innovative treatment options for pelvic organ prolapse travis l. bullock, md
TRANSCRIPT
Innovative Treatment Options for Pelvic Organ
Prolapse
Travis L. Bullock, MD
A condition in which the pelvic organs (bladder, uterus, or rectum) “fall” onto the vaginal wall and in some patients bulge outside the vagina.
A type of “hernia” due to weakening of the muscles and connective tissues of the pelvis.
Affects 50% of women, however only 20% of those women have significant symptoms.
Unfortunately, only about half of these women seek medical help despite a significant impact on their quality of life.
Epidemiology of POP
Epidemiology of POP
One of the most common gynecologic surgeries performed
>500,000 procedures performed annually
> $1 Billion spent yearly on surgery alone
11% lifetime risk of surgery by 80yo
Up to 30% will have >1 surgery for POP highlighting the high failure rate of current procedures
Surgery for POP
20-29 30-39 40-49 50-59 60-69 70-790
2
4
6
8
10
12
Projected Female Population
2000 2010 2030 20500
5
10
15
20
25
60-69 yrs70-79 yrs80+ yrs
Population of women >60yo is expected to increase by 72%
Women >60yo are more likely to seek care than their younger counterparts
Prevalence of Pelvic Floor Disorders
50s 60s 70s 80s0
50000
100000
150000
200000
250000
300000
350000
20002030
Demand for services to care for pelvic floor disorders will increase at twice the rate of the growth of the general population!
– Age– Parity– Family history of prolapse (collagen)– Post menopausal state– Repetitive pressure on the pelvis
(constipation, chronic cough, obesity)– Prior pelvic surgery such as hysterectomy. – Caucasian 3X more common than African
American women
Risk Factors
Many women may have no symptoms. More advanced prolapse may experience some or all of the following:
– Vaginal or rectal pressure– You may feel or see a bulge protruding from
the vagina– Difficulty emptying the bladder– Inconsistent urinary stream– Trapping of stool in the rectum– The need to place a finger in the vagina to
empty the bladder or bowel– Vaginal irritation– Low backache– Spotting of blood on the underwear– Recurrent bladder infections
Prolapse Symptoms
Named for the anatomic area or organ prolapsing
– Anterior wall = Cystocele– Posterior wall = Rectocele– Apical Prolapse
EnteroceleUterine prolapseVaginal vault prolapse
Often have more than one type of prolapse
Types of Prolapse
Cystocele
Rectocele
Apical prolapse
Enterocele
Anatomy of Pelvic Support
Boney pelvic framework
Endopelvic fascia
Levator ani muscles
Collagenous connective tissue attachments to the pelvic side walls
Anatomy of Pelvic Support
Level I: Parametrium and paracolpium (Uterosacral and Cardinal ligaments). Supports the upper 1/3 of vagina
Level II: Direct lateral attachments to the arcus tendineus (pubocervical fascia). Supports the mid 1/3 of vagina
Level III: Vagina fuses with urethra and perineal body. Supports distal 1/3 of vagina.
Evaluation Examine in lithotomy position
Standing if degree of prolapse does not correlate with symptomatology
Bottom blade of speculum
Valsalva or cough vigorously and note relationship of pelvic organs
Rectovaginal exam
Perineal body
Vaginal mucosa (atrophy, fissures, ulcers)
Incontinence with and without prolapse reduction
PVR
Baden-Walker or “Half-way” system
Easy to use and widely understood
Most dependent position of pelvic organs during maximal straining
1st degree– Half-way to the hymen
2nd degree– To the hymen
3rd degree– Beyond the hymen
Prolapse Grading4 grades popularized by
Raz
1: minimal hypermobility of the bladder
2: bladder base to introitus with straining
3: bladder base outside introitus with straining
4: bladder base outside introitus at rest
POP-QIn 1996 ISC/AUGS developed the POPQ
Standardized, site specific system to quantify and classify POP
Measurements at 9 specific sites relative to the hymen
Inter-examiner and Intra-examiner reproducibility
Can be bulky and time consuming
Used mostly for research
Treatment Options for POP
Non-surgical– PFME and Behavioral techniques– Pessary
Surgical– >100 procedures described– Colporrhaphy– Sacrospinous fixation– Mesh augmentation– Sacral Culpopexy
Open Laparoscopic Robotic
Behavioral changes– Weight loss, avoiding heavy lifting, correcting a chronic
cough (quitting smoking), or preventing constipation that contributes to straining to have a bowel movement.
Pelvic floor exercises (Kegels)– Cannot reverse the prolapse, but contracting strong
pelvic floor muscles when lifting or bearing down may prevent pelvic organ prolapse from becoming worse or help relieve symptoms.
Vaginal pessary – the most common non-surgical treatment for prolapse.
