Purandares cervicopexy

Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.Cervicopexy is fertility conserving surgical management of prolapse.

1. PURANDARE’S CERVICOPEXY

2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member , Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. HISTORY Dr B. N. Purandare was an illustrious son of an illustrious father. He graduated from The Seth G S Medical College and KEM Hospital with flying colours . He went on to London and Edinburgh to train in surgery and gynecology after medical education in India, and became Fellow, Royal College of surgeons .

4. HISTORY A premier vaginal surgeon with excellent skills, he devised the ABDOMINAL CERVICOPEXY operation for prolapse which revolutionized the conservative surgeries for prolapsed and the surgery is named after him. It is widely performed even today. His special interests included performing Vaginal hysterectomy, Vaginal sterilization, Schauta’s operation, Abdominal cervicopexy , and Tubal recanalisation , where he has left his mark on these surgeries.

5. INTRODUCTION Prolapse literally means " to fall out of place ." Uterine prolapse (also called descensus or procidentia ) means the uterus has descended from its normal position in the pelvis farther down into the vagina.

6. EPIDEMIOLOGY The global prevalence of genital prolapse is 2 to 20 % under 45 years of age. In India, more than 1 million of women suffer from genital prolapse and majority of them falls under the reproductive age group. It is estimated that about half of the women loss their pelvic floor support and result in some degree of prolapse and among them only 10- 20 % seek treatment for the problem. 11% life time risk of surgery for prolapse. Incidence of Nulliparous Prolapse 2-5%. Bang RA, Bang AT, Baitule M, Choudhary Y, Sarmukaddam S, Tale O. High prevalence of gynaecological diseases in rural Indian women. Lancet 14;1(8629):85-8.

7. EPIDEMIOLOGY Pelvic Organ Support Study (POSST ): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects showed a bell-shaped curve distribution with the majority of women having Stage 1 or 2 prolapse in a population of 497 women greater than or equal to 18 years of age with a mean age of 44 years. Pelvic organ prolapse and stress urinary incontinence: A review of etiological factors AJOG .  2005 Mar;192(3):795-806.

8. ETIOLOGY Stretching and tearing of the endopelvic fascia and the levator muscles and perineal bodyduring difficult childbirth. Multiparous women Genital atrophy Hypoestrogenism Pelvic tumors Sacral nerve disorders Diabetic neuropathy Medical conditions associated with increases in intra-abdominal pressure ( eg , obesity, chronic pulmonary disease, smoking, constipation) Certain rare abnormalities in connective tissue (collagen), such as Marfan disease

9. SUPPORTS OF UTERUS

10. DEGREE OF UTERINE PROLAPSE

11. COMPARTMENT DEFECTS

12. MANAGEMENT

13. AIM OF RESTORATIVE SURGERIES Restorative surgeries play a definitive role: To relieve the symptoms To restore the anatomy to normal To restore the functions to normal To prevent recurrence in future To maintain child bearing potential To maintain menstrual function

14. RESTORATIVE SURGERIES COLPORRHAPHY ( ANTERIOR/ POSTERIOR) FOTHERGILL’S REPAIR (MANCHESTER OPERATION) SHIRODKAR’S PROCEDURE ABDOMINAL SLING OPERATION A) ABDOMINOCERVICOPEXY PURANDARE’S CERVICOPEXY B) SHIRODKAR’S ABDOMINAL SLING OPERATION C) KHANNA’S ABDOMINAL SLING OPERATION D) VIRKUD’S COMPOSITE SLING E)OTHERS [ SOONAWALA/ VIVEK JOSHI’S ] LAPAROSCOPIC SLING SURGERY

15. PRINCIPLE OF PURANDARE’S CERVICOPEXY The objective of this operation is to buttress the weakened supports ( Mackenrodt’s and Uterosacral ligaments) of the uterus by providing a substitute in the form of Mersiline tape , used as slings to support the uterus and anchor it to the anterior abdominal wall.

16. INDICATIONS CONTRAINDICATIONS Pregnancy Poor abdominal wall tone Suspected malignancy of lower genital tract Nulliparous prolapse Second and third degree prolapse with no or minimal cystocele and/or rectocele and no supravaginal elongation of cervix. Woman desirous of child bearing.

17. PREOPERATIVE REQUISITES Good abdominal muscle tone Exfoliative cytology of the cervix to rule out cervical neoplasia At least 6 weeks since last delivery or abortion if any OPERATIVE POSITION : Supine

18. Anterior Abdominal Wall Anterior aspect of isthmus OPERATIVE TECHNIQUE

19. STEPS

20. The round ligaments are plicated with linen sutures. The parietal peritoneum and recti are approximated. Ends of tape are crossed in front of recti and sutured to each other. Abdomen is then closed in layers

21. POST OPERATIVE PICTURE

22. POST-OPERATIVE CARE Parental fluids until bowel sounds return. Early oral fluids are now advocated. Antibiotics, sedatives, metronidazole for 24 hours IV. Indwelling catheter for 48 hours. Early ambulation DVT prophylaxis

23. ADVANTAGES Technically easy to perform Provides dynamic support to uterus

24. DISADVANTAGES Uterus may become retroverted . There is tendency to enterocoele (Deepens pouch of douglas ). Tape may be damaged during subsquent cesarean section. Risk of bowel obstruction between it and anterior abdominal wall.

25. STUDIES Anterior abdominal wall cervicopexy for treatment of stage III and stage IV uterine prolapse :2010 Among 37 patients, AWC was performed in 21 women with stage III and 16 women with stage IV uterine prolapse. Overcorrection was observed in 3 women. Postoperatively, 2 women experienced febrile morbidity and 5 had urinary retention. Thirteen women complained of urinary frequency, but all reported improvement at 3-month follow up. Among 24 women who became pregnant, 14 delivered vaginally, 5 delivered by cesarean , and 5 had an ongoing pregnancy. Four recurrences occurred: 2 stage II and 2 stage III prolapses. Three of these women had delivered by cesarean , while the fourth recurrence occurred after the patient's third vaginal birth. AWC is a simple and effective procedure to treat stage II and stage III uterine prolapse. However, some surgical modifications and more studies are required to ascertain its validity. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2010

26. One thousand three hundred and eighty patients having uterovaginal descent were admitted at L.T.M. General Hospital, Sion, Mumbai, from Jan ‘03 - Dec ‘04. 139 patients underwent conservative surgery. Sixty four (46.67%) patients were in the child-bearing age group and 12.94 % underwent Purandare’s Cervicopexy. STUDIES Evaluation of Shirodkar’s Sling Surgery for Conservative Management of Uterovaginal Descent During Child Bearing Age Group 2007

27. STUDIES POP being the most common indication for benign gynecological surgery could be due to higher number of unsupervised home conducted vaginal births with tendency for premature bearing down during labor in rural and tribal populations. Majority of the surgeries were done abdominally. Younger women in third decade of life were mostly offered conservative approach of Fothergill's operation and Purandare's cervicopexy. A total of 287 (31%) women had pelvic organ prolapse (POP); VH was done in 267, Fothergill's repair in 14 and Purandare's cervicopexy in 6. Gynecological diseases in rural India: A critical appraisal of indications and route of surgery along with histopathology correlation of 922 women undergoing major gynecological surgery J Midlife Health. 2014 Apr-Jun