Pelvic Prolapse

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Dr. Larry Demco:  “I’m Dr. Demco reporting from the AAGL World Congress here in Orlando. This is a World Congress and we’d like to have some views from our southern neighbors from Australia, and we have Dr. Lam from Australia here whose special interest is in pelvic reconstructive surgery. Dr. Lam, could you give us a little bit of the scope of how much of a problem pelvic floor problems are in the community?”

Dr. Alan Lam:  “It is a very common problem, Dr. Demco, almost every woman who’s ever been through the childbirth process can be expected to sustain some type of damage to the pelvic floor. Obviously, the range could be from a mild degree to a very severe end of the spectrum. I would estimate that some 30%-50% of women may experience problems and many of whom unfortunately are not aware of the extent of their damage and may not have been asking for the appropriate advice.”

Dr. Larry Demco:  “We think many times that pelvic prolapse is a disease of older women. Can you clarify that for us?”

Dr. Alan Lam:  “Because it is a disease that has the major cause arising from childbirth, it is a much more common problem in younger women. Having said that, the problem often presents or comes to the attention of the woman later in life, usually after the onset of menopause because of the loss of estrogen accelerating the manifestation of the damage but the damage does occur early in a woman’s reproductive life.”

Dr. Larry Demco:  “You say that menopause has an important role, has anything been suggested about prevention of prolapse by HRT therapy?”

Dr. Alan Lam:  “Yes, there is plenty of evidence to suggest that hormone replacement therapy starting premenopausally and carried on into the menopause, whether that is in the systemic oral form or the local delivery form into the vaginal region, is of great benefit.”

Dr. Larry Demco:  “One of the common thoughts about pelvic prolapse with many general gynecologists is that this is either a cystocele or a uterine prolapse and they do not really appreciate the full scope of what really needs to be looked at. Could you bring us up to date on that?”

Dr. Alan Lam:  “The traditional view of approaching or looking at prolapse has been as a cystocele or a rectocele, a view that has predominantly been because of our approach of the problem from the vaginal way but now with the ability to view and assess the problem both from above using laparoscopy and using what we already know from the vaginal approach, we now should view the problem very much as a three-dimensional problem and as a total front-back-central problem, the whole of the pelvic problem. Terms such as rectocele and cystocele, I feel, should be discarded. We should now view the problem as which organ is prolapsing and from what defect is it prolapsing through, and that I view is the best way to approach the repair for the patients.”

Dr. Larry Demco:  “From the laparoscopic side of this view that you have mentioned, what structures should we be looking at to properly assess the pelvic floor when we view this through the laparoscope?”

Dr. Alan Lam:  “What we should do is to start by appreciating through the laparoscope and vaginal examination what the normal pelvic support is. This includes the layer from the peritoneum, the ligaments, peel the peritoneum covering down, and look at the endopelvic fascial support. Then take that out and look at the muscular support and look at how the uterus plays a central role in integrating the support to the bladder in front and the rectum behind and how then together these organs are attached to the pelvic floor musculature and in turn to the boney pelvis. Then look at how all of these structures interact dynamically supplied by the live neurovascular innovation that keep the whole of the pelvic floor support alive if you like.”

Dr. Larry Demco:  “Many of the average gynecologists haven’t had an opportunity to do this. With the cadaver demonstrations in courses that are currently available, do you think that this is an appropriate way for further insight into the pelvic floor?”

Dr. Alan Lam:  “I feel it has been of great benefit to all gynecologists. The cadaver courses, particularly those that have been running at the AAGL meetings by Dr. Bob Rogers and his colleagues, I feel has really opened up the kind of anatomy that many gynecologists have not been able to see. We have been doing a lot of the laparoscopic pelvic reconstructive surgeries so the residents and the registrars who have been working under us have had the benefit of seeing live demonstrations of the type of defects that were previously not seen by the vaginal approach. They also have been able to see the defects repaired at the same time as well. I feel that’s actually going to be the next extension from the cadaver dissection into live surgery to help them assess at the beginning of the operation by vaginal examination, by laparoscopy, open up the defects, demonstrate them, see how they reconstruct, re-examine the patient at the end of the procedure, and see how they appear at the follow-up at six months and some years down the line. We have been very impressed with our results as a result of the laparoscopic benefits.”

Dr. Larry Demco:  “The traditional method of recreating normal anatomy is by shortening the ligaments by a surgical approach. How do you view some of the new technology like radiotherapy or radiofrequency modalities in using this approach to try to shorten the musculature and the fascia?”

Dr. Alan Lam:  “I think it is an interesting development. We are only beginning to appreciate the specific defects or damages, and we are only now beginning to explore many exciting ways of repairing defects. My view is that in addition to radiofrequency, radiotherapy, electrosurgery, and sutures, we are probably going to be using and hopefully be developing a lot of synthetic fascial support or even glue-type of structures that might help us repair defects without having to resort to the difficult suturing method, for example. So I think we’re entering a very exciting decade of pelvic reconstructive surgery.”

Dr. Larry Demco:  “With that, I’d like to thank you very much for showing us this vulva view and the view from across the pond there in Australia and to see that this is not only a local problem to Canada and the United States but is a worldwide problem. Thank you very much, Dr. Lam.”

Dr. Alan Lam:  “Thank you, Dr. Demco.”