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A new trend in laparoscopic rectocele repair
Oral Presentations
prolapse among LUSUS patients, while three (12%) of TVH patients underwent surgery for recurrent apical prolapse during the followup period. Corzclusiorz. In this study population, LUSUS yielded similar subjective and objective outcomes and a similarly low complication rate compared with TVH, and demonstrated lower blood loss and shorter hospitalization. LUSUS is an effective treatment for women with uterovaginal prolapse who opt for uterine preservation.
118. The Use of Reabsorbable Small Intestinal Submucosa (SIS) Mesh versus Non-Reabsorbable Prolene Mesh in Laparoscopic Promontofixation: A Prospective Randomized Comparison F Vianello, R Seracchioli, F Govoni, B Gualerzi, S Missiroli, S. Venturoli. Center for Reconstructive Pelvic Endosurgery, S. Orsola Hospital, Bologna, Italy.
Objective. The study evaluate the efficacy and the tolerance in the use of intestinal submucosa versus Prolene mesh in laparoscopic promontofixation. Desigrz. Randomized prospective study. Settirzg. Centre of Reconstructive Pelvic Endosurgery. Reproductive Medicine Unit, S.Orsola Hospital, University of Bologna, Bologna, Italy. Patierzts. Twenty-four consecutive patients (age 54 + 9) with genital prolapse. 15 of them had associated stress incontinence. Irzterverztiorzs. Laparoscopic promontofixation using reabsorbable natural prosthesis (Surgisis ES, Cook, Spencer, IN) or non reabsorbable prosthesis (Prolene PMI, Ethicon) and laparoscopic Burch colposuspension in case of urinary stress incontinence. Results. In 10 cases the Prolene mesh was used and in 14 the Surgisis mesh was adopted. Good anatomical results were obtained in the two group of patients. No intraoperarive complications occurred. All the 24 patients well tolerated the procedure. No complications due to infection was observed. No recurrence of prolapse after an average follow-up of 30 + 9 months was noticed. After the positioning of Prolene mesh, two patients had pelvic pain for 4-5 months and a sensation of pelvic tension for one year. Where laparoscopic Burch colposuspension was associated there was a good restore of urinary continence. Corzc/usiorz. Laparoscopic promontofixation is feasible with good results for genital prolapse. Surgisis and Prolene meshes are useful when performing laparoscopic promontofixation. The results using Surgisis or Prolene are good and comparable. In some cases the use of Surgisis could be better tolerated since the prosthesis used is less rigid and exposes to minor risks of infection, being the inert material in the retroperitoneum totally absent.
119. A New Vaginal and Laparoscopic Technique for the Treatment of Genital Prolapse Described as an Alternative to Laparoscopic Promontofixation (PF) 1P Descamps, 2H Geoffrion. ~Centre Hospitalier; 2University Hospital, Angers, France.
Major changes have occurred in the surgical treatment of genital prolapse in the past couple of years. This evolution can be explained by the fact that laparoscopic promontofixation is still considered as an advanced procedure, and the success of the "TVT" procedure helped us to understand that it is possible to put in place by vaginal route prosthetic materials with a very low rate of complications. Conclusions drawn from those two points helped the development of new surgical procedures with different prosthetic materials, either by vaginal or laparoscopic route. We are describing a new procedure, using both vaginal and laparoscopic route, for the treatment of genital prolapse for young women wishing to keep their uterus. The first step of the procedure deals with the anterior prolapse. A prosthetic material (Prolbnefi) is placed between bladder and vagina. A second prosthetic implant is cut in the shape of a "Y" and is placed on the uterus isthmus. The two arms of this implant are pulled under laparoscopic control through a retroperitoneal route behind the round ligament and through the aponevrosis. A posterior prothetic implant is placed between the vaginal and rectal wall, to avoid elytrocele and rectal prolapse. We have treated 25 patients (age 32-45, mean 36) with this technique. Average operating time was 75 minutes (60-150). We encountered no major post-operative complications only 1 case of transitional dyspareunia and 2 cases of femoro-cutaneous nerve anesthesia. Taking into consideration that we only have an average of 15 months follow-up, results can be considered as positive but may change when we have longer follow-up periods. Furthermore we also used this technique for women requiring hysterectomy, thus achieving vaginal vault suspension. In conclusion, this surgical procedure is simple, quick and reproducible, but is still under evaluation.
