karanvir virk m.d. minimally invasive & pelvic ...examine office diagnosis of pelvic organ...
TRANSCRIPT
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Karanvir Virk M.D.
Minimally Invasive & Pelvic Reconstructive Surgery
01/28/2015
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I have none
Disclosures
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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
Objectives
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History
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History
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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
What is Prolapse?
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Newest data suggests 1in 2 women will have POP
1 in 5 will need surgery in their lifetime for POP
Is the incidence increasing???
POP
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NO
The reporting is increasing
More and more women talk to their physicians about this problem
POP
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29.2% Recurrences
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!!!!
POP Facts
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Why?
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Why?
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We were doing wrong repairs
We didn’t know the real anatomic reason for prolapse
Traditional repairs were making prolapse worse
Why such high failure?
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John DeLancey
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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
Delancey’s levels of support
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Muscular: Levator ani/pelvic floor muscles
Ligaments: Uterosacral-Cardinal complex
Fascial: Endopelvic( Pubocervical & Rectovaginal)
Anatomic supports
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Predispose
Incite
Promote
Decompensate
Risk Factors for POP
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Genetic: Collagen defects
Race: Latina and white women 4-5 times higher than AA
Gender: Female> Male
Being human: Erect posture
Predispose
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Pregnancy & Delievery
1st birth: 4 fold
2nd birth: 8 fold
3rd birth: 9 fold
4th birth: 10 fold
Hysterectomy: Vaginal> abdominal
Myopathy
Neuropathy
Incite
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Obesity 40-75%
Smoking
Chronic cough
Constipation
Heavy ligting
Promote
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Aging
Menopause
Neuropathy
Myopathy
Debilitation
Medication??
Decompensate
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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
Symptoms
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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
Baden-Walker Halfway system
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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.
Treatment
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Patients age
Sexual function
Symptoms
Vaginal/abdominal/laparoscopic/Robotic
Again…. NEVER treat an asymptomatic patient
Treatment
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Pessarries
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Fewer wound complications
Less post operative pain
Less cost
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
Vaginal Surgeries
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Old frail patients
Quick and easy procedure
90-95% success rate
Can be combined with sling/incontinence procedure
LeForte’s Colpoclesis and complete colpoclesis
Colpoclesis
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Colpoclesis
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Anterior repair
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Posterior repair
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Paravaginal repair
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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
Apical support
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Uterosacral
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Sacrospinous
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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 87-100%
Technically difficult
Risk of injury to major organs
Abdominal
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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
Grafts
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Synthetic
Polypropylene
Inert
High objective success
More complications
Grafts
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Vaginal mesh erosion
Pain/dyspareunia
Infection
Urinary problems
Bleeding
Organ perforation
Recurrent prolapse
Vaginal scarring/shrinkage
Emotional problems
FDA 2011
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Reported 7 deaths from 2008-2010
3 deaths with mesh placement procedures( 2 bowel perforation, 1 hemorrhage)
4 deaths postop medical complications
FDA
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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
The problem is??
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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.
Pearls to success
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Thank You Questions?