Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1010 - файл
.pdf
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
Fig. 16.2a–h. Anterior colporrhaphy with central and vaginal/paravaginal repair of a combined
cystocele. a The combined cystocele with the central and paravaginal defect presents with a prolapse of the anterior vaginal wall; rugae and sulci disappeared as shown.First, the vaginal sulcus
is marked on both sides by single knots, then the anterior vaginal wall is dissected medially.
b The prolapsed cystocele is gathered up by U-sutures.This tightens the fascia pelvina also sagittally to both sides, compare the small picture. c,d The central defect is corrected. Superfluous lateral fatty tissue of the Retzius space appears at the site of paravaginal defect. e The Retzius space
is bluntly opened by the surgeon’s fingers.f Anatomy in the area of paravaginal defect. g Closure
of the paravaginal defect; fascia vesicalis, arcus tendineus fascialis and fascia vaginalis are connected in the area of vaginal sulci by nonabsorbable sutures,strength 0. The paravaginal defect
is closed by three to five single knots; closure extends from 1 cm ventral to the spina ischiadica
up to 1.5 cm paraurethral.h Postoperative situs
16.3 Needle Suspension
Needle suspension after Pereyra (1959), Stamey (1973) and Raz (1981) seemed to be
very promising for quite a long time.Here again,more recent analyses show less promising results.
In a prospective study Park and Miller (1988) report success rates of 70% after
5 years and 56% after 10 years.
GF Jarvis (1994) calculates an objective cure rate of 70.5% by meta-analysis.
Trockman et al. (1995) report that after 10 years 73% of the patients were satisfied
with surgery, 71% of the patients stated improvement in continence but only 20% of
the patients showed no symptoms and counted themselves as cured.A total of 22% had
to undergo one or more surgeries because of relapse.
Jongen et al. (1999) report a cure rate of 68% after 5 years. However, the investigated number of 25 patients seems to be very small. Moreover, Bergman and Elia (1995)
mention a cure rate of 43% after 5 years; the total number of analyzed cases totaled 30
patients.Colombo et al. (1997) report an objective success rate of 57% after 6 years and
a subjective success rate of 71% (total number of patients, 21).
Tamussino et al. (1999) could show that 49% of 121 patients who had a needle suspension in combination with anterior colporrhaphy are still continent after 5 years.
Masson and Govier (2000) followed up 135 cases,of which only 14% were still continent after 4 years. The so-called endoscopic approaches in general deliver much
better results. That does not imply that the needle suspension is done endoscopically.
It means that it is done under cystoscopic control (Fig. 16.3).This method also proved
to be disappointing despite of early reported high success rates. Irrespective of methodical differences, all the above mentioned studies summarize a mean long-term
success rate of 43%. Here again, more recent studies tend to describe poorer success
rates.
Few authors describe complications and side effects. Jarvis (1994) shows with a
meta-analysis the complications of needle suspension. Twenty-seven percent of the
patients complain about persistent traumatic pain. In 6% of the cases, sutures had to
be removed postoperatively and 10.3% had postsurgical voiding difficulties.
237
238
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
16
Fig. 16.3. Needle suspension/urethrovesical suspension by Pereyra and Lebherz (from Käser et al.
1983). Left Frontal view; right figure: lateral view. After a small suprapubic incision the double
needle is guided through paraurethral tissue towards the vesicourethral border. This procedure
is repeated on the contralateral side, which results in suspension of the bladder neck by the
placed strings
16.4 Different Colposuspension Techniques
In 1949 Marshall,Marchetti and Krantz introduced colposuspension as a treatment for
female incontinence.McDuffie et al.presented long-term data already in 1981.The success rate was 90% after 1 year, 86% after 5 years, 72% after 10 years and 75% after
15 years. In the following years,the modification of this technique by Burch (1961) was
more and more accepted.
Milani et al. (1985) showed in a retrospective study that cure of incontinence was
achieved to a similar extent by both procedures, 71% after the Marshall-MarchettiKrantz (MMK) procedure and 79% after the Burch operation. Other studies confirmed
these results.The surgical technique was modified several times. The Burch operation
seems to be the procedure of choice,also because complications involving the periost
can be avoided.
Park and Miller (1988) reported a cure-rate of 70% after 5 years and of 75% after
10 years.
Feyereisl et al.(1994) described a cure-rate of 81.6% 5–10 years postoperatively. This
was confirmed by other authors: a cure rate of 75% (by Harris et al.1995) and 82% (by
Bergman and Elia 1995), both 5 years retrospectively.