120. A New Trend in Laparoscopic Rectocele Repair 1A Wattiez, 2R Mashiach, 1R Botchorishvili, ~M Canis, 1JL Pouly, 1G Mage. 1Polyclinique De L'HoteI-Dieu Chu, Clermont Ferrand, France; 2Tel Aviv "Souraski" Medical Center, Tel Aviv, Israel.
Twenty percent of the patients with a pelvic floor disorder have an anorectal dysfunction. Nevertheless, only 6.5 % of the surgeons who perform pelvic reconstructive surgery systematically assess their patients for this problem. Laparoscopic surgery is used for pelvic prolapse repair since a decade. As opposed to laparotomy, laparoscopy allows an optimal approach to every compartment of the pelvis. Moreover, the most innovative role of laparoscopy is for rectocele treatment.
$38
August 2003, Vol. 10, No. 3 Supplement
TheJournal of the American Association of Gynecologic Laparoscopists
Since decades the posterior compartment was better accessed and treated vaginally. Even during open sacrocolpopexy, the posterior reparation was carried out vaginally. Laparoscopy brings a better access and vision. More importantly, it allows keeping constant the ratio eye/ instrument/tissue. It is this last remarkable character which makes it possible for a new approach and a new concept for posterior defects to be implemented. The scope allows attaching a mesh to the pubo rectalis muscle, instead of performing the conventional posterior myorraphy. The attachment can be pushed down to reach the ischial spine allowing complete reparation of the rectocele. In case of rectal prolapse, with Intussusception, the rectum can be pulled up and attached to the mesh in order to correct the defect and allow a normal function. In order to restore the normal double axis of the vagina the operation ends with an upper culdoplasty. This method brings better anatomical and functional correction and therefore provides better results and fewer side effects. Laparoscopy allows an exhaustive repair of posterior defects with better results and less trauma using a single route.
Plenary 16--Adnexa / Pain 121. Surgical Management of Ovarian Tumors During Pregnancy CF Yen, C Lee. Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.
Objective. To compare the outcomes of pregnancies in managing the ovarian tumors during pregnancy. Design. Retrospective analysis. Setting. University affiliated hospital. Patients. All the pregnant women with adnexal tumors noted in CGMH since January 1989 till December 2002. Interventions. Either early management with laparoscopy, or laparotomy in the first or second trimester, or managed during Cesarean section. Results. For total 160 patients, 106 have their ovarian surgery in C/S, and 54 patients during the first or second trimester and continue their pregnancies. 13 (24.1%) of them underwent laparoscopic surgery and 41 (75.9 %) laparotomy. Mature cystic teratoma is the most frequent pathology in this series. In comparing between the different surgical interventions, the operation time is statistically different, whereas other operation and fetal outcomes are all not significantly different. In comparing between the different surgical timing, all the differences are not statistically significant. In comparison of the tumor size between the early intervention group and the C-section group, the tumor sizes are similar (9.2 vs. 9.6 cm). No operative or postoperative maternal or fetal complication occurred in each group. No miscarriage nor newborn malformation was noted in the first trimester or second trimester treatu~ent group. Two cases of ovarian adenocarcinoma were noted in C-section group.
Conclusion. Early surgical intervention of the adnexal tumor appears to be safe in pregnancy and reduces Cesarean section rate. Besides, this study also confirms the safety of the laparoscopic surgeries performed in the first or the second trimester of pregnancy.
122. The Laparoscopic Management of Adnexal Torsion S Ginath, M Glezerman, A Golan. The Edith Wolfson Medical Center, Holon, Israel.
