colpocele anteriore recidivante: riparazione fasciale
TRANSCRIPT
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Colpocele anteriore recidivante:Colpocele anteriore recidivante:
- riparazione fasciale- riparazione fascialeMichele MeschiaMichele Meschia
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What’s old is new again
Owing to reports of high recurrence, the traditional, plication-based, native-tissue repairs have been seemingly relegated to sideshow curiosity, while, on the other hand, mesh-augmented repairs have been thrust into the spotlight.
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Kaplan-Meier survival curve of recurrent prolapse within 10 years
Overall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate ofOverall there were 36 recurrences out of 142 pts (25.3%) for an incidence rate of
recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)recurrence of 3.7 per 100 woman years (95% CI= 2.6-5.1 per 100 woman-years)
Incidence of recurrent pelvic organ prolapse 10 years following
primary surgical management: a retrospective cohort study.Fialkow MF, Newton KM, Weiss NS. Int Urogynecol J 2008;19:1483-7
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Prolapse recurrence 5 years after surgeryProlapse recurrence 5 years after surgery
Compartment Anatomical Symptomatic
Any vaginal site
31% 7.4%
Anterior 20% 5.5%
Apical 7% 4.2%
Posterior 15% 2.4%
Dietz-Itza, 2007
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What is cure?
• Any definition of success after POP surgery should include the absence of bulge symptoms
• Many patients with unsatisfactory anatomical results (POPQ stage II) are asymptomatic
• Using the hymen as a threshold for anatomic success seems a reasonable and defensible approach
• Patient perspective of cure must be considered to ensure a mutually agreement on definition of an acceptable outcome
An ideal outcome measure should be clinically relevant
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• Inclusion criteria are often poorly specified primary and recurrent cases
different POP classifications
• Outcomes often include only anatomical factors• Inadequate description of the surgical technique (i.e.
concomitant apical support procedures)
• Functional outcome data poorly investigated
Anterior Repair
Reports bias
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1-year results of 699 women having had native tissue repair for POP from 2002 to 2005
• 94% subjective satisfaction• 84% had stage 0-1 in any compartment• 1.1% 1-year re-operation rate• 4.7% 5-year re-operation rate
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Reoperation rate for traditional anterior vaginal repair: analysis
of 207 cases with a median 4-year follow-up.Kapoor DS, Nemcova M, Pantazis K, Brockman P, Bombieri L, Freeman RM. Int Urogynecol J 2010;21:27-31
Methods:
Retrospective case note review of 207 cases of primary anterior colporrhaphy
with/without other prolapse surgery.
Results:
While the anatomical recurrence rate of cystoceles at 3 months postoperatively
was 12%, the reoperation rate for recurrent cystocele by 50 months was 3.4%.
Comclusions:
While the anatomical recurrence rates for cystocele following traditional anterior
colporrhaphy might be high, the low reoperation rate at more than 4 years (3.4%)
suggests that patient's symptoms might not be bothersome enough to require
further surgery.
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Outcome data from Olsen et al., with a 40% non-return correction factor applied to the known failure count. Repairing recurrent prolapse by traditional re-suture of native tissues was associated with approximately 60% higher failure rates, compared with surgical outcome in primary cases (67% v
41%).
The challenge of recurrent POPThe challenge of recurrent POP
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Mission impossible?Mission impossible?
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Primary versus recurrent prolapse surgery: differences in
outcomes.Peterson TV, Karp DR, Aguilar VC, Davila GW Int Urogynecol J 2010; 21;483-8
Methods:
A retrospective study was performed comparing patients who underwent AC for
recurrent cystocele (group I) and a matched control group who underwent
primary AC (group II).
Results:
At 1 year
Successful anterior vaginal support was obtained in 78.2% of patients in group I
and in 81% in group II (p = 1.000)
At 2 years
42.8% of patients in group I and 71.4% in group II (p = 0.031) had no evidence
of POP
Conclusions:
Alternative surgical techniques that provide better long-term durability may be beneficial in repair of recurrent anterior wall prolapse.
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• inappropriate choice of procedure (plan of surgery)
• defect in restoring fascial attachments
• inappropriate choice of suture materials
• inadequate control of bleeding (pelvic hemathoma)
• persistent increase in intra-abdominal pressure
• poor connective tissue quality
Birch C and Fynes MM, 2002Birch C and Fynes MM, 2002
Pelvic Organ Prolapse repairPelvic Organ Prolapse repair
Surgical failuresSurgical failures
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Wide genital hiatus is a risk factor for recurrence following
anterior vaginal repair.Medina CA, Candiotti K, Takacs P. Int J Ob/Gyn 2008; 101:184-7
Methods:
A retrospective cohort study was performed on patients who had undergone an
anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide
genital hiatus (> or =5 cm) or normal genital hiatus (<5 cm). The wide genital
hiatus group (n=35) was compared with the normal genital hiatus group (n=30)
for surgical failure.
