didactic (live cadaveric demo): advanced urogynecology ... · anatomy of support for the pelvic...

AAGL acknowledges that it has received support in part by educational grants and equipment (in-kind) from the following companies:

Coloplast, CONMED Corporation, CooperSurgical, Covidien, Inc., Ethicon US, LLC, Intuitive Surgical, Olympus America, Inc., Karl Storz Endoscopy-America, Inc.,

Stryker Endoscopy, Welmed

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic (Live Cadaveric Demo): Advanced Urogynecology: Overcoming Challenges in the

Patient with Pelvic Organ Prolapse

PROGRAM CHAIR

Kevin J.E. Stepp, MD

PROGRAM CO-CHAIR

Patrick J. Culligan, MD

Matthew Clark, MDNazema Siddiqui, MD

Catherine A. Matthews, MDBernard Taylor, MD

GLOBAL CONGRESSON MINIMALLY INVASIVE GYNECOLOGYNOV. 17-21, 2014 | Vancouver, British Columbia

43rd AAGL

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Anatomy of Pelvic Organ Support K.J.E. Stepp .................................................................................................................................................... 4 Approach to Pelvic Organ Prolapse – Patient Selection P.J. Culligan ................................................................................................................................................. 10 What about Retropubic Surgery? Paravaginal Repairs – When and How? B. Taylor ...................................................................................................................................................... 13 Complications of Laparoscopic Repairs – How to Manage Laparoscopically N. Siddiqui ................................................................................................................................................... 18 Future Trends for Prolapse Surgery C.A. Matthews .................................................................................................................................. 23 Pearls for Sacral Colpopexy – Techniques for Difficult Anterior Dissection M. Clark ....................................................................................................................................................... 33 Pearls for Sacral Colpopexy – Techniques for Posterior Dissection – How Far Do I Go? N. Siddiqui ................................................................................................................................................... 36 Pearls for Sacral Colpopexy – What about the Patient with a Uterus? Matthews .................................................................................................................................................... 37 Pearls for Sacral Colpopexy – Techniques for Sacrum Exposure and Tensioning the Mesh M. Clark ....................................................................................................................................................... 42 Cultural and Linguistics Competency ......................................................................................................... 45

URO-‐708 Didactic (Live Cadaveric Demo): Advanced Urogynecology:

Overcoming Challenges in the Patient with Pelvic Organ Prolapse

Kevin J.E. Stepp, Chair Patrick J. Culligan, Co-‐Chair

Faculty: Matthew Clark, Catherine A. Matthews, Nazema Siddiqui, Bernard Taylor This is a ½-‐day didactics course focusing on building an in-‐depth understanding of pelvic organ prolapse and its treatment.

This course is targeted to the advanced pelvic surgeon who treats patients with pelvic organ prolapse but is looking to understand the three dimensional anatomy that plays a role in pelvic support. This course will begin with a detailed anatomic discussion of pelvic support. Then experts will discuss their approach and techniques for treating prolapse. A step-‐by-‐step explanation of the sacral colpopexy, including each expert’s tips and tricks will be presented.

The unique design of this course includes an interactive cadaveric demonstration of robotic sacral colpopexy. Clinical pearls and experts technique will be demonstrated live.

Patient selection, tips for shortening the learning curve, technique nuances, and prevention / management of complications will be covered.

Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Discuss the anatomy of pelvic organ support including the ischio-‐anal fossa, deep pelvic spaces, space of Retzius, and pre-‐sacral space; 2) discuss the current theories of pelvic support and how to apply these for individual patients; 3) identify the selection criteria for sacral colpopexy; 4) articulate the complications associated with pelvic organ prolapse procedures; and 5) identify steps to avoid and manage complications of prolapse surgery.

Course Outline 7:00 Welcome, Introductions and Course Overview K.J.E. Stepp 7:10 Anatomy of Pelvic Organ Support K.J.E. Stepp 7:35 Approach to Pelvic Organ Prolapse – Patient Selection P.J. Culligan 8:00 What about Retropubic Surgery? Paravaginal Repairs – When and How? B. Taylor 8:25 Complications of Laparoscopic Repairs – How to Manage Laparoscopically N. Siddiqui 8:50 Future Trends for Prolapse Surgery C.A. Matthews 9:15 Break 9:25 Pearls for Sacral Colpopexy M. Clark • Techniques for Difficult Anterior Dissection 9:45 Pearls for Sacral Colpopexy N. Siddiqui • Techniques for Posterior Dissection – How Far Do I Go? 10:05 Pearls for Sacral Colpopexy C.A. Matthews • What about the Patient with a Uterus? 10:25 Pearls for Sacral Colpopexy M. Clark • Techniques for Sacrum Exposure and Tensioning the Mesh 10:45 Panel Discussion / Tricks of the Trade: All Faculty • Surgical Nuances • New Technology • Same Day Surgery? 11:00 Adjourn

Page 1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor* Kimberly A. Kho* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathon Solnik* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Blue Endo, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical William M. Burke* Rosanne M. Kho* Ted T.M. Lee Consultant: Ethicon Endo-‐Surgery Javier F. Magrina* Ceana H. Nezhat Consultant: Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Other: Stock Ownership: Titan Medical Robert K. Zurawin Consultant: Bayer Healthcare Corp., CONMED Corporation, Ethicon Endo-‐Surgery, Hologic, Intuitive Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Matthew Clark Grants/Research: American Medical Systems Speakers Bureau: Allergan, American Medical Systems, Bard Medical Division, Intuitive Surgical Patrick J. Culligan Grants/Research: American Medical Systems, Intuitive Surgical Consultant: Boston Scientific Corp. Inc., Bard Urological Division Other: Stock Ownership: Origami Surgical Catherine A. Matthews Grants/Research: Boston Scientific Corp. Inc. Nazema Siddiqui Other: Honorarium: Intuitive Surgical Grants/Research: Medtronic

Page 2

Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Other: Stock Ownership: Titan Medical Bernard Taylor Speakers Bureau: American Medical Systems, Boston Scientific Corp. Inc., Intuitive Surgical Asterisk (*) denotes no financial relationships to disclose.

