Surgical Management of Genito-Urinary Prolapse at the Gynecology and Obstetrics Department of Ouakam Military Hospital: About 72 Cases

  

    
Caractéristiques de l’intervention 
    
Effectif 
    
Fréquence (%) 
  
  

    
Anterior time 
    

    

  
  

    
-         plicationofHalban’sfascia 
    
50 
    
89,2 
  
  

    
-         Marion Kelly’stechnique 
    
3 
    
5,3 
  
  

    
-         Bologna’stechnique 
    
3 
    
5,3 
  
  

    
Middle time 
    

    

  
  

    
-         hysterectomy 
    
61 
    
98,4 
  
  

    
-         Richter’s technique 
    
1 
    
1,6 
  
  

    
Posterior time 
    

    

  
  

    
-         Plication of thepre rectalfascia
    
15 
    
50 
  
  

    
-         Posteriorcolpoperineorraphy 
    
11 
    
35,4 
  
  

    
-         Myorraphy of levator 
    
5 
    
14,6 
  

Table 2: Characteristics of the surgery.

The operative time was on average 73 minutes with extremes of 30 and 150 minutes. No incidents were reported. The duration of hospital stay was on average 3 days and a half.

In follow-up, nearly one-quarter of patients were lost to follow-up. For the one who was still followed only one recurrence was reported (1.38%) after 24 months and a patient had secondarily presented a urinary incontinence.

Discussion

Epidemiological and socio-demographic aspects

Genital prolapse is pathology of the elderly woman whose real incidence is unknown in our countries because of the few studies of large cohort dealing with this pathology. In Mali, in 2010, Coulibaly [1], found a hospital frequency of 3.5% which is comparable to the results of Timothé [2], which found a frequency of 2.5%. In European studies Laurence found in 2008 a frequency of 6.3% lower than the results of Slicker [3], which found rates of 11.4%. This higher prevalence in European studies could be explained by the fact that in our developing countries the number of consultants is lower than what is found in these countries. In our study, all cases of prolapse were not included; these were the cases that required surgical management.

The average age of our patients was 61 years; it is superior to Sidibé’s results which was 36.8 years old. This significant difference shows that genital prolapse is a disease that can affect women at all ages. However, the prevalence increases with age up to 50 years and then remains stable. Tegerstedt reports the following rates: 4.1% between 30 and 39 years and 6.2% between 40 and 49 years [4]. Nygaard found lower prevalence: 1.6% between 20 and 39 years, 3.8% between 40 and 59 years [5]. Conventionally known risk factors such as age, parity or obstetric trauma were found in our study with a relatively high average age at diagnosis and 13.9% of patients with a history of obstructed labor. However, these factors are no longer sufficient to explain the genesis and evolution of genitourinary prolapse. Bump and Norton [6], divide the risk factors for genital prolapse into predisposing factors, decompensating factors, stimulating factors and promoters. With regard to predisposing risk factors, a family history of genital prolapse (maternal involvement) is a risk factor for the occurrence of prolapse in the offspring. Recent studies have demonstrated this relationship [7]. Ethnically, an epidemiological study in 2007 found that North American women had a higher risk of POPs among Caucasians compared to African- Americans [8]. Anatomical differences have been found to explain these ethnic variations: a small pelvis in farican women or ultrasound differences in thickness of the puborectal muscle. Among the incentives, multiparity is often incriminated [4].

Clinical aspects

In our study, 77.8% of cystoceles and 43.1% of rectoceles were found. The middle floor was reached in 62 cases, a frequency of 86.1%. This was different from what was found in the literature with Versi who found 51% of cystocele, 27% of rectocele and 20% of hysterocele. Handa found 24.6% of cystocele, 12.9% of rectocele and 3.8% of hysterocele and Dietz 73% of cystocele, 65% of rectocele and 23% of hysterocele [3]. This difference could be explained by the higher age at diagnosis in our study. In fact, a correlation was found between the age at the time of diagnosis and the degree of impairment with a greater frequency of attaining the three floors at that age. Stress urinary incontinence was associated with the genital prolapse in 8 patients (11.1%). The proportion of women with genital prolapse describing stress urinary incontinence varies from one author to another (3.7 to 40%) [9]. But it is traditional to say that the pelotic effect of genital prolapse masks, for many patients, these leaks to the effort. An intraoperative urodynamic assessment would distinguish true urinary incontinence from urinary incontinence and bladder instability resulting from prolapse.

