Microsoft PowerPoint - (2009-04-11 TAMIG) Debate hysterectomize or not in pelvic reconstructive surgery.ppt2008.06.22



Problems to be resolved during pelvic reconstructive surgery (PRS)?
• To mesh or not ? (Wu MP 2008 Taiwanese J Obstet Gynecol)
• Two-step or one-step for SUI and POP? • To hysterectomize or not?
– Is hysterectomy mandatory during pelvic reconstructive surgery?
The myth of uterus --Hysterectomize or not?
woman= man with womb?
To hysterectomize or not during PRS
– Q1: Is hysterectomy mandatory during PRS? – Q2: Does hysterectomy (or uterine preservation)
compromise the success rate? – Q3: Does hysterectomy increase the surgical
complication rate? – Q4: Does hysterectomy affect vesico-urinary
function? – Q5: The further pathologic condition after surgery?
• Cervical malignancy, uterine malignancy, • Abnormal uterine bleeding, Childbearing,

•
– 75
– 80
VTH+ A-P colporrhaphy
Vaginal repair of anterior, posterior compartment + mesh
Sacro-spinous lig. suspension
Biologic materials**
Huang & Wu 2008 Incont Pelvic Floor Dysfun
*Prolift (J&J); Perigee+Apogee (AMS); post. IVS (Tyco); Nazca (Promedon)
**SIS (Cook); Pelvicol (Bard)
Hysterectomize ?
X
• Efficacy & surgical failure rate • Alternatives to hysterectomy • The effect on utero-vesical function • The effect on surgical complications • Further cancerous or pre-cancerous lesion • Further surgery for abnormal uterine bleeding • Other factors
Standard procedure vs alternative
hysterectomy and uterine preservation – No available
• Non-inferiority trial – No available
Abdominal sacrocolpopexy (ASC)
• Abdominal sacrocolpopexy: a comprehensive review (Nygaard IE et al. 2004 Obstet Gynecol).
• Follow-up duration for most studies ranged from 6 months to 3 years.
• The success rate, when defined as lack of apical prolapse postoperatively, ranged from 78-100% and when defined as no postoperative prolapse, from 58- 100%.
• The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range 0-18.2%) and 4.9% (range 1.2% to 30.9%), respectively.
Alternatives to hysterectomy • Transvaginal
• Abdominal – Sacrohysteropexy/sacrocervicopexy – Pectineal ligament suspension
• Combined: – Retropubic suspension
Efficacy & surgical failure rate
transvaginal sacrospinous uterine suspension (SSUS)
• 60 patients – 33 in the risk factor assessment 84.8% (28/33) – 27 in a modified treatment to eliminate identified risk
factors 96.3% (26/27). • failure rate
– elongated cervix (3 of 4, 75%) – third degree uterine prolapse (3 of 4, 75%) – without either of these risk factors (6.9%, 2/29) [p =
0.007]. – Rx: Concomitant partial trachelectomy
Lin TY, Su TH et al. 2005 J Formos Med Assoc
The effect of hysterectomy on utero-vesical function
The impact of simple hysterectomy upon lower urinary function is still controversial.
• urinary symptoms • urodynamic parameters • Mobility bladder neck • cross-sectional studies • prospective controlled studied
• Long CY: 2008 Incont Pelvic Floor Dysfunct
Epidemiological cross-sectional studies
The influence of age, parity, duration of previous oral contraceptive use, hysterectomy and menopause on the prevalence of urinary incontinence was evaluated by means of a postal questionnaire in women 46 to 86 years old who resided in Göteborg, Sweden. Urinary incontinence was more prevalent in women who had undergone hysterectomy (p < 0.05) (20.8% VS 16.4%)
Prospective studies of urinary symptoms
Urodynamic controlled studies
ATH and BSO did not change the postoperative bladder loading functions in asymptomatic patients but that significant changes occurred in urethral functions. - average urethral length, functional urethral length and maximum urethral closing pressure were decreased - bladder discharging time was increased
Prospective studies of bladder neck mobility
• Demerci et al concluded that the cephalocaudal mobility of the bladder neck decreased during stress after ATH.
• Long et al who reported that the ventrodorsal mobility of the bladder neck decreased significantly following LH.
• Hypermobility of the bladder neck improved following hysterectomy.
The effect of hysterectomy on utero-vesical function
• Several cross-sectional studies – retrospective analyses, – an increase in the relative risk of urinary symptoms
• Numerous prospective controlled studied – urinary symptoms: improved – urodynamic parameters: improved or stable – Mobility bladder neck: decreased
• Simple hysterectomy has no detrimental effects on vesico-urethral function.
• Long CY: 2008 Incont Pelvic Floor Dysfunct
Complications: infection & mesh erosion
(Imparato E et al. 1992) 71 women who underwent sacrocolpopexy,
• 57 with concurrent hysterectomy; 21/57 had synthetic mesh, 36/ 57, the vaginal apex was directly approximated to the anterior vertebral longitudinal ligament.
• Mesh “rejection” occurred in 3 of 21 (14%) patients after hysterectomy, (2 women with Teflon; 1 woman with Mersilene), compared with none of the other women.
(Culligan PJ et al. 2002) Similarly, mesh erosion in 3 of 11 (27%) women who underwent concomitant total hysterectomy, compared with 3 of 234 (1.3%) who did not (P <0.001).
Complications: infection & mesh erosion
(Brizzolara S et al. 2002) reported no mesh erosion in 60 women undergoing sacrocolpopexy with hysterectomy compared with 1 of 64 without concurrent hysterectomy.
(Fedorkow DM and Kalbfleisch RE 1993) examined early postoperative febrile morbidity
• in 86 women undergoing sacrocolpopexy and concomitant hysterectomy
• 149 women undergoing sacrocolpopexy alone. • Prophylactic antibiotics and polypropylene (Prolene)
mesh were used. Of note, surgeons left the vaginal cuff open to heal by secondary intention.
• no difference in early febrile morbidity or length of hospitalization.
Further cancerous or pre- cancerous lesion
• Cervical Cancer • Endometrial Cancer • Ovarian cancer • Other cancer demanding pelvic surgery

, 81-92
81 82 83 84 85 86 87 88 89 90 91 92

0
10
20
30
( % )




41.9 47.8 52.1 53.9 54.4 53.5 10.89 9.68 11.57 12.09 18.94 22.08 27.94 32.09 30.09 29.27 27.01 25.86 23.78 23.9 27.99 26.1 26.51 24.86 23.73 20.54
11.28 10.57 10.83 10.86 10.29 10.35 9.81 8.98 8.72 8.08 7.84 7.44
: 2000
Summary-I – Q1: Is hysterectomy mandatory during PRS? – Ans: individualized with informed consent after
sufficient information – Q2: Does hysterectomy (or uterine preservation)
compromise the success rate? – Ans: some studies reported higher failure rate in
uterine preservation group. – Q3: Does hysterectomy increase the surgical
complication rate? – Ans: controversial; some favored, some against
Summary-II • Q4: Does hysterectomy affect vesico-urinary function?
– Ans: retrospective study: increased risk; – prospective study decreased or stable symptoms and
urodynamic parameters • Q5: The further pathologic condition after surgery?
• Cervical malignancy, uterine malignancy, – Ans: The concurrent malignancy should be well
evaluated – The potential risks and higher difficulties to deal with
further pelvic malignancy should be fully informed, • Q6: The further Childbearing condition after surgery?
– Ans: The potential risks of failure after childbearing should be fully informed
• Thank you!