Novel approach for pelvic floor descent Arun Rojanasakul Colorectal Division, Department of surgery Chulalongkorn University, Bangkok, Thailand Pelvic floor disorders are always combination of anatomical, functional and symptomatic disorders. Anatomical disorders • Descending perineum • Prolapse (Uterus, Vagina, Rectum) • Hernia (Rectocele, Cystocele, Enterocele) Functional and symptomatic disorders • Bowel dysfunction (ODS, FI) • Bladder dysfunction (SUI, UUI) • Sexual dysfunction • Pelvic pain (proctalgia, vulvodynia) Descending perineum syndrome (DPS) a condition where the perineum "balloons" several centimeters below the bony outlet of the during strain, although this descent may happen without straining Parks,1966 Descending perineum syndrome (DPS) “It is not a wholly satisfactory title but is descriptive, as perineal descent on straining is both the cause of the symptomatology and the most obvious physical sign.” Parks 1966 Female pelvic medicine and reconstructive surgery Integral theory Damaged ligaments weaken the force of pelvic muscle contraction, causing prolapse and abnormal bladder and bowel symptoms Peter E. P. Petros, 1993 Integral theory “Repair the structure and you will repair the function” Peter E. P. Petros, 1993 Treatment options for pelvic floor descent • Non-surgical treatments • Biofeedback • Sacral nerve stimulation • Perineum pushing device • Acupuncture Surgical options for pelvic floor descent • Retro-anal levator plate myorrhaphy • Post-anal repair (Parks’) • Other related techniques • ventral rectopexy , SIR (Longo’s) • sacral colpopexy , sacrospinous colpopexy Posterior Approach Pelvic Organs Suspension (PAPOS) Newly proposed technique for the treatment of pelvic floor descent Posterior Approach Pelvic Organs Suspension (PAPOS) Surgical steps Prone position suture closure of anus coccyx “lightning” incision coccyx anococcygeal ligament coccyx rectum levator ani vagina finger in vagina suture vagina to sacrospinous ligament using Prolene no. 1 suture vagina to sacrospinous ligament on the contralateral side suture rectum to sacrospinous ligament, distal sacrum & coccyx suture closure of anococcygeal ligament vacuum drainage suture closure of anococcygeal ligament Pre-operative dynamic MRI compare to Post operative dynamic MRI Pre-op Post-op At rest Pre-op Post-op Disappear of rectocele and cystocele Pre-op perineal descent 4 cm. Post-op perineal descent 2 cm. Short-term Outcome 2013-2014 • 9 cases of perineum descent • ODS. 5 cases • ODS. + Fecal incontinence 1case • ODS. + Pelvic pain 1 case • Rectal prolapse 2 cases • Success 8 cases • Fail 1 case: inadequate lift up the perineum Advantage of PAPOS • Simple technique • Incision through anatomy planes • Inexpensive • No mesh used • Satisfactory short term outcomes Future Issues in PAPOS • Technique modifications ?? • Long-term outcome ?? • Complications ?? • Viable option ?? Thank you for your attention [email protected]