Vestibulectomy. Hope K. Haefner, MD Michigan Medicine Ann Arbor, MI USA

Transcription

1 Vestibulectomy Hope K. Haefner, MD Michigan Medicine Ann Arbor, MI USA Learning Objectives At the end of this lecture, the participant will: Understand the surgical techniques used to treat localized vulvodynia Recognize that this is generally the last resort (other treatments have failed) 1

2 Important Thoughts Prior to Surgery Rule out vaginismus Determine area to excise? Remove or conserve hymen Methods for hemostasis Undermining posterior and lateral vaginal walls Bartholin's gland? 2

3 Hart s line JOL DeLancey, MD collection 3

4 4

5 Classic Closure Technique Classic Closure Technique 5

6 Newer Thoughts? 6

7 V to Y Flaps 7

8 8

9 Role of Vestibulectomy Use only when all else has failed? Use in selected patients? Differentiate primary vs secondary vestibulodynia Role of Vestibulectomy Use only when all else has failed? Use in selected patients? Differentiate primary vs secondary vestibulodynia 9

10 Role of Vestibulectomy Use only when all else has failed? Use in selected patients Differentiate primary vs secondary vestibulodynia Results of Vestibulectomy Bornstein et al, 1995 Vestibuloplasty (0/10) v perineoplasty (9/11) Schneider et al, % moderate to excellent improvement Goldstein et al, pts 104 = 97 (93%)satisfied / very satisfied Traas et al, pts 155: 93% coitus 62% no pain Goetsch et al, 2007 & pts: muscle therapy: 64% dyspareunia resolved 133 pts: 119: 68% cured, 24% lessened Eva et al, pts: 83% would recommend procedure Bohm Starke & Rylander, pts: 56% complete or major improvement 10

11 More Recent Articles on Vestibulectomy Donders GG, Bellen G, Peperstraete B, Folens S. Simple posterior vestibuloplasty for central introital dyspareunia. Gynecological Surgery 2012;9: Eighty percent had less pain during intercourse Longitudinal incision of the mucosa and underlying muscle over a length of 4 cm and depth of about 1.5 cm Swanson CL, Rueter JA, Olson JE, Weaver AL, Stanhope CR. Localized provoked vestibulodynia: outcomes after modified vestibulectomy J Reprod Med 2014;59(3 4): patients received modified vestibulectomy for localized provoked vestibulodynia (Mayo Clinic in Rochester, Minnesota) 115 patients returned the questionnaire 71 patients had pain with tampon insertion, 52 reported attempting to insert a tampon after surgery 90.4% noticed moderate to substantial improvement Pain with sexual intercourse in 97.3% patients before surgery 84.1% noted moderate to substantial improvement in their pain Modified vestibulectomy is a successful treatment for localized provoked vestibulodynia 11

12 Kliethermes CJ, Shah M, Hoffstetter S, Gavard JA, Steele A. Effect of vestibulectomy for intractable vulvodynia J Min Inv Gyn 2016; 23(7): patients Vestibulectomy is an effective treatment for vulvodynia For those with intractable pain, vestibulectomy is an appropriate next step after unsuccessful medical treatment Surgical Complications Vestibule too tight Hematoma Separation Bartholin s cyst Granulation tissue Surgical failure / persisting symptoms 12

13 What About Surgery for Other Forms of Vulvodynia? What about the nerves? Surgery in nongynecologic areas? Vallinga MS, Spoelstra SK, Hemel IL, van de Wiel HB, Weijmar Schultz WC. Transcutaneous electrical nerve stimulation as an additional treatment for women suffering from therapy resistant provoked vestibulodynia: a feasibility study. J Sex Med 2015; 12(1): Andres JD. Sanchis Lopez N. Asensio Samper JM. Fabregat Cid G. Dolz VM. Peripheral subcutaneous vulvar stimulation in the management of severe and refractory vulvodynia. Obstet Gynecol 2013;121(2 Pt 2 Suppl 1):

14 Neuromodulation with Sacral Nerve Stimulator Modulation of efferent signals to spinal cord Refractory pain in distribution of specific nerve root (S3 or S4) Pudendal Nerve Pudendal Nerve Entrapment Rectum: symptoms Perineum: symptoms Clitoris: symptoms 14

15 Ilioinguinal n. Dellon AL. Pain with sitting related to injury of the posterior femoral cutaneous nerve, Microsurgery April 2015;35(6). Neuroma vs. Compression of Branches of the Pudendal Nerve FEMALE MALE NEUROMA COMPRESSION NEUROMA COMPRESSION PUDENDAL NERVE BRANCH DORSAL INJURY CYCLING,?PGAD INJURY 00 CYCLING PERINEAL EPISIOTOMY, VESTIBULECTOMY CYCLING, SURGERY WEIGHT LIFTING CYCLING, SURGERY RECTAL HEMORRHOID SURGERY INJURY HEMORRHOID SURGERY INJURY 15

16 COMPRESSION DORSAL BRANCH PUDENDAL NERVE IN FEMALE: FEMALE (PERSISTANT GENITAL AROUSAL DISORDER Dellon, AL, Coady, D, Harris, D, Pelvic pain of pudendal nerve origin: surgical outcomes and learning curve lessons. J Reconstr Microsurg, 31: ,