Page 3

Anatomy of Support for the Pelvic Surgeon

Kevin J. E. Stepp, MDDirector, Advanced Surgical Specialties for Women

Chief, Urogynecology and Minimally Invasive Surgery

Carolinas Healthcare SystemCharlotte, North Carolina

[email protected]

Disclosures

Consultant: CONMED Corporation, Teleflex

Other: Stock Ownership: Titan Medical

Objectives

• Discuss endopelvic fascia network and supportive structures.

• How do they interact to maintain pelvic organ support?

• Understand the levels of pelvic support and goals for reconstructive surgery.

Page 4

Role of Levator Ani

• Main mechanism of support

• Maintains constant tone

• Rapid contraction with cough, etc.

• Relaxation with defecation/urination

Ischium

Role of the endopelvic fascia and supportive ligaments

Page 5

• Normal axis of vagina

- Upper 2/3 – Nearly horizontal

- Distal 1/3 – Nearly vertical

- Endopelvic fascia is responsible for maintaining position of pelvic organs over the levator plate so that they may be supported.

Endopelvic Fascia

• Collagen, elastin, adipose tissue, nerves, vessels, lymph channels, and smooth muscle

• Provide stabilization and support yet allow for the mobility

The Dry Dock Analogy

Failure of Level 1 support

Page 6

Endopelvic Fascia

• Arcus Tendineous Levator Ani

Endopelvic Fascia

• Arcus Tendineous Fascia Pelvis

Endopelvic Fascia

• Arcus Tendineous Rectovaginalis

Page 7

Endopelvic Fascia

• Arcus Tendineous Fascia Pelvis

Failure of Level 2 support

Failure of Level 3 support Posterior Support Defects

• Rectocele, Perineocele

Page 8

Female analogue of Denonvilliers’ Fascia

Rectovaginal Fascia

Restore Level III Support

Is all prolapse treated equally?

Sacral Colpopexy

Carolinas Medical CenterAdvanced Surgical Specialties for Women

Page 9

Patient SelectionPatrick J. Culligan, M.D., FACOG, FACSUrogynecology Division & Fellowship DirectorAtlantic Health System, Morristown & Summit, New Jersey

Professor of Obstetrics, Gynecology & Reproductive ScienceMount Sinai School of MedicineNew York, NY

Disclosure

Grants/Research: American Medical Systems, Intuitive SurgicalConsultant: Boston Scientific Corp. Inc., Bard Urological DivisionOther: Stock Ownership: Origami Surgical

Advanced review of anatomy and surgical techniques for sacrocolopopexy

12 August 2014

Sacrocolpopexy Key Elements

When uterus present: Supracervical Hysterectomy

Anterior dissection to level of trigone

Posterior dissection to perineum

Vaginal sutures – CV4 GoreTex

6 to 10 per compartment

Sacral Sutures - Two CV4 GoreTex

Re-peritonealization (Zero Monocryl)

Advanced review of anatomy and surgical techniques for sacrocolopopexy

12 August 2014

In my opinion, this is not a true Sacrocolpopexy

If your’re just fixing the mesh to the apex, you’re not taking advantage of the possibilities of the sacrocolpopexyprocedure.

Worse yet – your mesh may be too light for this technique

Some Perspective…

(MRI courtesy of Peter Rosenblatt, M.D.)

Robotic‐Assisted Laparoscopic Sacrocolpopexy

My progression to robotic surgery

1110‐35

Page 10

My approach to reconstructive prolapse surgery before

2011

1110‐35

Current approach to reconstructive prolapse surgery

Offer Native Tissue AND Sacrocolpopexy to all At this point (for me) operative times are the same Vaginal surgery is “less invasive” – but only technically

speaking

Offer Vaginal Mesh to “older, less active” patients as always Very few takers these days

Offer isolated defect repairs as appropriate (simple cystocele or rectocele repairs without mesh)

Page 8

Patient Selection

Recent Case – 130 minutes

75 years old, vibrant, active, otherwise healthy

1st prolapse operation 1985 - TVH A&P repair2nd Prolapse operation - Vaginal mesh 2006 (me)3rd Prolapse operation - Robotic Sacrocolpopexy

Isolated Cystocele

Page 11

Perfect Sacrocolpopexy Patient

Page 12

Page 11

camera

4 cm

8.5 cm 8.5 cm

10 cm

assist

R 1

R 3

R 2

xyphoid

pubis

2 cm

ASISASIS

Anterior axillary line

Perfect Patient for Native Tissue Repair (or Colpocleisis)

Page 14

Perineal Decent (Think Sacrocolpopexy or Vaginal Mesh)

Could go either way(She chose sacrocolpopexy)

Page 16

Page 12

What About Retropubic Surgery: Paravaginal Repairs – When and

How?

Bernard Taylor, MD

Assistant Clinical Professor

Associate Program Director

Female Pelvic Medicine and Reconstructive Surgery

Department of Obstetrics and Gynecology

Carolinas Medical Center

Disclosures

Speakers Bureau: American Medical Systems, Boston Scientific Corp. Inc., Intuitive Surgical

Learning Objectives

• Review the anatomy of the retropubic space and paravaginal defect

• Discuss the clinical significance of paravaginal support

• Discuss when and how to perform laparoscopic and robotic assisted laparoscopic paravaginal repair

CystoceleA Radical Cure by Suturing Lateral Sulci of

Vagina to White Line of Pelvic Fascia

G. White. JAMA. 1909;LIII(21):1707‐1710

A New Look at Pelvic Relaxation

• Introduced concept that cystoceles result from isolated defects in connective tissue

• Identified 4 defects of the anterior compartment –– Lateral (Paravaginal), Midline, Transverse, and Pubourethral

ligament defect

• Surgical management consist of direct defect closure –Paravaginal Repair

• Initial experience– 63 patients with PVD/SUI treated with PVD repair

– Results: Excellent 91.7%; Improved 5%; Failure 3%

A.C. Richardson. AJOG. 1976;126(5):568‐571.