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
In another retrospective study, Alcalay et al. (1995) reviewed the outcome of Burch
colposuspension up to 20 years after surgery (median, 13.8 years). The subjective and
objective cure rate amounted 82% after 5 years. However, cure of incontinence following Burch colposuspension seems to be time-dependent with a decline. A plateau of
69% is reached after 10–12 years postoperatively. The authors also described factors
which influenced the postoperative outcome negatively. For example, previous bladder
neck surgeries, preoperative weight greater than 80 kg and intraoperative blood loss of
more than 1,000 ml affected the cure rate adversely. Postoperative complications include de novo detrusor instability (14.7%), long-term complaints of voiding difficulties (22%) and recurrent urinary tract infection (4.6%).
A cure rate of 88% 3 years after surgery was described by Liapis et al.(1996). Tamussino et al. (1999) reported a cure rate of 79% after 5 years,Colombo et al. (2000) talked
about an objective cure-rate of 74% after 14 years and a subjective cure-rate of 86%.
Aargaard et al. (1994) found a cure rate of 54% after 18years.
Petri (2001) registered within a follow-up period of at least 2 years 2,450 operations
and a calculated a cure rate of 81%. Primary surgery showed success in 89% of the cases; operations for relapse in 72% of the cases.
Colposuspension is convincing not only for its very good-long term results but also for its high success rates,consistently published over decades. These data held up in
future studies, which benefits colposuspension compared to other techniques. Just analyzing the studies with a follow-up period of 5 years or more, the cure rate amounts to
70%–80%. Colposuspension is the best studied surgical procedure for urinary incontinence and its success is most scientifically proved.
However, complications are also mentioned.Jarvis (1994) combined different studies by a meta-analysis and showed the occurrence of persistent lower gastric pain in
12% and the de novo urge incontinence in 12.5%. Only in 41% or 52%, respectively, a
great surgical outcome without any complications could be found.
In a meta-analysis by Vierhout and Mulder (1992), the incidence of de novo urge incontinence was described in 17% of 396 patients.
McDuffie et al. (1981) reported more severe complications in 7.8% of all cases
(Fig. 16.4).
239
16.5 Comparison Between Anterior Colporrhaphy
and Colposuspension
In a prospective study, Liapis et al. compared the success rates of anterior colporrhaphy with Burch colposuspension. After postsurgical evaluation of 36 months, 57% of
the women with anterior colporrhaphy and 88% of the women with Burch colposuspension were continent.
Bergman and Elia conducted a prospective study with the objective of comparing
the long-term results of anterior colporrhaphy, needle suspension and colposuspension. The objective success rate for anterior colporrhaphy was 37%,for needle suspension 43% and for colposuspension 82% after 5 years.
Tamussino et al. (1999) evaluated in a retrospective study the continence rates
5 years after anterior colporrhaphy, anterior colporrhaphy with needle suspension of
the bladder neck, and Burch colposuspension. A similar study had been published
earlier by Tamussino et al. (1995) and Zivkovic et al. (1995).Five years postoperatively
the objective overall continence rates were 61% after anterior repair,49% after anterior
repair with needle suspension, and 79% after Burch colposuspension. Continence
240
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
Fig. 16.4.
The Burch colposuspension
(from Käser et al. 1983).
Suspended sutures attach
the fascia pelvina to
Cooper’s ligament, thereby
elevating vaginal fascia
more laterally than seen
with the original MarshallMarchetti-Krantz technique
16
rates after anterior colporrhaphy were 82% among patients with mild stress incontinence.
Hutchings and Black (2001) compared the three mentioned operative procedures in
a retrospective nonrandomized multicenter trial. After 1 year they could indicate similar trends, but in general with much lower success rates. The cure rate was 34% for colposuspension,19% for anterior colporrhaphy and 13% for needle suspension. However, the subjective postoperative evaluation showed better results: 75% of the patients
stated improvement of their symptoms after colposuspension, 68% after needle suspension and 55% after colporrhaphy.
Peters and Thornton (1988) retrospectively compared the results of anterior colporrhaphy plus Kelly-Kennedy plication with colposuspension by Marschall-MarchettiKrantz.Here,they took the grade of anterior genital prolapse and the technique of surgical correction into consideration.The abdominal approach showed higher cure rates
than the vaginal approach if anterior prolapse was less prominent (93% vs 40%,5 years
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
postoperatively). Both procedures resulted in equal success rates (between 75% and
100%) if genital prolapse was more prominent.
