Malaysian Urogynaecology Mission to Vientiane, Laos

A team of Malaysian urogynaecologists participated in a mission to Vientiane, Laos on the invitation of the officials from the Ministry of Health, Laos & The Obstetrics & Gynaecology society Of LOAS  . This team comprised Dato Dr Aruku Naidu ( Team Leader  from Hospital Raja Permaisuri Bainun, Ipoh), Dr Ng Poh Yin (Senior consultant urogynaecologist of Hospital Kuala Lumpur), Prof Lim Pei Shan (consultant urogynaecologist  from Hospital Universiti Kebangsaan Malaysia), Dr Ida Liliwaty Latar (consultant urogynaecologist from Pusat Perubatan Universiti Malaya), Dr Tan Gaik Imm (urogynaecology fellow from Hospital Pulau Pinang), Sr Tan Lee Khan (Hospital Kuala Lumpur) Sr Lee Fong Hoo (Hospital Kuala Lumpur). This mission was partially sponsored by the Obstetrics and Gynaecology Society Malaysia (OGSM), with the support of The Malaysian Urogynaecology Society (MUGS). 

       

 The team arrived in Vientiane on 28^th October and proceeded to work soon after arriving. The mission was held at the Women and Neonate Hospital Vientiane. This was the first and only Maternal & New born Hospital in Laos.  After a quick tour of the hospital premises and facilities, the team proceeded to assess women with urogynaecological problems, who had been screened beforehand by the local hospital doctors. Out of 10 women was reviewed, but only 3 patients were identified for surgical intervention, including 2 women with advanced Stage 4 pelvic organ prolapse and 1 patient with  3^rd degree tear repair with bad wound dehiscence.

The following day, the Malaysian team conducted the Obstetric Anal Sphincter Injury (OASIS) Workshop for the benefit of the local obstetric specialist and registrars. This workshop was attended by 60 participants. They were junior doctors and specialist from all over Laos. The workshop comprised lectures delivered by the mission urogynaecologists. The topics discussed include pelvic and anal sphincter anatomy, risk factors and prevention of OASIS, and methods of repair of OASIS. The lectures were delivered with the help of a local translator. The afternoon was spent on a hands-on workshop using life animal models & life porcine specimen. The participants had the invaluable opportunity to practise their skills in the repair of the anal sphincter tears on sow perineum.

On the 31 October 2017, the team performed pelvic reconstructive surgeries on the 3 patients who had been identified and prepared for surgery. Two teams of Dr Ng/ Dr Ida and Dr Aruku/ Dr Lim performed the surgeries which included vaginal hysterectomy, pelvic floor repair, McCall culdoplasty and perineal body reconstruction. The aim of the surgical workshop was not only to offer symptom relief to the patients but also to demonstrate surgical techniques and train the Laotian doctors in repair methods, and this was aptly demonstrated by the team. The nursing team of Sr Tan and Sr Hoo were also able to educate the local nurses on the proper technique to safely assist and sterilize equipment for the operation.

 

On the final day of the mission, the team visited the hospital to conduct a post operative ward round to ensure that the patients were on the road to an uncomplicated recovery. We found that the 3 patients were nursed in the recovery area of the operating theatre. Although somewhat uncomfortable for the patients, this enabled them to have better monitoring in the critical post operative period due to logistic reasons in the local setting. All 3 patients were recovering well, and we educated the local registrars about post operative management for urogynecology patients, which included pain relief, prevention of thromboembolism, catheter care and the trial of void protocol and follow up. As with the common problems with mission such as this, the importance of post operative care cannot be overemphasized as the team cannot be present onsite throughout the entire recovery period and also to assess patients in the immediate and short term post operative period, which would be the ideal situation. We however ensured that the local doctors would be able to contact the operating team for advice should the need arise so as not to compromise patient care.

Overall it was a very successful inaugural mission to Vientiane for both the Malaysian and Laotian teams. We were able to build networks and learn from one another. It was enlightening to experience working in a different country’s settings with challenging logistics, manpower, experience and equipment. We hope to assist our foreign counterparts in setting up and running an organized urogynaecology service by periodical missions over the coming years and hope to foster goodwill and better friendships for future collaboration within the Asia-Pacific region.