Anterior Compartment Fascial Defects

Central Defect

Lateral Defect

Transverse

A.C. Richardson

Page 13

Pelvic Organ Support

• Level I– Uterosacral –Cardinal

Ligament Complex

• Level II– Pars Endopelvina Faciae

Pelvis

• Level III– Perineal body

Paravaginal DefectDetachment of Arcus Tendineus Fascia

Paravaginal DefectDetachment of Arcus Tendineus Fascia

Abdominal Paravaginal Defect

Normal Anterior Compartment Paravaginal Defect

Page 14

Clinical Paravaginal Defect

video

Paravaginal Defect RepairTreatment for SUI?

• Initial indications were for anatomic and functional repair of patients with anterior compartment prolapse and SUI

• Initial results for both correction of prolapse and incontinence were 80-90% at up to 2 years

• Objective results (postoperative Urodynamics) reveal only 61% success rate for treatment of SUI

• PVD repair not recommended for treatment of SUI

Richardson AC. AJOG. 1976;126(5):568‐571.RichardsonAC. Obstet Gynecol. 1981; 57:357‐363.Bruce RG. Urology. 1999;54(4):647‐651Colombo M. Am J Obstet Gynecol. 1996; 175(1):78‐84.

Anterior Vaginal Wall ProlapseParavaginal Defect

Courtesy of John Miklos, MD and Robert Moore, MD

Paravaginal Defect Repair

Baggish MS, Karram MM, [eds]: Atlas of Pelvic Anatomy and Gynecologic Surgery. New York, Harcourt, 2001.

Abdominal Approach …

• Total Abdominal Hysterectomy +/- BSO

• Sacral Colpopexy

• Paravaginal repair

• Burch Colposuspension

• Posterior repair/perineorrhaphy

Indications for MIV Gynecologic Surgery

• Adoption of Robotic/Laparoscopic sacral colpopexy parallels other MIV gynecologic procedures

Intuitive Surgical

Page 15

Robotic Sacral Colpopexy

Intuitive Surgical

Abdominal Paravaginal Defect

Obturator artery/vein

Location of Ischial SpineBladder

Paravaginal Anatomy

Arcus Tendineus Fascia Pelvis

Paravaginal Defect Repair Step by Step …

• The apical suspension procedure is completed

• The abdominal wall peritoneum above the bladder is transversely incised between the medial umbilical ligaments and the retropubic space is developed opened

• Dissection of the the retropubic space is carried to the pubic symphysis and then to the paravaginal space lateral to the bladder

• A vaginal probe is place to assure proper lateral vaginal suture placement

• Beginning just distal to the ischial spine and progressing towards the pubic symphysis 3 to 4 sutures are placed reapproximating the detached vaginal fascia endopelvina to the obturator internus fascia

• The repair is performed bilaterally

• After completion of the PVDR perform cystoscopy

Robotic assisted Laparoscopic Paravaginal Defect Repair

video

Cystoscopy

Page 16

Laparoscopic and Robotic Assisted Paravaginal Repair

• Laparoscopic PVDR associated with low complication rate

• Success rate at 2-5 years 76-80%

• Initially laparoscopic experience was limited to a small group of expert laparoscopic urogynecologists

• Recent popularity of robotic assisted laparoscopic prolapse surgery has renewed interest in PVDR

Miklos J. Urology 56 (suppl 6A) 2000; 64‐69: 64‐69.Behnia‐Willison F. J Minim Invasive Gynecol. 2007;14(4):475‐480.O’Shea RT. J Minim Invasive Gynecolo. 2012;19: S61 (Abstract).

Goal of Pelvic Organ Prolapse Treatment

Restore normal anatomical supportive relationships in order to improve function and eliminate symptoms

References

1. G. White. JAMA. 1909;LIII(21):1707-1710. Cystocele: A Radical Cure by Suturing Lateral Sulci of Vagina to White Line of Pelvic Fascia.

2. A.C. Richardson. AJOG. 1976;126(5):568-571. A New Look at Pelvic Relaxation.

3. RichardsonAC. Obstet Gynecol. 1981; 57:357-363. Treatment of Stress Urinary Incontinence Due to Paravaginal Fascial Defect

4. Bruce RG. Urology. 1999;54(4):647-651. Paravaginal Defect Repair in the Treatment of Female Stress Urinary Incontinence.

5. Colombo M. Am J Obstet Gynecol. 1996; 175(1):78-84. A Randomized Comparison of Burch Colposuspension and Abdominal Paravaginal Defect Repair for Female Stress Urinary Incontinence.

6. Miklos J. Urology 56 (suppl 6A) 2000; 64-69: 64-69. Laparoscopic Paravaginal Repair Plus Burch Colposuspension: Review and Descriptive Technique.

7. Behnia-Willison F. J Minim Invasive Gynecol. 2007;14(4):475-480. Laparoscopic Paravaginal Repair of Anterior Compartment Prolapse.

8. O’Shea RT. J Minim Invasive Gynecolo. 2012;19: S61 (Abstract). Laparoscopic Paravaginal Repair – Objective Outcomes at Five Years and Beyond.

