Difficult Cases: Reconstruction on Stage IV Uterovaginal Prolapse in a Patient With End Stage Renal Disease

A 67-year-old retired teacher who had three vaginal deliveries presented after one year of vaginal bulge symptoms. She had chronic end stage renal disease and was on peritoneal dialysis. Prior to the vaginal bulge symptoms, she was able to perform most daily activities. Her medical history included hypertension, Type II diabetes mellitus, hypothyroidism, aortic and mitral valve stenosis, pulmonary hypertension, as well as a previous femur fracture and pulmonary embolism.

Examination: This well oriented woman had a Tenckoff catheter in the right lower quadrant of her abdomen and a stage IV uterovaginal prolapse. There was no evidence of urogenital tract infection or urinary incontinence. Her preoperative hemoglobin was 8.3gm/dL; fasting glucose 150, blood urea nitrogen 162, and serum creatinine 8.8 mg/dL.

Treatment objectives: Treat the uterovaginal prolapse and restore function and preserve the right intraabdominal and retroperitoneal anatomic integrity for a future renal transplant.

What is the best surgical approach in this case?

• Le Fort’s colpocleisis
• Abdominal sacrocolpopexy
• Hysteropexy
• Vaginal hysterectomy with apical sacrospinous ligament fixation
• Vaginal hysterectomy with uterosacral ligament suspension

Extensive preoperative evaluations were performed. Thrombo-prophylaxis with enoxaparin was recommended by the cardiology service; pulmonary hypertension treatment with sildenafil was endorsed by the pneumologist; and post-operative hemodialysis was proposed by the nephrologist. With an ASA IV, epidural anesthesia was elected. After explaining the potential risks and benefits of all treatment options to the patient, the informed consent was signed.

Surgery: The patient received a preoperative transfusion of one unit of red blood cells and was given thromboprophylaxis and antibiotics. Vaginal hysterectomy, bilateral sacrospinous fixation, anterior and posterior colporrhaphy and perineoplasty were performed. Other than the copious efflux of peritoneal fluid, no unexpected intraoperative events occurred. Surgical duration was 160 minutes.  The estimated blood loss was 500mL. An additional unit of blood was transfused during the surgery.

Post-operative Course: Her immediate post-operative recovery was uneventful. She was discharged home on the fifth post-operative day, with a hemoglobin of 11.2 gm/dL, and creatinine of 4.8mg/dL. Four weeks later, she resumed intraperitoneal dialysis. Eight months after surgery, the patient has remained stable with a POP-Q = C-10.  She can comfortably walk, sit and do most daily activities and is very satisfied with the outcome.

Expert Response: Yi Ling Chan, United Kingdom

The following information was not included in the case history but would help inform development of an appropriate treatment plan for this patient.

• Is the patient sexually active?
• Is she overweight or obese? BMI may be inaccurate due to presence of abdominal fluid. To exclude peritoneal fluid in the BMI calculation, 2-3 liters/kg.
• Any assessment regarding pelvic floor incoordination or pelvic floor exercise technique issue? Any Valsalva while attempting pelvic floor contractions? Any pelvic floor rehabilitation program put in place for long term recurrence prevention? Any input from Women’s Health physiotherapists?
• Has she had hemodialysis as proposed by nephrologist?
• What were pre-operative parameters for C and TVL on POP-Q?

The management of high-risk patients with severe pelvic organ prolapse is challenging. The treatment package should aim to meet the patient’s goals as above. In addition, the treatment should aim to improve quality of life, carry acceptable treatment-associated risks and post-operative recurrence risk. The following should be taken into consideration:

• Risk assessment – treatment associated risks and recurrent prolapse risk
• Consideration of non-surgical and surgical treatment options
• Pre-operative optimization
• Post-operative recurrence prevention

One in 10 women require treatment for pelvic organ prolapse (POP). The recurrence rate following traditional surgery for POP is approximately one in three. Surgery for prolapse can sometimes be associated with various adverse events and potentially poorer quality of life than the original condition.

Multiple factors contribute to the development of primary and recurrent POP. These factors include childbirth, constipation, weightlifting, congenital connective tissue weakness, obesity, menopause, chronic increased intraabdominal pressure, and iatrogenic causes.

