Chirurgia ricostruttiva pelvica fasciale :Il compartimento centrale

P.S. Anastasio

3° Congr Naz GLUP

2-10-2015 Treviso

Direttore Dipartimento Donna Maternità Infanzia ASL Matera

Chirurgia fasciale :compartimento centrale2 contesti

Chirurgia primaria di POP ≥ 2Chirurgia del prolasso di cupola

DIFFERENTI ?

Bladder DescentBladder Descent

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Bladder Prolapse versus Uterine ProlapseBladder Prolapse versus Uterine ProlapseSummers et al, Obstet Gynecol 2006Summers et al, Obstet Gynecol 2006

60% of bladder descent explained by apical descent*60% of bladder descent explained by apical descent*

r = 0.73r = 0.73

Principi di chirurgia ricostruttiva pelvica

Per assicurare un supporto apicale Per assicurare un supporto apicale duraturo occorre ristabilire la duraturo occorre ristabilire la continuità della fascia vaginale continuità della fascia vaginale anteriore e posteriore a livello della anteriore e posteriore a livello della cupola o della cervice.cupola o della cervice.

Se il tetto della tenda sprofonda, le pareti seguirannoSe il tetto della tenda sprofonda, le pareti seguiranno

““ il primo step di qualunque il primo step di qualunque riparazione anteriore o posteriore riparazione anteriore o posteriore consiste nel garantire un supporto consiste nel garantire un supporto grado 0 al segmento apicale ” grado 0 al segmento apicale ”

Baden WF, Walker T Baden WF, Walker T Surgical repair of vaginal defects,1992Surgical repair of vaginal defects,1992

Obstet Gynecol. 2013 Nov;122(5):981-7.

Outcomes of vaginal prolapse surgery among female Medicare beneficiaries: the role of apical

supportEilber KS1, Alperin M, Khan A, Wu N, Pashos CL, Clemens JQ, Anger JT.

1999 : 3244 / 21245 donne con diagnosi di prolasso sottoposte a chirurgia per POP con o senza sospensione dell’apice

tassi di re- intervento dopo 10 aasenza supporto apicale 20.2 % con supporto apicale 11.6 %

P <.0.03“This analysis of a national cohort suggests that the appropriate use of a vaginal apical support procedure at the time of surgical treatment of POP might reduce the long-term risk of prolapse recurrence.”

Am J Obstet Gynecol. 2015 Apr;212(4):463.e1-8..

Trends in management of pelvic organ prolapse among female Medicare beneficiaries

Khan AA1, Eilber KS2, Clemens JQ3, Wu N4, Pashos CL4, Anger JT5.

• Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception of a rapid rise in mesh use.

• The majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the United States.

• There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP

Sacral colpopexy has superior outcomes to a variety of vaginal procedures including • Sacrospinous colpopexy• Uterosacral colpopexy• Transvaginal mesh

PERCHÈ CONTINUARE A DISCUTERE ?

Maher C, Feiner B, Baessler K, Glazener C : Surgical management of POP in women Cochrane Database Syst Rev 4 , 2013

Int Urogynecol J. 2013 Nov;24(11):1815-33. doi: 10.1007/s00192-013-2172-1.

Apical prolapse

•Barber MD, Maher C.

• Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse.

• Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy.

Int Urogynecol J. 2015 Jul;26(7):937-9. Epub 2015 May 12.

Systematic reviews of apical prolapse surgery: are we being misled down a

dangerous path?

Moen M1, Gebhart J, Tamussino K.

La dichiarata superiorità di SC nella riparazione del prolasso apicale basata :• Numero limitato studi di livello 1• Studi focalizzati su esiti anatomici a breve termine• Mancata valutazione del rischio di reintervento mesh related• Mancato confronto dei dati di RCT con “ real life “ (registri e database)

PERCHÈ CONTINUARE A DISCUTERE ?

JAMA. 2013 May 15;309(19):2016-24.

Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse

Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, Fine P, Menefee S, Ridgeway B, Visco A, Warren LK, Zhang M, Meikle S.

Abdominal sacrocolpopexy is considered the most durable POP surgery, but little is known

about safety and long-term effectiveness

treatment failure for anatomic POP 0.27 and 0.22 symptomatic POP

0.29 and 0.24

SUI 0.268 to 0.33 overall UI 0.75 and 0.81

Mesh erosion probability at 7 years was 10.5% (95% CI, 6.8%to 16.1%).