Page 17

Sacrocolpopexy complications

Nazema Y. Siddiqui, MD MHScAssistant Professor, Department of Obstetrics and Gynecology

Division of Urogynecology and Reconstructive Pelvic Surgery

2

Disclosures

Other: Honorarium: Intuitive Surgical

Grants/Research: Medtronic

3

MIS Sacrocolpopexy

4

Potential Complications

✴ Intraoperative risks

✓ Injury to bladder/ureters

✓ Injury to bowel/rectum

✓ Pre-sacral bleeding

✴Postoperative risks

✓ Sacral discitis/osteomyelitis

✓ Mesh erosion

5

All Rights Reserved, Duke Medicine 2007

Intraoperative Risks

5

6


✴ Intraoperative risks

✓ Injury to bladder/ureters

✓ Injury to bowel/rectum

✓ Pre-sacral bleeding

Page 18

7

Vascular Anatomy

8

Vascular Anatomy

Vascular boundaries and contents

of the presacral space:

LCIV: left common iliac vein

MSA: middle sacral artery

MSV: middle sacral vein

LSV: lateral sacral veins

* : midsacral promontory

Wieslander et al.; AJOG 2006

9

Vascular Anatomy

10

Vascular Anatomy

27mm between left common iliac vein and midsacral promontory

Wieslander et al.; AJOG 2006

11

Vascular Anatomy

12

Vascular Anatomy

Fresh frozen cadaver - blind suture placement

Flynn et al; AJOG 2005

Page 19

13

Vascular Anatomy



✓ Vascular injury in 5/10 cadavers (50%)

✓ 4 sutures through middle sacral artery

✓ 1 suture through left common iliac vein

14

Vascular Anatomy



✓ Vascular injury in 5/10 cadavers (50%)

✓ 4 sutures through middle sacral artery

✓ 1 suture through left common iliac vein

Basics of surgery: Open and dissect the presacral

space

15

Vascular Anatomy

Avoiding injury:

Thorough dissection

Know where you are

16

Tips & Tricks

✓Understand your midline

✓Get under the fat pad early!!!

✓Small amounts of monopolar cautery and blunt dissection to

get to the ligament

✓Use bipolar on small vessels

✓Complete the presacral dissection before opening the

remainder of the peritoneum (reduces need for assistant)

17

What if there is bleeding?

✓ PAUSE if you can and don’t lose your cool

✓ Use the heel of an instrument to tamponade

✓ Bipolar cautery (parallel to vessel)

✓ Can use FloSeal +/- Raytec

18

All Rights Reserved, Duke Medicine 2007

Postoperative Risks

18

Page 20

19


✴Postoperative risks

✓ Sacral discitis/osteomyelitis

✓ Mesh erosion

20

Sacral discitis/osteomyelitis

21

Managing Mesh Erosion

✓ Try to avoid it!!!

22

Mesh Erosion

✓ Good surgical technique

Wise use of cautery on vagina

Avoid vaginotomy (...or cystotomy, or proctotomy...)

✓ Consider the type of synthetic material you use

✓ Consider patient factors

23

Type of Mesh

24

Type of Mesh

✓ CARE trial (Brubaker et al. NEJM 2006):

✓322 abdominal sacrocolpopexies

✓Surgeons could choose type of mesh

✓ Interim analysis higher rates of erosion with GoreTex

mesh

✓ Investigators stopped using GoreTex mesh

Page 21

25

Type of Mesh

26

Mesh Erosion


Wise use of cautery on vagina

Avoid vaginotomy (...or cystotomy, or proctotomy...)

✓ Consider the type of synthetic material you use

✓ Consider patient factors

27

Type of Mesh

28

Mesh Erosion

✓Risk factors for mesh erosion in CARE (ASC in 322 women):

Smoking (OR 5.2)

Concomitant hysterectomy (OR 4.9)

Gore-Tex mesh (OR 4.2)

✓Overall 6% mesh erosion 2 years after ASC

✓E-CARE (7 years of follow up): mesh erosion 10.5%

Cundiff et al.; AJOG 2006Brubaker et al; JAMA 2006Nygaard et al; JAMA 2013

29

Avoiding Mesh Erosion


✓ Use Type I polypropylene mesh

✓ Consider patient factors (smoking, concomitant total

hysterectomy) that you might be able to avoid

✓ COUNSEL patients on possibility of mesh erosion

Page 22

Future trends for prolapse surgery

Catherine A. Matthews MD, FACOG, FACS

Associate Professor and Division Chief

Urogynecology and Reconstructive Pelvic Surgery

University of North Carolina

Chapel Hill, NC

DISCLOSURES

Grants/Research: Boston Scientific Corp. Inc.

Objectives

• At the conclusion of this activity, the participant will be able to understand the following:• Projected rates of pelvic floor disorders over

the next 3 decades

• Current rates of prolapse surgery in the US

• Short and Long term outcomes of prolapse repairs

• Risk factors for surgical failure

• Future trends for prolapse surgery with regards to machines, materials, and methods

People are living longer…

And they are getting progressively heavier…

Page 23

PFDs in the Future

# Older adults

2010: 40.2 million

2030: 72.1 million

2050: 88.5 million

U.S. Census Bureau, Population Projections, 2008

PFDs in the Future

Wu et al. Obstet Gynecol, 2009

0

10

20

30

40

50

2010 2020 2030 2040 2050

44 million

28 million

Lifetime Risk of Surgery (SUI or POP)

Wu et al. AUGS, Oct 2013.

0%

5%

10%

15%

20%

20 30 40 50 60 70 80

Cum

ulat

ive

inci

denc

e (%

)

Age (years)

60 yrs: 11.4%

80 yrs: 20.2%

Lifetime Risk of Surgery (SUI or POP)

Wu et al. Obstet Gynecol, 2014.

