Surgical Management in Urogynecology

Preoperative Assessment & Principles - Pre-Op Game Plan

• History: Voiding diary (≥3 days), POP-Q, symptom scores (e.g., UDI-6, IIQ-7), obstetric/surgical history.
• Examination: Pelvic exam (assess prolapse stage, levator ani function), cough stress test, Q-tip test (urethral hypermobility).
• Investigations: Urinalysis, urine culture. Consider urodynamics (UDS) for complex cases or prior failed surgery.
• Counseling & Consent: Discuss risks, benefits, alternatives, realistic expectations.
• Optimization: Treat UTIs, manage comorbidities, smoking cessation, weight management.

⭐ Preoperative urodynamics are indicated for recurrent SUI or complex voiding dysfunction, especially if invasive surgery is planned.

Surgical Management of SUI - SUI: Stop That Leak!

Primary goal: Restore urethral support and continence.

• Mid-Urethral Slings (MUS): Gold standard, synthetic mesh.
  • Retropubic (TVT): Passes behind pubic bone.
  • Transobturator (TOT): Through obturator foramen (avoids retropubic space).
  • 📌 TVT: ↑Bladder injury risk; TOT: ↑Groin pain/neuropathy risk.
• Burch Colposuspension: Abdominal/laparoscopic; sutures vagina to Cooper's ligament.
• Autologous Fascial Sling: Patient's fascia (rectus/fascia lata). For complex/recurrent SUI.
• Urethral Bulking Agents: Periurethral injection. Less invasive, ↓efficacy; for poor surgical candidates.

⭐ Mid-urethral slings (TVT/TOT) demonstrate long-term cure rates of approximately 80-90% for SUI.

Surgical Management of POP - POP: Hoist the Sails!

• Principles: Restore normal anatomy, alleviate symptoms, preserve/restore organ function (urinary, bowel, sexual).
• Approaches:
  • Vaginal: Preferred for anterior/posterior repairs, some apical.
  • Abdominal (laparoscopic/robotic/open): Often for apical prolapse (e.g., sacrocolpopexy).
• Key Procedures:
  • Anterior Colporrhaphy: For cystocele.
  • Posterior Colporrhaphy & Perineorrhaphy: For rectocele, perineal defects.
  • Apical Suspensions:
    • Vaginal: Sacrospinous Fixation (SSF), Uterosacral Ligament Suspension (USLS).
    • Abdominal: Sacrocolpopexy (gold standard for vault prolapse).
• Obliterative: Colpocleisis (e.g., LeFort) for elderly/frail, not desiring sexual function.
• Mesh Use: Selective; native tissue repair often prioritized due to mesh-related complications.

⭐ > Sacrocolpopexy (abdominal) has the highest long-term success rates (often >90%) for correcting apical vaginal prolapse.

Surgical Management of Fistulas - Fistula Fix-Up Crew

• Principles: Delayed repair (3-6 months), layered closure, tension-free, good vascularity, bladder drainage.
• Vesicovaginal Fistula (VVF) Repair:
  • Transvaginal (common): Latzko (partial colpocleisis for apical VVF), Flap-splitting techniques.
  • Transabdominal: For complex, high, or recurrent fistulas.
• Interposition Grafts: Martius (bulbocavernosus fat pad), Gracilis muscle, Omental flap.
• Rectovaginal Fistula (RVF) Repair: Layered closure; consider sphincteroplasty if sphincter involved.
• Post-op: Indwelling catheter for 2-3 weeks, antibiotics.

⭐ Martius graft is frequently used for complex or recurrent VVF to improve healing by providing a well-vascularized tissue layer. 📌 FISTULA Fix: Fresh edges, Interposition graft, Suture (tension-free), Tissue viability, Urinary diversion, Layered closure, Antibiotics/Antiseptics.

Postoperative Care & Complications - Post-Op Watchtower

• Key Monitoring: Pain (VAS), vitals, urine output, wound (REEDA scale).
• Prophylaxis: Antibiotics (if indicated), DVT prevention (early ambulation, SCDs/LMWH).
• Catheter Care: Aseptic technique; timely voiding trial (VT).
• Patient Education: Red flags (fever, ↑pain, discharge), activity restrictions.
• Complications:
  • Early: Infection (UTI, SSI), hematoma, voiding dysfunction (VD).
  • Late: Mesh erosion/exposure, chronic pain, recurrence, fistula.

⭐ Post-operative voiding dysfunction (POVD) is a key concern; failure of voiding trial (PVR > 100-150mL) needs active management.

High-Yield Points - ⚡ Biggest Takeaways

• Mid-urethral slings (TVT/TOT): gold standard for SUI, high efficacy, minimally invasive.
• Burch colposuspension: effective retropubic suspension for SUI, often with abdominal procedures.
• Sacrocolpopexy: most durable for apical prolapse (vaginal vault), abdominal or laparoscopic.
• Native tissue repairs (colporrhaphy): higher POP recurrence than mesh-augmented repairs.
• Mesh complications (erosion, pain): significant concerns in POP surgery, counsel patients.
• Colpocleisis: obliterative procedure for severe POP in frail, non-sexually active women.
• Ureteric injury: key iatrogenic risk in sacrocolpopexy and complex pelvic surgeries.