1. ABDOMINAL SACRAL COLPOPEXY
MICKEY KARRAM MD THE CHRIST HOSPITAL UNIVERSITY OF CINCINNATI

2. CONTRAVERSIES ABOUT ASC
What are indications?
What are real outcomes
Is it difficult to perform?
Is it standardized?
Are TV mesh repairs comparable?
Do we need to do additional vaginal procedures ?

3. ASC Outcomes I. Nygaard´s Review (f-up 3-36 months): Success
Apical prolapse %
All prolapse %
Satisfaction %
Cochrane: Better than SSF
lower rate of recurrent vault prolapse
Less dyspareunia
BUT…
Longer operation, longer recovery,
more expensive, later return to activities of daily living
More complications
Nygaard IE, et al. Pelvic Floor Disorders Network. Obstet Gynecol, 2004;104(4):
Maher C et al. Cochrane Incont.Group Cochrane Database of Systematic Reviews. 4, 2008.

5. History 1957: Arthure y Savage: L5-S1 1962: Lane: Graft
1970: Nichols: Vaginal Orientation
1973: Birnbaum: S3-S4
1981: Sutton: Back to S1-S2 due to bleeding
1991: Snyder: Rectovaginal dissection for less dettachment
1989: Addison: 2 strips Theory
1992 – 1994: Querleu – Nezhat: Laparoscopy
1997: Cundiff: Sacroperineopexy
2004: Roboticcs

6. Techniques in use TODAY
Open
Laparoscopic
Robotics

8. Cleveland Clinic Experience: 1998 – 2004 Cure rates
100% apical
A.W. failures: 6% overall
P.W. failures: 15%

10. Laparoscopic vs Robotic SCP Paraiso et al. 2011
78 patients
Lap 38
Robotic 40
Comparable
Anatomic Results
Complications
Robotic + U$S 1900

14. Retrospective
Multicenter
Johns Hopkins based study

16. Vascular anatomy of the presacral space
MK Flynn et al: AJOG 2005, 192: 1005

18. Obstet Gynecol 2009, 113: 367

19. Complications / Reoperation

20. Additional Procedures
Burch colposuspension
Systematic
Tailored
Posterior repair
Hysterectomy

23. 2yr. Outcome of SCP +/- Burch L. Brubaker et al
2yr. Outcome of SCP +/- Burch L. Brubaker et al. O&G 2008, 112: / 322 (CARE TRIAL)
OVERALL SUI
Burch 32% P=0,026
Controls 45,2%
BOTHERSOME SUI
Burch 11,6% P=0,004
Controls 25.2%
URGENCY
Burch 32% P=0,085
Controls 44,5

24. AJOG, May 2007 e45

25. ASC +/- PR Nonrandomized Retrospective review
3 Centers in Texas
191 patients
34 posterior colporraphy (18%)
Indicated in the most severe cases
14 perineorraphy (7%)
Max follow up 34mo

27. Hysterectomy or Graft 168 patients retrospective review follow up 36mo
Group 1
TAH + SCP with mesh 63pt
Group 2
SCHysteropexy with mesh 35pt
Group 3
TAH + A Usacral Colpopexy

31. CRADI: ColoRectalAnal Distress Inventory
AJOG 2007, 197: 642
CRADI: ColoRectalAnal Distress Inventory
CRAIQ: ColoRectalAnal Impact Questionnaire

32. Limitations Not the primary endpoint
PR were not randomized as Burch was
PR were performed according to the surgeons discretion

35. Conclusion
Effective apical surgery reduces obstructive symptoms (with or without PR)
Apical defects may have a higher impact in PC symptoms than previously thought!!!
Patients receiving systematic posterior repairs at the time of SCP may be more prone to new onset PC symptoms like incontinence and pain

36. Sexual Function

37. PISQ 12: PopIncontinenceSexualQuestionnaire
AJOG 2007, 197: 629
PISQ 12: PopIncontinenceSexualQuestionnaire

40. Secual Activity after SCP Conclusion
Improvement of sexual activity after SCP
Substantial decrease in dyspareunia
34/76 non S.A. became sexually active
NO increase in dyspareunia after Burch
Dyspareunia more frequent after PR (N/S)
USEFUL INFORMATION ON COUNSELING