficulties.

An additional and very important dimension of these issues is their potential impact on the family unit.

VVA can diminish overall well-being

In a 2007 survey reported at the North American Menopause Society (NAMS), one third to one half of 506 respondents said that VVA had a bad effect on their sexual interest, mood, self-esteem, and the intimate relationship (FIGURE 1).⁹ Reports from in-depth interviews were consistent with survey results and offered further insight into a woman’s emotional response to the condition of vaginal dryness and its impact on her life. Women found the condition “embarrassing,” something they had to endure but didn’t talk about, and felt that it had a major impact on their self-esteem and intimate relationship.

FIGURE 1 Dyspareunia affects more than interest in sex—relationships, mood, and self-esteem suffer

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

Clinicians often don’t ask about VVA, and patients are reluctant to talk

Among women of all ages, dyspareunia is underreported and undertreated. In the survey reported at NAMS, 40% of respondents said that their physician had never asked them about the problem of VVA (FIGURE 2).⁹

Women themselves may be reluctant to discuss the problem with physicians, nurse practitioners, or other health-care providers out of embarrassment or the assumption that there is nothing to be done about the problem. Nevertheless, more than 40% of respondents said they would be highly likely to seek treatment for VVA if they had a concern about urogenital complications of the condition (FIGURE 3).⁹

Another barrier may be the sense that asking the health-care provider about sex may embarrass him or her. As a result, sufferers do not anticipate help from their physician and other members of the health-care profession and fail to seek treatment or counseling for this chronic medical condition.^10,11

In a 1999 telephone survey of 500 adults 25 years of age or older, 71% said they thought that their doctor would dismiss concerns about sexual problems, but 85% said they would talk to their physician anyway if they had a problem, even though they might not get treatment.¹¹ In that survey, 91% of married men and 84% of married women rated a satisfying sex life as important to quality of life.¹¹

Another important and often overlooked limitation on this type of discussion is the time constraints that busy clinicians face, especially with the low reimbursement offered by managed care. Sexual problems can hardly be adequately discussed in 7 to 10 minutes.

FIGURE 2 Do physicians ask about dyspareunia? Most women surveyed said “rarely” or “never”

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

FIGURE 3 Are these women likely to seek treatment?

Simon JA, Komi J. Vulvovaginal atrophy (VVA) negatively impacts sexual function, psychosocial well-being, and partner relationships. Poster presented at North American Menopause Association Annual Meeting; October 3-6, 2007; Dallas, Texas.

Women have performance anxiety, too

It is well known that men with even a mild degree of erectile dysfunction can suffer from performance anxiety, but the fact that women can also suffer from this phenomenon is not given as much attention. Such anxiety can be a factor in relationship difficulties. With both partners perhaps feeling anxious about sexual performance, a couple may avoid even simple acts of affection, such as holding hands, to avoid raising the other’s expectations.

Exacerbating the situation is the fact that many men use widely prescribed phosphodiesterase type 5 (PDE5) inhibitors, whereas women are contending with barriers to continued sexual activity as they age. It does not take a psychologist to understand that this imbalance often adds to emotional strain and tension between partners.

Popular media address the issue

Look beyond what our postmenopausal patients tell us directly—to the popular media and online forums—to appreciate the scope of sexual pain as a major issue among postmenopausal women. Evidence of psychosocial effects is found on numerous Web sites—some from organizations, others designed by women seeking help from each other.

Red Hot Mamas

(www.redhotmamas.org)

This organization aims to empower women through menopause education. Highlighted in the Winter 2007/2008 Red Hot Mamas Report is a survey done in conjunction with Harris Interactive exploring the impact of menopausal symptoms on a woman’s sex life, which found that 47% of women who have VVA have avoided or stopped sex completely because it was uncomfortable, compared with 23% of normal women.

Power Surge

(www.power-surge.com)

This Web site offers a list of strategies for dealing with sexual pain, including an overview of hormone-based prescription and nonprescription products, along with a variety of over-the-counter, natural, holistic, and herbal therapies for treating dyspareunia.

What is the physician’s role?

Given the epidemic of sexual pain, it is crucial that physicians and others who care for postmenopausal women increase their awareness of this issue and pay special attention to its psychosocial parameters.

Ask patients about sexual function in general and dyspareunia in particular as part of the routine annual visit. A simple opening “Yes/No” question, such as “Are you sexually active?” can lead to further questions appropriate to the patient. For example, if the answer is “No,” the follow-up question might be, “Does that bother you or your partner?” Further discussion may uncover whether the lack of sexual activity is a cause of distress and identify which variables are involved.

If, instead, the answer is “Yes,” follow-up questions can identify the presence of common postmenopausal physical issues, such as vaginal dryness and difficulty with lubrication. The visit then can turn to strategies to ameliorate those conditions.

When a patient reports dyspareunia, further diagnostic information such as precise location, degree of arousal, and reaction to pain can help determine the appropriate course of treatment. For an approach to this aspect of ascertaining patient history, see the list of sample questions above.¹²

During the physical, pay particular attention to any physical abnormalities or organic causes of sexual pain. Questions designed to characterize the location and nature of the pain can pinpoint the cause. Sexual pain arising from VVA is likely to 1) be localized at the introitus and 2) occur with penile entry.