By N. Gembak. Colorado Technical University.
Unipolar mapping has 82 identified large epicardial abnormalities in this population buy 2mg imodium with mastercard, the pathology of which has been known to have early 81 epicardial involvement cheap imodium 2 mg online. Hypertrophic cardiomyopathy discount imodium 2 mg on line, both with and without obstruction order imodium 2 mg, is associated with a high incidence of sudden cardiac death. As noted above, I have not found endocardial unipolar mapping to be of value in this population. Further work is necessary to characterize the sites and mechanism of conduction abnormalities in patients with all forms of cardiomyopathy. Patterns of voltage mapping abnormalities were typically related to perivalular areas: near the tricuspid valve (pattern 1), the pulmonic valve (pattern 2) or both (pattern 3). Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in the setting of right ventricular cardiomyopathy. Both the number of sites and duration of this fragmented activity 92 influence the ability to record a late potential using signal averaging. In coronary artery disease and prior 93 94 infarction, 88% of signals recorded during the late potential are from the endocardium (Fig. These findings are 92 93 directly related to the abnormal electrograms noted on the endocardium during sinus rhythm mapping. Note the symmetric configuration of the filtered complex, which is 100 msec in duration. These findings form the basis for the use of programmed stimulation to determine the risk of sudden cardiac arrest postmyocardial infarction. These data suggest that the substrate of slow conduction in patients with cardiomyopathy resides in the midmyocardium or epicardium. Sites 43 and 53 are epicardial sites The bar represents duration of the electrogram. Note that the low-amplitude late potential (arrow) is associated with late endocardial activity from four sites and late epicardial activity from one site. Relation between late potentials on the body surface and directly recorded fragmented electrograms in patients with ventricular tachycardia. Differences in excitability, refractoriness, and dispersion of refractoriness are other potential arrhythmogenic abnormalities. We evaluated the effects of infarction on the threshold of excitability, refractoriness, and strength- 106 interval curves. These studies demonstrated that sites of infarction characterized by abnormal electrograms have higher thresholds than normal sites in patients with infarction (1. This higher threshold corresponds to a strength-interval curve that has shifted upward, particularly during late coupling intervals (Fig 11-37). Refractory periods determined at threshold were longer at sites of infarction, but the steep part of the strength-interval curves were not significantly different (Fig 11-38). Furthermore, the effect of change in cycle length of the refractory period measured as the steep part of the strength-interval curve was similar in normal sites and sites of infarction (39 ± 9 vs. The current at which the steep part of the strength-interval curve was achieved was also comparable. The X denotes measurements from a normal site and O from an infarcted site from the infarct patient group. Electrophysiologic sequelae of chronic myocardial infarction: local refractoriness and electrographic characteristics of the left ventricle. This was true whether or not the parameters were evaluated for the entire left ventricle or at adjacent sites. Thus, one must consider abnormalities of conduction to be of primary importance in the genesis of sustained uniform ventricular arrhythmias. The greater these abnormalities, the more likely uniform tachycardias occur spontaneously or can be induced. Invasive or noninvasive methods to demonstrate abnormalities of conduction are, therefore, useful markers of an arrhythmogenic substrate. The strength-interval curves measured at each site are also shown with the measured refractory period plotted from threshold to 10 mA. Alterations characteristic of chronic infarction are seen in both the local electrogram and strength-interval curve. Electrophysiologic sequelae of chronic myocardial infarction: local refractoriness and electrographic characteristics of the left ventricle. Electrophysiologic sequelae of chronic myocardial infarction: local refractoriness and electrographic characteristics of the left ventricle. On the horizontal axis is time duration and on the vertical axis are the mapped left ventricular sites. The right-hand edge of each bar represents the end of total recovery time (the sum of activation time and local refractoriness). Most of the recent knowledge of cellular mechanisms of