Modified Purandare's Cervicopexy Versus Abdominal Sacral Hysteropexy
Condition: Pelvic Organ Prolapse
MeSH terms: Prolapse; Pelvic Organ Prolapse
Study type: Interventional

Summary: 
      This study aims to compare safety, efficacy and complications of modified Purandare's
      cervicopexy with abdominal sacral hysteropexy as conservative surgery in the treatment of
      genital prolapse in reproductive age group patients at Ain Shams Maternity hospital.
    

Detailed description: 
      Pelvic organ prolapse (POP), the herniation of the pelvic organs to or beyond the vaginal
      walls, is a common condition. Many women with prolapse experience symptoms that impact daily
      activities, sexual function, and exercise. The presence of POP can have a detrimental impact
      on body image and sexuality. Nulliparous prolapse is reported to account for 1.5% to 2% of
      all cases of genital prolapse . The incidence rises to 5 -8 % for young women who have
      delivered one or two children. As this type of prolapse occurs at a younger age, the surgical
      technique should not only reduce the prolapse but also retain the reproductive function.
      Various conservative surgeries have been described in the past, each having their own merits
      and de-merits .

      Pelvic organ prolapse (POP) is affecting women of all ages. Epidemiological studies suggest a
      lifetime risk of prolapse or incontinence surgery of between 7 and 19% . In an ageing
      population, the incidence of these surgeries would only be expected to increase, although the
      increasing Caesarean Section rates and smaller family size in recent years will have a
      negative impact on the prevalence of these conditions. There are many approaches to the
      surgical correction of POP, which frequently reflect the nature and anatomical site of the
      defective support, but essentially the surgeon has to decide whether to perform this surgery
      vaginally or via the abdomen as an open or laparoscopic procedure. If performed vaginally,
      further decisions regarding the use of synthetic or biological graft to reinforce the repair
      need to be made.

      The core of the modified purandare's cervicopexy is fixation of the uterine isthmus by a
      25-30 cm long strip of polypropylene mesh to the rectus muscle by criss crossing using No. 1
      polypropylene sutures.

      Modified purandare's cervicopexy is easy to perform and provides dynamic support to the
      uterus, improves fertility, doesn't interfere with vaginal birth and if caesarean delivery is
      required doesn't damage the mesh thus reducing the recurrence of prolapse and has many
      advantages compared to the original operation which can favourably affect the outcome, such
      as: criss crossing of mesh on rectus muscle which provides a space for low transverse
      incision for caesarean section without compromising the mesh anchoring and retaining the
      support. This surgery is technically easy to perform and complications like Periosteitis,
      ureteric and sigmoid injuries are avoided.

      Abdominal sacral hysteropexy remains a viable alternative for women undergoing pelvic
      reconstructive surgery who wish to retain their uteri, providing comparable rates of overall
      improvement and symptom change. Avoiding hysterectomy decreases the risk of mesh erosion but
      may increase the risk of subsequent recurrent prolapse, specifically in the anterior
      compartment.
    

Intervention name(s): Modified Purandare cervicopexy; Abdominal sacral hysteropexy
Intervention type(s): Procedure; Procedure
Intervention description(s): The modified Purandare's cervicopexy will be performed in low lithotomy position . Pfannenstiel incision was utilized and the abdomen was opened in layers maintaining perfect hemostasis. Uterus will be delivered through the incision and held with uterus holding forceps. The bladder was dissected inferiorly. A 25-30 cm long strip of polypropylene mesh was prepared by soaking. The mesh was fixed anteriorly at the level of isthmus by No.1 polypropylene sutures . The ends of the mesh were brought lateral to rectus muscle retroperitoneally on both sides taking care not to injure the inferior epigastric vessels. After confirming the correct fixation and haemostasis the uterovesical fold of peritoneum was approximated. The ends of the mesh were fixed to the rectus muscle by criss crossing using No. 1 polypropylene sutures. After confirming the haemostasis, the abdomen was closed in layers. Per speculum examination was done to note the reduction of prolapse.; After peritoneal entry through pfannenstiel incision was, the bladder is mobilized off the cervix. Windows are made in the broad ligament at the level of the isthmus. Posteriorly, the rectovaginal space is entered at the level of the uterosacral ligaments. Next, a 15x15-cm polypropylene mesh is used to fashion two 4.5- to 5-cm-wide strips of mesh; one is bisected for a distance of 5 cm to produce a Y-configuration for the anterior mesh.The anterior mesh arms are passed through the broad ligament windows and attached to the cervix and pubocervical fascia using interrupted 2-0 PDS. The posterior mesh is attached to the rectovaginal fascia using transverse-interrupted 2-0 PDS sutures. Once the sacral dissection has exposed the anterior longitudinal ligament, the proximal ends of the 2 mesh strips are attached to the sacral promontory using two 2-0 polyester sutures to provide elevation of the uterus without tension. The peritoneum is closed over the mesh using a 3-0 vicryl suture
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment