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Posterior and Anterior Coloporrhapy

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Posterior and Anterior Colporraphy - Indications and Complications

Indications:

  1. Anterior colporraphy
    1. pelvic pressure due to anterior vaginal wall prolapse of midline defect into or out of vagina
    2. difficulty voiding urine due to urethral kinking (obstructed voiding, intermittent stream)
    3. frequent UTIs and irritative voiding symptoms due to balder being outside of vagina (Deg 3 or 4)
    4. ulceration of vaginal mucosa due to anterior wall prolapse and exposure
  2. Posterior colporraphy
    1. pelvic pressure due to posterior vaginal wall prolapse into or out of vagina
    2. defecation difficulty usually requiring intravaginal digital assistance to defecate

Contraindications

  1. anterior wall paravaginal defects (for cystocele repair)
  2. undiagnosed rectal sphincter dysfunction (for rectocele repair)

Complications

  1. Dyspareunia
  2. Post operative persistent pain
  3. Bleeding /hematoma – Intraoperative, postoperative
  4. Bladder injury
  5. Cystotomy with urine leakage
  6. Fistula formation – vescovaginal,
  7. Suture in bladder
  8. Rectal/sigmoid injury
  9. Proctotomy
  10. Rectal vaginal fistula
  11. Vaginal granulation tissue
  12. Incision infection
  13. Incision dehissence/separation
  14. Post procedure recurrence of cystocoele or rectocoele or vaginal vault prolapse
  15. Low back pain

Complication Prevention

  1. Dyspareunia
    1. Avoid removing too much mucosa (too wide) and narrowing the vaginal aperature
    2. Avoid removing too much mucosa (too high toward cuff) and shortening the vagina
    3. Use rapidly absorbing suture material (chromic catgut, Monocryl) to prevent granulomas
    4. Avoid leaving knot(s) at hymeneal ring of introitus
  2. Post operative persistent pain
    1. Avoid placing sutures in levator ani muscles
  3. Bleeding /hematoma – Intraoperative, postoperative
    1. Discontinue ASA (5 days), Plavix (3 days) and other anti-clotting medications prior to surgery
    2. Inject under vaginal mucosa with a pitressin solution (10-20U/100ccNS)
  4. Bladder injury
    1. Cystotomy with urine leakage
      1. dissect with metzenbaum scissors curved away from bladder muscularis toward the vaginal muscularis
    2. Fistula formation – vescovaginal,
      1. Keep urine in bladder during procedure in order to recognize and repair any incidental cystotomy incision
    3. Suture in bladder
      1. Suture vaginal muscularis and mucosa together without including bladder muscularis
  5. Rectal/sigmoid injury
    1. Proctotomy
      1. dissect with metzenbaum scissors curved away from rectal muscularis toward the vaginal muscularis
    2. Rectal vaginal fistula
      1. avoid cautery use on rectal muscularis
  6. Vaginal granulation tissue
    1. Avoid using permanent or slowly absorbing suture materials
    2. Avoid using permanent mesh in repair if possible
  7. Incision infection
    1. Screen for bacterial vaginosis and treat patients if positive
    2. Recommend to clip perineal hair prior to surgery
    3. Order prophylactic antibiotics, at least 30-60 minutes before incision
    4. Avoid stool contamination of incision or needles
  8. Incision dehissence/separation
    1. Avoid excessive tension on vaginal suture lines with a vaginal pack if used
    2. Order mechanical bowel prep for the day before surgery
  9. Post procedure recurrence of cystocoele or rectocoele or vaginal vault prolapse
    1. If paravaginal defect is present it should be repaired
    2. Identify any vault descensus and if present, suspend it
    3. Excise vaginal mucosa/attenuated muscularis over rectocoele laterally to ruggated vaginal mucosa/muscularis
  10. Low back pain
    1. Use Allen stirrups for positioning rather than candy cane stirrups
    2. Avoid hyperelevation of legs

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