arrhythmias are derived from isolated atrial, Purkinje, ventricular muscle fibers, and P. More recently molecular genetics has provided information relevant to the mechanisms of certain arrhythmias. The exact mechanism by which these ion channelopathies cause arrhythmias is unresolved and is under active investigation. Debate therefore continues as to the role of early afterdepolarizations, abnormal automaticity, and reentry in these polymorphic tachycardias that are the hallmark of these syndromes. This is particularly true in the Brugada syndrome in which controversy remains as to 120 121 whether it is a problem of conduction or repolarization. However, dispersion of refractoriness is 90 msec (the longest refractory period being 320 msec at site 1). Because of the irregular and prolonged activation times, there is prolongation of total dispersion of recovery of 15 msec. Despite the differences in experimental design, in my opinion, generalizations regarding arrhythmia mechanisms can be made by comparing the mode of initiation of tachycardias and influence of stimulation during tachycardias in in vitro and in vivo experimental preparations to comparable situations in humans. The bulk of evidence derived from these studies, albeit indirect, suggests that reentry is the mechanism of sustained uniform 1 122 123 tachycardias associated with coronary artery disease. Moreover, their response to programmed stimulation and pharmacologic agents suggests a common mechanism. How these responses differ from those expected for other mechanisms is discussed in more detail subsequently. Table 11-7 Data Based on Adjacent Left Ventricle Sites Endocardial Activation Dispersion of Dispersion of Total Time (msec) Refractoriness (msec) Recovery Time (msec) Normal left ventricle (no ventricular 25 ± 7 32 ± 11 41 ± 14 tachycardia) Coronary artery disease (with 42 ± 11 75 ± 41 42 ± 20 ventricular tachycardia) p <0. While infarction provides gross fibrosis and macro nonuniform anisotropy, abnormal propagation in cardiomyopathies with less fibrosis may be related to the abnormalities of gap junction number, structure, function, and location. Tachyarrhythmias that are believed to be due to early afterdepolarization are bradycardia dependent, and although they can be initiated in the experimental laboratory, they are not well suited for study by programmed stimulation, which automatically necessitates a relative “tachycardic” 125 126 129 130 state. As such I do not believe this mode of stimulation can distinguish triggered activity from reentrant rhythms. Some even report the results in patients who have never had a sustained arrhythmia, but who might be at risk for its occurrence. As mentioned earlier in this chapter, the anatomic and 22 23 32 89 95 electrophysiologic substrates of these arrhythmias differ. Therefore, sensitivity and specificity should only be applied to the use of programmed stimulation for a single arrhythmia type. In addition to the type of arrhythmia and the underlying anatomic substrate, specific features of the methodology of programmed stimulation can influence the ability to initiate the tachycardia. They include distance from the origin of the arrhythmia, refractoriness at the site of stimulation, and conduction to the potential site of the tachycardia circuit or focus. Thus, although some generalities exist regarding the effects of increasing number of extrastimuli, altering drive cycle lengths, and increasing current, the investigator must interpret the response to programmed stimulation in light of the specific arrhythmia being evaluated or whether stimulation is being used for risk stratification postmyocardial infarction. In general, the greater the number of extrastimuli employed, the increased sensitivity of induction of any arrhythmia; however, this is associated with a decreasing specificity of the technique (Fig. The various modes of initiation are shown on the horizontal axis from least to most aggressive, and the percentage of inducibility rate is shown on the vertical axis. It can be seen that the more aggressive the stimulation, the higher the sensitivity but the lower the specificity. A protocol involving three extrastimuli at twice diastolic threshold gives the best balance of sensitivity and specificity. Importantly, the initiating stimulus is associated with marked latency, compatible with local conduction delay at the stimulus site. Thus, in patients without a prior history of sustained ventricular arrhythmias, we try to avoid using coupling intervals <180 msec.
