stephen t jeffery - 2016.iuga.org€¦ · stephen t jeffery university of cape town, south africa....

Stephen T Jeffery

University of Cape Town, South Africa

Disclosures

Educational Grants

J&J, Bard, AMS, Karl Storz, Boston Scientific, Covidien, Allergan

Travel Grants

Bard, Boston Scientific, Covidien

Some of you may be thinking

It’s impossible to do it safely so don’t do it at all.

Now sit down!

How to do it “safely”

Rules for safe mesh placement

① Get proper consent

② Robust indications

③ Make sure sacrocolpopexy or native tissue is not a better idea

④ Only for high volume surgeons

⑤ Avoid posterior mesh

⑥ Choose an appropriate kit

How to choose a mesh

Single incision device

Apical support

Small size mesh

Lightweight mesh

Full post-insertion adjustability

Avoid the trocar systems

Possible products?

Uphold

Nuvia

Uphold

Dyspareunia with Uphold

Pre –op 13.4%

Post-op 8.3%

No significant change

Of the 13 with pre-op, 12 had none post op

7 post –op and none were related to mesh tenderness

Technique

Consent

1. Vaginal preparation

Estrogen cream pre-operatively

2. Infiltration

2. Infiltration

Use between 150 and 200ml

2. The incision and dissection

3. Dissection to Sacrospinous Ligament

4. Placement of mesh

5. Adjustment of mesh

Dealing with complications

Bladder injury

Deeper dissection with mesh kits

Careful in scarred / previous surgery

Check for the ‘chardonnay sign’ during dissection

Bladder injury

If injured - ?Avoid putting in mesh

Routine cystoscopy after mesh insertion

Rectal Injury

DON’T insert the mesh!

Erosion / Exposure

Risk factors for Exposure

Erosions 16.8%

Increase in erosion risk

Concomitant hysterectomy

Decreased erosion risk

Vaginal estrogens

Experienced surgeon

Gullibert F et al Gynecol Obstet Fertil. 2009 Jun;37(6):470-5

How to avoid Exposure

Beware

Pelvic pain syndromes

Endometriosis

Vulvodynia

IC

Dyspareunia

Sexual dysfunction

Who else would I do a mesh in?

Large hiatus

GH+PB>10?

Avulsion injury

Case

• 52 year old with recurrent

stage III anterior wall

prolapse

• Central defect remains

with apical support

• Options?