Patients requiring peritoneal dialysis carry 2-3 liters of peritoneal fluid. Therefore the pelvic floor is exposed to chronic raised intraabdominal pressure. This is one of the risk factors for development of severe prolapse and will remain as one of the significant risk factors for post-operative recurrence.

The risk may be compounded by other factors such as excess body weight and pelvic floor incoordination. Evidence shows that between 30-40% of women do not do pelvic floor exercises (PFEs) correctly. Approximately 15% do the Valsalva maneuver while attempting PFEs. The pelvic floor incoordination results in failure of involuntary reflexive pelvic floor contractions during routine daily activities involving strains to the pelvic floor.

In this case, the nephrologist proposed hemodialysis post-operatively. Hemodialysis before embarking on surgery is an option. Cessation of peritoneal dialysis following hemodialysis removes one of the significant risks of long term post-operative recurrence by reducing persistent increased intraabdominal pressure secondary to high volume peritoneal fluid.

While waiting to mitigate this risk, the patient could be considered for non-surgical treatments using support pessaries such as Gellhorn or Popy pessaries. In the event of pessary expulsion, double pessary such as insertion of a ring pessary in addition to a more robust pessary could be a suitable option until the patient is optimized for surgery.

In terms of the surgical options, the vaginal approach is certainly preferable to the abdominal route. The abdominal approach carries risk of compromising peritoneal dialysis which she still relied on at the time of surgery. Abdominal entry also carries higher risks of introducing intraabdominal infection and post-operative scarring which could complicate future renal transplant.

This patient has several other significant comorbidities, and some could be complicated by excess body weight in addition to prolapse recurrence. A weight management program should be put in place to reduce long term health risks and prolapse recurrence.

Input from pelvic floor physiotherapists should be sought to assess the pelvic floor and to supervise pelvic floor muscle training (PFMT), ideally before embarking on surgery. Alternatively, post-operative physiotherapy should be put in place, however one needs to ensure that the post-operative pelvic floor physiotherapy is not via mere verbal instructions without prior/previous digital examination and supervision by a physiotherapist to avoid missing the opportunity to detect the patient’s inadvertent Valsalva while attempting PFEs.

Last but not least, if this patient is still on peritoneal dialysis, this should be replaced with other treatments such as hemodialysis or even renal transplant as soon as feasible, to minimize prolapse recurrence risk due to chronic raised intraabdominal pressure.

REFERENCES

Bø K, Larsen S, Oseid S. Knowledge about and ability to correct pelvic floor muscle exercise in women with stress urinary incontinence. Neurourology and Urodynamics. 1988:69;261-262.

Bump RC, Hunt WG, Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991;165(2);322-329.

Enoch C, Aslam N, Piraino B. Intra-abdominal pressure, peritoneal dialysis exchange volume, and tolerance in APD. Semin Dial. 2002;15:403–6.

Glazener C, Breeman S, Elders A, Hemming C, Cooper K, Freeman R et al. Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compart prolapse surgery: two parallel-group, multicentre, randomized, controlled trials (PROSPECT). The Lancet. 2017;389(10067):381-392.

Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. The Lancet. 2007; 369(9566):1027–1038.

Lew SQ, Robinson JK III. A Conservative Approach to Peritoneal Dialysis-Associated Rectocele. Perit Dial Int. 2014 Sep-Oct; 34(6):655–657. doi: 10.3747/pdi.2012.00026.

Nygaard IE, McCreery R, Brubaker O, Connolly A, Cundiff G, Weber AM, Pelvic Floor Disorders Network, et al. Abdominal sacrocolpopexy: a comprehensive review. Obstet Gynecol. 2004;104:805-823.

Soligo M, Salvatore S, Emmanuel AV, De Ponti E, Zoccatelli M, Cortese M, et al. Patterns of constipation in urogynecology: Clinical importance and pathophysiologic insights. Am J Obstet Gynecol. 2006;195(1):50–55.

Twardowski ZJ, Khanna R, Nolph KD, Scalamogna A, Metzler MH, Schneider TW, et al. Intra-abdominal pressures during natural activities in patients treated with continuous ambulatory peritoneal dialysis. Nephron. 1986;44:129–35.

Urinary incontinence and pelvic organ prolapse in women: management NICE guideline [NG123]. Published date: 02 April 2019 Last updated: 24 June 2019.