Appetite Initially good Anorexic Eventually with worsening of condition order 2mg imodium with mastercard, marasmic child also becomes anorexic generic imodium 2mg with amex. Anemia Mild to moderate Moderate to severe Superimposed infection(s) Frequent Common Serum proteins Low Very low purchase imodium 2mg on-line, albumin less than 2 cheap imodium 2mg otc. Te supervisory staf is part tion, household budget teaching, homecraft teaching and time and includes a doctor, a medical assistant/nurse, a actual feeding, using locally available foodstufs and local home economist/nutritionist, and an agriculture teacher/ methods of cooking and preparation. Children who fail to gain weight over a period of three Hospital Management months. Etiology A detailed description of etiology is available at the outset of this very chapter. Superimposed sepsis is often coexisting underlying household determinants that infuence the in such a situation. Fulminant infection(s) Management z Severe lower respiratory tract infection (pneumonia) Treatment of malnutrition is increasingly being shifted z Extensive superficial infection from facility based management to community based Lethargy, drowsiness, apathy, seizures. Tis decentralization aims to increase access Criteria for Admission to services promoting early presentation and compliance. To educate the mothers and care givers about appro- priate feeding of infants and young children. Stabilization: In this phase, child is stabilized with treatment of acute complications and then initiated on F-75 diet. Transition: Child comes to this phase when he is active and alert, appetite returns; there is beginning of loss of edema, no nasogastric feeds, infusions and Box 13. Stabilization phase:Stabilization phase, comprising of frst 7 days Tere is transition from starter to catch-up diet. Rehabilitation: Child enters this phase when he has hypoglycemia, dehydration and electrolyte imbalance, infections reasonable appetite and fnishes 90% of the feed, major and heart failure, etc. Rehabilitation phase: Here, spotlight is on building up the oral z General principles for routine care (10 steps) dietary intake over several weeks (say 2–6 weeks) in order to z Emergency treatment of shock and severe anemia rebuild the wasted muscles and other tissues. If dextrostix less than 54 mg/dL, 50 mL of 10% dextrose z Suspected meningitis: Cefotaxim/ceftriaxone along with amikacin. Step 2: Treatment and prevention of hypothermia Supplement potassium at 3–4 mEq/kg/day for 2 weeks. Further hike Te corrective/preventive measures are: in already high sodium may predispose to heart failure. Rewarm the child with warm blanket, heater or skin to Step 5: Treatment and prevention of infection skin contact. Notwithstanding absence of overt signs such as fever, chil- Treat hypoglycemia if present. Antibiotics Monitor temperature 2 hourly till temperature more are recommended for overt and even hidden infection than 36. Multivitamin skin to skin contact and give warmed intravenous supplementation with vitamin A, C, D, E and B in 12 fuids. Instead packed cell transfusion Give 15 mL/kg over 1hour of Ringer’s lactate or should be given. Infants less than 6 months: Breastfeeding should be If it fails to show improvement, treat as septic shock reinitiated or continued. When starting catch-up diet, it has to be diluted by extra one third water to make 135 mL Step 10: Preparation for follow-up after recovery 217 instead of 100 mL. At the point when the child’s weight for height (not weight Supplementary suckling technique: Tis can be for age which is bound to be low because of stunting) practiced to enhance breastfeeding till lactation is touches 90% of the expected and he is edema free, he is established. Subsequently, each 5–10 cms below the level of the nipple to help the weak feed in increased by 10 mL till some amount remains infant suck, and gradually lowered down to 30 cms. Child’s Infants more than 6 months and children: Feeding weight should be monitored regularly. If child is taking less than 80% of the feeds, maintenance of hygiene and immunization dur- feed ofered, nasogastric feeding should be given. Feeding in stabilization phase aims at giving just suf- Structured play therapyand loving care for emotional, cient calories and proteins to maintain the basic physiologic physical and mental stimulation have to be provided. Small frequent feeds should be given orally or by Te child should be encouraged to spend time with the nasogastric tube. A total of 100 kcal/kg/day along with his mother and other children on large play mats. Children receiving psychosocial stimulation have better mental development and Step 8: Achieving catch-up growth weight gain compared to those without stimulation. A 15% weight gain has been Step 9: Provision of sensory stimulation and emotional recommended