T h e C o m p l e t e Tr e a t m e n t o f P e l v i c F l o o r P r o l a p s e by Laparoscopy Technique, Tips and Tricks

Transcription

1 T h e C o m p l e t e Tr e a t m e n t o f P e l v i c F l o o r P r o l a p s e by Laparoscopy Technique, Tips and Tricks R Botchorishvili, A Wattiez, G Mage, M Canis, B Rabischong, K Jardon, C Rivoire, JL Pouly, H Manhes, MA Bruhat The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. DeLancey JO. Am J Obstet Gynecol May;192(5): Each year, pelvic floor dysfunction affects between 300,000 and 400,000 American women so severely that they require surgery. Approximately 30% of the operations performed are reoperations. The high prevalence of this problem indicates the need for preventive strategies, and the common occurrence of re-operation indicates the need for treatment improvement.. Long-term follow-up studies in pelvic floor dysfunction: the Holy Grail or a realistic aim? P Hilton Directorate of Women s Services, Royal Victoria Infirmary, Newcastle upon Tyne, UK Correspondence: Mr P Hilton, Directorate of Women s Services 3rd floor, Leazes Wing Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK. paul.hilton@ncl.ac.uk Accepted 23 September Published OnlineEarly 12 November Please cite this paper as: Hilton P. Long-term follow-up studies in pelvic floor dysfunction: the Holy Grail or a realistic aim? BJOG 2008;115: Trends in finished consultant episodes for surgery for SUI between and (using the left-hand vertical axis) and prolapse and (using right-hand vertical axis) in the NHS in England. 2 EBNNS, endoscopic bladder neck needle suspension. «The number of women with POP will increase by 47% from 3.3 to 4.9 million from the years 2010 to The highest projections for the 2050 estimate were that as many as 9.2 million women will have POP»

2 ANATOMY hammock or trampoline theory DeLancey, Richardson Importance of fascia : the«hammock» theory De Lancey, Richardson support the bladder base (as illustrated in the trampoline analogy ). PROLAPSE = PELVIC SUPPORT DEFECT Fig Potential sites of damage: 1. Midline defect (central part of PCF); 2. Paravaginal defect (collagenous glue and ATFP); 3. High cystocoele (attachment of PCF to cervical ring, transverse defect. Schematic 2D view from below. Perspective: looking into the anterior wall of the vagina.

3 Attachment of the rectovaginal septum to the pelvic sidewall Kenneth S. Leffler, and all. Am J Obstet Gynecol 2001;185:41-3 The rectovaginal fascia supports the posterior compartment analogous to the pubocervical fascia in the anterior compartment Recto-vaginal defects that contribute to rectocele Richardson

4 Uterosacral ligament: description of anatomic relationships to optimize surgical safety DeLancey Jerome L. Buller MD,, Jason R. and all. Obstetrics & Gynecology June 2001, P The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure.

5 Int Urogynecol J (1997) 8: ~; 1997 Springer-Verlag London Ltd International Urogynecology Journal Posterior suspension to the lumbo-sacral disk; abdominal method of replacement of the uterosacral ligaments. [La suspension postérieure au disque lombo-sacré; technique de remplacement des ligaments utérosacrés par voie abdominale] Review Article Apical Vault Repair, the Cornerstone or Pelvic Vault Reconstruction J. W. Ross Center for Reproductive Medicine and Laparoscopic Surgery, Salinas, California, USA AMELINE, A; HUGUIER, J Gynecologie Et Obstetrique Volume 56, Issue 1, January - March 1957, Pages SCALI Technique 1974 TECHNIQUE OF REFERENCE Variety of techniques STANDARD technique since 1998 Supracervical hysterectomy if none before, no opening of the vagina Vesicovaginal mesh Rectovaginal mesh fixed to the LAM Promontofixation A. WATTIEZ CLERMONT-FERRAND, 1991, Operations of support-suspension by upper route in the treatment of vaginal prolapse [Les Nezhat opérations C.H.; de soutènement-suspension Nezhat F.; Nezhat C. par voie haute dans le traitement des prolapsus vaginaux] Laparoscopic sacral colpopexy for vaginal vault prolapse Scali, P; Blondon, J; Bethoux, A; Gérard, M Journal Obstetrics De Gynecologie, and Gynecology, Obstetrique Volume 84, Et Issue Biologie 5, 1994, De La Pages Reproduction;1974, Pages Reziuplastie with mesh Burch colposuspension or TVT-O

6 EXPOSITION FIRST! TIPS and TRICKS T Lift vectec SACRAL PROMONTORY SACRAL PROMONTORY

7 POSTERIOR DISSECTION POSTERIOR DISSECTION 1 CM FOLLOW THE BUBBLES! POSTERIOR DISSECTION POSTERIOR FIXATION FALSE CLEAVAGE PLANE

8 POSTERIOR FIXATION ANTERIOR DISSECTION 1 CM ANTERIOR DISSECTION ANTERIOR DISSECTION FOLLOW THE BUBBLES! FOLLOW THE BUBBLES!

9 ANTERIOR FIXATION ANTERIOR FIXATION PERITONISATION Uterine conservation

10 CONTRA-INDICATIONS FOR SUPRACERVICAL HYSTERECTOMY Uterine conservation Known or suspected gynecologic cancer Current or recent cervical dysplasia a recent normal Pap test is required! Endometrial hyperplasia

11 John C. BURCH Urethrovaginal fixation to Cooper s ligament for correction of stress incontinence, cystocèle and prolaps. Am J Obstet Gynecol 1961;81: PARA VAGINAL REPARATION «Stress incontinence is a very difficult symptom to relieve surgically» Home > Medical Devices > Medical Device Safety > Alerts and Notices (Medical Devices) Medical Devices FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse Date Issued: July 13, 2011 Audience: A mesh procedure may put the patient at risk for requiring additional surgery or for the development of new complications. Removal of mesh due to mesh complications may involve multiple surgeries and significantly impair the patient s quality of life. Complete removal of mesh may not be possible and may not result in complete resolution of complications, including pain. Home > Medical Devices > Medical Device Safety > Alerts and Notices (Medical Devices) Medical Devices FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse Date Issued: July 13, 2011 Audience: Mesh placed abdominally for POP repair may result in lower rates of mesh complications compared to transvaginal POP surgery with mesh.