Therapeutic aspects

Surgical management consisted of a vaginal surgery using autologous tissue. Conventional vaginal prolapse surgery incorporates two complementary surgical principles with “suspension” techniques similar to high-path techniques of suspending vaginal tissue to a ligament by a wire. The other large family of techniques is based on a theoretical principle of “support” and consists of the use of autologous tissues that are re-tensioned under the prolapsed viscera. It is thus possible to make plications of the vesical and pre-rectal fascias. These two main principles have been applied in our study with the anterior time a plication of the fascia of Halban which was performed in 89.2% of cases and the posterior time a plication of the fascia pre-recti (50%) and a posterior colpoperineorraphy (35,4%) were realized in almost all the patients. But nowadays there is the problem of the use or not of prothetic equipment. Many authors have attempted to evaluate the predominance of either technique. A Cochrane review included all randomized trials published up to February 2009 including surgery for female genital prolapse [10]. The use of vaginal prothetic reinforcement implants for the cystocele treatment seems to reduce the risk of anatomical recurrence but the improvement of the satisfaction, the quality of life and the rate of reintervention could not be demonstrated. Other studies also confirmed that, these were the N’Guyen studies in 2008 that had 55% success in the group of patients in whom a prothesis had been used versus 89% for the control group as well as Sivaslioglu in the same year which found 72% against 91%. In our series, the recurrence rate was relatively low after a decline of at least 24 months with a recurrence rate of 1.38%. This low level could be explained by the large number of patients lost to follow-up and for whom the anatomical benefit could not be appreciated. This could also be explained by advanced age (64 years) at the time of diagnosis and management. But these techniques are still under evaluation and cannot be considered as systematic indications in simple cases of genital prolapse [10,11]. The report of the High Authority of Health (HAH) published in July 2007 on the “Evaluation of reinforcement implants for the treatment of female stress urinary incontinence and for the treatment of prolapsed pelvic organs of women” concluded that “the current data in the literature do not show the interest of these implants in the management of genital prolapse by vaginal route”, but that they could present “an interest in second intention after failure of a surgical procedure, or if a particular clinical element raises the risk of a high risk of recurrence “[12].

More recently, in November 2009, HAH published a guide to “Good Use of Health Technologies: What Reinforcement Implants to Treat Female Pelvic Organs Prolapse”? Which recalls the need for comparative prospective studies between conventional vaginal surgery techniques and these implants [13]?

Thus, even if the use of vaginal protheses is prefered for the management, the indications for its use should be better evaluated according to the socio-economic context, the age of the patient and the patient degree of impairment.

References

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2. Thimoté D. Contribution à l’étude des prolapsus génitaux: bases anatomiques, étiopathologiques et indications thérapeutiques à l’hôpital Gabriel Touré : à propos de 63 cas. Thèse de médecine, Bamako. 1987; N° 47.
3. Lousquy R, Costa P, Delmas V, Haab F. État des lieux de l’épidémiologie des prolapsus génitaux. ProgUrol. 2009; 19, 13: 907-915.
4. Tegerstedt G, Maehle-Schmidt M, Nyrén O, Hammarström M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. IntUrogynecol J Pelvic Floor Dysfunct. 2005; 16: 497-503.
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11. Sand PK, Koduri S, Lobel RW, Winkler HA, Tomezsko J, Culligan PJ, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J ObstetGynecol. 2001; 8.
12. HAS. Evaluation des implants de renfort pour le traitement de l’incontinence urinaire d’effort féminine et pour le traitement du prolapsus des organes pelviens de la femme. 2007.
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