as the discharge criteria. It is important to provide a holistic, cheerful and stimu- Te discharge criteria, using the weight once edema lating environment for proper cognitive and behavioral has disappeared, should be taken for those admitted with development during the course of nutritional therapy and edematous malnutrition. Tis prevents it from being used on a large scale at the Promotion of appropriate infant and young child feeding community level. Tey are soft crushable ready ment to the families as well as increasing the access to to use foods, which are energy dense and enriched with treatment. It can be consumed without the Community mobilization to encourage early presen- addition of water. It Supplementary feeding protocols for moderate acute also contains iron and is oil based with an extremely low malnutrition with no medical complications through water activity. Resumption of alertness as shown by a smile and Kahn syndrome: Even more rarely, a transient syn- interaction with mother drome marked by coarse tremors, Parkinsonian rigid- Initiation of weight gain ity, bradykinesia and myoclonus (Kahn syndrome) Disappearance of edema (by 7–10 post-therapy day) may appear six to several days after starting the dietary Disappearance of enteropathy and hepatomegaly rehabilitation. Tremors during recovery (kwashi-shakes): Some- Elevation of serum protein times, tremors (the so-calledkwashi-shakes) may occur Attainment of normal weight for height in 1–3 months during the recovery phase and may take even months to (clinical recovery). Tese encephalitis-like states are considered to Unfavorable be the result of far too much of proteins in the diet. Refeeding Edema Refeeding Syndrome Some infants and children with marasmus may develop It denotes fuid and electrolyte disturbances, especially edema following some correction in their nutrition. Te severe hypophosphatemia, with neurologic, pulmonary, so-called refeeding edema results from hyperinsulinemia cardiac, neuromuscular, and hematologic complications causing decrease in sodium excretion. Associated hypokalemia and hypomagnesemia may cause cardiac arrhythmias which may prove fatal. Pseudotumor Cerebri Etiopathogenesis Overenergetic nutritional correction in malnourished infants may be accompanied by a transient rise of intracranial During prolonged fasting, the body aims to conserve muscle tension. Te Nutritional Recovery Syndrome (Gomez Syndrome) liver decreases its rate of gluconeogenesis thus conserving Te term refers to interesting sequelae of events seen in muscle and protein. Many intracellular minerals become children who are being treated with very high quantity severely depleted during this period, although serum levels of proteins during the course of rehabilitation from gross remain normal. Te syndrome is characterized by increas- in this fasted state and glucagon secretion is increased. Tough the syndrome phosphates, magnesium and potassium which are already was initially described in kwashiorkor from Africa, we have depleted and the stores rapidly become used up. Forma- recorded its occurrence in both kwashiorkor and marasmus tion of phosphorylated carbohydrate compounds in the in India. Clinical manifestations of severe hypophos- Its development may well be related to endocrinal Box 13. Tis z Neurologic: Weakness, lethargy, paresthesia, disorientation, seizures and coma response of the pituitary to the state of poor dietary intake z Pulmonary: Impaired contractility of diaphragm, dyspnea and appears to be an adaptive mechanism that permits survival respiratory failure of the patient by reducing body activity and metabolic rate, z Cardiac: Hypotension and poor stroke volume and by retarding growth. During nutritional rehabilitation, z Hematologic: Leukocyte dysfunction, hemolysis and thrombocy- the greater utilization of the hormone by the body stimulates topenia the pituitary to produce its trophic hormones. Refeeding increases Now a sort of consensus seems to have emerged con- the basal metabolic rate. Glu- warrant hospitalization, may cause retardation in mental cose, and levels of the B vitamin thiamine may also fall. Secondly, it is advisable observation that incidence of cirrhosis in Africa, the home to monitor phosphate levels during refeeding. At Family Level Rickets Te most signifcant in the preventive measures at family During nutritional recovery, as a result of rapid growth, level is what is called nutritional education. Nutritional vitamin D, calcium and phosphate consumption may fall education consists of: short of the body needs, causing rickets. In some children, Good antenatal care so that mother’s own nutrition the pre-existing, but hidden rickets become manifest remains up to the mark and she does not develop malnutrition and anemia. Tis will be of much help in following restoration of bone growth during nutritional reducing the incidence of intrauterine growth retarda- rehabilitation. In addition to the pre-existing anemia as a part of mal- Encouragement to the mothers to breastfeed the nutrition, the child may manifest further worsening in infants for as long as they can.