Last but not least, the Malaysian urogynaecology Mission Team likes to thank all the team players for their valuable support either morally or physically. A very big thanks to OGSM for the timely partial financial support to make this event a successful event.  

Prevention of Vault prolapse during hysterectomy (PHVP)

Prevention of vault prolapsed, needs some understanding on pelvic organ support system.  De Lancey’s 3 Levels of Pelvic Support ( Delancey JOL: Am J Obstet Gynecol 166: 1717, 1992 ) is one of the essential components in preventing PHVP.  The method & techniques’ for prevention depends on the type of hysterectomy carried out ( Abdominal as well as Vaginal). If the Abdominal Hysterectomy, one can Re-anchor uterosacral ligament pedicles to vaginal vault during vault closure / pelvic peritonisation or pericervical tissues ( Level B evidence),  Moscowitz sutures (Circumferential sutures to obliterate a deep cul-de-sac) & Halban cul-de-sac closure are some other procedures to prevent PHVP. When doing vaginal hysterectomy, one can do peritoneal closure of the cul-de-sac, a vaginal Moschowitz operation, McCall’s culdoplasty. However The authors found significantly fewer cases of posterior-apical vaginal prolapse (stage 2) at three years following  the McCall’s culdoplasty 2/32 (6%) than with either peritoneal closure 13/33 (39%) or the vaginal  Moschowitz procedure 10/33 (30%)  (p=.004)* (Stephen H Cruikshank, Am J 427 Obstet Gynecol 1999;180:859-65). Therefore McCall Culdoplasty at the time of vaginal hysterectomy is effective in preventing subsequent PHVP (Level B evidence). Sacrospinous ligament fixation (SSF) & abdominal sacral colpopexy are not recommended for the prevention of prolapse at the time of hysterectomy for non-related disease (Level C). SSF can be added to a post vaginal hysterectomy and McCall culdoplasty if the cuff (point C) is ≥ Stage 2 to prevent vault prolapse. Subtotal hysterectomy is not recommended for the prevention of PHVP (Level A). In cases of total Laparoscopic hysterectomy (TLH). The only study evaluating 22 laparoscopic uterosacral ligament suspension in comparison to 96 vaginal uterosacral ligament suspension retrospectively found no significant difference in recurrent apical prolapse (6% in the vaginal group vs 0% in the laparoscopic group. This study identified no statistical significance in the  ureteral compromise recognized intraoperatively 4% in the vaginal group, 0% in the laparoscopic group (Rardin CR, Erekson EA, Sung VW, Ward RM, Myers DL. Comparison of laparoscopic and vaginal.Uterosacral colpopexy at the time of vaginal hysterectomy's J Reprod Med 2009: 54: 273-80). Of course there are other confounding factors involved in the success in preventing the PHVP which include surgeon factor, patient factors, materials & techniques used.

Below is AN technique which is the modification of Mc Culdoplasty to address vault prolapse after Vaginal Hysterectomy. 

DE LANCEY'S 3 LEVEL  PELVIC SUPPORTS

                                                  METHODS OF PREVENTION OF PHVP

                                                          Abdominal Hysterectomy

• Peritonisation of pelvis- transfixing anterior leaf of peritoneum, round ligament, ovarian ligaments, uterosacral ligaments and vaginal wall of vault. This is repeated on both sides.

