PROLASSO E CHIRURGIA FASCIALE - Compartimento posteriore

PROLASSO E CHIRURGIA FASCIALE
Compartimento posteriore
marco soligo
Azienda Ospedaliera
Istituti Clinici di Perfezionamento
Ospedale di rilievo nazionale e di alta specializzazione convenzionato con l’Università degli Studi di Milano
Ospedale dei Bambini V. Buzzi
Dipartimento della Donna, Mamma e Neonato
Direttore prof. Enrico Ferrazzi
3°CongressoNazionaleGLUP
Treviso1-2Ottobre2015

To date we are unaware of any studies that have addressed how
often a posterior enterocele and or sigmoidocele coexist with a
rectocele and how the presence of these defects impacts on
ultimate surgical outcomes.
Am J Obstet Gynecol. 2015 Sep 5. pii: S0002-9378(15)01025-X. doi:
10.1016/j.ajog.2015.09.001. [Epub ahead of print]
Consistently Inconsistent, the Posterior Vaginal Wall.
Hale DS, Fenner D.

Vaginal approach 99%
Native tissues 98.8%
Posterior repair

Traditional posterior colporraphy
Success rate 83% (76%-96%)
Dyspareunia 18%
Defecatory dysfunction 17%

Karram & Maher 2013

vs
Vaginal approach
Tansanal approach

Vaginal approach Tansanal approach
vs
… which one the Outcome?
Vaginal bulging (POP)?
Functional: (Constipation/OD)?

Posterior Colporraphy vs Transanal surgery
Further Surgery
(enterocele)
TA TV
Post. Vag. Prolapse
Ap
TA TV
Kahn et al 1999* 27% 8% -0.2 -1.4 -1.0 -1.4
57 pts. (f-up 25 m.os) p=0.10 p< 0.0001 p= 0.40
Author
Rectal Exam
TA TV
Nieminen et al. 2003# 67% 7% -1.36 -2.8
30 pts. (f-up 12 m.os) p=0.01 p=0.01
# No L.A. plication
Post. POP
TA TV
* L.A. plication
No Statistically Significant Difference for Ano-rectal Symptoms nor
Dyspareunia

Farid et al 2010:
Transperineal (+ LA plication) vs Transanal
Rectocele Significant smaller on
defaecography
Functional outcome
(modified OD questionnaire)
better after transperineal repair

Preoperative n.
(%)
Postoperative n.
(%)
Value of p
Constipation 64/115 (55%) 39/116 (34%) 0.002
Difficult stool passage 62/64(97%) 38/39 (97%) n.s
Mean Wexner’s score for
Constipation 11.9
10.4 n.s §
Anal Incontinence (A.I.) 25/107 (23%) 12/109 (11%) 0.019
Mean Wexner’s score for
A.I. 6,8 3.7
n.s. §
Sexually active 45/84 (53,6) 47/95 (49,5) n.s.
Dyspareunia 23/84 (27,4) 23/95 (24,2) n.s.
Soligo et al. ICS 2005Fisher’s exact test; § Student t-test
Functional aspects
116 pts. Mean age 64 y (35-
87); BMI 26
Mean F-Up 22 months (3-65)
Posterior vaginal repair

Vaginal approach Tansanal approach
&
Combined
Success rate 71% (Defecography, 6 months)
Dyspareunia 41%
Van Dam et al 2000:
Transperineal (+ LA plication) vs Transanal

Site specific defect repair
Author N pts F-Up Mean
Months
Anatomical
Efficacy %
Constip
Pre / Post %
A.I.
I Pre / Post %
DeNovo
dyspareunia
Cundiff et al 1998 69 12 82 46 /13 13 / 8 1 (2)
Porter et al 1999 125 6 82 60 /50 24 /21 3(4)
Kenton et al 1999 66 12 90 41/57 30 / - 3 (7)
Glavind & Madsen
2000
67 3 100 / / 2 (3)
Singh et al 2003 42 18 92 / 9 / 5 0

Posterior Colporraphy vs Site specific defect repair
(retrospective analysis)
Posterior Colporrhaphy* 14% 4% -2.7
(183 pts.)
Discrete Site-Specific 33% 11%
-2.2
Defect Repair (124 pts.)
Rectocele
II
P= .001
Bp point
* Plication of the endopelvic connective tissues in the midline
307 women (F-up 1 year)
Abramov et al. 2005
P= .001
Rectocele
≥ III
P= .02

Prospective randomized trial
(F-up 1 year)
Post. Colporraphy
(37 pts)
Site specific repair
(37 pts)
Site specific repair +
biologic mesh
(32 pts)
Anatomical Failure rate
4/28 (14%)
6/27 (22%)
12/26 (46%)*
* Significantly different
No significant differences
in sexual & bowel
symptoms
Paraiso et al. 2006

Key points for surgery
• In patients with advanced prolapse and a widened genital
hiatus the only way to address the gaping vagina is to
routinely perform a distal levatorplasty.
•…aggressive reattachment of the uppermost portion of the full
thickness of the posterior vaginal wall (level III support) to the
uterosacral ligament provides significant support to the
posterior vaginal wall in patients with high rectoceles or
rectoceles in conjunction with a posterior enterocele.
Karram & Maher 2013

• Elytrorrhaphy:
• Posterior
colporrhaphy:
• Colpoperineorrhaphy
denudation and closure of
the posterior vaginal wall
Fricke JC 1833
more aggressive plication in
the inferior vaginal portion
Simon G 1867
Hegar 1870
Levator ani muscle
approximation in the
lower part of the vagina

Grazie

PROLASSO E CHIRURGIA FASCIALE - Compartimento posteriore

More Related Content

What's hot

Viewers also liked

More from GLUP2010

Recently uploaded

PROLASSO E CHIRURGIA FASCIALE - Compartimento posteriore