Van Geelen et al. (1988) showed in a prospective study that the transmitted intraabdominal pressure to the urethra is much more effective after Burch colposuspension
than colporrhaphy. This might explain the superiority of colposuspension compared
to colporrhaphy as surgery for stress incontinence.
Luna et al. (1999) retrospectively compared the efficacy of both procedures over a
time period of 11.3 years. Anterior colporrhaphy had a success rate of 55% and colposuspension a success rate of 58%. The anterior colporrhaphy procedure had more
postoperative complications and shorter recurrence intervals (12 months after colporrhaphy vs 58 months after colposuspension). A questionnaire regarding the current
status of urinary incontinence was sent to all patients.
Colombo et al. (2000) also demonstrated the superiority of the colposuspension
over anterior colporrhaphy. The objective success rate was 74% vs 42%, respectively;
the subjective success rate was 86% vs 52%,respectively.
These comparative studies clarify that colposuspension is superior to anterior colporrhaphy by having fewer side effects,except for de novo urge incontinence. Positive
results of suburethral sutures and needle suspension cannot be reproduced persistently. These techniques as well as anterior colporrhaphy should be given up as incontinence operation.
16.6 Tension-Free Tape
241
After a colposuspension,the urethra loses its physiological position. Normally fixed a
few centimeters underneath the symphysis, now after colposuspension the urethra is
elevated and closely attached to the pubic bone. Despite good success rates for urinary
continence,the pelvic floor is weakened by colposuspension.Defects often occur in the
posterior compartment, especially if elevation is high and very close to the urethra
(Eberhard et al. 2003).This more or less iatrogenically caused descent of the posterior
compartment challenged the search for a surgical technique that delivers very good
cure rates and does not interfere with stability of the pelvic floor (Fig. 16.5).
Fig. 16.5.
This figure illustrates the
unphysiologic fixation of
the urethra after Marschall-Marchetti-Krantz
colposuspension.It leads
to the development of enteroceles and rectoceles
(from Käser et al. 1983)
242
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
While colposuspension is an empirically invented surgery for urinary stress incontinence (12 years after its introduction by Marschall et al.,the theory of pressure transmission was finally founded by Enhörning (1961),in order to explain the effects of colposuspension), the tension-free vaginal tape (TVT) method was based from the beginning on the integral theory of female stress incontinence, described by Petros and
Ulmsten (1990).According to this theory,Ulmsten et al. (1996) developed a retropubic
suburethral sling made of alloplastic material. This tape was placed underneath the
middle of the urethra in order to stabilize the insufficient pubourethral ligaments.The
TVT is put in position by a small incision after local anesthesia. The surgical approach
and methods of correction are described by Zubke et al. (2001, 2004a–c).
Excellent surgical outcome and cure rates of at least 90% can be mentioned (Olson
and Kroon 1999; Rezapour et al. 2001). Liapis et al. (2001) also report success rates of
90% 44 months after surgery (Fig. 16.6).
Meschia et al.(2001) conducted a prospective multicenter study to evaluate 404 patients during a median follow-up time of 21 months. The subjective and objective cure
rates were 92% and 90%, respectively. Intra- and postoperative complications were
bladder perforations (6%) and postsurgical bleeding requiring surgery (5%). The
authors conclude that the TVT has proved its success, also in combination with other
surgical procedures.
Soulie et al. (2001) present a prospective multicenter trail. After a mean follow-up of
15.2 months, 83% of patients were continent. Bladder injuries occurred in 11.5%. No
case of de novo urge incontinence was identified.
In a retrospective analysis, Jeffry et al. (2001) assessed the cure rate after 2 years.
The objective cure rate was 89.3%,the subjective cure rate was only 66%,11.6% of patients had bladder injuries, 13% had voiding difficulties and in 25% de novo urge
symptoms occurred.
Sevestre et al. (2003) report results of the tension-free vaginal tape (TVT) technique
in women with 70 years and older.Of these patients, 67% were cured postoperatively,
13.7% had persistent stress urinary incontinence,18.4% of patients showed urge symptoms. Overall,82% of the patients were satisfied with the result of the surgery.
16
Fig. 16.6.
Tension-free position of the
TVT underneath the middle of the urethra; fixation
of the Prolene-tape within
the pelvic diaphragm and
abdominal muscles (from
Bettin et al. 2000)
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
Peschers et al.(2000) calculated an objective cure rate of 87% during a mean followup time of 17.5 months. The subjective cure rate was 90% after 1 year. In 5.4% of patients, bladder injuries occurred; 5.1% of patients complained about de novo urge incontinence; erosions of the tape were diagnosed in 9.1%.