• Richardson's cuff angle closure, in-cooperating broad ligaments, uterosacral ligament & vaginal vault ( most gynaecologist do this during abdominal hysterectomy)

• Moschowitz Suturing ( usually done if there concurrent enterocele)

• Halbans Cul do sac closure ( Done if there is concurrent enterocele)

Abdominal / Total Laparoscopic Hysterectomy

• Pericervical And Uterosacral plication ( most laparoscopic surgeons do this technique at the time of TLH

Vaginal Hysterectomy / LAVH

• Mc Call Culdoplasty ( very effective operation, has small risk of ureteric injury esp with regards to high suture placement)

• Vaginal approach Moschowitz ( most vaginal surgeon like this technique, in cooperating all the ligaments-round, ovarian and  uterosacral ligaments and in-cooperating them as purse string closure )

• AN (Aruku Naidu) modified Mc Call ( In-cooperation of low-mid uterosacral and anchored to vaginal vault ipsilaterally and brought to centre) = provide goo vault support & reduce post vaginal skin bleeding

          

The above are some of the technique, which can be used to prevent vault prolapse during hysterectomy after abdominal, laparoscopic or vaginal approach.

Credits to all the authors of the pictures, which was taken from internet/ google images.

Consent has been obtained for the video clip on AN technique from the patient

The above picture & video are purely for teaching junior doctors.

REPAIR OF VAGINAL APICAL SUPPORT DEFECTS

Apical support defects can occur alone but usually one or more of the following segmental prolapses coexist:

      ·        Uterine prolapse when a uterus is in place

·      vaginal vault prolapse is reserved to apical support defect when a hysterectomy was performed previously

·       Cystocele

·        Rectocele

·        Enterocele

These defects should be recognized prior to surgery and their repair carried out at the same time.

Several surgical procedures have been described for the correction of apical support defects. The repair can be performed transvaginally, transabdominally, or laparoscopically. Surgical procedures available include as day care procedure include:

Abdominal Appraoch

 Abdominal sacral colpopexy (Open/  laparoscopic)

This approach is usually preferred when a preservation of cervical length to allow sexual intercourse is desired or when vaginal approach failed. The bladder, rectum and ureters can be directly visualized; hence the chances of injury to these structures is minimized. This procedure aims at supporting the vaginal apex to the sacral promontory using a synthetic or facial bridge.

Procedure:

 ·         The patient is in frog-leg like position with a foley catheter inside the bladder.

 ·         Three port or single port technique can be employed.

 ·         The peritoneal cavity is entered and the bowel is displaced out of the field.

 ·         A sponge stick introduced into the vagina is helpful in identification of the vagina. The peritoneum overlying the vagina is then dissected of the vaginal wall.

 ·      A synthetic graft polypropelene mesh are used are sutured to the vaginal apex using permanent suture material using 3/0 daflon or prolene sutures. 

 ·         The peritoneum covering over the sacrum is opened from the sacral promontory to the level of S3. Permanent sutures are passed through the periosteum of the sacral promontory, alternatively protex tagger/ bone anchors can be used to fix the free end of the graft.

 ·      Once the sutures are tied, the vaginal apex is approximated to the sacral promontory. The graft material should be tension free. 

 ·         The peritoneum is then closed with absorbable suture material.

Complications

·         Injuries to bowels, bladder, ureter, and vessels

·         Bleeding

·         Infection

·         Mesh related complication like erosion, irritations to bowels

·         Chronic pelvic pain, defecation pain

·         Herniation

Vaginal Apparoach

Vaginal sacrospinous fixation ( TVSSF)

This procedure aims at suspension of vaginal apex to the sacrospinous ligament (SSL) or the coccygeous-sacrospinous ligament that extend from the ischial spine to the lower portion of the sacrum and coccyx.

The surgeon should be aware of the close proximity of the pudendal nerve and vessels running directly posterior to the ischial spine and the sciatic nerve that runs superior and laterally to the ligament.

Procedure:

·       The patient is put in the dorsal lithotomy position. 

·       The ischial spine and sacrospinous ligament should be identified by palpation before surgery begins.

·      The apex of the vagina is grasped and fully retracted out of the vagina to evaluate the extent of the defect. Stay sutures are put to mark the apex of the vagina and then the apex is reduced to verify its relationship to the SSL. At times, the vagina is too short to reach the SSL so that the fixation is dependant on the sutures connecting the two structures (vaginal apex and SSL).

·      Cystocele repair, +/- bladder neck suspension or a sling procedure, if needed, is usually performed at this point. 

