Bekkenbodemchirurgie nu en in de toekomst. Susanne Housmans 31/01/2019

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1 Bekkenbodemchirurgie nu en in de toekomst Susanne Housmans 31/01/2019

2 Incontinentiechirurgie

3 Actueel probleem July 2018 January 2019

4 EAU guidelines: evidence for MUS

5 Single incision slings (SIS) 31 trials, n=3290 TVT-Secur, MiniArc, Ajust, Needleless, Ophira, Tissue Fixation System and CureMesh SIS vs retropubic slings: More incontinence 41% vs 26%; RR 2.08 [1,04-4,14] Shorter surgery time 2 min Higher risk on de novo urgency RR 2,39 [1,25-4,56] SIS vs transobturator slings: More incontinence 30% vs 11%; RR 2,55 [1,93-3,36] Less post-operative pain RR 0,29 [0,20-0,43] More complications Mesh exposure, erosion urethra, blood loss Slide: Ann-Sophie Page

6 Altis SIS Slide Ann-Sophie Page E. Kocjancic Neurourology and Urodynamics. 2017;36:

7 Autologe pubovaginale sling Mahdy et al Neurourology and Urodynamics. 2018;1 8 Eerste maal beschreven door Price in 1933 fascia lata Verder Aldridge: rectus fascia 1942 Vooral gefaalde of gecompliceerde gevallen na synthetische MUS of waar synthetische sling minder gewenst is (fragiele weefsels, na eerdere chirurgie, RT, congenitale afwijkingen )

8 EAU: Colposuspension

9 Colposuspension or MUS for recurrence

10 Open vs laparoscopische colposuspensie Cochrane Dean et al 2017 Subjectieve en objectieve cure binnen 5 jaar vergelijkbaar Laparoscopisch: minder bloedverlies en snellere terugkeer naar normale activiteit Laparoscopisch: bij voorkeur 2 paravaginale hechtingen Kosteneffectief laparoscopisch na 2 jaar beter dan open Objectieve cure rate en ziekenhuisverblijf zijn beter bij slings, doch minder detrusoroveractiviteit bij Burch

11 Laparoscopic Burch Accepting (nearly) equivalent outcomes higher morbidity potentially highercosts Today, colposuspension uncommon procedure Laparoscopic modification is complex procedure This may compromise efficacy Slide: Jan Deprest Effectiveness: how can we train a new generation of laparoscopic burch surgeons?

12 Prolapschirurgie

13 50 % will develop POP 10-20% will seek help Up to 50% in vaginal exam 3-6% has symptoms Surgery 6-18% (twice as much as incontinence surgery) Incidence of POP surgery /1000 and peaks at age 60-69

14 POP chirurgie o Primair herstel of recidief? o o o o Vaginaal klassiek met en zonder uterusbehoud Abdominaal open laparoscopisch robotisch Synthetische mesh Nieuwe materialen en technieken?

15 Klassiek vaginaal prolapsherstel SAVE-U trial R. Detollenaere et al BMJ 2015

16 SSF versus uterosacral ligament suspension Bij hysterectomie vanwege prolaps: herstel van Level 1 defect E-OPTIMAL trial (JAMA. 2018;319(15): o Apical descent + SUI, +/- PFMT o Na 5 jaar geen significant verschil tussen SSF en USLS Kissane et al Neurourology and Urodynamics. 2018;37: : o o o zowel <70 als >70 jaar gelijkaardige outcome op medium en lange termijn (Mediane FU 58 maanden) rond 80% succes rate, 641 ptes, vaginaal herstel met natief weefsel 60% kreeg een hysterectomie

17 Uterussparend of niet? B. Anglim et al International Urogynecology Journal (2018) 29: Traditioneel concomittante hysterectomie bij POP chirurgie Waarom behouden? o o o o Behoud van mogelijkheid op zwangerschap Wens vd pte Innocent bystander in het prolapsproces Chirurgische voorkeur

18 Patient preference N. Korbly et al. Am J Obstet Gynecol 2013;209:470.e1-6. To describe patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse symptoms and to describe predictors of preference for uterine preservation Multicenter, cross-sectional study, 213 ptes A higher proportion of women with prolapse symptoms who were examined for urogynecologic evaluation preferred uterine preservation, compared with hysterectomy. Geographic region, education level, and belief that the uterus is important for a sense of self were predictors of preference for uterine preservation M. van Ijsselmuiden et al Eur J Obstet Gynecol Reprod Biol Jan;220:79-83 This study demonstrated that women referred with prolapse complaints have a preference for uterus preservation in case the outcomes after both interventions are equal. The majority of women expected that body image and sexual function would equally improve after both interventions. (43% vs 27%, 30% no strong preference).

19 SAVE-U trial R. Detollenaere et al BMJ 2015 en J. Sex. Med ptes, RCT After 1 year: Sacrospinous hysteropexy was non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for recurrent prolapse of the apical compartment with bothersome bulge symptoms or repeat surgery After 2 years: no significant difference in overall sexual functioning (total PISQ-12 scores)

20 Cochrane review Maher et al 2016 Vaginal mesh vs native tissue POP repair POP grade 2 at 1-3 y postop in 38% of native repair vs 11-20% with synthetic mesh, even more pronounced in anterior repair Absorbable and Biological mesh: less clear

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22 Laparoscopisch herstel FDA warning about vaginal mesh leads to more use of abominale route Outcome/ QOL/ complications abdominal robotic and laparoscopic similar RASCP more pain, high cost LSCP long learning curve G. Callewaert et al Gynecol Surg (2016) 13: A. Wattiez et al Curr Opin Obstet Gynecol 2016, 28:

23 Wat nog? Zoektocht naar nieuwe technieken Bv Vaginale sacrocolpopexie (C. Hanes Journal of Minimally Invasive Gynecology (2018) 25, 47 52) Nieuwe materialen, tissue engineering (L. Hympanova et al. Journal of the Mechanical Behavior of Biomedical Materials 88 (2018) W. Wang et al Int Urogynecol J (2018) 29: )

24 Non surgical laserbased devices IUGA committee opinion (IUJ 2018) In the treatment for vulva-vaginal atrophy (VVA), vaginal laxity (VL) and stress urinary incontinence Heating the connective tissue of the vaginal wall induces collagen contraction, neocollagenesis, vascularization, and growth factor infiltration that ultimately revitalize and restore elasticity and moisture to the vaginal epithelium June 2018: FDA warning protests the wide-spread use of laser devices without scientific evidence for various indications and the use of false advertising for nonapproved pathologies On genitourinary syndrome of menopause (GMS) is effective in short term Arunkalaivanan A et al,int Urogynecol J. 2017;28: The only available well-designed RCT, Cruz et al. Menopause. 2018;25(1):21 8. In that study, participants were randomized to one of three treatment arms: laser + estriol treatment (LE), laser + placebo treatment (L), and estriol + sham laser treatment (E). After 20 weeks, the L and LE group presented significant improvement in all examined GSM symptoms For SUI this article concludes teir analysis does not allow firm conclusions of recommendations

25 Wat mogen we verwachten? Gezien de aard van de pathologie zal het aantal ingrepen voor prolaps en incontinentie blijven stijgen Er zal steeds meer vraag komen naar ingrepen zonder synthetisch materiaal en met uteruspreservatie Nieuwe materialen zijn nog niet klinisch te gebruiken en nieuwe technieken nog onvoldoende onderzocht Hierdoor zullen we teruggrijpen naar oudere ingrepen, waar de jonge artsen nog niet/niet meer voor opgeleid zijn We mogen het nut van conservatieve therapie niet onderschatten

26 Vragen?