ABDOMINAL SACRAL COLPOPEXY

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Presentation transcript:

ABDOMINAL SACRAL COLPOPEXY MICKEY KARRAM MD THE CHRIST HOSPITAL UNIVERSITY OF CINCINNATI

CONTRAVERSIES ABOUT ASC What are indications? What are real outcomes Is it difficult to perform? Is it standardized? Are TV mesh repairs comparable? Do we need to do additional vaginal procedures ?

ASC Outcomes I. Nygaard´s Review (f-up 3-36 months): Success Apical prolapse 78-100% All prolapse 58-100% Satisfaction 85-100% Cochrane: Better than SSF lower rate of recurrent vault prolapse Less dyspareunia BUT… Longer operation, longer recovery, more expensive, later return to activities of daily living More complications Nygaard IE, et al. Pelvic Floor Disorders Network. Obstet Gynecol, 2004;104(4):805-23. Maher C et al. Cochrane Incont.Group Cochrane Database of Systematic Reviews. 4, 2008.

History 1957: Arthure y Savage: L5-S1 1962: Lane: Graft 1970: Nichols: Vaginal Orientation 1973: Birnbaum: S3-S4 1981: Sutton: Back to S1-S2 due to bleeding 1991: Snyder: Rectovaginal dissection for less dettachment 1989: Addison: 2 strips Theory 1992 – 1994: Querleu – Nezhat: Laparoscopy 1997: Cundiff: Sacroperineopexy 2004: Roboticcs

Techniques in use TODAY Open Laparoscopic Robotics

Cleveland Clinic Experience: 1998 – 2004 Cure rates 100% apical A.W. failures: 6% overall P.W. failures: 15%

Laparoscopic vs Robotic SCP Paraiso et al. 2011 78 patients Lap 38 Robotic 40 Comparable Anatomic Results Complications Robotic + U$S 1900

Retrospective Multicenter Johns Hopkins based study

Vascular anatomy of the presacral space MK Flynn et al: AJOG 2005, 192: 1005

Obstet Gynecol 2009, 113: 367

Complications / Reoperation

Additional Procedures Burch colposuspension Systematic Tailored Posterior repair Hysterectomy

2yr. Outcome of SCP +/- Burch L. Brubaker et al 2yr. Outcome of SCP +/- Burch L. Brubaker et al. O&G 2008, 112:49 302 / 322 (CARE TRIAL) OVERALL SUI Burch 32% P=0,026 Controls 45,2% BOTHERSOME SUI Burch 11,6% P=0,004 Controls 25.2% URGENCY Burch 32% P=0,085 Controls 44,5

AJOG, May 2007 e45

ASC +/- PR Nonrandomized Retrospective review 3 Centers in Texas 1997-2004 191 patients 34 posterior colporraphy (18%) Indicated in the most severe cases 14 perineorraphy (7%) Max follow up 34mo

Hysterectomy or Graft 168 patients retrospective review follow up 36mo Group 1 TAH + SCP with mesh 63pt Group 2 SCHysteropexy with mesh 35pt Group 3 TAH + A Usacral Colpopexy

CRADI: ColoRectalAnal Distress Inventory AJOG 2007, 197: 642 CRADI: ColoRectalAnal Distress Inventory CRAIQ: ColoRectalAnal Impact Questionnaire

Limitations Not the primary endpoint PR were not randomized as Burch was PR were performed according to the surgeons discretion

Conclusion Effective apical surgery reduces obstructive symptoms (with or without PR) Apical defects may have a higher impact in PC symptoms than previously thought!!! Patients receiving systematic posterior repairs at the time of SCP may be more prone to new onset PC symptoms like incontinence and pain

Sexual Function

PISQ 12: PopIncontinenceSexualQuestionnaire AJOG 2007, 197: 629 PISQ 12: PopIncontinenceSexualQuestionnaire

Secual Activity after SCP Conclusion Improvement of sexual activity after SCP Substantial decrease in dyspareunia 34/76 non S.A. became sexually active NO increase in dyspareunia after Burch Dyspareunia more frequent after PR (N/S) USEFUL INFORMATION ON COUNSELING