stephen t jeffery - 2016.iuga.org€¦ · stephen t jeffery university of cape town, south africa....
TRANSCRIPT
Stephen T Jeffery
University of Cape Town, South Africa
Disclosures
Educational Grants
J&J, Bard, AMS, Karl Storz, Boston Scientific, Covidien, Allergan
Travel Grants
Bard, Boston Scientific, Covidien
Some of you may be thinking
It’s impossible to do it safely so don’t do it at all.
Now sit down!
How to do it “safely”
Rules for safe mesh placement
① Get proper consent
② Robust indications
③ Make sure sacrocolpopexy or native tissue is not a better idea
④ Only for high volume surgeons
⑤ Avoid posterior mesh
⑥ Choose an appropriate kit
How to choose a mesh
Single incision device
Apical support
Small size mesh
Lightweight mesh
Full post-insertion adjustability
Avoid the trocar systems
Possible products?
Uphold
Nuvia
Uphold
Dyspareunia with Uphold
Pre –op 13.4%
Post-op 8.3%
No significant change
Of the 13 with pre-op, 12 had none post op
7 post –op and none were related to mesh tenderness
Technique
Consent
1. Vaginal preparation
Estrogen cream pre-operatively
2. Infiltration
2. Infiltration
Use between 150 and 200ml
2. The incision and dissection
3. Dissection to Sacrospinous Ligament
4. Placement of mesh
5. Adjustment of mesh
Dealing with complications
Bladder injury
Deeper dissection with mesh kits
Careful in scarred / previous surgery
Check for the ‘chardonnay sign’ during dissection
Bladder injury
If injured - ?Avoid putting in mesh
Routine cystoscopy after mesh insertion
Rectal Injury
DON’T insert the mesh!
Erosion / Exposure
Risk factors for Exposure
Erosions 16.8%
Increase in erosion risk
Concomitant hysterectomy
Decreased erosion risk
Vaginal estrogens
Experienced surgeon
Gullibert F et al Gynecol Obstet Fertil. 2009 Jun;37(6):470-5
How to avoid Exposure
Beware
Pelvic pain syndromes
Endometriosis
Vulvodynia
IC
Dyspareunia
Sexual dysfunction
Who else would I do a mesh in?
Large hiatus
GH+PB>10?
Avulsion injury
Case
• 52 year old with recurrent
stage III anterior wall
prolapse
• Central defect remains
with apical support
• Options?