Surgical approach to perineal descent and concomitant pelvic organ prolapse, the Integral Perineal Sacrocolpopexy

López-Fando Lavalle L1, Fernandez Alcalde A1, Diaz Perez D1, Ruiz Hernandez M1, Brasero Burgos J1, Lorca Alvaro J1, Santiago Gonzalez M1, Sanchez Guerrero C1, Sanchez Gonzalez A1, Jiménez Cidre M1, Burgos Revilla F1

Research Type

Clinical

Abstract Category

Pelvic Organ Prolapse

Abstract 477
Video Session 2 - Prolapse and Incontinence
Scientific Podium Video Session 24
Thursday 5th September 2019
16:09 - 16:18
Hall G1
Pelvic Organ Prolapse Pelvic Floor Surgery Constipation Fistulas
1.Hospital Ramon y Cajal
Presenter
L

Luis Lopez-Fando Lavalle

Links

Abstract

Introduction
Perineal descent (PD) is a coloproctology disease which is frequently related with pelvic organ prolapse (POP). While laparoscopic approach is an accepted treatment por POP, treatments for PD are less well-known. The first therapeutic step for this disease consists of conservative measures in the form of laxatives, suppository use, enema use and biofeedback, with no clear surgical approach to this condition. We present a surgical technique that provides hold to the whole perineum restoring the PD and POP in one procedure, the Integral Perineal Sacrocolpopexy (IPSC).
Design
We present the case of 66-year-old woman who was referred to our service due to POP sensation of 3 years. She also complained about constipation with no urinary symptoms. She had no history of abdominal surgeries, or other medical issues. Physical exploration revealed a grade III cystocele and non-functioning pelvic floor muscles without urinary leak. A dynamic MRN showed a moderate PD with a cystocele during Valsalva manoeuvre. Laparoscopic approach was offered.
Results
The laparoscopy approached was performed in a 30° Trendelenburg position with 3 5-mm trocars, two placed medially to the anterior superior iliac spines and one placed at the midpoint between the pubis and umbilicus, and a 10-mm umbilical telescope port over the umbilicus.  We used polypropylene, macroporous, monofilament, mesh which must be prepared before the implant. 
We opened the posterior peritoneum over the sacral promontory. Careful dissection over the promontory was performed to avoid bleeding of presacral vessels. We extended the incision inferiorly along the right lateral aspect of the rectum to expose recto-vaginal space. Then the dissection was continued toward the muscle laterally to the rectum. The posterior mesh was fixed in both sides of the rectum, as anterior as possible, avoiding the middle rectal artery and nerve, and to the uterosacral ligaments and the upper dorsal side of the vagina. 
Then we performed a vesico-vaginal dissection until identifying the bladder neck. After that two latero-vesical spaces were created until the endopelvic-fascia was exposed, and then communicated with the vesicovaginal space. The anterior mesh was placed through these communications and fixed to the muscle and the anterior vaginal wall with non-reabsorbed sutures. 
The anterior mesh was placed with the posterior and both meshes fixed to the promontory. We covered the meshes with peritoneum with reabsorbed sutures. The operation time was 130 minutes and the patient was discharged 2 days after the surgery without any complication. She referred no constipation, POP symptoms or pain 6 month after the surgery. We have performed this surgery in 11 more cases with PD and POP, with a mean surgical time of 130 minutes and a surgical succeed of 100% of solving POP and PD, without complications or pain.
Conclusion
The IPSC ensures a hold for the whole perineum and pelvic organs. It is an option for patients with symptomatic pelvic organ prolapse and perineum descent.
Disclosures
<span class="text-strong">Funding</span> We recieved no funding or grant <span class="text-strong">Clinical Trial</span> No <span class="text-strong">Subjects</span> Human <span class="text-strong">Ethics not Req'd</span> It is a retrospective analysis <span class="text-strong">Helsinki</span> Yes <span class="text-strong">Informed Consent</span> Yes