A skillful operator is needed to maneuver the catheter precisely back to the target site provided by the system 2 mg imodium with mastercard. Mapping additional tachycardias buy discount imodium 2mg line, cheap imodium 2mg on line, and 148 314 315 318 376 377 377 378 379 380 390 evaluating the response of electrograms to programmed stimulation buy discount imodium 2 mg line, , , , , , , , , , significantly prolongs the procedure. In the future, mapping technologies may be refined to demonstrate critical diastolic pathways and eliminate the need for programmed stimulation. Point-by-point endocardial mapping usually requires the use of three or more catheters. We usually use catheters placed at the right ventricular apex and outflow tract to serve both as reference electrograms and as an anatomic guide to the position of the right ventricular side of the septum. In addition, we do not infrequently use a coronary sinus catheter to provide an anatomic reference for the base of the heart. We usually use a standard #6 or #7 French quadripolar ablation catheter (4-mm tip electrode) with a 2-5-2 or 2-2-2 mm interelectrode distance for left ventricular mapping in most instances (see Chapter 1). Nevertheless, the ability to perform good maps using these tools depends more on the investigator than on the catheters or recording equipment. The use of multisite data acquisition systems (the Rhythmia basket catheter, the PentArray, or simple multipolar catheters) can provide more information more quickly. Until the automated annotation capabilities improve, either manual editing of activation data or use of additional localizing methods are needed to guide the ablation catheter to the critical site required for ablation. Hopefully, combinations of technologies will be developed and employed in the next five years. While the costs of these systems will be great, it is hoped (but not yet proven) that they will facilitate mapping of heretofore unmappable arrhythmias (transient or hemodynamically untolerated) and provide a cost advantage for their acquisition. Fluoroscopy in multiple views is required to assess the position of the catheters. Use of any of the electroanatomic mapping systems may eliminate the need for biplane fluoroscopy systems and prevent complications from excessive radiation exposure and save hundreds of thousands of dollars. Optimally, one should have the capability of recording the catheter positions on cineradiographic film or on videotape for subsequent review. We perform arterial catheterization via the Seldinger technique percutaneously from the femoral artery. In the presence of severe peripheral vascular disease or abdominal aneurysms, or in patients who have had previous vascular surgery on their aorta or femoral arteries, a brachial arteriotomy or puncture can be used for the left ventricular mapping catheter. The radial artery approach, while safer, may be impractical because use of the large size of catheters used for ablation. The transseptal approach can be used in such cases, although, in my experience with current catheter technology, accessing the entire ventricle is more difficult than by the retrograde approach. The use of noncontact mapping catheters may require a transseptal approach for their placement. A transseptal puncture is necessary to place the ablation catheter if the retrograde approach is not feasible. In all instances, we use full heparinization with 5,000 to 10,000 U as a bolus and 1,200 to 3,000 U/h drip, adjusted to maintain an activated clotting time of 250 to 350 seconds. During the spontaneous or induced tachycardia, we record bipolar and unipolar electrograms (poles 1 and 2) as the catheter is positioned at each new mapping site. In patients with large scars unfiltered unipolar signals are dominated by cavity potentials making it difficult/impossible to see small, local activity. If possible we record at variable and fixed (l cm = 1 mV) gains to be able to standardize duration measurements. Normal values for voltage need to be ascertained for each electrode catheter because electrogram amplitude and duration are affected by electrode size (the tip is the largest) and interelectrode distance, as well as the relation of the distal and proximal poles to