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INTROITAL TIGHTENING FOR HUGE PROLAPSE IN ELDERLY UNFIT PATIENTS
Anahita Pandole*, Ranjit Akolekar**,Nishchal Vaidya***, Shailesh Kore***, Vr Ambiye****
*Associate Professor; **Lecturer; ***Registrar; ****Hon. Professor and Head of Unit; Dept of Obstetrics and Gynaecology, LTMG Hospital, Sion, Mumbai.
With limited data in this procedure the initial experience suggests introital tightening can be good, simple, effective alternative for prolapse in elderly patients.
INTRODUCTION
Prolapse of uterus with cystourethrocoele is one of the commonest problems seen in the gynaecological OPD. Majority of these patients are elderly and require hysterectomy with repair. But some of these elderly patients are unfit for anaesthesia or for prolonged surgery. Use of vaginal tampoons, pessaries and options like Le Fort’s colpocleisis are the common modalities of treatment in such cases with their own limitations and complications. We tried to evaluate the use of introital tightening as an alternative procedure and as a conservative operation for geriatric women who are unfit for prolonged lithotomy or anaesthesia due to their age and related medical or surgical disorders.
MATERIAL AND METHODS
We present our initial experience of introital tightening in five patients over a period of one year at one of the working units at LTMG Hospital, Sion, Mumbai.
All these patients were above the age of 60 years and parous. All had huge procidentia with cystourethrocoele. One patient had keratinization and two had developed decubitus ulcers. All of these patients were totally investigated. All had one or more medical or surgical problems and were unfit for anaesthesia or standard surgeries.
Detailed history and complete examination was done. Patients with decubitus ulcer were treated initially with antibiotics and prolapse was kept reduced with an acriflavine tampoon. After the ulcer healed, PAP smear was done in all patients to rule out early malignancy.
The procedure was explained to patients and their relatives and written consent was taken. The palliative nature of the procedure was explained to the patient.
The procedure was done under local anaesthesia and 1% lignocaine was injected all around the introitus. A small transverse inicision was taken on anterior vaginal wall just 1 cm below the external urethral meatus. A small vertical incision was taken on the posterior wall just inside the posterior fouchette. Any non-absorbable material (quadruple braided) or umbilical tape was taken on a large round body needle. It was inserted through the anterior incision and brought out through the posterior incision going submucosaly. Similar procedure was done on other side so that both loose ends of sutures were on posterior side. The introitus was tightened by pulling two loose ends so that one finger PV was possible and then 5-6 knots were tied. The knot was buried in the posterior incision (as shown in the figure). Both anterior and posterior incisions were closed with catgut. Post operatively, all were given antibiotics, analgesicsand local analgesics. All patients were discharged within three days.
Fig 1 Fig 2 Fig 3 Fig 4
RESULTS
The average procedure time was five minutes. In one patient, the sutures cut through and there was recurrence or failure. But, the procedure was repeated after two weeks by taking deeper stitches. The postoperative period was uneventful in all patients and no complications were noted. One patient complained of slight irritation and pain near posterior incision where the knot was buried. The average hospital stay was 2.5 days.
DISCUSSION
Huge prolapse of uterus with cystocoele and rectocoele or enterocoele in elderly patients who are not fit for operation (i.e. lithotomy position or anaesthesia) is a challenge for the gynaecologist. Apart from being very uncomfortable, it can lead to infection, decubitus ulceration and keratinization. Reduction of prolapse by tampoon, pessary or Le Fort’s colpoclesis was an answer to such problem in past. Tampoon treatment may be used temporarily till the healing of ulcer occurs, but not suitable as a long term treatment. Pessaries require regular follow up and cleansing and can cause vaginal discharge, ulceration, fistula formation, impactation, stress urinary incontinence.
Le Fort’s operation requires surgical exposure, lithotomy position and bleeding. Injury to bladder, postoperative SUI, sepsis are common problems.
Hence, there was a good for a conservative operation which is simple, quick and short and which can be performed without any special skill. Dani et al introduced the concept of introital tightening for such patients. [1] The principle is similar to that of ‘Theirsh stitch’ done for rectal prolapse.
The advantages of introital tightening are :
1.Technically easy, surgical skill not required.
2.Short surgical time.
3.Cervix remains accessible for cytology
4.Vaginal drainage possible, less trauma, minimal bleeding, without any adverse effects or complications and cost effective.
Though in our series, stitch got cut through in one patient requiring repeat procedure, it can be avoided by taking slightly deeper stitches. Nandanwar et al published a series of 55 patients requiring introital tightening. [2] In that series, incidence of stitch cut through and recurrence was 7%. Apart from this, there was no major complication in his series.
Age
(years)Parity Risk
factorsType of
prolapseSuture material
usedPost-up Operation time
(mins.)Hospital
stay (days)65 4 HT/DM/RHD Procidentia Quadruple braided black silk Stitch cut through.Repeat procedure > two weeks 8 4 62 3 DM/IHD Procidentia/
Cystocoele/
EnterocoeleMersilene
tapeNil 5 2 64 5 IHD/HT Procidentia/
Decubitus ulcer
Mersilene tape Nil 5 3 61 4 DM/bilateral
LL surgeryProcidentia/
EnterocoeleEthilon Pain/ irritation near site of incision 6 2 72 3 RHD/IHD Procidentia Mersilene
tapeNil 6 2 HT - Hypertension, DM - Diabetes mellitus, RHD - Rheumatic heart disease, IHD - Ischaemic heart disease, LL - Lower limb.
CONCLUSION
Though our data in this procedure is limited, the initial experience does suggest that introital tightening can be a good, simple, effective alternative for huge prolapse in elderly patients who are not fit for lithotomy position, anaesthesia or surgery.
ACKNOWLEDGEMENT
We thank our Head of Department of Dean for allowing us to use and publish the hospitaldata.
REFERENCES
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