0%

5%

10%

15%

20%

20 30 40 50 60 70 80

Cum

ulat

ive

inci

denc

e (%

)

Age (years)

80 yrs: 20.2%

1 in 5 women will undergo surgery for stress incontinence

or prolapse by the age of 80

Age-specific Incidence Rates Either SUI or POP Surgery

0.0

1.0

2.0

3.0

4.0

5.0

6.0

20 30 40 50 60 70 80 90 100

Inci

dent

sur

ger

y ra

te p

er 1

,000

p-y

r

Age (years)

Either

Page 24

Age-specific Incidence Rates

0.0

1.0

2.0

3.0

4.0

5.0

6.0

20 30 40 50 60 70 80 90 100

Inci

dent

sur

ger

y ra

te p

er 1

,000

p-y

r

Age (years)

Either

SUI

POP

Cumulative Lifetime Risk

0%

5%

10%

15%

20%

20 30 40 50 60 70 80

Cum

ulat

ive

inci

denc

e (%

)

Age (years)

Either SUI POP Either: 20.2%(95%CI: 19.2, 21.2)

SUI: 14.5%(95%CI: 13.4, 15.5)

POP: 13.7%(95%CI: 12.6, 14.8)

0%

5%

10%

15%

20%

20 30 40 50 60 70 80

Cum

ulat

ive

inci

denc

e (%

)

Age (years)

Either SUI POP

70 yrs: 15.9%

60 yrs: 11.4%

80 yrs: 20.2%

X

X

X

Cumulative Lifetime RiskWe’re going to be doing a lot of

surgery…

• How long can anything last?

• What is the “right” operation?

Apical Prolapse: Options

Vaginal (+/-Hysterectomy)

• Uterosacral Ligament Suspension

• Sacrospinous Fixation

• Manchester Repair

• Mesh procedure

• Colpocleisis

Sacrocolpopexy +/- TAH

SCH

No TAH

Efficacy

MorbidityCost

Page 25

Barber et al. JAMA, 2014

Primary Outcome

• Surgical “Success” at 24 months defined as absence of all the following:

• Prolapse of anterior or posterior vaginal wall beyond the hymen (POPQ point Aa, Ba, Ap, Bp > 0)

• Descent of the vaginal apex more than 1/3 of vaginal length (POPQ point C>-2/3 TVL)

• Bothersome vaginal bulge symptoms

• Retreatment for POP with either pessary or surgery

Surgical Success at 24 Months

ULS SSL (95% CI)

90/154 90/152

58.4% 60.5% 0.9 (0.6-1.4)

18% were symptomatic17.5% had prolapse beyond the hymen5% retreatment

30% recurrence; 10% mesh exposure

17%

Bulge symptoms

27%

3% reoperation rate

Page 26

2012 Cochrane review: Surgical

management of Pelvic Organ

Prolapse

Schmid C, Feiner, B, Baessler K, Glazener C, Maher C

IUGA 2012

Results of 2012 Review

• 54 RCTs totaling 5775 women

• 15 new trials 165 women (Altman 2011, Farid 2010; Feldner 2010; Hiviid 2010;Maher 2011; Iglesia 2010; Withagen 2011; Menefee 2011; Minassian 2010 abstract; Paraiso 2011; Rondini 2011 abstract; Sung 2012; Thijs 2010 abstract; Vijaya 2011 abstract; Vollebregt 2010 abstract)

• 10 major updates of prior work(Borstad 2010; Carey 2009; Costantini 2008; Culligan 2005; Dietz 2010; Guerette 2009; Natale 2010; Nieminen 2008; Pantazis 2011 abstract; Sokol2011)

ASC ↑success rate, ↓dyspareunia

↑operating & recovery time & cost

Apical (upper) Compartment3 RCT: Benson 1996; Lo 1998,

Maher 2004Vaginal Approach Abdominal Approach

RCT: TVM vs LSCP

• Prospectively compare Total vaginal mesh (Prolift) and Lap sacral colpopexy for vaginal vault prolapse

• Short & Long-term symptomatic & Objective Follow-up

• All pelvic floor symptoms

• Validated condition specific & QoL question

• Cost Analysis

Maher et al. AJOG 2010

LSC

↑ operating time

blood loss, admission days,

quicker RADL

improved findings at all POPq sites

> TVL

> patient satisfaction

reoperation rate

As compared to total prolift

Conclusion Vault study

Maher 2010 AJOG

Who is likely to fail surgical repair?

• Anatomic risk factors?

• Genetic risk factors

• Epidemiologic risk factors?

Page 27

Whiteside et. al.

• 1 year post-op, 58% had ≥ Stage II recurrent POP

• Identified risk factors:• Age < 60: OR 3.2; 95% CI 1.6-6.4

• Stage III or IV pre-op POP: OR 2.7; 95% CI 1.3- 5.3

Salvatore study

• N= 360

• Mean follow up of 26 months

• 10% had ≥ recurrent Stage II POP

• Only identified risk factor: Pre-op ≥ Stage III POP: OR 2.4, 95% CI 1.1-5.1

N=212

Main risk factor was advanced prolapse (Grade 3,4)

Page 28

Risk factors of reoperation

• Cumulative incidence 5.6%

• Risk factors:• POP in > 2 vaginal compartments: OR 5.2,

95% CI 2.8-9.7

• Sexual activity: OR 2.0; 95% CI 1.5-7.1

Urogenital Hiatus

Urogenital Hiatus Recurrence< 5 cm 10%> 5 cm 34%

Odds ratio 4.7 [95% confidence interval, 1.0-24.1] P=0.02

Summary: The data tells us that

• SCP is superior to a native tissue and a vaginal mesh repair for VAULT prolapse: Unless significant intraperitoneal risk factors exist, use SCP for all VVP

• The data for UTERINE prolapse is largely unknown

• The greatest risk factors of recurrent prolapse with native tissue repair is YOUNG AGE and > Stage II prolapse

• Should one consider SCP as primary approach in these patients or “save” the SCP for a 2nd operation?

