A novel technique using autologous rectus sheath for treatment of genital prolapse in reproductive age women: beyond the traditional

Deoghare M1, Sharma J1, Kumari R1, Aggarwal A1, Nisha N1, Khan M1

Research Type

Clinical

Abstract Category

Pelvic Organ Prolapse

Abstract 160
Pelvic Organ Prolapse
Scientific Podium Short Oral Session 16
Thursday 24th October 2024
15:37 - 15:45
Hall N105
Pelvic Organ Prolapse Surgery Female Questionnaire Retrospective Study
1. All India Institute of Medical Sciences, New Delhi
Presenter
Links

Abstract

Hypothesis / aims of study
This is the first of its kind approach for surgical management of genital prolapse in reproductive age women. Pelvic organ prolapse (POP) is defined by ICS as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus, or the apex of the vagina (vaginal vault after hysterectomy) (1). POP causes significant discomfort and greatly affects the quality of life, activities of daily living, sexual activity and exercise and has a negative impact on a woman’s body image. According to existing studies, the reported prevalence of POP varies widely, ranging from 3 to 50%. In India, nulliparous prolapse constitutes 1.5 to 2% of prolapse. The incidence is even higher (5–8%) for young women who have delivered one or two children, thus making it one of the highest rates in the world (2). In women with nulliparous prolapse, there usually is a component of cervical elongation without associated anterior (cystocele) or posterior (rectocele) compartment prolapse.
There are a variety of surgical management options, both conservative and extirpative for repair of pelvic organ prolapse (POP). Surgical treatment for POP includes native tissue repair, augmentation with mesh, and minimally invasive surgeries by laparoscopy and robotics; each one with its own advantages and disadvantages.
Among the various sling surgeries described for treatment of nulliparous prolapse, one was described by Purandare in 1965 (3). He created sling from strips of rectus sheath and anchored it anteriorly at the level of isthmus of uterus. The advantages of Purandare sling are it is technically easy to perform and provides dynamic support to the uterus. The disadvantages are, the uterus becomes retroverted and there is a tendency of enterocele formation. Also, as the sling is anchored anteriorly, it maybe damaged at subsequent caesarean sections. To overcome these shortcomings, we introduced a novel technique, in which the strips of rectus sheath are created 1.5 cm wide and 8 cm long on both sides of midline, stay sutures are taken from the medial free ends of the strips with No. 1 Prolene suture. The strips are then brought into the peritoneal cavity just lateral to the rectus muscle and then to the posterior surface of uterus through an avascular area in broad ligament, passed under the visceral peritoneum of posterior surface of uterus on both the sides from lateral to medial and brought out in midline. The stay Prolene sutures on both sides are tied to each other and the strips of rectus sheath are anchored to the posterior surface of uterus at the mid point at the level of isthmus, just above the uterosacral ligaments. The overlying visceral peritoneum of uterus is closed. 
In literature, there have been reports on usage of mersilene tape and attaching it posteriorly to the uterus. But, this technique of anchoring the strips of rectus sheath posteriorly to the uterus has not been described in literature previously. 
The aims of this study are to evaluate the role of novel technique using autologous rectus sheath for treatment of genital prolapse in reproductive age women and to study the operative time, blood loss and intraoperative and post operative complications if any.
Study design, materials and methods