JAMA. 2013 May 15;309(19):2016-24.

Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse

Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, Fine P, Menefee S, Ridgeway B, Visco A, Warren LK, Zhang M, Meikle S.

CONCLUSIONS AND RELEVANCE:

•During 7 years of follow-up, abdominal sacrocolpopexy failure rates increased in both groups. •Urethropexy prevented SUI longer than no urethropexy. •Abdominal sacrocolpopexy effectiveness should be balanced with long-term risks of mesh or suture erosion

Standardization and Terminology Committees IUGA* & ICS#, Joint IUGA / ICS Working Group on Female POP Terminology^

AN INTERNATIONAL UROGYNECOLOGICALASSOCIATION (IUGA) / INTERNATIONAL

CONTINENCESOCIETY (ICS) JOINT REPORT ON THE

TERMINOLOGYFOR FEMALE PELVIC ORGAN PROLAPSE (POP)

Bernard T. Haylen *^, Christopher F. Maher*^, Matthew D. Barber^, Sérgio Camargo^, Vani Dandolu^, Alex Digesu^, Howard B. Goldman^, Martin Huser^, Alfredo L. Milani^, Paul A. Moran*^, Gabriel. N. Schaer *^, Mariëlla I.J. Withagen^

VAGINAL VAULT REPAIR INVOLVING UTERUS

VAGINAL VAULT REPAIR (POST-HYSTERECTOMY)

• Vaginal hysterectomy• Vaginal hysterectomy with adjunctive McCall culdoplasty

(culdoplasty sutures incorporate the uterosacral ligaments into the posterior vaginal vault to obliterate the cul-de-sac and support and suspend the vaginal apex )

• Sacrospinous hysteropexy

VAGINAL VAULT REPAIR INVOLVING UTERUS

• Unilaterale o bilaterale• Approccio anteriore o posteriore• Numero di prese del ligamento• Suture assorbibili o non riassorbibili • Device utilizzati

VARIANTI ISTEROPESSI SACROSPINOSO

• Colpopessi al sacrospinoso (varianti come isteropessi + Michigan 4 wall suspension(pfrg.smugmug.com)

• Sospensione ai ligamenti uterosacrali a) Approccio intraperitoneale (variante laparoscopica)

b) Approccio extraperitoneale • Sospensione ai mm. ilio-coccigei

VAGINAL VAULT REPAIR (post-hysterectomy)

Standardization and Terminology Committees IUGA* & ICS#, Joint IUGA / ICS Working Group on Female POP Terminology^

AN INTERNATIONAL UROGYNECOLOGICALASSOCIATION (IUGA) / INTERNATIONAL

CONTINENCESOCIETY (ICS) JOINT REPORT ON THE

TERMINOLOGYFOR FEMALE PELVIC ORGAN PROLAPSE (POP)

Bernard T. Haylen *^, Christopher F. Maher*^, Matthew D. Barber^, Sérgio Camargo^, Vani Dandolu^, Alex Digesu^, Howard B. Goldman^, Martin Huser^, Alfredo L. Milani^, Paul A. Moran*^, Gabriel. N. Schaer *^, Mariëlla I.J. Withagen^

Obstet Gynecol. 2001 Jul;98(1):40-4.

ILIOCOCCYGEUS OR SACROSPINOUS FIXATION FOR VAGINAL VAULT PROLAPSE.•Maher CF1, Murray CJ, Carey MP, Dwyer PL, Ugoni AM.

Sacrospinous and iliococcygeus fixation are •Equally effective procedures for vaginal vault prolapse • Have similar rates of postoperative cystocele, buttock pain, and hemorrhage requiring transfusion.Sacrospinous ligament fixation should not be discarded in favor of the iliococcygeus fixation in the management of vaginal vault prolapse.

Pelviperineology 2010 29: 11-14

BILATERAL ILIOCOCCYGEUS FIXATION TECHNICQUE FOR ENTEROCELE

AND VAGINAL VAULT PROLAPSE REPAIR

HAIM KRISSI 1,2*, STUART L STANTON1**1 Pelvic Reconstruction & Urogynaecology Unit, Department of Obstetrics and Gynecology, St. George’s Hospital, London, UK.2 Department of Obstetrics and Gynecology, Beilinson Hospital, Petah-Tiqva, and Sackler Faculty Of Medicine, Tel-Aviv University, Israel.*Clinical and Research Fellow in Pelvic Reconstruction and Urogynaecology** Professor of Pelvic Reconstruction and Urogynaecology

Int Urogynecol J. 2014 Feb;25(2):279-84. doi: 10.1007/s00192-013-2216-6. Epub 2013 Sep 13.