the site of contact and wavefront of activation (see discussion below). This is very important if one tries to compare substrate voltage using very small electrodes and small interelectrode distance (Rhythmia and PentArray catheters). If catheters have a 2-5-2 or greater interelectrode distance, we obtain distal and proximal bipolar electrograms by recording from the tip and the third electrode (distal pair) of the quadripolar catheter and use the second and fourth poles to record electrical activity adjacent to or overlapping the site of origin (proximal pair) when we use stimulation from the distal and third poles. Thus, recording and stimulation occur over a shared area, which electrophysiologically is “large” in terms of source of recorded signal. If we use a catheter with a 2- mm interelectrode distance, poles 1 and 2 are used as the distal pair and 3 and 4 as the proximal pair. Recording from multiple bipolar pairs from a multipolar electrode catheter in the left ventricle (particularly if bipolar pairs are >1 cm apart) is inappropriate, because one has no control over the degree of contact of the proximal electrode pairs and/or their distance from the ventricular wall. The only accurate data are from electrograms recorded from electrodes in contact with the endocardium. One should therefore use only electrograms recorded from a bipolar pair that includes the tip electrode, because it is almost always in contact with the endocardium. A proximal electrode pair is useful for analyzing events during pacing since polarization of the distal electrodes makes simultaneous recording and pacing not possible in most available laboratory systems. Contact is critical when a standard quadripolar, decapolar, or basket catheters are used. The degree of contact can be assessed by pacing thresholds or impedance measurements at each electrode pair. This “chamber” is limited by the absence of direct confirmation of contact of the roving catheter. Newer technology is being incorporated into this system, which has improved and will continue to improve its anatomic localizing capability. However as noted above, the activation times are interpolated on the basis of the inverse solution for 64 poles. The advantages of unipolar electrograms are that they provide a more precise measure of local activation, because the maximum negative dV/dt corresponds to the maximum Na+ conductance. The disadvantages of unipolar recordings are that they have a poor signal-to-noise ratio and distant activity can be difficult to separate from local activity. On the other hand, bipolar recording techniques provide an improved signal-to-noise ratio and reduce the effect of distant activity on the local electrogram (Fig. While local activation is less precisely defined, the peak amplitude of a filtered (30 to 500 Hz) close (2 to 5mm) bipolar recording of a “normal” electrogram corresponds to the maximum negative dV/dt of the unipolar recording. Variable low- and/or high-pass filters can give different amplitudes, duration, shape, etc. Although a bipolar electrode pair, positioned perpendicular to the direction of propagation of the wavefront, should theoretically result in the absence of an electrical signal, this is rarely a problem. Nevertheless, the electrogram amplitude may be diminished when propagation is relatively perpendicular to the recording electrodes. Use of very small electrodes and interelectrode distance (1 mm) overcomes many of the limitations that standard mapping/ablation catheters have because their tip is 3. One therefore cannot obtain directional information from an isolated bipolar electrogram recorded from a standard mapping/ablation catheter. Defining the site of origin (or exit from a protected isthmus in a reentrant circuit) and the overall pattern of activation of impulse propagation requires detailed recordings from multiple sites. Filtered or unfiltered unipolar recordings are valuable in determining the relative contributions of the distal and second pole of the bipolar pair. Clear demonstration that the distal pole is earliest is necessary to assure the highest success of ablation (see Chapter 13). As stated in earlier paragraphs, several factors affect electrogram amplitude and width, including (a) conduction velocity (the greater the velocity the higher the peak amplitude of the unfiltered and filtered bipolar electrogram); (b) the mass of activated tissue; (c) the distance between the electrodes and the propagating wavefront; (d) the direction of the propagation relative to the bipoles (Figs. The fact that most catheters used for mapping have a 4-mm ablation tip results in inherent limitations of accuracy, even for 2 unipolar recordings. This takes away some of the theoretical advantages of unipolar over bipolar recordings. The very small electrodes and small interelectrode distance of the Rhythmia basket have recorded discrete potentials in areas of <0. The larger tip records from a larger area that can lead to cancellation effects on the recorded signal. Unipolar and derived 2 bipolar recordings are shown from electrodes G1, G2, and H2 which are each 0. The unipolar signals show G1 and G2 are activated nearly simultaneously producing a bipolar signal of 0. When the bipolar signal is recorded between G2 and H2, there is a slight difference in local activation and the recorded electrogram has a normal voltage of 1.