Non-surgical Treatment
Worn in the vagina to support prolapsed organ
Must be specially fitted
Removed for periodic cleanings
May be associated with vaginal discharge and erosions
Favorable risk-benefit ratio
Vaginal Pessary
Colporrhaphy
Plication of fibromuscular tissues of vaginal wall
Most common prolapse procedure performed
Minimally invasive
May be associated with vaginal scaring or shortening
10-70% failure rate, 30% reoperation rate
Sacrospinous Ligament Fixation
Attachment of the apex of the vagina to the sacrospinous ligament
Often combined with colporrhaphy
Hysterectomy not always required
Technically challenging
Extensive dissection and retraction may be required
Deviates the vagina
Mesh Augmentation
Substitute “damaged” tissues with synthetic material
Decreased recurrence rate as compared to traditional plication
Easy to perform with familiar trocar passes
Can be associated with pain and erosions if not familiar with the technique
Short term data is favorable, but still maturing
Mesh Augmentation
American Medical Systems– Apogee, Perigee,
Elevate
Gynecare– Prolift
Bard– Avaulta
Boston Scientific– Pinnacle, Uphold
Sacral Culpopexy“Gold Standard” for uterine and vaginal
vault prolapse
A graft if used to suspend the vagina to the inside of the sacrum
Maintains anatomical position
Preserves vaginal axis and maintains vaginal length
Low recurrence rate
Traditionally performed with an abdominal incision
Can be completed laparoscopically using the da Vinci robotic system
Sacral Culpopexy
Open (abdominal)– Good long-term results: 93-100%
success rates with durable repair– Increased morbidity: invasive mid-line
incision leading to prolonged recovery time (5-6 hospital days)
– 5% of all prolapse proceduresLaparoscopic
– Reproduce open approach minimally invasively
– Technically difficult learning curve due to complex suturing and dissection
Now Robotic …
History of Robotics in Medicine
Term “robot” was first coined in 1921 by the Czeck writer Karel Capek is his play Rossum’s Universal Robots
Robota = forced labor
History of Robotics in Medicine
1985-PUMA 560 CT guided brain biopsy
1987-first CCK with robotic assistance
1998-PROBOT for transurethral resection
1992-ROBODOC (Integrated
Surgical Supplies) used in orthopedics
History of Robots in Medicine
1993-AESOP (Computer Motion, INC).
First robot approved by the FDA
1998-Zeus– Surgeon control center and 3
robotic arms. – First fully endoscopic robotic
procedure (CABG)– Computer Motion and Intuitive
Surgical merged in June 2003
2000-da Vinci Surgical System.
da Vinci Surgical SystemApproved by the FDA in 2000
for laparoscopic surgery
Surgeon console and patient side robotic cart with 3 or 4 arms
“Master-Slave” surgical system
High-Definition 3-D Visualization
EndoWrist instruments
>800 in use in the United States and Europe
Cost = $1.2-1.75 million
Surgeon Benefits
High resolution 3D vision
EndoWristed Instruments with 7 degrees of freedom
Filters out tremor
Enhanced dexterity
Comfortable
Ease of suturing
Short learning curve
Overcomes limitations of traditional laparoscopy while replicating open approach
Drawbacks with Conventional Laparoscopic Surgery
Surgeon operates from a 2D image
Straight, rigid instruments (limited range of motion)
Reduced dexterity, precision and control
Unsteady camera controlled by assistant
Greater surgeon fatigue
Makes complex operations more difficult
Applications
General surgery– Pancreatectomy, Whipple, Liver resection and
Transplantation, CCK, Nissen, Gastric bypass
Cardiothoracic Surgery– CABG, Mitral valve repair, Lung resection
GYN– Hysterectomy, Myomectomy, Oncology
Urology– Prostatectomy, Nephrectomy, Partial Nephrectomy,
Cystectomy, Adrenalectomy, Pyeloplasy, Ureteral Reimplantation, VV fistula, Sacral Culpopexy
da Vinci Sacrocolpopexy
Represents a state-of-the-art minimally invasive approach to surgical correction of vaginal vault or uterine prolapse by resupporting the vagina to the sacrum using a polypropylene mesh.
Preparation
Patient Selection (First 5 cases):
Relatively thin patient (BMI<30)
Healthy with few comorbidites
No or few abdominal surgeries
Reasonable sized uterus, if present
Vaginal vault prolapse before uterine prolapse
Patient Positioning
Place the patient on the table in the supine position.
Pad all bony prominences and employ anti-skid methods (e.g., vacuum bean bag, etc.) due to moderate to steep Trendelenburg position (>20).
A modified dorsal lithotomy position is utilized; the patient’s legs are separated and flexed using adjustable leg stirrups with boots (e.g., Allen stirrups).
Port Placement and Set-up
Vaginal Manipulation
Vaginal manipulation is necessarySpecial planning is required to maintain intra-
operative access to the vaginal and rectal manipulators:
– Use rounded EEA™ (End-to-End Anastomosis) sizers to manipulate the vagina
– An EEA™ sizer in both the vagina (31-33 mm) and rectum (29 mm) allows for clear identification and easy dissection of the rectovaginal septum
EEA™ sizers from Autosuture™
Develop Anterior Bladder Flap
Develop Rectovaginal space
Polyproplylene Mesh
Durable
Permanent
Porous
Non-immunogenic
Anterior Mesh Placement
Posterior Mesh Attachment
Develop Presacral Space and Locate Anterior Longitudinal Ligament
Adjust Mesh Tension
Attach Mesh to Sacral Promontory
Close Peritoneum
Patient Benefits
“Gold Standard”
Less invasive
Less pain
Less scaring
Less blood loss and need for transfusion
Shorter hospital stay
Faster recovery and quicker return to activities
Robotic Sacrocolpopexy: Results
30 consecutive patients with high-grade apical prolapseGreatly reduced morbidity: patients left the hospital in 1 day as
opposed to 2-5 daysDurability of results equals long-term results of open procedureLow complication rate and high patient satisfactionPotentially, many more women will be able to be offered the
strongest repair of prolapse while minimizing morbidity
Management of Urethra
Significant prolapse may mask SUI due to urethral kinking.
Occult SUI and may be seen in up to 25% of patients
Concomitant sling may be performed based on urodynamics
Conclusions POP is a common condition
Demand for treatment is expected to exponentially increase as the population ages
Treatment options include observation, pessary, or surgery
Colporrhaphy is minimally invasive, but with a high recurrence rate
Mesh vaginal procedures may decrease this risk, but data still maturing
Open Sacral Culpopexy is the “gold standard”, but maximally invasive
Robotic surgery may combine the best of all worlds
Questions?