·         A midline longitudinal posterior vaginal wall incision is performed from the vaginal intoitus to 2cm caudal to the vaginal apex previously marked.

·    An enterocele sac, when present, should be dissected free from the posterior vaginal wall and reduced as discussed separately (see enterocele repair).

·       The plane between rectocele and posterior vaginal wall is developed as in any rectocele repair, this dissection is extended, however, usually on the right side of the patient, to the perirectal space. 

·       The perirectal space at the level of the ischial spine is entered by blunt and sharp dissection of the fibroareolar tissue medial to the rectum until the SSL can be palpated. 

·     The SSL is further dissected clean. Briesky-Navratil retractors (long straight retractors) are used by the assistant to allow easy approach to the deeply situated SSL and medial retraction of the rectum. A Deschamps ligature carrier and a nerve hook or a Miya hook ligature carrier are traditionally used to pass 2 sutures through the SSL 3-4 cm medial to the ischial spine, 1 cm apart. Passing the sutures more laterally can cause injury to the underlying pudendal nerve and internal pudendal vessels which course posteriorly to the ischial spine. Other commercially available kits ( Capio applicators) for passing the sutures are also available. An Allis or a Babcock clamp can be used to hold the SSL, during this sometimes difficult to perform step. 

·      The sutures are then passed through vaginal apex. A pulley stitch can be used so that the knot is buried between the vaginal wall and the SSL. 

·      The vaginal apex incision is closed. Only then, the stitches passed through the SSL and the vaginal apex are tied so that the vaginal apex is approximated to the SSL. Tying these sutures beforehand will cause difficulty in closing the vaginal apex. 

·      The posterior vaginal wall is closed as in posterior colporraphy.

·        Check cystoscopy & PR are performed to exclude any injuries to the bladder or bowels

This are two main appoach to support in my practice, there are other options like Uterosacral ligament plication and others 

 

 

 The above are perrecatal dissection & placement of sutures to SSL and vault

 Consent Has been Taken from Patient to publish this Pictures ( For Teaching Purpose)

VAGINAL PESSARIES FOR PELVIC ORGAN PROLAPSE

Vaginal pessary is a device used in conservative management of pelvic organ prolapse (POP) or urinary incontinence. Vaginal pessary is placed in the vagina to provide support and prevent pelvic organ prolapse. Continence pessaries act by providing mechanical support to the urethra. In the pass, various materials had been used which include: Pomegranate soaked in vinegar, fruits, mould, cotton etc. Modern vaginal pessaries are made of silicone as it is inert, does not absorb secretions and resistant to degradation by the majority of the antiseptics. Patients satisfaction rate ranges 70-92%.  

Types of pessaries 

·         There different sizes, shapes and configurations.

·         Mainly two basic mechanisms: supportive and/or space occupying

·         Space occupying pessaries preclude sexual intercourse

·         Commonly used vaginal pessaries: Ring, Gellhorn , Hodge, Cube and Donut

·    Continence pessary: usually equipped with a knob which should be placed in the midline under the urethra. For example: incontinence ring pessary, ring pessary with knob, and incontinence dish pessary Mar-land pessary and Uresta pessary are incontinence pessary which are unique in the design.

 Indications

      ·         Symptomatic pelvic organ prolapse or stress urinary incontinence

·         In frail elderly with multiple co-morbid and not fit for surgery

·         In women prefer conservative management

·         In women with prolapse in pregnancy or awaiting surgery for temporary support

·    Temporary use for diagnostic purposes: to demonstrate occult stress incontinence along with POP, to determine whether surgery would alleviate vague symptoms such as backache/dragging pain

Pessary selection

      ·         Ring pessary is commonly used as first choice due to its easy insertion and removal.

·         Ring pessary can be used in most of the stages of POP.

·         In concurrent stress incontinence, ring pessary with knob can be used

·         If failed fitting of ring pessary or advanced POP, a Gellhorn, cube or donut pessary can be used.

Procedure 

·      This is usually done as out-patient setting

·       Can be inserted on supine or lithotomy position, the severity of prolapse, type of prolapsed will help in the choice of pessary

·       Often the correct fitting is trial and error. However, the size of pessary can be estimated by measuring the distance between the symphysis pubis and posterior fornix.

