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Saturday, May 10, 2008

Surgical Footprints, then and now.

“Learning without thought is labour lost; thought without learning is perilous.”confucius

Looking down the timeline of vaginal reconstruction surgery, one probably need to start in 1909 when George White, a gynecologist from the rural United States, found that the reason for the anterior vaginal wall to prolapse is tears that happened in the support tissue of the bladder on its lateral attachments to the pelvic sidewalls. This para-vaginal tears -which propably occurs during preceding childbirth- could be reproduced by him by cutting through this collagen, with resultant anterior vaginal wall prolapse with a “cystocoel” forming. He rectified this by a simple side stitch through the vaginal wall, through the underlying tissue and onto the sidewall of the pelvis, thus pulling it upwards and the prolapsed bladder out of the vagina.

These outstanding findings were unfortunately overshadowed by the teachings of a more prominent member of the medical fraternity, Howard Kelly. Howard Kelly looked into the vagina, saw a bulge coming down in the midline on the anterior wall and named it after the organ which it must contain - a cystocoel - and rectified this bulge by folding the overlying central tissue between bladder and vaginal skin onto itself, thus augmenting the stretched tissue onto itself.
White saw the anterior vaginal wall as a prolapsed organ, Kelly saw it as a bladder prolapsing into the vagina. White wanted to re-build the support of the anterior vaginal wall, Kelly only focused on getting rid of the bulging bladder into the vagina.

These two pathogenetic and resultant treatment modalities are in total conflict with each other. On the one hand the pathogenesis is based on a mechanical tear happening on the attachment of the support tissue of the bladder to the pelvic sidewall, and the oposing view is based on a central stretching -later to be viewed as a "central defect"- of support tissue. In the first instant one needs to rectify the lateral defect, in the other one needs to fold the stretched tissue on itself, thus pushing the bladder upwards and out of the vagina.
Being the “father” of American Gynecology, Howard Kelly's teachings were adopted and George White’s did not get any attention.

This still persists in modern vaginal reconstructive surgery. The general teaching is that the inexperienced surgeon should only do this type of surgery - your first attempt at correcting prolapse is your best chance- and this is left to the inexperienced! The experienced is keeping himself busy with the "complex" repairs - a rather nice way to describe the failures!

The period from 1909- when White wrote his article- to 1914 -when Kelly introduced his teachings to the world- can be seen as the first sliding door opening where the wrong door probably was entered.

The second sliding door happened in the 1970’s and 1990’s with the rise of laparoscopic surgery, where the defects on the pelvic side walls were seen by Richardson and these “para-vaginal tears” were sutured by either open surgery or through the laparoscope. A few articles appeared with results, but with no standardized methodology and with no universal results. Before this could be universally tested, the sliding door opened in a different direction with the advent of Mesh kits whereby a bridge is put between the bladder and the vaginal wall stretching from sidewall to sidewall and cervix to symphysis pubis.

The ensuing mesh kits that came on the market were attractive due to the simplicity involved in the placing of these, and - to put it bluntly - incompetent surgeons found themselves suddenly looking rather competent! The focus changed from reconstruction of the defects present to constructing a support for the centrally prolapsed organ in the form of a bridge. The anterior wall was opened, the lateral attachments were severed from the sidewall of the pelvis (thus creating a bilateral defect) and the mesh was used as a permanent bridge to support the bladder.
With experiences of this type of graft over only weeks or months, products came on the market for general use, being basically untested in the pelvis. Debates ranged over the type of meshes to use for this bridge, with the lighter being put forward as the better and synthetic graphs as being superior to different biological grafts. In all these debates there was a total disregard for the normal anatomy and the deviation from this normality due to disruption in the collagen support.
Around the turn of the century everyone was also caught in the clamour of the TVT and TVT-O era. Add to this the marketing and involvement of big business, and what happened should have been expected.

The aspiring vaginal pelvic organ reconstruction surgeon is thus confronted in 2008 with basically two choices: either use the “classical” central bulge reducing methods as taught by Kelly, or follow the mesh bridge teachings of the “modern” pelvic organ reconstruction surgeons.
The followers of the “mesh kits” are honest enough to report failures and complications of these kits, with different types of “innovations” with each ensuing congress. The cracks in the wall are showing already in a relatively early stage.

What to do if, or shall I say when, complications appear, will be the new science of the future.

The aspiring surgeon has thus a choice between two evils.

In all this the sliding door leading towards the recognition of the pathology present and directly restoring that, is once again totally ignored.

Standing back from this, one only has to look at what needs to be done: one needs to know the anatomy, recognize what is the underlying cause of the central prolapse in the vaginal wall (mechanical defects with collagen degradation), and then follow the simple rules of proper reconstructive surgical techniques to rectify the defective anatomy. This had already been proposed by George White in 1909 and resurrected by others.

In teaching the aspiring surgeon these basic principles, we the teachers, will leave a less harmful trail. Only then one can follow the simple rule of “do no harm”.

The footprints laid down in the pelvis by childbirth and degeneration of collagen in the surrounding tissue is the reason for the prolapse. How this can be prevented is not clear. The surgical footprints laid down by the pelvic organ reconstruction surgeon, however, can be.

Our function is to see to that. We must be reconstructive surgeons, not destructive surgeons.

this editorial had been accepted for publication by the International Urogynecology Journal on 22 june 2008: the original publication is available
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    Blogger Clare said...

    I am a female doctor myself and so have some understanding of the basic anatomy. I have also had a "prolapsed bladder" or cystocoel which I know is from a tear in the anterior vaginal wall and has probably bee there since childbirth 40 years ago!. The baby was in the POP position and I was in labour for 36 hrs. They sewed up an episiotomy, but I feel neglected a tear in the muscle.This was OK until after menopause. I don't know if I can get a gynaecologist to simply sew the muscle tissue together or "sliding door" technique as you suggest. I think most of them here (canada) use the mesh method. The prolapse in now external and I have to wait three months to see an OBGYN. Any palliative treatment I can do in the meantime. What about Estrogen creme? would it help?

    12:55 PM  
    Blogger andri nieuwoudt said...

    To start with your last question: if you are pre menopausal, oestrogen cream is not going to help at all! Your endogenous oestrgen should be enough for the basic hormonal needs. When a prolapse is at a advanced stage where the vaginal wall is everting ( "the prolapse is now external") the only posible sulution is surgery/or use of a temporary method like a pessary for instance. When surgery is contemplated I personally do not underwrite placing of a synthetic mesh between two hollow organs, or the more classical method (plicating the herniated vaginal wall). If you send me your adres I can send you a DVD's (free of charge) of the recommended techniques that I do underwrite.

    9:32 AM  
    Blogger Nott van Heyningen said...

    Yes Dr Nieuwoudt, It seems to me you have hit the nail on the head. I am also a man who has left many footprints on the wrong path and I am very excited to have been pointed onto what is almost certainly the correct path. The anatomical repair of the defects that are caused by both childbirth and the genetic predisposition of collagen weakening.It makes infinite sense now that I have seen these repairs. The most wonderful thing to me is that the repair of anatomical defects lies in the recognition of these defects both in the clinical setting and then at surgery. Once recognised they stand out and cannot easily be missed. You see them and then repair them. Using biomesh bolstering also make sense because the already established weakening of collagen should also be addressed. We do need polypropylene meshes as well but they should perhaps be used with greater circumspect.
    The fact that there are serious and innovate thinkers in POP surgery augers well for the improvement of quality of life for women all over the world.

    Dr C F van Heyningen

    3:48 AM  

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