12 The American College of Obstetricians and Gynecologists Women s Health Care Physicians COMMITTEE OPINION Number 513 December 2011 Committee on Gynecologic Practice This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Vaginal Placement of Synthetic Mesh for Pelvic Organ Prolapse Pelvic organ prolapse vaginal mesh repair should be reserved for high-risk individuals in whom the benefit of mesh placement may justify the risk, such as individuals with recurrent prolapse (particularly of the anterior compartment) or with medical comorbidities that preclude more invasive and lengthier open and endoscopic procedures. Surgeons placing vaginal mesh should undergo training specific to each device and have experience with reconstructive surgical procedures and a thorough understanding of pelvic anatomy. Impact of hospital and surgeon volumes on outcomes following pelvic reconstructive surgery in the United States. Sung VW, Rogers ML, Myers DL, Clark MA. Am J Obstet Gynecol. 2006, 195(6): HOSPITAL VOLUME SURGEON VOLUME LOW <92 <8 MEDIUM 92_ HIGH >185 >18 RESULTS: There were 310,759 women and 2986 hospitals. Women who had procedures at low-volume hospitals were 2.75 (95% CI ) times more likely to die and 1.63 (95% CI ) times more likely to have a nonroutine discharge, compared to those at highvolume hospitals. Risk Factors for Exposure, Pain, and Dyspareunia After Tension-Free Vaginal Mesh Procedure Marie lla I. Withagen, MD, Mark E. Vierhout, MD, PhD, Jan C. Hendriks, PhD, Kirsten B. Kluivers, MD, PhD, and Alfredo L. Milani, MD Obstet Gynecol 2011;118: Table 3. Crude Odds Ratios for the Risk of Mesh Exposure, Risk of Pain, and Risk of Dyspareunia Within 12 Months Postoperatively Using Univariable Logistic Regression Exposure Pain Dyspareunia n OR (95% CI) n OR (95% CI) n OR (95% CI) Age (y) ( ) ( ) ( ) Menopause (p) ( ) ( ) ( ) Previous POP repair (p) ( ) ( ) ( ) Smoking (p) ( ) ( ) ( ) Diabetes (p) ( ) ( ) ( ) Parity (n) ( ) ( ) ( ) Preoperative POP stage Stage II 1.00 (reference) 1.00 (reference) 1.00 (reference) Stage III or IV 0.59 ( ) 0.66 ( ) 0.65 ( ) Postoperative sexual activity (p) ( ) ( ) Body mass index (kg/m 2 ) ( ) ( ) ( ) Location of mesh Total 1.00 (reference) 1.00 (reference) 1.00 (reference) Anterior 0.31 ( ) 0.47 ( ) 0.81 ( ) Posterior 0.50 ( ) 1.06 ( ) 1.27 ( ) Anterior and posterior 0.38 ( ) 0.97 ( ) 0.77 ( ) Mesh combined (p) ( ) ( ) ( ) Operating time per 20 min ( ) ( ) ( ) Blood loss per 100 ml ( ) ( ) ( ) Any complication (p) ( ) ( ) ( ) Failure (p) ( ) ( ) ( ) Bladder injury (p) ( ) ( ) ( ) Postoperative hematoma (p) ( ) ( ) ( ) Surgeon Surgeon A 1.00 (reference) 1.00 (reference) 1.00 (reference) Surgeon B 0.87 ( ) 1.75 ( ) 6.20 ( ) Surgeon C 3.89 ( ) 1.79 ( ) 8.27 ( ) Surgeon D 2.19 ( ) 3.01 ( ) 4.51 ( ) Experience per 10 y ( ) ( ) ( ) Number of mesh procedures per ( ) ( ) ( ) Pain preoperative (p) ( ) ( ) ( ) Dyspareunia preoperative (p) ( ) ( ) ( ) Health score preoperative ( ) ( ) ( ) Surgeon Surgeon A 1.00 (reference) 1.00 (reference) 1.00 (reference) Surgeon B 0.87 ( ) 1.75 ( ) 6.20 ( ) Surgeon C 3.89 ( ) 1.79 ( ) 8.27 ( ) Surgeon D 2.19 ( ) 3.01 ( ) 4.51 ( ) Experience per 10 y ( ) ( ) ( ) Number of mesh procedures per ( ) ( ) ( ) CI indicates confidence interval; OR, odds ratio; p, absent coded as 0, present coded as 1; POP, pelvic organ prolapse. Failure indicates failure in treated compartment (POP stage II or higher). Bold indicates variables reaching statistical significance at the P.10 level and valid for entry in the selection procedure. Stage III or IV indicates that stage III and stage IV are put in one category because of small numbers with prolapse stage IV. Conclusions Laparoscopic treatment of genital prolapse: -is feasible, effective and reproductible with a small rate of complications after an adequate learning, -give excellent anatomical results, -should be applied with para-vaginal prosthetic reparation and routinely associated with a surgical treatment for stress incontinence -Knowledge of retroperitoneal anatomy, of ergonomic rules and laparoscopic sutures is mandatory