·         Following insertion, the patients are instructed to perform Valsava, maneuvers to confirm fitting.

·         Ability to void without difficulty should be checked before sending home.

·      Patients or caregivers can be thought to remove and insert the pessaries. This is usually permissible in ring pessary or cube pessary.

·     Follow up period between 2-3 months to clean and re-insertion if patient is unable to do it. An interval follow-up of 6-12 months is acceptable if the patients are able to manage themselves.

Complications

·       Minor complications include: vaginal discharge, odor, bleeding, abrasion

·     Erosion or ulceration of the vagina wall, particularly if the pessary is left unattended for long periods of time. It can be managed by a short period of rest and use of topical oestrogen.

·        Concurrent use of topical oestrogen may reduce the incidence of erosion and ulceration.

·     Decreased efficacy over time, a larger pessary may be necessary. Though an improvement of POP-Q stage had been reported.

·         Impaction of pessary, fistula formation especially in neglected cases

·         Vaginal cancer has been reported in long term use

·         Proper patient education and counseling are essential to minimize neglected cases 

Factors predicting success or failure of fitting

      ·         The likelihood of successful fitting ranges from 74%-94%

·         Some women may need a second fitting

·    Prior hysterectomy, short vaginal length (<6cm), wide introitus (≥ 4 fingers breath), large posterior prolapse and poor perineal support may give a higher failure of fitting

 

Consent & permission has been obtained from patients to use the pictures for teaching purposes

 References

 1. Scott Miller D. Contemporary use of the pessary. Gynecol Obstet 1991; 39: 1-12

 2. Baydock SA, Farrell SA. Chapter 5. Selection of pessaries for pelvic organ prolapse. Pessaries in clinical practice. 32-45 

3. Farrell SA. Pessaries for the management of stress urinary incontinence. J Obstet Gynaecol Can. 2001; 23: 1184-1189

4. Cundiff GW, Weidner AC, Visco AG, Bump RC, Addison WA. A survey of pessary use be members of the American Urogynecology Society. Obstet Gynecol 2000; 95(6): 931-935

 5. Baydock SA. Chapter 2. Pessaries for pelvic organ prolapse: The evidence. Pessaries in clinical practice 10-16

 6. Amir-Khalkhali B, Farrel SA. Chapter 6 Selection of pessaries for urinary incontinence. Pessaries in clinical practice 46-53

 7. Schraub A, Sun XS, Maingon P et al. Cervical and vaginal cancer associated with pessary use. Cancer 1992; 69(10): 2505-2509

 8. Handa VL, Jones M. Do pessaries prevent the progression of pelvic organ prolapse? Int Urogynecol J 2002; 13: 349-352

 9. Wu V, Farrel SA, Baskett TF, Flowerdew G. A simplified protocol for pessary management. Obstet Gynecol 1997; 90: 990-994

 10. Clemons JL, Anguilar VC, Tillinghast TA, Jackson ND, Myers DL. Risk factors associated with an unsuccessful pessary fitting trial in women with pelvic organ prolapse. Am J Obstet Gynecol 2004; 190: 345-350

COLPOCLEISIS: VAGINAL OBLITERATIVE PROCEDURE

Colpocleisis is a vaginal obliteration procedure for treatment of advanced pelvic organ prolapsed (POP) or Global pelvic floor failure (GPFF).  Obliteration of the vagina is a surgical option for patients with advanced symptomatic POP who are not engaging in vaginal intercourse.

Colpoclesis can be divided into total (complete) colpoclesis or partial (Le Fort) colpocleisis.

These procedures are indicated in a selected group of patients, usually frail elderly patients, who are unable or do not wish to undergo more involved procedures such as hysterectomy and vaginal vault suspension. These patients are no longer desire for sexual function. These procedures can sometimes be performed under local, pudendal blocks, intravenous sedation or regional anaesthesia.

It has  relatively good success rate  of between 85-100% patients claim to be satisfied or very satisfied with the sugery.