This often occurs in the presence of anterior and/or posterior compartment prolapse purchase imodium 2mg. Identifying the extent of apical prolapse during the clinical examination and then addressing the apex during prolapse surgery is crucial to providing a durable repair generic imodium 2mg with visa. The route by which prolapse surgery takes place is a decision based on patient characteristics as well as surgeon preference and experience discount imodium 2mg with mastercard. Both abdominal (open generic imodium 2mg free shipping, laparoscopic, and robotic) and vaginal routes are utilized with varying surgical techniques performed in order to recreate Level 1 support. This chapter will focus on the open abdominal techniques used to repair apical prolapse, both in the posthysterectomy patient and in the patient with uterine descent wishing to preserve her uterus. It is performed in the posthysterectomy patient and involves resupporting the vaginal apex to the sacrum with the use of an intervening graft, most commonly made of synthetic polypropylene mesh. In brief, the patient is placed in low lithotomy, and once the abdomen has been opened and with a probe in the vagina to aide dissection, the peritoneum, bladder, and rectum are dissected off the vagina. The graft material (either self-made strips, self-made “Y,” or precut “Y”) is then attached to the vagina using either delayed- absorbable or permanent sutures. The anterior longitudinal ligament overlying the sacral promontory is exposed by incising the overlying peritoneum. Care must be taken to identify the right ureter and right and left iliac vessels as these structures are all within 3 cm of the promontory . The dissection is then continued caudally down the right paracolic gutter to the posterior vagina. The tail of the graft is attached to the anterior longitudinal ligament just below the most prominent point of the sacral promontory (Figure 86. Therefore, attaching the graft with permanent suture or surgical tacks just below the prominence may avoid the complication of discitis. Care must be taken not to over suspend the vagina—the graft material needs to be an adequate length (15–20 cm) in order to achieve tension-free attachment to the sacrum. Oversuspension in our opinion can lead to an increased incidence of de novo stress urinary incontinence and anterior compartment prolapse. The peritoneum is closed over the graft in order to avoid entrapment of the sigmoid colon and development of bowel adhesions to the graft. Vaginal assessment is performed to ascertain if any concomitant anterior or posterior compartment repairs are required. Patients with uterine prolapse may undergo a concomitant total hysterectomy at the time of sacrocolpopexy. In an effort to mitigate this risk, a number of authors advocate that supracervical hysterectomy be performed. Efficacy was reported on 64 studies; with mean follow-up between 6 months and 3 years, the success rate for apical prolapse was reported as 78%–100%, and that for all compartment cure was 58%–100%. Many of these studies were retrospective case series or cohort studies with relatively short follow-up. When using a composite definition of treatment failure for prolapse incorporating both anatomical and symptom definitions, this study reported prolapse failure rates considerably higher than previously published. The estimated probability of failure at 7 years for the urethropexy group was 34% and that of the no urethropexy group was 48%. Despite this high failure rate, only 5% of women underwent surgical correction of the recurrent prolapse. This study highlights the need for long-term reporting of efficacy of prolapse repair procedures, as failure rates appear to increase over time. Comparisons to other vaginal apical suspension procedures in the literature are lacking. The choice of graft material, synthetic versus biologic, has not been extensively studied. Objective results at 5 years reflected 1 year data, with superior results in the