Results:
The rate of postoperative anterior vaginal wall prolapse was greater in patients
with a wide genital hiatus compared with those with a normal genital hiatus
(34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0
24.1]; P=0.02).
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Ensure apical fixationEnsure apical fixation
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The cumulative reoperation rates were highest among women who had an isolated anterior repair (20.2%) and significantly exceeded reoperation rates among women who had a concomitant apical support procedure (11.6%; P<.01).
32.8% (95% CI 30.4-35.1) had a colporrhaphy without colpopexy
Role of apical support
Eilber et al, Obstet Gynecol 2013
Fairchild et al, Am J Obstet Gynecol 2015
3244 women underwent POP surgery
1557 hysterectomies performed for POP
Use of colpopexy was independently associated with a surgeon specializing in urogynecology (OR 8.2, 95% CI 5.156-12.923).
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Repair of recurrent AVW prolapse
• Midline PCF plication• Bilateral fixation of PCF to USL
remnants• Bilateral re-attachment of PCF
to the ATFP proximal to the
ischial spine
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Enterocele repair
• Commonly found in association with vault prolapse• Ligation of hernia sac and obliteration of the pouch of
Douglas
Associated defectsAssociated defects
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Permanent suture used in uterosacral ligament suspension
offers better anatomical support than delayed absorbable
suture.Chung CP, Miskimins R, Kuehl TJ, Yandell PM, Shull BL.
Prospective series of 248 women• 1% vs 6% loss of support beyond the hymen, p=0.034 Int Urogynecol J 2012
Reattachment of the endopelvic fascia to the apex during anterior colporrhaphy: does the type of suture matter?Zebede S, Smith AL, Lefevre R, Aguilar VC, Davila GW.
230 patients were reviewed (permanent vs absorbable suture)
• Statistically significant improvement in anterior wall anatomy Ba (-2.68±0.65cm vs -2.51±0.73cm, p=0.03) with permanent suture• Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure.
Int Urogynecol J 2013
Type of suture
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Poor tissue quality
Khaja et al IUJ 2014 25:181–187
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5 year cumulative risk of any repeat surgery• Vaginal mesh: 15.2% (5.9% risk of mesh revision/removal)• Native tissue: 9.8% p<0.0001
5-year risk of surgery for recurrent prolapse• Vaginal mesh: 10.4%• Native tissue: 9.3% p=0.70
27,809 anterior prolapse surgeries • 20,938 (75.3 %) native tissue repairs • 6,871 (24.7 %) vaginal mesh
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Trocar-guided mesh compared with conventional vaginal
repair in recurrent prolapse: a randomized controlled trial.Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME.
Methods: Patients were randomly assigned to either conventional vaginal prolapse surgery
or polypropylene mesh insertion.
Results:
97 women underwent conventional repair and 93 mesh repair.
Twelve months post-surgery, anatomic failure in the treated compartment was
observed in 45.2% of patients in the conventional group and in 9.6% in the mesh
group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18).
Patients in either group reported less bulge and overactive bladder symptoms.
Subjective improvement was reported by 80% of patients in the conventional
group compared with 81% in the mesh group.
Mesh exposure was detected in 14 of 83 patients (16.9%).
Obstet Gynecol 2011; 117:242-50Obstet Gynecol 2011; 117:242-50
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The UK national prolapse survey: 5 years on.
Jha S, Moran P.Int Urogynecol J 2012; 22:517-28Int Urogynecol J 2012; 22:517-28
5 years ago
Current
Procedure of choice for recurrent anterior vaginal wall prolapse
Ant. colporraphy
Graft + fascial plication
45%
34%
21%
56%
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Recurrent prolapse surgery
• Reasonable anatomic results without mesh• Significant symptoms improvement • No erosions, few infections, quick recovery• Mesh complications remain a challenging issue
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The fear of unknownThe fear of unknown
Thus conscience does make cowards of us allThus conscience does make cowards of us all
Hamlet: Act III, scene 1, line 82 Hamlet: Act III, scene 1, line 82
The decision to perform a mesh augmented POP repair is often
a difficult one for even the most experienced pelvic surgeon
Pelvic organ prolapse (POP) surgery: the evidence for the repairsPelvic organ prolapse (POP) surgery: the evidence for the repairsAlex Gomelsky, David F Penson and Roger DomochowskiAlex Gomelsky, David F Penson and Roger Domochowski
BJU 2011; 107:1704-1719 Review articleBJU 2011; 107:1704-1719 Review article