Cirurgia Vaginal Para Urologistas

Prof Paulo PalmaTitular Urologia Feminina

UNICAMP

PP

UterusUterus

VaginaVagina Lateral DefectLateral Defect

Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)

Central DefectCentral Defect

Tendineous Arc

Tendineous Arc

Davila, Guerette.IUGA 2004Davila, Guerette.IUGA 2004

Possible fascial tearings

Transverse defectTransverse defect

Anterior Anterior repair repair

Anterior Vaginal ProlapseAnterior Vaginal Prolapse

Paravaginal repairParavaginal repair

Richardson, 1976Richardson, 1976

PP

UterusUterus

VaginaVagina

Anterior Vaginal Prolapse (AVP)Anterior Vaginal Prolapse (AVP)

Anterior Vaginal ProlapseAnterior Vaginal Prolapse

JulianJulian MarlexMarlex 100100

Mesh vs Anterior repairMesh vs Anterior repair

SandSand PoliglactinaPoliglactina 7575

WeberWeber PoliglactinaPoliglactina 4242

Colp. Ant.Colp. Ant. 5757

3737

Colp. Ant.Colp. Ant. 66661212

7373

2626

7070

5757

12122424

1212

2323

1212

2323

242425% erosion25% erosion

nono

n0n0

nono

nono

nono

Colp. Ant.Colp. Ant.

nn TT(m)(m)

SuccessSuccess(%)(%)

ComplicationsComplications

Modified from Tayrac el al Int Urogyn J 2006, 17:100

Posterior vaginal wall prolapsesPosterior vaginal wall prolapses

The past

Levator ani Miorraphy

The Present

Pericervical ring reconstruction

Posterior Slings

Anti Anti anatomicanatomic

Pain, dypareunia, Pain, dypareunia, recurrencyrecurrency

Levator miorraphyLevator miorraphy

Rectovaginal FasciaRectovaginal Fascia

Connective Tissue between Connective Tissue between the vagina and the rectumthe vagina and the rectum

Smooth Muscle fibersSmooth Muscle fibers

Rectovaginal FasciaRectovaginal Fascia

Preserve vaginal lengh and Preserve vaginal lengh and

helps rectal functionhelps rectal function

Main supportive element of Main supportive element of

the posterior wallthe posterior wall

Stenchever,Urogynecology and Reconstructive Pelvic Surgery, Vol. V

Anatomical levelsAnatomical levels

Support

Lateral

Fusion

PERICERVICAL RING

AT THE LEVEL OF THE ISCHIAL SPINES;

COMPLEX REPRESENTED BY THE CONTINUITY OF THE CARDINAL-UTEROSACRAL LIGAMENTS

WITH:

PUBOCERVICAL AND RECTOVAGINAL FASCIA.

ONE OF THE MOST IMPORTANT CONCEPTS FOR

RECONSTRUCTIVE VAGINAL SURGEONS;

Adapted from Netter, Atlas of Human Anatomy

CHILDBIRTH AND PVP

ON THE DESCEND AND EXTENSION OF THE FETAL HEAD,

INTENSE PRESSURE IS EXERTED ON THE

SUSPENSORY FUNCTION OF THE UTEROSACRAL

LIGAMENTS;

CONTINUATION OF THIS PROCESS RESULTS IN A PROXIMAL

TRANSVERSE SEPARATION OF THE RECTOVAGINAL

SEPTUM FROM THE UTEROSACRAL LIGAMENT AND

THE PERICERVICAL RING;

Adapted from Williams, Obstetrics

Pericervical Ring

PP Tndinous Arc

RectumUterus

Vagina

Posterior vaginal wall Prolapse

Levator Ani

PericervicalDefect

PPTendineous Arc

Tendineous Arc

RectumRectum

UterusUterus

VaginaVagina

Levator ani

Levator ani

Posterior Posterior DefectDefect

Posterior Vaginal Prolapse (PVP)Posterior Vaginal Prolapse (PVP)

Pericervical Ring

PPTendinous Arc

RectumRectumUterus

Vagina

Posterior vaginal wall Prolapse

Levator Ani

““Rectocele”

Surgical Approach

PPTendinous Arc

RectumUterus

Vagina

Pericervical Ring Repair

Levator Ani

PPArco te

ndineo

RetoUtero

Vagina

Elevador ânus

Surgical Approach

SacrospinalSacrospinalLigamentLigament

PPTendineous Arc

Tendineous Arc

RectumRectum

UterusUterus

VaginaVagina

Levator a

ni

Levator a

ni

Posterior Vaginal Prolapse RepairPosterior Vaginal Prolapse Repair