Laparoscopic Pelvic Reconstruction
TAOG 2008.01
吳銘斌 (Ming-Ping Wu, M.D., Assn Prof.) 奇美醫院婦產部 婦女泌尿科主任
台北醫學大學醫學院 婦產學科助理教授 成功大學醫學院臨床醫學研究所博士候選人
also Tension-free vaginal mesh (TVM)
Contents
• Background
¾Surgical landmarks in pelvic reconstruction
¾The evolution of pelvic reconstructive surgeries
• Laparoscopic pelvic reconstruction
¾Advantages and disadvantages
• Tension-free vaginal mesh (TVM)
¾Advantages and disadvantages
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E-mail: [email protected] UG & PFR
References
865-873
• Weber AM: New approaches to surgery for UI and POP from laparoscopic perspective. Clin Obstet Gynecol
46(1): 44-60; 2003
• Natale F et al. : Pelvic floor reconstrutive surgery: which aspects remain controversial? Curr Opin Urol 16:407- 412;2006.
The standardization of
terminology in lower urinary tract
1.Lower urinary tract symptoms (LUTS) 2.Signs suggestive of lower urinary tract
dysfunction (LUTD)
3.Urodynamic observations and conditions:
¾The indispensable roles of urodynamic study in LUTD
4.Conditions 5.Treatment:
¾Behavioral, medical, surgical
ICS 2002 Am J Obstet Gynecol; ICS 2002 Neurourol Urodyn
Stress urinary incontinence (SUI)
Urodynamic stress incontinence (USI)
Pelvic organ prolapse (POP)
•
Anterior compartment¾ Cystocele central type, lateral type,
(para-vaginal defect)
•
Middle compartment¾ Uterine prolapse
¾ Vaginal stump prolapse
•
Posterior compartment¾ Enterocele, rectocele
Pelvic organ prolapse-quantitation (POP-Q)
Bump RC 1996 AJOG
POP-Q
Bump RC 1996 AJOG
Post-OP Pre-OP
Mechanism of pelvic floor support
•
Muscular contraction•
Fixation by ligaments•
Mechanical pressure- barrier¾ Formed by the levator ani m.
Mechanism of pelvic floor support
Three levels of support axes
•
level 1: superior suspension¾ vagina to the uterosacral- cardinal complex
•
level 2: lateral attachment¾ upper 2/3 vagina to ATFP
•
level 3: distal fusion¾ vagina into the urogenital
diaphragm and perineal body
DeLancey JOL1992 Am J Obstet Gynecol
Utero-sacral lig
Pubocervical fas.
Rectovaginal sep.
Sacro-spinous lig.
Pelvic Anatomy: Fascia and Ligaments
Uterosacral lig.
Cardinal lig.
Pubo-cervical fas.
ATFP
Key Anatomical Landmarks for Pelvic Reconstructive Surgery
Internal pudendal n.
Sciatic n.
ATFP
Ischial spine Sacrao-spinous lig.
Pelvic Anatomy: Muscle
Obturator m.
Levator ani m:
• Iliococcygeus
• Pubococcygeus
ATFP
Sacrospinous lig.
Ischial spine
pubovervical f.
Rectovaginal f.
bladder rectum
vagina
bladder rectum
vagina
Pelvic support
Sacro-spinous lig.
ATFP
P. S.
U.
Bladder
Cooper’s Lig.
O. I.
A.T
.F.P.
I. S.
C-SSL A. T
.L. A .
Int. Pud. V, N.
ATFP PUL
Cardinal U-S lig.
Cooper’s Lig
B U
PCF OIMF
Cx
SS. Lig.
Peri-cervical ring
Pelvic organ support
ATFP: arcus tendinous fascia pelvis; OIMF: Obturator internus muscle fascia;
PCF: pubo-cervical fascia; PUL: pubo-urethral ligament; SS: sacrospinous
The Evolution of Pelvic Reconstructive Surgeries
VTH+ A-P colporrhaphy
Laparoscopic PFR± mesh
Vaginal repair of anterior, posterior compartment + mesh
Sacro-spinous lig. suspension
Tension-free vaginal mesh + procedural kits*
Biologic materials**
Huang KH & Wu MP Incont Pelvic Floor Dysfunc
*Prolift (J&J); Perigee+Apogee (AMS);
post. IVS (Tyco); Nazca (Promedon)
**SIS (Cook); Pelvicol (Bard)
???
Abdominal sacro- colpopexy± mesh
Major aims of pelvic reconstructive surgery
•
Correcting all defects•
Re-establishing vaginal support•
Facilitating micturition and defecation•
Improving the function of other pelvic floor structures•
Reducing recurrence rates• Reducing postoperative pain
• Improving the healing process
• Avoiding difficulties with intercourse after
surgery
Open & LSC Burch colposuspension
Walters MD & Karram MM: 1999 Mosby Inc.