polypropylene group (93% vs. These results have driven the development of new procedures using laparoscopy and robotics to potentially mitigate the negative aspects of what is an anatomically superior approach to apical prolapse repair. While the laparoscopic approaches to sacrocolpopexy appear to have some advantages over the open approach, they do require a different skill set. There is a definite learning curve for both techniques, and the surgeon embarking on these must undergo the appropriate training. Current cervical or uterine pathology is excluded prior to this procedure, and women at high risk of developing endometrial carcinoma should not undergo uterine conservation. Women need to continue to have their cervical screening following the procedure and are counseled about the potential difficulties of future pelvic surgery in the presence of pericervical mesh. Synthetic mesh may be attached over the upper posterior vagina and cervix and suspended to the anterior sacrum. If there is significant anterior compartment prolapse, synthetic mesh can also be attached over the anterior vaginal wall. An incision is made in the anterior leaf of the broad ligament bilaterally, inferior to the fallopian tubes, and extended down to the uterovesical fold. The bladder is mobilized off the cervix to expose 3–4 cm of the underlying anterior vaginal wall. Windows are made in the broad ligament bilaterally at the level of the cervicouterine junction, lateral to the uterine artery. Two mesh strips are then fashioned; one is bisected to produce a Y-configuration for the anterior mesh. Both the anterior and posterior mesh strips are attached to the vagina using permanent or delayed absorbable sutures (Figure 86. Other authors attach the broad end of the anterior Y mesh to the vagina and pass the arms of the Y through the broad ligament, attaching these to the posterior mesh [20,22,23], or have reported on the use of a single mesh strip attached only posteriorly . With a mean objective follow-up of 44 months and mean subjective follow-up of 94 months, failure rates were 6. One patient (5%) developed early recurrence with Stage 2 anterior and posterior prolapse within 1 month of surgery. Subjective improvement based on a prolapse-specific symptom inventory and quality of life questionnaire showed significant reduction in total scores, signifying improvement in prolapse symptoms postoperatively. Both Urinary Distress Inventory (short form) and Incontinence Impact Questionnaire (short form) scores were significantly reduced postoperatively showing improvement in both urinary symptoms and quality of life. Satisfaction with prolapse surgery was measured on a 10-point visual analogue scale, with a mean score of 8. No cervical or uterine abnormalities were detected with annual screening postoperatively. Subjective success based on change in Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores was seen in both groups postoperatively with no statistical difference between surgical groups. There are currently no studies comparing abdominal to vaginal uterine preservation techniques. Anterior and posterior compartment results are variable and may reflect differences in configuration of the mesh (use of posterior mesh only), the anchoring of the anterior mesh (broad end or mesh arms), and whether concomitant anterior or posterior vaginal repairs are performed. There may be an advantage in intraoperative and short-term postoperative morbidity in avoiding hysterectomy at time of uterine prolapse surgery. Intraoperative Complications These are similar to those of any open abdominal procedure. Bleeding from these vessels can be difficult to control as they retract into the bony surface of the sacrum and often require the use of bone wax or sterile thumb tacks to achieve hemostasis. Postoperative Complications Urinary tract infection is the commonest postoperative complication (10. Rarely does conservative management with application of topical estrogen rectify the problem. Most women will require surgical revision of the mesh with an initial vaginal approach to excise the exposed mesh. Complete excision of the mesh may be required if the initial partial excision fails. Most women required more than one mesh revision, often through an abdominal approach . All required open exploration and removal of the mesh, with debridement of the L5–S1 disc. However, the significant morbidity associated with the abdominal approach must be carefully weighed against potential benefits when considering this option. There are advantages and disadvantages of all techniques, and the decision should be based on the patient’s needs and wishes once sensible discussion has occurred.