Indications:

·         Advanced pelvic organ prolapsed/ Global Pelvic Floor Failure 

·         Medical unfit patients/ patients with comorbidity

·         Frail elderly patients

·         Patient request simpler operation

·         Patient who could not stand long surgery

·         Sexually not active/ disinterested in maintain sexual function

·         Unsuccessful trial of vaginal pessaries or surgeries 

 Advantage:

  ·      Shorter operating time, takes half the time of vaginal  hysterectomy

 ·       Minimal blood loss and complications

 ·       Excellent cure rates or success rate

 Disadvantage: 

·         Recurrence of Pelvic organ prolapse

·         Injuries to bladder/ rectum

·         Unable to perform sexual intercourse

·         If uterus still in situ as in Le Fort operation, there is a remote possibility of cervical or endometrial carcinoma.

A.  Partial Colpocleisis ( Le Fort): 

First performed by Neugebaucer in 1867, in this procedure the cervix and uterus is left behind and segment of anterior and posterior vaginal mucosa are removed.

Procedure:

 ·         Can be done under local, iv sedation, pudendal block or regional anesthesia

·         The rectangular epithelial areas on the anterior and posterior vaginal wall are denuded.

·         The denuded epithelial areas are then sutured to each other with the uterus reduced to a proximal position            so that the anterior rectal wall and the base of the perivesical fascia around the bladder base are fused.

·         Approximating the opposing walls of the vagina prevents descent of the uterus and practically obliterates              the vagina.

·        The rectangular areas are designed so that a continuous lumen from the vaginal apex on both sides of                  the obliterated space will persist. This lumen serves to drain vaginal and uterine secretions.

B. Total Colpoclesis (Complete Colpectomy):

Total colpocleisis can be performed in post-hysterectomised vaginal vault prolapse patients or after a vaginal hysterectomy. This procedure was first described by DeLancey and Morley.

 Procedure:

 ·         The vaginal mucosa is completely excised from the base of the prolase by a circumscribing incision.                      Subsequently the vaginal skin is denuded. 

·         A series of purse-string sutures are placed so that the vaginal fascial and muscular layers are inverted                  cephalad. 

·         The vagina is completely obliterated. 

·         This can be followed by standard Kelly’s placation, Levator ani plication or perineorhaphy

 Complications:

 Immediate/ Intermediate:

 ·         De novo urinary incontinence in 27%

 ·         Persistent stress urinary incontinence in 28% patients

 ·         Transient Ureteral occlusion in 10% patients

 Late/delayed:

·         Risk of injuries to bladder or rectum

·         Infection

·         De Nova or persistence of stress urinary incontinence   (25-30%)

·         Vaginal Evisceration ( very rarely)

·         Post operative regret of loss of sexual function in 5% of patients

Consent & permission has been taken to publish this pictures & video from the patients for the purpose of teaching junior doctors)

References:

1. Denehy TR, Choe JY, Greori CA et al. Modified Le Fort Partial Colpoclesis with Kelly urethral placation and posterior colpoperineoplasty in medically compromised elderly. Am J Obstet Gynaecol 1995; 173(6): 1697-1702.

 2. Le Fort L. Nouveau precede pour ia guerison du prolapsus uterin. Bull Gen Therp. 1877; 92:337-346

3.  DeLancey Jo, Morley GW. Total colpocleisis for vaginal eversion. Am J Obstet Gynaecol, 1997;176(6): 12278-1235.

 4. FitzGerald MP, Brubaker L. Colpoclesis and urinary incontinence. Am J obstet Gynaecol, 2003;189(5): 1241-1244.

 5. Von Pechmann WS, Mutone M, Fyffe J et al. Total Colpocleisis with high levator plication for the treatment of advance pelvic organ prolapsed. Am J Obstet Gynaecol, 2003;189(1): 121-126

 6. Ubachs JM, Van santé TJ, Schellekens LA. Partial colpocleisis by a modification of Le Fort’s operation. Obstet Gynaecol, 1973; 42(3): 415-420