Management of pelvic prolapse in women with bladder exstrophy is challenging. Anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina can result in technical difficulties. An abdominal approach and the use of mesh repair have been encouraged to deliver more durable results. The authors report on a case of high grade uterine prolapse successfully managed with a transcoccygeal approach and use of a polypropylene mesh.
KEYWORDS: Uterine prolapse; Bladder exstrophy; Nazca R Mesh; Transcoccygeal sacropexy
CORRESPONDENCE: Paulo Palma MD, State University of Campinas, Division of Urology, Rua Durval Cardoso, 172, Campinas, Sao Paulo, 13100-213, Brazil. ().
INTRODUCTION
The traditional surgical treatment for uterovaginal prolapse has been vaginal hysterectomy, but women may request uterine preservation at the time of prolapse surgery because they desire future pregnancies. Additionally, Masters and Johnson [1] suggested that the uterus and cervix may have a vital role in orgasm and sexual function. Vomvolaki et al [2] reported depressive psychological changes in women following hysterectomy.
The concept of uterine preservation during surgery for prolapse was suggested by Bonney in the early 1900s. He emphasized the passive role of the uterus in uterovaginal prolapse. Ross [3] later described the pericervical fascia as the cornerstone of pelvic reconstruction. There are many surgical techniques to treat uterine prolapse, but the surgeon must be aware of some unique aspects in patients with congenital disorders in order to choose the most suitable surgical procedure.
The authors present a case of high-grade uterine prolapse in a young woman who underwent bladder diversion to treat congenital exstrophy (ureterosigmoidostomy). Vaginal sacrospinous hysteropexy using a mesh was indicated to address the prolapse because previous corrective abdominal surgeries had failed.
CASE REPORT
A 30-year-old female nulliparous patient presented with high-grade uterine prolapse with point C at +3 cm under POP-Q score [4]. Her previous history included congenital bladder exstrophy treated at an early age with an ureterosigmoidostomy.
The patient was married and presented with severe dyspareunia associated with abdominal pain during intercourse. She also had recurrent vaginal infections and uterine cervical ulcerations. Physical examination revealed uterine prolapse (Figure 1). The prolapse was also seen with a nuclear magnetic resonance image (Figure 2).
The patient refused vaginal hysterectomy, proposed elsewhere, on the grounds of eventual future pregnancy. A three-dimensional (3D) multi-slice CT reconstruction was performed in order to identify the anatomical landmarks and pelvic bone anatomy to facilitate mesh implantation.
The surgeons performed a transcoccygeal sacropexy using special radiopaque Naza R Kit (Promedon, Argentina). The surgeons were able to clearly identify the ischial spines and the distorted anatomy. The procedure was uneventful.
In this technique, arched needles are driven from a puncture site at 3 cm laterally and below the anus through the levator ani muscles to an exit point 1 cm medial to the ischial spines, in order to avoid the Alcock canal. Mesh silicon arms are hooked to the needle ends and pulled out in a way that restores the pericervical ring anatomy.
A 16F Foley catheter was left inserted overnight. Prophylactic antibiotics were given only at the time of surgery (1st generation cephalosporin). Short-term recovery was uneventful and the patient was discharged 2 days after the procedure.
The patient resumed sexual activity after 3 months, with no dyspareunia or abdominal pain. Physical examination reassessment showed point C at -6 cm. At that time, she underwent another 3D CT scan reconstruction that disclosed the body of the mesh restoring level II and the arms of the mesh at the level of the ischial spine repairing level I, according to the De Lancey classification [5] (Figure 3).
DISCUSSION
Bladder exstrophy is a rare malformation among the female population (1 in 125,000/250,000) [6]. A few cases of pregnancy have been described in the literature.
Pelvic organ prolapse is believed to affect 18% of female patients with bladder exstrophy, with onset at a mean age of 16 years [7]. The results of the present case lead to questions regarding the use of mesh in young patients and also reinforce the concept of a uterus-sparing procedure in selected situations. This patient wanted not only to get rid of the bulk sensation, but also to resume her normal sexual life and a chance for pregnancy. The surgery successfully achieved these goals.
REFERENCES
- Masters WH, Johnson VE. The human female: anatomy of sexual response. Minn Med. 1960;43:31-36. PubMed
- Vomvolaki E, Kalmantis K, Kioses E, Antsaklis A. The effect of hysterectomy on sexuality and psychological changes. Eur J Contracept Reprod Health Care. 2006;11(1):23-27. PubMed
- Ross JW. Apical vault repair, the cornerstone or pelvic vault reconstruction. Int Urogynecol J Pelvic Floor Dysfunct. 1997;8(3):146-152. PubMed
- Bump RC, Mattiasson A, Bo K, et al. The standardisation of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10-17. PubMed
- Wei JT, De Lancey JO. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004;47(1):3-17. PubMed
- Muir TW, Aspera AM, Rackley RR, Walters MD. Recurrent pelvic organ prolapse in a woman with bladder exstrophy: a case report of surgical management and review of the literature. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15(6):436-438. PubMed
- Mathews RI, Gan M, Gearhart JP. Urogynaecological and obstetric issues in women with the exstrophy-epispadias complex. BJU Int. 2003;91(9):845-849. PubMed
To Cite this Article: Palma P, de Fraga R, Ramos L, Riccetto C, Miyaoka R. Transcoccygeal Sacropexy Using a Mesh Repair for Resolution of High Grade Uterine Prolapse Associated with Bladder Exstrophy. UIJ 2009 Jun;2(3). doi:10.3834/uij.1944-5784.2009.06.17