ILIOCOCCYGEUS FIXATION OR ABDOMINAL SACRAL COLPOPEXY FOR THE TREATMENT OF VAGINAL VAULT PROLAPSE: A RETROSPECTIVE

COHORT STUDY.•Milani R1, Cesana MC, Spelzini F, Sicuri M, Manodoro S, Fruscio R.

Prolasso di cupola : 41 SCP versus 36 ICG fixationICG : più breve , maggiore perdita ematica , recidiva 22% vs 15%

Int Urogynecol J. 2014 Feb;25(2):279-84. doi: 10.1007/s00192-013-2216-6. Epub 2013 Sep 13.

ILIOCOCCYGEUS FIXATION OR ABDOMINAL SACRAL COLPOPEXY FOR THE TREATMENT OF VAGINAL VAULT PROLAPSE: A RETROSPECTIVE

COHORT STUDY.•Milani R1, Cesana MC, Spelzini F, Sicuri M, Manodoro S, Fruscio R.

• Both ICG fixation and SCP are effective in restoring normal anatomy in patients with vaginal vault prolapse and in relieving associated symptoms.

• Owing to its lower morbidity and to the advantage of not using a synthetic device, ICG might be an excellent option for the treatment of recurrent vaginal vault prolapse following hysterectomy

Int Urogynecol J (2015) 26:1007-1012 DOI 10,1907/s00 192-015-2629- 5

Iliococcygeus fixation for the treatment of apical vaginal prolapse:

efficacy and safety at 5 years of follow-upMaurizio Serati • Andrea Braga • Giorgio Bogani • Umberto Leone Roberti Maggiore • Paola Sorice • Fabio Ghezzi • Stefano Salvatore

• Studio prospettico di 44 pz seguite per 5 aa• Valutazione operata da # dagli operatori • Nessuna perdita al follow-up• Valutazione outcomes soggettivi ed oggettivi con

strumenti validati

Sospensione ai mm. ilio-coccigei• Incisione longitudinale parete vaginale posteriore• Dissezione bilaterale degli spazi pararettali• Identificazione del muscolo elevatore dell’ano • Trasfissione distalmente alla spina ischiatica del muscolo e della fascia con 3 suture riassorbibili• Sospensione dell’apice alle suture passate trasversalmente• Tensionamento successivo alla colporaffia

• POP stage 4 13.6%• POP recidivo 16%• No complicanze intraoperatorie • Correlazione tra stadio del prolasso e recidiva

OPTIMAL RANDOMIZED TRIAL (JAMA 2014)S LSS VERSUS S USL A 2 AA

Nessuna differenza per : •Successo chirurgico•Sintomi di bulge fastidioso•Descensus anteriore o posteriore all’imene•Necessità di re-trattamento per POP

S LSS : dolore neurologico. 12.4% vs 6.9%S USL : ostruzione ureterale 3.2% vs 0%S USL : ileo < 0.5%

Non chiedetevi quanto grande è il prolasso Chiedetevi perché è avvenuto La capacità di riparare il difetto che ha generato il prolasso determinerà l’esito chirurgicoGli impianti devono essere utilizzati come un aiuto al processo di guarigione dei tessuti Ciò avviene solo seguendo i principi della chirurgia rigenerativa nel maneggiamento dei tessuti  Nieuwoudt : Native tissue and pelvic floor ( editorial ) . Pelviperineology ,2014;4.99

Chirurgia vaginale rigenerativa Ricostruzione anatomo-morfo-funzionale con cicatrice minima Tessuto nativo + processo di guarigione •Dissezione in piani anatomici •Approssimare i bordi lacerati dei tessuti lacerati •Eliminare tensione •Utilizzare materiali che non aumentano la risposta infiammatoria •Supportare il rimodellamento da parte della matrice extracellulare con scaffolds biodegradabili A, Nieuwoudt : Native tissue and pelvic floor ( editorial ) . Pelviperineology ,2014;4.99