Objective. To report our changing trend in the operative management of adnexal torsion. Design. Retrospective study covering a period of 13 years. Setting. University affiliated teaching hospital. Patients. One hundred eighty-seven women with adnexal torsion. Intervention. Operative laparoscopy and laparotomy. Measurements and Main Results. One hundred eightyseven operations performed for adnexal torsion following the demonstration of an ovarian mass were reviewed. The mean age of the patients was 32 years (range 1-95 years). Eight patients (4.3%) were premenarchal and 20 patients (10.6%) were postmenopansal. Eighteen patients (9.6%) were diagnosed with adnexal torsion during pregnancy. The vast majority of the histopathological specimens were benign. Malignant ovarian lesions were found in 4 (2.2%) including 2 borderline ovarian tumors, one epithelial ovarian cancer stage la, and one ovarian germ cell tumor. Detorsion, cystectomy, or oophorectomy were performed in these women. Forty percent of the patients underwent laparotomy and 60% underwent laparoscopy, reflecting the changed surgical approach. During the last decade our management of torted adnexa changed and virtually all surgical procedures for adnexal masses are based on laparoscopy and are also more conservative and tissue preserving. Conclusion. The optimal management for adnexal torsion should be laparoscopic, with emphasis on tissue preservation during the reproductive years and earlier.
123. Laparoscopic Surgery in Management of Adnexal Tumors T Guerra Perez, E Herrero, J Gregorio, J. Xercavins. University Hospital of Vail D'Hebron, Barcelona, Spain.
Objective. To assess the efficacy and safety of laparoscopic surgery in the management of adnexal tumors with no sings of malignancy. Measurements and Main Results. A total of 763 adnexal tumors were removed from 686 women (age 20-72 yrs.). The procedures performed were total cystectomy, and ovariectomy or adnexectomy in those beyond menopause. Preoperative assessment was the same as for conventional surgery. Transvaginal ultrasonography was performed to evaluate the size and internal characteristics of masses to exclude malignancy, also was evaluated the IR by dopplercolour. Serum CA 125 and CA 19.9 level was measured in
$39
prolapse among LUSUS patients, while three (12%) of TVH patients underwent surgery for recurrent apical prolapse during the followup period. Corzclusiorz. In this study population, LUSUS yielded similar subjective and objective outcomes and a similarly low complication rate compared with TVH, and demonstrated lower blood loss and shorter hospitalization. LUSUS is an effective treatment for women with uterovaginal prolapse who opt for uterine preservation.
118. The Use of Reabsorbable Small Intestinal Submucosa (SIS) Mesh versus Non-Reabsorbable Prolene Mesh in Laparoscopic Promontofixation: A Prospective Randomized Comparison F Vianello, R Seracchioli, F Govoni, B Gualerzi, S Missiroli, S. Venturoli. Center for Reconstructive Pelvic Endosurgery, S. Orsola Hospital, Bologna, Italy.
Objective. The study evaluate the efficacy and the tolerance in the use of intestinal submucosa versus Prolene mesh in laparoscopic promontofixation. Desigrz. Randomized prospective study. Settirzg. Centre of Reconstructive Pelvic Endosurgery. Reproductive Medicine Unit, S.Orsola Hospital, University of Bologna, Bologna, Italy. Patierzts. Twenty-four consecutive patients (age 54 + 9) with genital prolapse. 15 of them had associated stress incontinence. Irzterverztiorzs. Laparoscopic promontofixation using reabsorbable natural prosthesis (Surgisis ES, Cook, Spencer, IN) or non reabsorbable prosthesis (Prolene PMI, Ethicon) and laparoscopic Burch colposuspension in case of urinary stress incontinence. Results. In 10 cases the Prolene mesh was used and in 14 the Surgisis mesh was adopted. Good anatomical results were obtained in the two group of patients. No intraoperarive complications occurred. All the 24 patients well tolerated the procedure. No complications due to infection was observed. No recurrence of prolapse after an average follow-up of 30 + 9 months was noticed. After the positioning of Prolene mesh, two patients had pelvic pain for 4-5 months and a sensation of pelvic tension for one year. Where laparoscopic Burch colposuspension was associated there was a good restore of urinary continence. Corzc/usiorz. Laparoscopic promontofixation is feasible with good results for genital prolapse. Surgisis and Prolene meshes are useful when performing laparoscopic promontofixation. The results using Surgisis or Prolene are good and comparable. In some cases the use of Surgisis could be better tolerated since the prosthesis used is less rigid and exposes to minor risks of infection, being the inert material in the retroperitoneum totally absent.
