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