It was a retrospective study conducted on 6 women in reproductive age group who underwent surgery for genital prolapse by this novel technique described above at a tertiary care hospital from March 2022 to March 2023. Data was retrieved for these patients from operation theatre records and admission case sheets. Presenting complaints, examination findings including POP-Q and preoperative PFDI-20 (Pelvic floor distress inventory) score was noted down from case sheets. PFDI-20 has 3 components, POPDI-6 (Pelvic Organ Prolapse Distress Inventory), CRAD-8 (Colorectal-Anal Distress Inventory) and UDI-6 (Urinary Distress Inventory). Intraoperative notes were reviewed to see the operating time, blood loss, complications or any additional procedure if done concomitantly. Patients were called for review 6 months and 12 months after procedure. On the follow up visits at 6 months and 12 months, patients were interviewed for vaginal bulge symptoms, urinary and bowel complaints, sexual dysfunction. PFDI-20 score was calculated at 6 months. Patients were examined and anatomical success was defined as POP-Q stage 0 to1.
Results
The mean age of the patients was 26.5 ± 3.68 years. All the patients(100%) presented with mass descending through vagina. 2 patients (33.3%) had quite bothersome heaviness in lower abdomen and 1 patient (16.7%) had associated urinary urgency. None of the patients required digitation for urination and defecation. Among 6 patients, 5(83.3%) were nulliparous, while 1 (16.7%) had previous one 1 vaginal delivery. 2 patients(33.3%) had associated polycystic ovarian disease and had infertility. On examination, all the patients (100%) had POP-Q stage III prolapse with ‘C’ as the leading point. 1 patient (16.7%) also had grade I cystocele, while none had rectocele. All patients had component of cervical elongation with mean infravaginal cervical length of 5.33 ± 0.47 cm. Mean POPDI-6 score preoperatively was 40.95 ± 5.60, CRAD-8 was 0 and UDI-6 was 12.55 ± 9.55, making mean PFDI-20 SCORE 53.5 ± 7.38. 
Mean operating time was 27.5 ± 5.0 mins. Average blood loss in all 5 cases was <50 ml. As an additional procedure, B/L ovarian drilling was done in 2 patients (33.3%) who had PCOD. No intraoperative complications were noted. For all patients, catheter was removed on post operative day 1 and all were discharged on postoperative day 2.
On follow up visit at 6 months, all patients (100%) were relieved of their complaint of mass descending through vagina. 1 patient (16.7%) had heaviness in lower abdomen while 1 patient (16.7%) had urinary urgency, and was started on anticholinergic drug treatment. Mean POPDI-6 score was 6.2 ± 4.65, CRAD-8 was 0. Mean UDI-6 was 7.6 ± 6.07 while mean PFDI-20 was 13.85 ± 5.69. Table 1 shows that change in POPDI-6 and PFDI-20 was statistically significant (p <0.0001). On examination, 4 patients (66.6%) had stage 0 prolapse, while 2 (33.33%) had stage I.
At 12 months also, no patient had complaint of mass descending through vagina or heaviness in lower abdomen. The one with urinary urgency also was symptomatically better. Examination findings were same as that at 6 months.
Interpretation of results
No patient had colorectal-anal symptoms either at baseline or post-operatively. Surgery was 100% effective at 6 months and 12 months as patients were symptomatically improved as well as there was anatomical success. There was a statistically significant fall in POPDI-6 and PFDI-20 score.
Concluding message
This novel technique using autologous rectus sheath for treatment of genital prolapse is a very effective technique with no significant complications. Also mesh cost and mesh related complications are avoided.
Figure 1 Table 1- Comparison of POPDI-6, UDI-6 and PFDI-20 score at baseline and 6 months after surgery
Figure 2 Bite taken with Prolene suture from the medial end of the cut rectus sheath strip
Figure 3 Both the strips of the rectus sheath with Prolene sutures at their medial ends brought to the posterior surface of uterus under the visceral peritoneum of the uterus
References
  1. Haylen BT, Maher CF, Barber MD, Camargo S, Dandolu V, Digesu A, et al. An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecology J. 2016 Feb;27(2):165–94.
  2. Virkud A. Conservative Operations in Genital Prolapse. J Obstet Gynaecol India. 2016 Jun;66(3):144–8.
  3. Purandare VN. New surgical technique for surgical correction of genital prolapse in young women. J Obstet Gynaecol India. 1965:53-62
Disclosures
Funding None Clinical Trial No Subjects Human Ethics Committee Institute Ethics Committee for Post Graduate Research, All India Institute of Medical Sciences, Ansari Nagar, New Delhi. Ref No: AIIMSA00009/26.10.2023, RT-26/13.12.2023 Helsinki Yes Informed Consent Yes
Citation

Continence 12S (2024) 101502
DOI: 10.1016/j.cont.2024.101502

13/11/2024 19:28:00