119. A New Vaginal and Laparoscopic Technique for the Treatment of Genital Prolapse Described as an Alternative to Laparoscopic Promontofixation (PF) 1P Descamps, 2H Geoffrion. ~Centre Hospitalier; 2University Hospital, Angers, France.
Major changes have occurred in the surgical treatment of genital prolapse in the past couple of years. This evolution can be explained by the fact that laparoscopic promontofixation is still considered as an advanced procedure, and the success of the "TVT" procedure helped us to understand that it is possible to put in place by vaginal route prosthetic materials with a very low rate of complications. Conclusions drawn from those two points helped the development of new surgical procedures with different prosthetic materials, either by vaginal or laparoscopic route. We are describing a new procedure, using both vaginal and laparoscopic route, for the treatment of genital prolapse for young women wishing to keep their uterus. The first step of the procedure deals with the anterior prolapse. A prosthetic material (Prolbnefi) is placed between bladder and vagina. A second prosthetic implant is cut in the shape of a "Y" and is placed on the uterus isthmus. The two arms of this implant are pulled under laparoscopic control through a retroperitoneal route behind the round ligament and through the aponevrosis. A posterior prothetic implant is placed between the vaginal and rectal wall, to avoid elytrocele and rectal prolapse. We have treated 25 patients (age 32-45, mean 36) with this technique. Average operating time was 75 minutes (60-150). We encountered no major post-operative complications only 1 case of transitional dyspareunia and 2 cases of femoro-cutaneous nerve anesthesia. Taking into consideration that we only have an average of 15 months follow-up, results can be considered as positive but may change when we have longer follow-up periods. Furthermore we also used this technique for women requiring hysterectomy, thus achieving vaginal vault suspension. In conclusion, this surgical procedure is simple, quick and reproducible, but is still under evaluation.
120. A New Trend in Laparoscopic Rectocele Repair 1A Wattiez, 2R Mashiach, 1R Botchorishvili, ~M Canis, 1JL Pouly, 1G Mage. 1Polyclinique De L'HoteI-Dieu Chu, Clermont Ferrand, France; 2Tel Aviv "Souraski" Medical Center, Tel Aviv, Israel.
Twenty percent of the patients with a pelvic floor disorder have an anorectal dysfunction. Nevertheless, only 6.5 % of the surgeons who perform pelvic reconstructive surgery systematically assess their patients for this problem. Laparoscopic surgery is used for pelvic prolapse repair since a decade. As opposed to laparotomy, laparoscopy allows an optimal approach to every compartment of the pelvis. Moreover, the most innovative role of laparoscopy is for rectocele treatment.
$38
August 2003, Vol. 10, No. 3 Supplement
TheJournal of the American Association of Gynecologic Laparoscopists
Since decades the posterior compartment was better accessed and treated vaginally. Even during open sacrocolpopexy, the posterior reparation was carried out vaginally. Laparoscopy brings a better access and vision. More importantly, it allows keeping constant the ratio eye/ instrument/tissue. It is this last remarkable character which makes it possible for a new approach and a new concept for posterior defects to be implemented. The scope allows attaching a mesh to the pubo rectalis muscle, instead of performing the conventional posterior myorraphy. The attachment can be pushed down to reach the ischial spine allowing complete reparation of the rectocele. In case of rectal prolapse, with Intussusception, the rectum can be pulled up and attached to the mesh in order to correct the defect and allow a normal function. In order to restore the normal double axis of the vagina the operation ends with an upper culdoplasty. This method brings better anatomical and functional correction and therefore provides better results and fewer side effects. Laparoscopy allows an exhaustive repair of posterior defects with better results and less trauma using a single route.