Page 29

My Current Approach to Prolapse Surgery

What is the age and activity level of the patient?

“Younger”“Very Active”

“Older”“Less Active”

Laparoscopic Sacral Colpopexy(+/- hyst)

Vaginal surgery Mesh for recurrent

anterior compartment only

Analysis of Robotic Performance Times to Improve Operative

Efficiency

Elizabeth J. Geller, MD

Catherine A. Matthews, MD

J Min Invasive Gynecol. 2012 Nov 8

Performance TimesFirst 10 Cases vs Later Cases

Page 30

Performance TimesFirst 10 Cases vs Later Cases Trends in machines

Robots are big and expensive

WEIGHT: 2.2 LBS (1 KG)PRICE: $4000

200 g$25

Materials?

• Is ultra-lightweight Type 1 mesh the answer? Probably not

• Is permanent suture for mesh attachment the answer? Probably not

• I suspect that future trends will see the use of new graft materials

Page 31

Conclusions

• Future trend will likely be more native tissue repairs for primary prolapse

• Robotic surgery will have to be cost equivalent to sustain use

• Mesh materials will evolve beyond polypropylene

• SCP will remain a good operation, but it’s not fail-proof

References• 1. Wu JM, Matthews CA, Conover MM, Pate V, Jonsson Funk M. Lifetime Risk of Stress Urinary Incontinence

or Pelvic Organ Prolapse Surgery. Obstet Gynecol 2014.

• 2. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol 2014;123:141-8.

• 3. Barber MD, Brubaker L, Burgio KL, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. Jama 2014;311:1023-34.

• 4. Geller EJ, Matthews C. Impact of robotic operative efficiency on profitability. Am J Obstet Gynecol 2014.

• 5. Crane AK, Geller EJ, Matthews CA. Trainee performance at robotic console and benchmark operative times. Int Urogynecol J 2013;24:1893-7.

• 6. Geller EJ, Lin FC, Matthews CA. Analysis of robotic performance times to improve operative efficiency. J Minim Invasive Gynecol 2013;20:43-8.

• 7. Nygaard I, Brubaker L, Zyczynski HM, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. Jama 2013;309:2016-24.

• 8. Whiteside JL, Weber AM, Meyn LA, Walters MD. Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol 2004;191:1533-8.

• 9. Salvatore S, Athanasiou S, Digesu GA, et al. Identification of risk factors for genital prolapse recurrence. Neurourol Urodyn 2009;28:301-4.

• 10. Jeon MJ, Chung SM, Jung HJ, Kim SK, Bai SW. Risk factors for the recurrence of pelvic organ prolapse. Gynecol Obstet Invest 2008;66:268-73.

• 11. Dallenbach P, Jungo Nancoz C, Eperon I, Dubuisson JB, Boulvain M. Incidence and risk factors for reoperation of surgically treated pelvic organ prolapse. Int Urogynecol J 2012;23:35-41.

• 12. Medina CA, Candiotti K, Takacs P. Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair. Int J Gynaecol Obstet 2008;101:184-7.

• 13. Dietz HP, Chantarasorn V, Shek KL. Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol 2010;36:76-80.

•

Page 32

“Pearls for sacrocolpopexy ‐Techniques for difficult anterior

dissection”

Matthew H Clark MD

Hoag Hospital

Newport Beach, CA

Disclosure

Grants/Research: American Medical Systems

Speakers Bureau: Allergan, American Medical Systems, Bard Medical Division, Intuitive Surgical

Objectives

• Learn about difficult dissections

• Demonstrate how to repair cystotomy

• See the cystocele

Learning Objectives: Anterior dissection challenges

• Learn how to handle scarred

– S/P C section, hysterectomy or prolapse repair

• See how to surgically treat large cystocele

• Demonstrate how to avoid cystotomy

Anterior dissection challenges

• Scarred

– Technique similar regardless the cause of the scarring

• See the bladder / vaginal border by filling the bladder or pulling the Foley bulb or tube

• Vaginal dilator

• Pull the vaginal wall tight

• Start with sharp dissection to establish the plane

Anterior dissection challenges

• Scarred

– Technique similar regardless the cause of the scarring

• Right hand with scissors

• Left with grasper

• Lift up the bladder flap with assistant

• Scissor tip 90 degree to the vagina and push forward and spread and pull backward.

Page 33

• Cadaveric Demonstration Live

Cystotomy

• Mechanical or cautery?

– Mechanical should heal without concerns

– Cautery beware of poor healing

• Where?

– At dome or the superior border ( not in contact with mesh ) Vs. between the bladder and vagina

Cystotomy

• Repair multilayer, tension free and using2‐0 vicryl

• Drain bladder x days

– Dependent vs. Non dependent

• I do not place mesh in direct contact with the cystotomy repair

• Confirm Ureter is not envolved

• Cadaveric Demonstration Live of cystotomy and repair

Large cystocele

• Cystocele is the most likely location for a Colpopexy to fail

• FDA transvaginal mesh warning pushing providers and patients to avoid TVM for repairs

• Extended the indications for ASC to include large cystocele dominate prolapse

Large Cystocele

• Apical Dominate Prolapse • Cystocele Dominate Prolapse

Page 34

Evolving indications for dVSC in light of the FDA mesh warning letters

• Challenge of ASC:

Controlling the Cystocele Recurrent ‘slide off cystocele’

Cystocele with ASC

Seeing the Cystocele

• Pull on anterior wall

– Without a Lucite rod

• Release the anterior wall

– Without a Lucite rod

– “see the cystocele”

