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Utrine Prolapse Vaginal Sugeries

Utrine Prolapse Vaginal Sugeries. Maryam Ashrafi. ratio surgery for prolapse vs incontinence: 2:1 prevalence of 31% in women aged 29-59 yrs 20% of women on gynecology waiting lists 11% lifetime risk of at least one operation re-operation in 30% of cases. Statistics.

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Utrine Prolapse Vaginal Sugeries

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  1. Utrine ProlapseVaginal Sugeries Maryam Ashrafi

  2. ratio surgery for prolapse vs incontinence: 2:1 prevalence of 31% in women aged 29-59 yrs 20% of women on gynecology waiting lists 11% lifetime risk of at least one operation re-operation in 30% of cases Statistics

  3. Restoration of pelvic structures to normal anatomical relationship • Restore and maintain urinary &/or fecal continence • Maintain coital function • Correct co-existing pelvic pathology • Obtain a durable result Principles of Pelvic Reconstructive Surgery The Surgical Management

  4. Approach • Approach to prolapse surgery include vaginal, abdominal, and laparoscopic routes or combination of approaches. • Vaginal approach results in: • fewer wound complications, • less postoperative pain, • shorter hospital stay The Surgical Management

  5. Vaginal procedures for prolapse • Restorative→ use the patient’s endogenous support structures • Sacrosinous Suspension • Uterosacral suspension • IliococcygeusFascia Suspension • Compensatory→ replace deficient support with some type of graft • Obliterative → close the vagina • Le fort colpoclisis • Total colpoclisis The Surgical Management

  6. Preoperative Evaluation And Preparation • A thorough pelvic floor history, • Assessment of bothersome urinary symptoms • and/or defecatoryproblems . • A thorough speculum and bimanual pelvic examination • The findings of the examination should be recorded using a quantitative and reproducible method for recording POP.

  7. Evaluation Of Urinary Dysfunction • Urinary incontinence • Reduced stress testing. • Urodynamics? • Urinary retention • Measure PVR • 13 to 65 percent of continent women develop symptoms of SUI after surgical correction of the prolapse. The Surgical Management

  8. Obliterative Procedure • Obliterative surgery corrects prolapse by removing and/or closing off all or a portion of the vaginal canal (colpocleisis) • Total colpocleisis • Partial colpocleisis (Le Fort colpocleisis) • Concomitant hysterectomy? • Concomitant stress urinary incontinence surgery? •  Kelly suburethral plication  • midurethral sling The Surgical Management

  9. Effects of colpocleisis on bowel symptoms • At baseline Bothersome bowel symptom(s) were present in 77% : • Obstructive (17-26%), • Incontinence (12-35%) and • Pain/irritation (3-34%) • Procedures performed: • partial colpocleisis (61%), • total colpocleisis (39%), • levatormyorrhaphy (71%), and • perineorrhaphy (97%).

  10. RESULTS: Of 121 (80%) subjects with complete data, Mean age was 79.2 +/- 5.4 years and all had stage 3-4 prolapse The majority of bothersome symptoms resolved (50-100%) with low rates of de novo symptoms (0-14%). CONCLUSIONS: Most bothersome bowel symptoms resolve after colpocleisis, especially obstructive and incontinence symptoms, with low rates of de novo symptoms.

  11. Sacrospinous Ligament Fixation • The surgeon should be familiar with the anatomy of the sacrospinousligament complex and of the pararectal space. • Obtaining adequate exposure can be difficult. • The sacrospinous ligament is a cordlike structure that exists within the body of the coccygeus muscle. • The sacrospinous ligament attaches medially to the sacrum and coccyx and attaches laterally to the ischial spine. The Surgical Management

  12. Sacrospinous Ligament Fixation • The pudendal nerve and vessels pass directly posterior to the ischial spine. • The sciatic nerve lies superior and lateral to the sacrospinous ligament. • Superior to the ligament lies the inferior gluteal vessels and the hypogastric venous plexus. • To avoid trauma to these structures, it is important to place the fixation sutures two fingers medial to the ischial spine. The Surgical Management

  13. Complications • Hemorrhage can result from injury to the hypogastricvenous plexus inferior gluteal vessels, and internal pudendal vessels. • Postoperative gluteal pain due to pudendal nerves and the sciatic nerve injury. • Approximately 10% to 15% of patients have transient moderate to severe buttock pain • Inadvertent proctotomy. • Potential stress incontinence.

  14. Results of sacrospineousLigament Suspension for Vaginal Vault Prolapse Follow-up in months (range) Author No. of patients Success

  15. Total transvaginalmesh (TVM) technique ProliftPelvic Floor Repair System™

  16. Complications • Febrile morbidity • Urinary tract infection • Deep hematoma • Granuloma (without exposure) • Mesh exposure • Shrinkage of mesh

  17. Ojectives: The objective of the study was to assess the effectiveness and complication rates for the transvaginal (TVM) technique in the treatment of pelvic organ prolapse (POP). Methods: All enrolled patients underwent prolapse repair surgery with GYNEMESH PS ProleneNonabsorbable Soft Mesh using the TVM technique

  18. Conclusions: • Five-year results indicated that TVM provided a stable anatomic repair. • Improvements in quality of life and associated improvements in specific prolapse symptoms were sustained over the 5-year period. • Mesh exposure was the most common complication

  19. Of 85 patients: • 16 comlicated with Mesh exposure • 9 required partial mesh excision. • 3patients with some degree of dyspareunia, (in 8, preexisting dyspareunia resolved). • 1rectovaginal fistula reported and • 2 reported ureteral injuries, one of which resulted in a ureteral-vaginal fistula; all resolved after repair • 5 required reoperation for prolapse by 5 years

  20. To elucidate the outcome of transvaginal pelvic reconstructive surgery using polypropylene mesh (Gynemesh; Ethicon, Somerville, NJ, USA) for patients with pelvic organ prolapse (POP) stage III or IV. RESULTS: The average age of the patients was 64.1 years and average parity was 3.9 The success rate was 97.4%. Only one patient (2.6%) had recurrent genital prolapse (stage II) postoperatively.). The complication rate was 10.3 %, including onevaginal mesh erosion (2.6%), one dyspareunia (2.6%) (and two prolonged bladder drainage (longer than 14 days Neither long-term nor major complication was identified CONCLUSION: Transvaginalpelvic reconstructivesurgerywith polypropylenemesh reinforcement is a safe and effective procedure for POP on 1.5 years' follow- up. It also has positive influence on quality of life.

  21. Sacrocolpopexy and paravaginal repair for total pelvic floor prolapse

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