Plenary 16--Adnexa / Pain 121. Surgical Management of Ovarian Tumors During Pregnancy CF Yen, C Lee. Chang Gung Memorial Hospital, Tao-Yuan, Taiwan.
Objective. To compare the outcomes of pregnancies in managing the ovarian tumors during pregnancy. Design. Retrospective analysis. Setting. University affiliated hospital. Patients. All the pregnant women with adnexal tumors noted in CGMH since January 1989 till December 2002. Interventions. Either early management with laparoscopy, or laparotomy in the first or second trimester, or managed during Cesarean section. Results. For total 160 patients, 106 have their ovarian surgery in C/S, and 54 patients during the first or second trimester and continue their pregnancies. 13 (24.1%) of them underwent laparoscopic surgery and 41 (75.9 %) laparotomy. Mature cystic teratoma is the most frequent pathology in this series. In comparing between the different surgical interventions, the operation time is statistically different, whereas other operation and fetal outcomes are all not significantly different. In comparing between the different surgical timing, all the differences are not statistically significant. In comparison of the tumor size between the early intervention group and the C-section group, the tumor sizes are similar (9.2 vs. 9.6 cm). No operative or postoperative maternal or fetal complication occurred in each group. No miscarriage nor newborn malformation was noted in the first trimester or second trimester treatu~ent group. Two cases of ovarian adenocarcinoma were noted in C-section group.
Conclusion. Early surgical intervention of the adnexal tumor appears to be safe in pregnancy and reduces Cesarean section rate. Besides, this study also confirms the safety of the laparoscopic surgeries performed in the first or the second trimester of pregnancy.
122. The Laparoscopic Management of Adnexal Torsion S Ginath, M Glezerman, A Golan. The Edith Wolfson Medical Center, Holon, Israel.
Objective. To report our changing trend in the operative management of adnexal torsion. Design. Retrospective study covering a period of 13 years. Setting. University affiliated teaching hospital. Patients. One hundred eighty-seven women with adnexal torsion. Intervention. Operative laparoscopy and laparotomy. Measurements and Main Results. One hundred eightyseven operations performed for adnexal torsion following the demonstration of an ovarian mass were reviewed. The mean age of the patients was 32 years (range 1-95 years). Eight patients (4.3%) were premenarchal and 20 patients (10.6%) were postmenopansal. Eighteen patients (9.6%) were diagnosed with adnexal torsion during pregnancy. The vast majority of the histopathological specimens were benign. Malignant ovarian lesions were found in 4 (2.2%) including 2 borderline ovarian tumors, one epithelial ovarian cancer stage la, and one ovarian germ cell tumor. Detorsion, cystectomy, or oophorectomy were performed in these women. Forty percent of the patients underwent laparotomy and 60% underwent laparoscopy, reflecting the changed surgical approach. During the last decade our management of torted adnexa changed and virtually all surgical procedures for adnexal masses are based on laparoscopy and are also more conservative and tissue preserving. Conclusion. The optimal management for adnexal torsion should be laparoscopic, with emphasis on tissue preservation during the reproductive years and earlier.
123. Laparoscopic Surgery in Management of Adnexal Tumors T Guerra Perez, E Herrero, J Gregorio, J. Xercavins. University Hospital of Vail D'Hebron, Barcelona, Spain.
Objective. To assess the efficacy and safety of laparoscopic surgery in the management of adnexal tumors with no sings of malignancy. Measurements and Main Results. A total of 763 adnexal tumors were removed from 686 women (age 20-72 yrs.). The procedures performed were total cystectomy, and ovariectomy or adnexectomy in those beyond menopause. Preoperative assessment was the same as for conventional surgery. Transvaginal ultrasonography was performed to evaluate the size and internal characteristics of masses to exclude malignancy, also was evaluated the IR by dopplercolour. Serum CA 125 and CA 19.9 level was measured in
$39