Vancaille, Liu, Nezhat, Wattiez, Ross
Weber AM 2003 Clin Obstet Gynecol
Cystocele
Cystocele
Anterior colporrhaphy vs para-vaginal repair
LSC para-vaginal repair
Walters MD & Karram MM: 1999 Mosby Inc.
Middle Compartment
• Sacrum longitudinal ligament
¾Sacral colpopexy (hysteropexy)
• Sacro-spinous ligament
¾Sacro-spinous colpopexy (hysteropexy)
• Cardinal utero-sacral complex
¾Suture colpopexy (hysteropexy)
¾High McCall colpopexy (hysteropexy)
•
Sacral colpopexy (hysteropexy)
Abdominal sacro-colpopexy (hysteropexy)
incision
Mesh attachment
closing Mesh attachment
LSC Sacral colpopexy
Sacral promontory Walters MD & Karram MM: 1999 Mosby Inc.
Sacral promontory Vag. vault
Sacro-spinous colpopexy (hysteropexy)
Benson JT: 2000 McGraw-Hill
Vaginal stump
Rectum
Uterosacral vaginal vault suspension
Walters MD & Karram MM: 1999 Mosby Inc.
U-S Lig
LSC Modified Halban colpopexy
Wu MP: J Gynecol Surg 1997
LSC High McCall colpopexy
Wu MP: Int J Gynecol Obstet 1997
Enterocele
• a pelvic floor hernia
¾the parietal peritoneum comes into direct contact with the vaginal epithelium
• with no intervening fascia
¾contains a protrusion of peritoneum
containing the small intestine
Laparoscopic approaches to
rectocele and enterocele
PCF
B U
PVRPVR Burch Burch VOSVOS
SSVS SSVS
Sacrocolpopexy, USS Sacrocolpopexy, USS
High High McCall McCall’’s s
OpOp
TVT,IVS TVT,IVS
Cx. V.
Cx. V.
Sling Sling
Cooper’s Lig.
Laparoscopic approaches to PFR
PVR= para-vaginal repair; SSVS : sacral spinous vaginal suspension ; USS: utero-sacral suspension; VOS: vaginal obturator shelf;
Laparoscopy vs laparotomy
•
Advantages¾ Improving visualization
¾ Decreasing blood loss
¾ Magnifying the pelvic floor defects
¾ Less postoperative pain
¾ Shorter hospital stay
¾ Shorter recovery time
¾ Earlier return to a better quality of life
•
Disadvantages¾ Technical difficulties
¾ Increased operative time
¾ increased costs due to expensive equipment
¾ Longer learning curve
¾ specific urinary tract complications
Advantages vs disadvantages
•
Laparoscopic surgery over laparotomy,¾ a shorter hospital stay
¾ more rapid recovery.
•
Laparoscopic over vaginal surgery¾ inconclusive
•
Disadvantage¾ technical difficulty
• esp. early in a surgeon’s experience,
¾ longer operative time
¾ higher complication rates.
• most commonly urinary tract, e.g. ureters, bladder, and urethra.
Weber AM 2003 Clin Obstet Gynecol
LSC vaginal apex suspension
•
LSC vaginal apex suspension.¾ Rozet et al. the largest recent series 363 cases
¾ LSC double promonto-fixation (14.6 mons)
¾ 4% rate of recurrence
¾ 96% of patients satisfied with the results
[Rozet F 2005 Eur Urol 47:230-236]
•
LSC vs open¾ The Cleveland Clinic Foundation
• 56 LSC sacral colpopexies (14 mons)
• 61 open colpopexies (16 mons)
¾ similar clinical outcomes and reoperation rate,
• operating time: sig. longer
• hospital stay: sig. shorter (4 versus 1.8 days)
¾ The sample size was too small to determine differences in complications
[Paraiso MF 2005 Am J Obstet Gynecol 192:1752-1758]
LSC vaginal apex suspension
•
LSC utero-sacral lig. suspension (n= 25) vs VTH + vaginal vault suspension (n= 25)¾ age-matched control, 40 mons f/u
¾ better POP-Q
¾ No re-operation for recurrent apical prolapse
• 3 cases in vaginal group
[Diwan A 2005 Int Urogyn J 17:79-83].
•
LSC sacral suture hysteropexy with uterine conservation¾ attaches the posterior cervix to the sacral promontory via the right uterosacral lig.
¾ prospective study (n= 81), 20.3 mons f/u.
¾ 94.7% had no recurrent prolapse (using POP-Q)
¾ 81.4% p’t satisfied (using VAS)
• [Krause HG 2006 Int Urogyn J 17:378-381]
Summary LSC in PFR
• Feasibility of laparoscopic access
¾Case reports and case series
• The paucity of comparative studies
¾esp. randomized trials
¾precludes definite conclusions the safety or effectiveness
¾compared with traditional procedures.
How do you read this?