A prospective study was undertaken by Levin et al. (2004) to examine the incidence
of surgical complications of TVT. Three hundred and thirteen patients were prospectively studied. The mean follow-up period was 21.4 months . In 5.1% of the cases, an
intravesical passage of the tape occurred, two of which were diagnosed at 3 and
15 months postoperatively. Five percent of the patients had postoperative voiding difficulties, necessitating catheterization for more than 7 days. However, excision of the
tape was required in one case only. Vaginal erosion of the tape was diagnosed in 1.3%
of the patients, all of whom were successfully treated by local excision of the eroded
tape. De novo urge incontinence developed postoperatively in 8.3% of the patients. The
subjective and objective cure rates were approximately 90%. However, most bladder
injuries occurred during the surgeons’ training-period; afterwards they rarely appeared.
Nilsson et al. (2001) conducted a long-term study over 5 years, with 85% of the patients completely cured. After 7 years the cure rates were 81%, shown by Nilsson et al.
(2003).
In order to reduce or avoid side effects of the conventional TVT, new versions of
suburethral slings have been introduced, for example, the transobturator tape.
De Leval et al.(2003) evaluated a new,simple surgical technique for the treatment of
female stress urinary incontinence. The procedure was carried out in 107 consecutive
patients. No perioperative complications were encountered. Of these patients, 2.8%
had voiding difficulties that improved after loosening the tape.All patients were continent after operation.This operative procedure was also evaluated by Reisenauer et al.
(2004).
Delorme et al. (2004) report their results of their technique of transobturator suburethral tape. Mean follow-up was 17 months with 90.6% of patients cured. One patient (3%) had complete postoperative bladder retention, 6% of patients developed de
novo urge incontinence, 15% of patients had voiding disorders indicating bladder outflow obstruction.
A prospective randomized study was undertaken by de Tayrac et al. (2004) to compare the conventional TVT with the transobturator suburethral tape (by Delorme).
Mean operating time was shorter with transobturator suburethral tape than with conventional TVT, 15 min vs 27 min. There were fewer cases of complete postoperative
bladder retention, 13% vs 26%, and the cure rate after a follow-up time of 1 year was
higher: 90% of patients were cured with the transobturator suburethral tape vs 83%
with conventional TVT.
243
16.7 Comparison of Colposuspension and TVT
Although colposuspension and TVT are performed frequently, only a few comparative
studies exist. Merlin et al. (2001) did a meta-analysis to compare the IVS, TVT, and
Burch colposuspension. They concluded that the TVT procedure appears to be as effective as Burch colposuspension and has shorter recovery times. Colposuspension is
associated with a higher risk for blood transfusion than the suburethral sling surgery.
In general it was difficult to accurately present the complications with meta-analysis.
In the authors’ opinion, the complications were clearly “under-reported.”
16
244
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
In a prospective randomized study, Koelbl et al. (2002) compared the perioperative
results of Burch colposuspension and TVT. The OR time was clearly shorter with TVT
than with Burch (27 vs 39 min respectively). Complications such as blood loss, infection, hematoma and urinary tract infections were more frequent with Burch than with
TVT. Patients with TVT could be discharged earlier than those treated with Burch
(3.3 days vs 8.5 days). Moreover, normal voiding occurred already 3.3 days after TVT,
but 7.8 days after Burch colposuspension.
A prospective randomized multicenter study was done by Ward and Hilton (2004)
to compare tension-free vaginal tape (TVT) with colposuspension.Of the TVT group,
63% were objectively cured at 2 years, as were 51% of the colposuspension group. The
TVT procedure appears to be as effective as colposuspension for the treatment of
urodynamic stress incontinence .Colposuspension is significantly more frequently associated with longer recovery times, with the complication of postoperative prolapse
and the necessity of re-operation.Moreover, they showed that this re-operation follows
colposuspension significantly more often than TVT, which the authors explain by the
surgical technique of colposuspension. These findings are also supported by other
authors.
In conclusion,compared to conventional colposuspension there is a trend towards
TVT.
16.8 Endoscopic Colposuspension
The difference between colposuspension procedures and TVT is the minimally invasive technique, whereas colposuspension requires a small laparotomy. In order to
perform colposuspension as a minimally invasive procedure, new laparoscopic approaches had to be developed, especially done by Wallwiener et al. (1994, 1995, 1996).
