Karanvir Virk M.D. Minimally Invasive & Pelvic Reconstructive Surgery 01/28/2015

Transcription

1 Karanvir Virk M.D. Minimally Invasive & Pelvic Reconstructive Surgery 01/28/2015

2 Disclosures I have none

3 Objectives Identify the basic Anatomy and causes of Pelvic Organ Prolapse Examine office diagnosis of Pelvic Organ prolapse Discuss treatment options available for Pelvic Organ Prolapse

4 History

5 History

6 What is Prolapse? Pts Definition: My insides are falling/bulging out Physicians definition: Your uterus is falling In reality it s a weakness in the support structures of the pelvis POP is actually a hernia Vagina is the most dependent part of the abdominal cavity

7 POP Newest data suggests 1in 2 women will have POP 1 in 5 will need surgery in their lifetime for POP Is the incidence increasing???

8 NO POP The reporting is increasing More and more women talk to their physicians about this problem

9 29.2% Recurrences POP Facts Scarring and fibrosis produced by conventional surgery restores only 50% of tissue strength 58% recurrence rate after 1 year of surgery Will any other surgery be acceptable in medical community with such high rates and the surgery is for quality of life!!!!

10 Why?

11 Why?

12 Why such high failure? We were doing wrong repairs We didn t know the real anatomic reason for prolapse Traditional repairs were making prolapse worse

13 John DeLancey

14 Delancey s levels of support Level 1: The uterosacral-cardinal ligament complex provides apical attachment to the uterus and vaginal vault to the bony sacrum Level 2: The arcus tendineous fascia pelvis and fascia overlying the levator ani muscles Level 3: The urogenital diaphregm and perineal body

15

16

17 Anatomic supports Muscular: Levator ani/pelvic floor muscles Ligaments: Uterosacral-Cardinal complex Fascial: Endopelvic( Pubocervical & Rectovaginal)

18

19 Risk Factors for POP Predispose Incite Promote Decompensate

20 Genetic: Collagen defects Race: Latina and white women 4-5 times higher than AA Gender: Female> Male Predispose Being human: Erect posture

21 Pregnancy & Delievery 1 st birth: 4 fold 2 nd birth: 8 fold 3 rd birth: 9 fold 4 th birth: 10 fold Hysterectomy: Vaginal> abdominal Myopathy Neuropathy Incite

22 Promote Obesity 40-75% Smoking Chronic cough Constipation Heavy ligting

23 Aging Menopause Neuropathy Myopathy Debilitation Medication?? Decompensate

24

25

26 Symptoms Not specific to compartment Bulge in the vagina Pelvic pressure/pain Dyspareunia Incomplete bladder emptying Recurrent UTI s in severe cases Incomplete rectal empting Putting fingers in vagina to empty bladder/bowels Acute urinary retention in severe cases

27

28 Baden-Walker Halfway system Most widely used Using hymen as a fixed point of reference Stage 1: Descends halfway to hymen Stage 2: Descends to the hymen Stage 3: Descends halfway past hymen Stage 4: Maximum descent

29 Treatment Every patient is different The best choice is first choice The first choice is the best choice NEVER treat an asymptomatic patient. You can only make it worse 40% patients with prolapse have dyspareunia. Document it.

30

31 Treatment Patients age Sexual function Symptoms Vaginal/abdominal/laparoscopic/Robotic Again. NEVER treat an asymptomatic patient

32 Pessarries

33

34

35

36 Fewer wound complications Less post operative pain Less cost Vaginal Surgeries Categorized into 3 groups 1) Restorative: Use of patients endogenous support structures 2) Compensatory: Replace deficient support with some form of graft 3) close the vagina

37 Colpoclesis Old frail patients Quick and easy procedure 90-95% success rate Can be combined with sling/incontinence procedure LeForte s Colpoclesis and complete colpoclesis

38 Colpoclesis

39 Anterior repair

40 Posterior repair

41 Paravaginal repair

42

43 Apical support A must in prolapse surgery Isolated anterior & posterior defects very rare 40% increase in success rates for all prolapse surgery if apical support surgery is done with anterior or posterior repair Uterosacral ligaments Sacrospinous ligaments

44 Uterosacral

45 Sacrospinous

46 Can be done open, laparoscopic/robotic Graft attached to the anterior and posterior vaginal apex and suspended to anterior longitudinal ligament of sacrum Excellent support for apex and anterior wall Cure rates % Technically difficult Abdominal Risk of injury to major organs

47

48

49

50 Grafts Biological 1) Human cadaver 2) Fascia lata Porcine 1) Dermis 2) Bladder Degraded/absorbed over time Help native tissue to regenerate Less success that synthetic grafts Less complications compared to synthetic grafts

51 Synthetic Polypropylene Inert High objective success More complications Grafts

52

53 FDA 2011 Vaginal mesh erosion Pain/dyspareunia Infection Urinary problems Bleeding Organ perforation Recurrent prolapse Vaginal scarring/shrinkage Emotional problems

54 FDA Reported 7 deaths from deaths with mesh placement procedures( 2 bowel perforation, 1 hemorrhage) 4 deaths postop medical complications

55 The problem is?? Surgeon 1) Lack of training with mesh kits 2) Lack of informed consent Patient 1)Why only few women develop symptomatic POP 2) Weak native tissue Mesh 1) No ideal material available 2) Foreign body 3) Contraction

56 Pearls to success NEVER repair asymptomatic prolapse Document dyspareunia If in doubt do urodynamics and fix incontinence at the same time High recurrence risk/recurrent cases, short vagina, younger patient; sacrocolpopexy Low recurrence risk, unable to tolerate abdominal procedure, vaginal surgery Use grafts only and only if you are familiar with dissection and use them on regular basis Synthetic graft used for Sacrocolpopexy and sling procedure have shown their safety over time. NO FDA WARNING.

57

58

59 Thank You Questions?