POP Flashcards
Describe the data comparing laparoscopic SCP to open SCP.
laparoscopic SCP- longer OR, less blood loss, short hospital stay
robot has more pain and more cost
what is the difference between mesh erosion vs exposure vs extrusion?
erosion into visera
exposure in the vagina, visible but flat
extrusion- visible and gradually protruding out
What does the evidence say about POSTERIOR colporrhaphy with synthetic or biologic grafts?
they do not improve outcomes!
What does the evidence say about ANTERIOR colporrhaphy with synthentic grafts?
synthetic polpropylene mesh improves anatomic outcomes, and some subjective outcomes. more blood loss, surgical time, cost
Name 6 contraindications to uterine preservation.
- history of uterine or cervical pathology
- AUB
- PMB
- Familial cancer syndrome
- tamofixen
- inability to follow up
Describe the step through which mesh is incorporated into the body.
Day 3
day 10
week 6
weeks 3-12
Day 3: inflammation process
Day 10; fibroblast ingrowth
Week 6: complete tissue ingrowth
week 3-12: doubling of the strength of the tissue
Name 3 categories of grafts
autologous graft- self
allograft- another human
xenograft- animal
How do biologic grafts compare to synthetic grafts in the following settings?
- SCP
- anterior compartment
- posterior compartment
- synthetic grafts are superior 91% subjective cure vs 68% subjective cure
- synthetic grafts have better outcomes than biologic. few studies show biologic grafts are better than native tissue.
- no difference or worse outcomes using synthetic grafts compared to biologic
What pore size is considered MACROporous?
> 75 micrometers
What pore size is considered MICROporous?
<10 micrometers
Describe the Amid Mesh Classification system?
I - totally macroporous
II - totally microporous (goretex)
III - macroporous with micorporous or braided components (merseline)
IV - biomaterial with submicronic pore size
what is the erosion rate of synthetic mesh in anterior compartment?
8.3-11%
What are some risk factors for SCP mesh erosion?
Properties of the mesh
- type of mesh, macro vs mircoporous
- weight of the mesh
TVH with SCP vs Abdominal SCP (8.6% vs 1.7%)
concomitant hysterectomy
Patient characteristics
smoking, DM, prolapse greater than stage 2, age >70
what size erosion is considered small?
<0.5 cm
how long could you treat a small <0.5cm mesh erosion with vaginal estrogen for before moving on?
6-12 weeks
committee opinion
What is the risk of reoperation after SCP?
6%
Describe the steps of the manchester procedure.
1.Mark 4 points on the vaginal epithelium (just proximal to the UVJ, one on either side of the anterior lip of the cervix, posterior fornix.
- dissect the vaginal epithelium from the underlying muscularis and excise the tissue.
- ligate the uterosacral ligaments at the level of the cervix.
- Dissect the bladder and rectum away from the cervix and amputate the cervix leaving about 3 cm of cervical tissue. Place a dilator in the cervical os to maintain patency.
- isolate the SSL and place a suture and pass it through the cervix.
- tie the uterosacral together in front of the cervix.
- anchor the anterior epithelium to the cervix. Anchor the posterior vaginal epithelium to the posterior cervix.
- close the vaginal epithelium ensuring cervical patency.
- suspend the uterus and cervix to the SSL
What types of patients would benefit from a manchester procedure?
-cervical elongation
-young, want to keep uterus
-stay extra peritoneal
whats the evidence for sex with pessary in place?
safe for patients, no evidence on their partners.
reasonable to attempt with ring, and dish
can you reuse pessaries that are not sent home with the patient after a fitting?
no clinical trials to say no, at the very least sterilize it
patient thinks the pessary makes her vagina smell. What should she use to reduce discharge?
drqy swab, water or saline,
no evidence for cleansing agents.
also, more frequent office visits do not reduce discharge
does a pessary prevent prolapse progression?
small studies suggest that it might, but there is limited evidence to say that definitively
What is the evidence for hydroxyquinoline-based gel and pessary use?
unlikely to improve patient satisfaction
What’s the evidence regarding vaginal estrogen and pessary?
can be offered but has not been proven to reduce epithelial abrasions.
it has been associated with longer pessary use.
What are the 4 classifications of vaginal epithelial injury with pessary use?
(1) erythema,
(2) abrasion- superficial injury
(3) erosion/ulceration-deep
(4) fistula
pessary patient has erosion. how do you manage?
pessary holiday for 4 weeks
add vaginal estrogen and keep the pessary in
change the pessary size and shape
pessary patient has an erosion which is not healing with holiday, change in pessary size/shape, or adding vaginal estrogen.
What next?
vaginal biopsy
pessaries do not cause cancer, but they can obscure cancer or precancer.
Incarcerted pessary, but the case is not urgent. name 2 conservative measures you can try?
vaginal estrogen and lidocaine gel
consider CT before removal in the OR to check for fistula.
Your longtem pessary patient, now needs a smaller size pessary. What is the proposed mechanism behind this?
pessary may allow the levator muscles to recover and shorten over time
pessary patient is very bothered by vaginal discharge.
What are your options?
consider swab for vaginitis or more frequent cleanings
contraindications to pessary use
history of vaginal mesh erosion
severe postirradiation scarring
nonhealing ulcers
undiagnosed vaginal bleeding
severe vaginal infection.