Cystocele with ASC

• Video vs Live demonstration: seeing the cystocele and sewing the anterior mesh

Page 35

Posterior Wall Dissection

Nazema Y. Siddiqui, MD MHScAssistant Professor, Department of Obstetrics and Gynecology

Division of Urogynecology and Reconstructive Pelvic Surgery

2

Disclosures

Other: Honorarium: Intuitive Surgical

Grants/Research: Medtronic

3

MIS Sacrocolpopexy

4

Posterior Wall Dissection

✴ Use a manipulator to distend the posterior fornix

✴ Incise the peritoneum

✴ Small pulses of electrocautery with blunt dissection

✴ Stay on the back of the vagina

✴ Consider a small manipulator (e.g. EEA sizer) if unsure of rectal anatomy

Page 36

Pearls for Sacral Colpopexy: What about the patient with a uterus?

Catherine A. Matthews, MD

Associate Professor and Division Chief

Urogynecology and Reconstructive Pelvic Surgery

University of North Carolina

Chapel Hill, NC

DISCLOSURES

Grants/Research: Boston Scientific Corp. Inc.

Objectives

• At the end of this presentation, the audience is expected to understand the following:• Rate of unanticipated uterine pathology in

women undergoing surgery for POP

• Risks and benefits of uterine preserving surgery

• Comparative outcomes of uterine preserving surgery

• Appropriate pre-operative case selection for hysteropexy

Case

• 57 yo with Stage III uterine prolapse

• Wants “the best” surgical treatment

• Had episode of PMP VB which was evaluated with EMBx- benign

• Should she have:• Sacrohysteropexy

• SCH + SCP

• TLH + SCP

• TVH/USS

Not all uterine prolapse is created equally

Effect of concurrent hysterectomy

• Does concurrent hysterectomy affect recurrence rates?

• Does concurrent hysterectomy affect mesh exposure rates?

• Is there a difference between total and supracervical hysterectomy in anatomic outcomes?

• What is the risk of unanticipated uterine pathology?

• If the uterus is left in situ, what is the risk of developing future uterine pathology?

Page 37

Total laparoscopic hysterectomy

Supracervical hysterectomy

Hysteropexy

Uterine pathologyCervical elongationCompromised result

Patient preferenceLower mesh erosion

Decreased blood lossLower OR time

Risks of mesh exposure AUTHOR Subjects Overall mesh exposure

OR TAH

Cundiff, 2008 322 6% 4.9

Akyol, 2014 292 6.5% 2.0

Warner, 2012 390 2.8% 2.0

Cvach, 2012 27 11% 33.0

Bensinger, 2005 121 3.3% 7.0

Nosti, 2009 264 5.7% 0.95

Brizzolara, 2003 124 0.8% No diff

Stepanian, 2008 446 2.3% No diff

Borahay, 2014 20 0% No diff

Marinkovic, 2008 67 0% No diff

OVERALL RATE OF MESH EXPOSURE ASCP 3.4%RATES OF MESH EXPOSURE RANGE FROM 0-33%

Rates of mesh exposure with supracervical hysterectomy +

cervicosacropexy = 0%

Conclusions regarding mesh exposure with concurrent TLH

• TLH does increase the risk, but to what degree?

• Mesh materials play a big role: Impact of lighter weight Type 1 polypropylene?

• Sutures seem to play a big role too: Permanent vs delayed absorbable suture material?

• RCT funded

Page 38

3.2%

Unanticipated uterine pathologyFrick et al. AJOG 2010

15 16

Ramm et al. Int Urogynecol J, 2012

(2.9%)Unanticipated

premalignant or malignant pathology

97.1%no concerning

pathology

N = 708

• Pipelle (aspiration) endometrial sampling devise• Detection rates of 67-92%

• Observed in symptomatic women with known endometrial malignancy

• Total surface area sampled is low: average 4% (0-12%)

• 20% of postmenopausal women can have uterine pathology with specimen ‘insufficient’ for analysis

• High rate of false negatives in patients with tumors less than 50% of endometrial surface area

17

Stoval et al., Ob&Gyn, 1991Rodriguez et al, AJOG, 1993Guido et al., J Repro Med, 1995

Preoperative assessment: Endometrial biopsy

Preoperative assessment: Transvaginal US

University of Pisa, Gambacciani et al.

Retrospective review of 850 postmenopausal women taking hormone therapy who underwent hysteroscopy

• 148 asymptomatic patients who underwent hysteroscopy secondary to transvaginal US stripe >4.5mm

• Adenocarcinoma - 1 (0.7%) patient

• Transvaginal Ultrasound generated 93% false positive rate

18

Page 39

Regarding uterine pathology

• There is no good way to screen for it pre-operatively

• Expect a 3% rate over time

• New patient awareness regarding morcellation complicates your pre-operative discussion

• Management once disease is detected is challenging and controversial

Cervical elongation

5/8 (62.5%) had cervical elongation by 12 months

Efficacy?

• TLH vs SCH / Hysteropexy

Anterior failure noted in 55% of ASHSubsequent uterine pathology in 22%

Page 40

Higher failure rate in hysteropexy group “evidence on safety and efficacy is lacking”

Summary of data

• Do not do SCH in a PMP woman with any vaginal bleeding

• Counsel all women regarding the overall 3% risk of unanticipated uterine pathology

• Recognize that this rate is similar to rates of mesh exposure: Individualize risk/benefit ratio

• Only offer SCH to women with a small cervix

• Think about native tissue repair or TLH/SCP with large anterior wall prolapse

Conclusions

• Carefully consider the unique risks of SCP when counseling for use as a primary operation for young women with advanced uterovaginal prolapse

• Don’t leave a big, bulky cervix behind

• Practice any minimally-invasive technique and do it often: volume and repetition count

References• Matthews CA, Carroll A, Hill A, Ramakrishnan V, Gill EJ. Prospective evaluation of surgical outcomes of robot-assisted sacrocolpopexy and

sacrocervicopexy for the management of apical pelvic support defects. South Med J. May 2012;105(5):274-278.