He introduced retziusscopy as an operative approach for colposuspension and proved
its surgical practicability in a comparative study. He also showed that the different
endoscopic techniques such as laparoscopy and retziusscopy, present equally good
results.
First, the question of whether laparoscopic Burch colposuspension produces similarly good results as the classic Burch colposuspension must be answered. Therefore
Fatthy et al. (2001) studied 74 patients and compared both procedures.Mean operating
times of laparoscopic vs open surgery were 70 vs 53 min, respectively. However, the
mean blood loss for laparoscopic Burch was only 42 ml vs 240 ml with colposuspension. The laparoscopic procedure required less postoperative analgesia and a mean
hospitalization period of 36 h vs 76 h. Moreover, average time to return to work
amounted 8.5 vs 31.5 days with the classic Burch. Success rates were 88% at 18 months
in the laparoscopic group, compared with 85% in the open group, demonstrating equal
efficacy of both procedures.
Dietz and Wilson (2002) analyzed a longer follow-up time, on average 3.3 years.
There was no significant difference between stress incontinence and urge incontinence. However, some endoscopic techniques that are no longer in use seem to show
less success: techniques that fix the vaginal fascia at the Cooper ligaments by an interponate (El-Toukhy and Davies 2001) and techniques using tissue glue instead of sutures (review by Weber 2003) (Fig. 16.7).
Fig. 16.7.
Laparoscopic Burch.To p in
correlation with the conventional Burch,the fascia
pelvina is elevated vaginally and is fixed with nonabsorbable sutures.Bottom
postoperative situs; the red
arrows mark on both sides
the sutures of colposuspension. On the left side,one
suture is still being tied.
The fascia between bladder
and vagina is elevated in
the same manner as modified laparotomy
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
245
16.9 Comparison of Endoscopic Burch and TVT
There are two minimally invasive surgical techniques in treating genuine stress urinary incontinence: the tension-free vaginal tape (TVT) and laparoscopic Burch procedures. Practicability, efficacy and side effects of both methods should be analyzed.
This was done by Chung and Chung (2002).
Operating time for the laparoscopic Burch procedure is significantly longer. The
hospitalization period was very short with both procedures (TVT as an ambulatory
intervention; 1.1 days for the laparoscopic Burch). No intraoperative complications
have been seen during TVT (91 patients),whereas in the Burch group (51 patients) one
bladder rupture and occlusion of the urethra occurred, which were corrected intraoperatively. Postoperatively, one TVT patient suffered from urinary retention that required loosening of the tape 4 months later.After the Burch procedure,six patients still
complained of urinary incontinence.
246
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
Paraiso et al. (2003) conducted a study to compare Burch colposuspension and the
TVT sling procedure at a total of 36 patients. The Burch procedure required clearly
more time for surgery than TVT. The hospitalization period was equally long for both
procedures.The objective rate of failure measured 3.6% with TVT and 23% with laparoscopic Burch 1 year after surgery.Detrusor overactivity occurred in 13.8% after TVT,
but only in 3.9% after Burch colposuspension. Patients with TVT complained about
more subjective symptoms than those with Burch. Two ruptures of the bladder occurred during TVT, which made postoperative removal of the sling necessary.In three
cases, the endoscopic Burch procedure had to be changed to laparotomy during surgery.
Brenner (2001) showed by a comparative study that the success rate was higher after TVT than laparoscopic Burch colposuspension (93% vs 83%).Accordingly, patients
with TVT were more satisfied. One perforation and two hematomas were seen after
TVT and three slings had to be cut.The Burch procedure resulted in three bladder perforations.In conclusion,the author favors TVT.
Other authors – Üstün et al. (2003) and Cosson et al. (2002) – have had similar results.We can conclude that TVT as well as the laparoscopic modification of the Burch
colposuspension have proved their worth and are equally successful.The cure rates are
good after both procedures, but the advantage goes to TVT. Intraoperative complications, which are easily manageable, are seen during both surgeries: 5%–10% laparoscopic Burch interventions had to be converted to laparotomy. The alloplastic material
of TVT is substantially more expensive than the Burch sutures. But this is partially
16
Fig. 16.8.
TVT-O.Left situs during surgery.Right illustration of the
surgery.TVT is placed underneath the middle of the urethra
and brought out through the
foramen obturatoria on both
sides (from de Leval 2003)
Соседние файлы в папке @xirurgi_2025