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Uterine prolapse Diagnostic and surgical management (1). Dr. Laleh AMINI French Board of OB&GYN Jam General Hospital Ir CS Annual Meeting June 2 nd 2011 Tehran-Iran. Definition.
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Uterine prolapseDiagnostic and surgical management (1) Dr. Laleh AMINI French Board of OB&GYN Jam General Hospital Ir CS Annual Meeting June 2nd 2011 Tehran-Iran
Definition ICS-IUGA Standardized Terminology in Urinary Incontinence and pelvic floor disorders in www. ir-cs.com Herniation of genital organ from vaginal mucosa (Different from herniation from rectum)
Classification • Baden et al/ Ingelmann-Sundberg POP-Q pelvic organ prolapse quantification • Anatomic • Should be associated to the health care questionnaire from ICIQ, ICIQ-SF
POP-Q stages • Stage 0 AaApBaBp C D -3 cm • Stage 1 -1 • Stage 2 -1- +1 • Stage 3 +1 • Stage 4 complete vaginal procidencia
Physiopathology It s essential to know anatomy / physiology then to understand patho-physiology in order to think of how to repair. Great Names: De Lancey and Papa Petros
SUI FACTORS POP FACTORS Parity Aging, menopause Hormonotherapie Diabete Obesite hysterectomie dementia Abdominal hyperpressure (sports),COPD Obstructifsanorectal symptoms Obesity Pregnancy VD Hysterectomie Age parity
Genetics and constitutional *Genetics and constitutional factors incriminated because of SUI and POP in nulliparous women ( Norvegian National Registry ( n=38 000) * homozygote and heterozygote twins ( Swedish) twin Registry n=3376/n=5067) * Chromosome 9q21 predisposition gene for Pelvic floor disorders *Connective tissue disease with 30% less collagen concentrations in the POP population
Surgical Treatment Are considered malpractice or obsolete all surgical procedures using natural defective tissus ( Macenroth, Kapanji, ventrofixation…) Patient will come back with recurrence or will not come back at all!
Pelvic Organ Prolapse Surgical Treatment • Abdominal Approach • Sacro-Colpopexy • Laparotomy • Laparoscopy • Vaginal approach • Without prosthesis Sacro-spinous fixation Richter • Unilateral • Bilateral • With prothesis
Cochrane Database Syst Revue 2006 on conservative Managament • >50 publications laparoscopic sacrocolpopexy since 15 years • Recurrence after laparoscopy <10% • NICE recommendations 2008 on vaginal surgeries based on 10 randomized clinical trials. • Recurrence 9%,18% and 30% with synthetique, biologic and without prothese • recommendations AFNOR NF S94-801 for mesh quality
+/- Anti-incontinence surgery? Associated to systematic prophylactic anti incontinence surgery in our practice • 30% de novo SUI without anti-incontinence surgery • Burch colpo suspension procedure with 2 or 4 sutures in laparotomy • Mid-urethral sling procedures when done by laparoscopy • When a rectocele repair is indicated it s done at the beginning of the surgery.