Dr Stephen JefferyUniversity of Cape TownSouth Africa
Disclosures
• Travel support from Bard, J&J, Boston Scientific, AMS
• Speakers fees Bard, J&J, Boston Scientific, AMS
• Educational grant Karl Storz, Boston Scientific
A number of questions?
Vaginally or Abdominally?
Hysterectomy or not ?
Mesh or no mesh?
And this one?
Does one size fit all in the selection of a surgical procedure for
uterine prolapse?
Uterine Prolapse: Options
Vaginal (+/- Hysterectomy)
Uterosacral Ligament Suspension
Sacrospinous Fixation
Manchester Repair
Mesh procedure
Colpocleisis
Abdominal Sacrocolpopexy(+/-Hysterectomy)
Total Hysterectomy
Supracervical Hysterectomy
Sacrohysteropexy
(Uterosacral ligament plication)
N=941Severe complications 3%Improvement in sexual activity 20%Satisfaction 93%OAB decrease 50%USI increase 14%
If you are doing somethingvaginally
You have to do something to support the vault
Support options
Uterosacral ligament suspension Sacrospinous ligament fixation
Sacrospinous Fixation
SSF: Outomes
Review: Beer et al
2390 Women
Cure 67% to 98%
Beer et al J Obs Gyn Repr Biol II9(2005) I44-I55
Sacrospinous fixation
Sacrospinous fixation
Miya Hook
Deschamps Ligature Carrier
Capio
FIXT
Digitex
Capio Traditional
Total op time 71 min (+/- 24) 105 min (+/-31)Blood loss 159 ml (+/- 82) 98 ml (+/-40)
30% reduction in operating time using the Capio
Sacrospinous Fixation
Complications of SSF:
Haemorrhage
Buttock pain
Nerve injury
Rectal injury
Stress incontinence
Vaginal stenosis
Anterior vaginal wall prolapse
Uterosacral Ligament Suspension: With vaginal hysterectomy
Uterosacral Ligament Suspension: With retention of the uterus
Ureteric Injury 1.8%
(0.6% re-implantation)
Blood transfusion 1.3%
Re-operation 9.4%
Type of suture for HUSLS
• PDS versus prolene
• No diffs in outcomes
• Higher erosion in prolene group
A question
Is it better to leave the prolapsing uterus or must we remove it then ?
Advantages of Uterine Preservation
Less bleeding
Psychological advantage
Fertility
Less ureteric injury
May be quicker
Uterosacral ligament suspension
Sacrospinous Hysteropexy vsSacrospinous colpopexy
ColpopexyN=36
HysteropexyN=34
P-value
Subjective 86% 78% 0.70
Objective 72% 74% 1.0
Op time 91 min 59 min 0.01
Blood Loss 402 ml 198ml 0.01
Maher CF IUJ 2001, 6; 381-385
My feelings about uterine sparing
If it is a large bulky barrel-shaped cervix then it should be removed
Manchester Repair
Manchester Repair
Amputation of Cervix
Shortening of Uterosacral Ligaments and Re-attachment
Closure with a Sturmdorf Suture
Manchester Repair
Leon Clement Le Fort(1829-1893)
Nouveau procédé pour la guérison du prolapsus utérin. Bull gén de thérapie. 1877: 92; 337-44)
You want to know but are too afraid to ask!
What about mesh?
Which products may be of use?
Uphold (Boston)
Nuvia (Bard)
Elevate (American Medical Systems)
Uphold
Elevate
Nuvia
Abdominal approach
Abdominal approach
Young women
Sexually active
Healthy, low BMI
Physically active
Abdominal approach: Options
Sacrohysteropexy
Total Hyst and sacrocolpopexy
Supracervical Hyst and sacrocolpopexy
Uterosacral ligament suspension
Sacrohysteropexy
Sacrohysteropexy
What is better
Sacrohysteropexyvs
Hysterectomy and Sacrocolpexy
Sacrohysteropexy Hysterectomyand Sacrocolpopexy
OP Time + +++
Mesh Erosion - +++
OP blood loss + +++
Addresses anterior prolapse
+/- +++
Option of pregnancy +++ -
Problem of future uterine pathology
++++ -
SacrocolpopexyN= 272
LAVH + SacrocolpopexyN= 130
P value
Erosion/Extrusion
0.7% 2.3% 0.18
What about Supracervical Hysterectomy?
Complications of colpopexy with and without hysterectomy
Tan-Kim Int Urogyn J 22(2):205-12
Data Comparing Vaginal vs Abdominal
Vaginal hyst and USLS vs Hysteropexy
If you are going to leave the uterus
Uterine Prolapse: Options
Vaginal (+/- Hysterectomy)
Uterosacral Ligament Suspension
Sacrospinous Fixation
Manchester Repair
Mesh procedure
Colpocleisis
Abdominal Sacrocolpopexy(+/-Hysterectomy)
Total Hysterectomy
Supracervical Hysterectomy
Sacrohysteropexy
(Uterosacral ligament plication)
Unanswered questions
Vaginal or abdominal approach for advanced uterine prolapse? What’s better?
Is HUSLS or SSF better?
Is hysteropexy as good as vaginal hyst at the vaginal approach
When you do a sacrocolpopexy for uterine prolapse –should you do Supracervical or Total Hysterectomy?
Role of Mesh Kits