• Nosti PA, Umoh Andy U, Kane S, et al. Outcomes of abdominal and minimally invasive sacrocolpopexy: a retrospective cohort study. Female Pelvic Med Reconstr Surg. Jan-Feb 2014;20(1):33-37.

• Osmundsen BC, Clark A, Goldsmith C, et al. Mesh erosion in robotic sacrocolpopexy. Female Pelvic Med Reconstr Surg. Mar-Apr 2012;18(2):86-88.

• Hill AJ, Carroll AW, Matthews CA. Unanticipated uterine pathologic finding after morcellation during robotic-assisted supracervical hysterectomy and cervicosacropexy for uterine prolapse. Female Pelvic Med Reconstr Surg. Mar-Apr 2014;20(2):113-115.

• Borahay MA, Oge T, Walsh TM, Patel PR, Rodriguez AM, Kilic GS. Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures. J Minim Invasive Gynecol. May-Jun 2014;21(3):412-416.

• Culligan PJ, Murphy M, Blackwell L, Hammons G, Graham C, Heit MH. Long-term success of abdominal sacral colpopexy using synthetic mesh. Am J Obstet Gynecol. Dec 2002;187(6):1473-1480; discussion 1481-1472.

• Cundiff GW, Varner E, Visco AG, et al. Risk factors for mesh/suture erosion following sacral colpopexy. Am J Obstet Gynecol. Dec 2008;199(6):688 e681-685.

• Akyol A, Akca A, Ulker V, et al. Additional surgical risk factors and patient characteristics for mesh erosion after abdominal sacrocolpopexy. J Obstet Gynaecol Res. May 2014;40(5):1368-1374.

• Bensinger G, Lind L, Lesser M, Guess M, Winkler HA. Abdominal sacral suspensions: analysis of complications using permanent mesh. Am J Obstet Gynecol. Dec 2005;193(6):2094-2098.

• Stepanian AA, Miklos JR, Moore RD, Mattox TF. Risk of mesh extrusion and other mesh-related complications after laparoscopic sacral colpopexy with or without concurrent laparoscopic-assisted vaginal hysterectomy: experience of 402 patients. J Minim Invasive Gynecol. Mar-Apr 2008;15(2):188-196.

• Brizzolara S, Pillai-Allen A. Risk of mesh erosion with sacral colpopexy and concurrent hysterectomy. Obstet Gynecol. Aug 2003;102(2):306-310.

• Nosti PA, Lowman JK, Zollinger TW, Hale DS, Woodman PJ. Risk of mesh erosion after abdominal sacral colpoperineopexy with concomitant hysterectomy. Am J Obstet Gynecol. Nov 2009;201(5):541 e541-544.

• Shepherd JP, Higdon HL, 3rd, Stanford EJ, Mattox TF. Effect of suture selection on the rate of suture or mesh erosion and surgery failure in abdominal sacrocolpopexy. Female Pelvic Med Reconstr Surg. Jul 2010;16(4):229-233.

• Marinkovic SP. Will hysterectomy at the time of sacrocolpopexy increase the rate of polypropylene mesh erosion? Int Urogynecol J Pelvic Floor Dysfunct. Feb 2008;19(2):199-203.

Page 41

Pearls for sacral colpopexy ‐Techniques for sacrum exposure

and securing the mesh.

Matthew H Clark MD

Hoag Hospital

Newport Beach, CA

Disclosure

Grants/Research: American Medical Systems

Speakers Bureau: Allergan, American Medical Systems, Bard Medical Division, Intuitive Surgical

Objectives

Learn the Anatomy

Review the Timing

Teach Technique

Talk about Tying

Anatomy Pearls

• Bones

• Lumbar Disc

• Vessels

– Large: IVC‐Aorta to the common iliac

– Small: Middle Sacral

• Ureter

• Sigmoid Colon

Anatomy Pearls Anatomy Pearls

• Video vs. Live demo of anatomy of sacrum

Page 42

Technique Pearls

• Find the correct place to start the dissection

–Avoid the sigmoid colon mesentery

–30 down scope if steep sacrum

–Depth sound

– Look up then down

– Look lateral then in

Technique Pearls

• Video Vs Live demo of Depth sounding and posterior dissection

Technique Pearls

• Dissection

– Pick up and cut and spread

– Pick up fat, vessels don’t usually follow

– Expose the promontory first

– Move down the sacrum

– Cauterize middle sacral vessels

– Stuff a raytec if needed to dry up mild oozing

Technique Pearls

• Cadaveric Live Demonstration

Timing Pearls

• Timing

– Always look first to see if possible

– IF patient is having a subtotal hysterectomy sacrum is my last space dissected

– If patient has post op hysterectomy prolapse then sacrum is the first space dissected

Tying Pearls

• Suture

– Permanent braided vs. monofilament

– 90 degrees, then skim the bone, then turn up

– Loop vessels

• Placement

– Anterior longitudinal ligament

– Two separate sutures if both are solid, Three if needed

– Sacral body one and two

Page 43

Tying Pearls

• Tying

– Slip knot or pulley stitch

– Pull up on the tail or push up the prolapse

• Tensioning

– Check below

– 1‐2 cm draw.

Tying Pearls

• Video of Pulley Suture vs. Live Cadaveric Demonstration

Challenges

• History of

– Diverticular Disease

– Sigmoid resection

– Rectopexy

– Lumbosacral fusion

• Obese

• Low riding great vessels

Page 44

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

Page 45

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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