Cirurgia Vaginal Para Urologistas Prof Paulo Palma Titular Urologia Feminina UNICAMP.
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Transcript of Cirurgia Vaginal Para Urologistas Prof Paulo Palma Titular Urologia Feminina UNICAMP.
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Cirurgia Vaginal Para Urologistas
Prof Paulo PalmaTitular Urologia Feminina
UNICAMP
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PP
UterusUterus
VaginaVagina Lateral DefectLateral Defect
Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)
Central DefectCentral Defect
Tendineous Arc
Tendineous Arc
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Davila, Guerette.IUGA 2004Davila, Guerette.IUGA 2004
Possible fascial tearings
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Transverse defectTransverse defect
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Anterior Anterior repair repair
Anterior Vaginal ProlapseAnterior Vaginal Prolapse
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Paravaginal repairParavaginal repair
Richardson, 1976Richardson, 1976
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PP
UterusUterus
VaginaVagina
Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)
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Anterior Vaginal ProlapseAnterior Vaginal Prolapse
JulianJulian MarlexMarlex 100100
Mesh vs Anterior repairMesh vs Anterior repair
SandSand PoliglactinaPoliglactina 7575
WeberWeber PoliglactinaPoliglactina 4242
Colp. Ant.Colp. Ant. 5757
3737
Colp. Ant.Colp. Ant. 66661212
7373
2626
7070
5757
12122424
1212
2323
1212
2323
242425% erosion25% erosion
nono
n0n0
nono
nono
nono
Colp. Ant.Colp. Ant.
nn TT(m)(m)
SuccessSuccess(%)(%)
ComplicationsComplications
Modified from Tayrac el al Int Urogyn J 2006, 17:100
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Posterior vaginal wall prolapsesPosterior vaginal wall prolapses
The past
Levator ani Miorraphy
The Present
Pericervical ring reconstruction
Posterior Slings
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Anti Anti anatomicanatomic
Pain, dypareunia, Pain, dypareunia, recurrencyrecurrency
Levator miorraphyLevator miorraphy
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Rectovaginal FasciaRectovaginal Fascia
Connective Tissue between Connective Tissue between the vagina and the rectumthe vagina and the rectum
Smooth Muscle fibersSmooth Muscle fibers
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Rectovaginal FasciaRectovaginal Fascia
Preserve vaginal lengh and Preserve vaginal lengh and
helps rectal functionhelps rectal function
Main supportive element of Main supportive element of
the posterior wallthe posterior wall
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Stenchever,Urogynecology and Reconstructive Pelvic Surgery, Vol. V
Anatomical levelsAnatomical levels
Support
Lateral
Fusion
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PERICERVICAL RING
AT THE LEVEL OF THE ISCHIAL SPINES;
COMPLEX REPRESENTED BY THE CONTINUITY OF THE CARDINAL-UTEROSACRAL LIGAMENTS
WITH:
PUBOCERVICAL AND RECTOVAGINAL FASCIA.
ONE OF THE MOST IMPORTANT CONCEPTS FOR
RECONSTRUCTIVE VAGINAL SURGEONS;
Adapted from Netter, Atlas of Human Anatomy
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CHILDBIRTH AND PVP
ON THE DESCEND AND EXTENSION OF THE FETAL HEAD,
INTENSE PRESSURE IS EXERTED ON THE
SUSPENSORY FUNCTION OF THE UTEROSACRAL
LIGAMENTS;
CONTINUATION OF THIS PROCESS RESULTS IN A PROXIMAL
TRANSVERSE SEPARATION OF THE RECTOVAGINAL
SEPTUM FROM THE UTEROSACRAL LIGAMENT AND
THE PERICERVICAL RING;
Adapted from Williams, Obstetrics
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Pericervical Ring
PP Tndinous Arc
RectumUterus
Vagina
Posterior vaginal wall Prolapse
Levator Ani
PericervicalDefect
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PPTendineous Arc
Tendineous Arc
RectumRectum
UterusUterus
VaginaVagina
Levator ani
Levator ani
Posterior Posterior DefectDefect
Posterior Vaginal Prolapse (PVP)Posterior Vaginal Prolapse (PVP)
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Pericervical Ring
PPTendinous Arc
RectumRectumUterus
Vagina
Posterior vaginal wall Prolapse
Levator Ani
““Rectocele”
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Surgical Approach
PPTendinous Arc
RectumUterus
Vagina
Pericervical Ring Repair
Levator Ani
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PPArco te
ndineo
RetoUtero
Vagina
Elevador ânus
Surgical Approach
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SacrospinalSacrospinalLigamentLigament
PPTendineous Arc
Tendineous Arc
RectumRectum
UterusUterus
VaginaVagina
Levator a
ni
Levator a
ni
Posterior Vaginal Prolapse RepairPosterior Vaginal Prolapse Repair