The Evolution of Pelvic Reconstructive Surgeries
VTH+ A-P colporrhaphy
Laparoscopic PFR± mesh
Vaginal repair of anterior, posterior compartment + mesh
Sacro-spinous lig. suspension
Tension-free vaginal mesh + procedural kits*
Biologic materials**
Huang KH & Wu MP Incont Pelvic Floor Dysfunc
*Prolift (J&J); Perigee+Apogee (AMS);
post. IVS (Tyco); Nazca (Promedon)
**SIS (Cook); Pelvicol (Bard)
???
Abdominal sacro- colpopexy± mesh
Classification pelvic reconstructive surgery
•
Anterior compartment¾ Anterior repair/ paravaginal repair + prosthestic reinforcement
¾ Continence surgery ± sling, Burch colposuspension, bulking agents
•
Middle compartment¾ Abdominal hysterectomy+ sacrocolpopexy
¾ Vaginal hysterectomy+ iliococcygeus/ sacrospinous fixation
¾ Abdominal or vaginal sacrospinous/ sacrohysteropexy
•
Posterior compartment¾ Posterior repair
¾ Rectopexy
¾ Anal sphincter repair
Birch C 2002 Curr Opin Obstet Gynecol
+ prosthestic reinforcement + prosthestic reinforcement
Why do we need prostheses in pelvic reconstructive surgery ?
•
The high recurrence rate after surgery for pelvic organ prolapse (POP) makes the more refined reconstructive surgery imperative¾ High failure rate 30% (Olsen AL 1997 Obstet Gynecol)
•
The long-term anatomic outcomes of traditional cystocele repair¾ High failure rate 37% (Quiroz LH 2006 Contemp Ob/Gyn)
•
Therefore, biological and synthetic prostheses merged as adjuvant materials.TVM- Gynecare Prolift System (J&J)
TVM- Gynecare Prolift System (J&J)
TVT-O or Monarc
Prolift (ant) or Perigee
Prolift (post) or Apogee
A B
Preserved uterus (80027B) Hysterectomized (80028B) Gynecare, J&J AMS; Tyco
TVM +/- anti-incontinence surgery
TVM- Prolift
•
A retrospective multicentric study (N=106),¾ perioperative and immediate post-operative results,
•
Success rate: 95.3% (failure rate 4.7%)¾ recurrent prolapse even asymptomatic or low grade symptomatic prolapse
•
Mesh exposure 4.7% (5/110)¾ 2/ 5 required a surgical management
• Prolift seems to be a safe technique to correct POP.
¾ However, anatomical and functional results of a long- term follow-up has not yet to confirm the effectiveness and safety of the procedure
¾ [Fatton B 2006 Int Urogyn J].
Mesh erosion or migration
•
Current available mesh¾ polypropylene 0.5%,
¾ polyethylene terephthalate (Mersilene) 3.1% (J&J)
¾ Gore-Tex 3.4% (Gore)
¾ polyethylene 5.0% (Marlex) (Bard)
¾ Teflon 5.6% (DuPont) Nygaard IE 2004 Obstet Gynecol.
Huang KH & Wu MP Incont Pelvic Floor Dysfu
EBM for PFR- I
•
level I studies about vault suspension¾ The equivalence of vaginal and abdominal surgery
¾ The higher morbidity with abdominal route
¾ (Grade A of research recommendation).
•
level II, transvaginal placement of permanent mesh may reduce anterior wall recurrence¾ but has an unacceptable high rate of complications
¾ its use should be confined to the context of approved clinical trials
¾ (Grade B of research recommendation).
¾ Urinary dysfunction may follow POP surgery
• these outcomes are variable and unpredictable.
Natale F, et al. 2006 Curr Opin Urol
EBM for PFR- II
• Level III the consideration that uterosacral ligament suspension
¾has high cure rates
¾but increased rates of ureteric compromise.
• Surgically distort the normal vaginal axis
¾associated with persistent or de-novo POP.
• Transvaginal placement of biological graft
¾reduce anterior prolapse recurrence rates.
Natale F, et al. 2006 Curr Opin Urol
EBM for PFR- III
•
Grade B recommendation¾ Levator plication for the cure of posterior colpocele
¾ the use should be limited
¾ the increase of sexual and defecatory dysfunction.
•
Grade C recommendation¾ The assessment of POP surgery should include a
minimum data set that describes anatomy, symptoms and function, quality of life and cost efficacy
Natale F, et al. 2006 Curr Opin Urol
Thank you!
奇美醫院婦產部
婦女泌尿科 吳銘斌醫師
Weber AM 2003 Clin Obstet Gynecol
Weber AM 2003 Clin Obstet Gynecol
Abdominal sacro-colpopexy with synthetic mesh
Birch C Fynes MM 202 Curr Opin Obstet Gynecol
Transvaginal cystocele repair with mesh enforcement
Birch C 2005 Best Practice & Research Sig.
Sig.
Transobturator cystocele repair
Natale F, et al. 2006 Curr Opin Urol
The available data on permanent synthetic prostheses
