Surgeries for urogynaecology Flashcards
If a woman presents to you asking about ‘mesh’ what would you tell her?
The US FDA have issued a warning against the use of TV mesh for pelvic organ prolapse
This is a separate issue to the use of mesh for mid urethral slings for the treatment of SUI
There is an extensive body of literature that supports the use of mesh in context of SUI
MUS is highly effective in the short and medium term for the treatment of SUI
MUS carries lower risk than other continence procedures
MUS is the operation of choice in USA, Europe and Australia for treatment of SUI
What are the main differences between the transobturator and retropubic approaches to MUS for SUI?
- TO approach associated with higher incidence of pelvic and groin pain post operatively
- RP approach associated with higher rate of visceral injury
- RP more effective than TO which has higher failure rate
- same rates of mesh exposure - 2% each
- easier to completely remove mesh when placed RP than TO
- higher recurrent operation rates with TO than RP
For which women would you offer TO approach over RP approach for Mid urethra sling?
- women who have had extensive abdominal surgery previously (higher rate of visceral injury)
- women who are on anti-coagulation and unable to cease it
- in women with compromised voiding pre-operatively
What are the complications that a women undergoing MUS procedure must be consented for?
bleeding, damage to the bladder, bowel, urethra and major vessel perforation
voiding difficulties which may require self catheterisation, loosening or even division of the sling later on - which may result in recurrent SUI
de novo urge incontinence or worsening of overactive bladder symptoms may occur
sling insertion may cause pain, and with the TO approach possibly groin pain
This may become intractable but is usually short lived
With regards to mesh erosion, how would you advise a women interested in MUS for SUI?
- mesh erosion occurs in about 5% of women who under insertion of mesh material
- only a small number of these women have ongoing issues
- 1/150 women will require removal of MUS for mesh erosion symptoms - in these cases 80% have no further symptoms
What is RANZCOG’s current stance on the use of Transvaginal mesh for vaginal prolapse repair?
- Transvaginal mesh is considered by the FDA as a class III ‘high risk device’ due to complications with mesh erosion
- a premarket approval must be undertaken before TV mesh can be used in Australia and NZ ‘special access scheme’
What are alternative management options to the TV mesh for vaginal prolapse?
- pelvic floor muscle training
- vaginal support pessaries
- conventional native tissue repair
- open or laparoscopic abdominal sacrocolpopexy
What are some complications of TV mesh placement for vaginal prolapse?
Note - women can only have placement of TV mesh for vaginal prolapse under the ‘special access scheme’
- mesh erosion
- mesh exposure
- scarring/stricture formation
- fistula formation
- dypaerunia
- chronic pain
What are some complications of TV mesh placement for vaginal prolapse?
Note - women can only have placement of TV mesh for vaginal prolapse under the ‘special access scheme’
- mesh erosion
- mesh exposure
- scarring/stricture formation
- fistula formation
- dypaerunia
- chronic pain
Which patients may benefit from the use of TV mesh placement for vaginal prolapse repair?
- difficult to answer as risk is acknowledged
- women with recurrent prolapse in the anterior compartment
- obese women
- those women with chronically raised intra-abdominal pressure (severe asthma, constipation)
- the young
- stage 3 and 4 prolapse
For an anterior compartment POP which surgical options are available?
anterior repair
fascial plication
site specific repair
paravaginal repair
for an apical compartment prolapse which surgical options are available?
sacrospinous colpopexy
uterosacral ligement fixation
sacrocolpopexy
manchester repair
For a posterior compartment POP which surgical options are available?
posterior repair fascial plication site-specific repair levator ani-plication perineorrhaphy
Describe sacrospinous colpopexy
- attachment of the vaginal vault to sacrospinous ligament using delayed absorbable suture - usually 2x sutures on the right
- accessed via posterior wall dissection - via pararectal space - ischial spine palpated and suture inserted into ligament (using a Miya hook)
Which nerve structure can be damaged during a sacrospinous colpopexy?
- pudendal neuromuscular bundle
