Prolasso e chirurgia fasciale:steps ed evidenze

COMPARTIMENTO ANTERIORE

GF. MININI

Shull 1992, Baden 1992Shull 1992, Baden 1992

Alla fine del secolo scorso alcuni Autori rilevavano la difficoltà nello stabilizzare un risultato efficace della chirurgia vaginale del prolasso con una possibilità di recidiva variabile dal 20% al 40%

CHIRURGIA “TRADIZIONALE” RECIDIVE

1997 OLSEN 29%

2004 TEGERSTEDT 44%

2007 DIETZ-ITZA 31%

Data 22.06.2009

La fascia endopelvica

Courtesy by Dr. T. Mouchel

“Fin de Siècle” Anatomy

• Livelli di DeLancey• Riparazione di difetto sito-specifico• Fossa Ischiorettale• Fossa Otturatoria• Arco Tendineo della Fascia Pelvica• Legamento Sacrospinoso

DeLancey

Apical Supports

Vaginal Wall

CervixArcusTendineus -Fascia Pelvis -Levator Ani

Fascia Pubocervicale e Rettovaginale

II° Livello di supporto nella pelvi

CentraleMediano

Trasversalebasso

Laterale

Trasversalealto

Riparazione Sito-Specifica dei Difetti Fasciali

I DIFETTI FASCIALI• Difetti fasciali del segmento anteriore

laterale dxlaterale sinmedianotrasversalepubouretrali

• Difetti fasciali del segmento superiorecomplesso cardinale/uterosacraleParacolpo superiore (1° livello di Delancey)

• Difetti fasciali del segmento posteriorelaterale dxlaterale sinmedianotrasversale altotrasversale basso

RICOSTRUZIONE FASCIALE“sito-specifica”

Identification and repair of each Identification and repair of each individual anatomical defect is individual anatomical defect is

essentialessential

““Leave the Leave the totaltotal tract intact” tract intact”

(Bob L. Shull)(Bob L. Shull)

Objective of anterior colporraphy is to plicate the layers of vaginal muscolaris and adventitia overlying the bladder (pubocervical fascia) or to plicate and reattach

the paravaginal tissue in such a way as to reduce the protrusion of the bladder and vagina.

Modifications of the standard repair

M.D.Walters –M.M.Karram Urogynecology and Reconstructive Pelvic Surgery 2007

Modifications of the technique depend on how lateral the dissection is carried, where the plicating sutures are placed, whether additional layers are placed in the pubocervical fascia for extra support.

The dissection should be carried further laterally to the ischiopubic rami with more advanced prolapse

Using sharp dissection is also important to mobilize the bladder base from the vaginal apex

M.D. Walters; M.M. Karram: Urogynecology and reconstructive pelvic surgery ( 2007 )

Descent of the vaginal apex induces the cystocele

DeLancey JO.Am J Obstet Gynecol. 2002;187:93-8.

60% OF BLADDER DESCENT EXPLAINED BY APICAL DESCENT

Fixation of the inferior part of the pubo-cervical fascia to the structures included in Mac Call stitches ( round, cardinal and utero-sacral ligaments )

Pubo-cervical fascia is so fixed to the perivaginal ring and the recto-vaginal septum

Further suspension is finally obtained using bilateral peritoneal sutures transfixed through the anterior vaginal wall

The anterior vaginal wall is closed with interrupted mattress sutures that include the underlying connective tissue.

M.D. Walters; M.M. Karram: Urogynecology and Reconstructive Pelvic Surgery ( 2007 )