STANDARIZATION

TREATMENT FOR AIP

INTRASURGICAL STRATIFICATION AND MANAGEMENT OPTIONS

PROF. DR. JOSÉ M PALACIOS-JARAQUEMADA

CEMIC, UNIVERSITY HOSPITAL, SCHOOL OF MEDICINE, UBA
FELLOW DE ROYAL COLLEGE OBSTETRICIAN AND GYNECOLOGYST (UK)
 LEARNING OBJECTIVES

1) EXPLAIN THE CONCEPT OF CONSERVATIVE INTRASURGICAL STRATIFICATION

2) TO SHOW SPECIFIC MANEUVERS TO PERFORM THE PROCEDURE

3) REVIEW THE MAIN SURGICAL RESULTS IN A LARGE SERIES

4) TO ASSESS STEPS FOR SIGNIFICATIVE TRAINING

 STRATIFICATION

OPENING OF PELVIC FASCIAS

VASCULAR SEPARATION OF INVOLVED ORGANS

ANALYZE PROPER PLACE FOR HYSTEROTOMY

EVALUATE POSSIBILITY FOR CONSERVATIVE OR RESECTIVE TREATMENT

 SURGICAL MANEUVERS: BLADDER DISSECTION-STRATIFICATION

APROACH BY MODIFIED PFANNENSTIEL

INCISION


PRIMARY DISSECTION: VESICO-UTERINE
NEWLY FORMED VESSELS


PARAMETRIAL SURGICAL VIEWING (INSIDE
OF ROUND LIGAMENTS)
SURGICAL MANEUVERS: BLADDER DISSECTION-STRATIFICATION
 SURGICAL MANEUVERS: DELIVERY-EXTERIORIZATION

2 CM OVER UPPER EDGE OF INVADED

AREA

PARALLEL HAND-BLUNT DISSECTION
BETWEN THE UTERUS AND THE
PLACENTA

AFTER BABY IS DELIVERED, THE UTERUS
IS EXTERIORIZED WITH THE PLACENTA
INSIDE
CONSERVATIVE-RESECTIVE AND REPAIR

RESECTIVE-ABLATIVE. TOTAL OR PARTIAL

PROF. JOSÉ PALACIOS-JARAQUEMADA 7

 SURGICAL MANEUVERS: DEEP BLADDER DISSECTION

2 ALLIS CLAMPS PULL THE BLADDER UP

FOR DEEP DISSECTION

PRESENCE OF HEALTHY (LOWER) UTERINE

TISSUE IS VERIFIED

ACCESS TO THE COLPO-UTERINE VESSELS

IS NEEDED
 SURGICAL MANEUVERS: COLPOUTERINE VESSELS LIGATURE

DEEP DISSECTION IS NECESSARY TO SEE LOWER

UTERUS AND VAGINA

COMPRESSION SUTURE IS APPLIED TO OCLUDE
COLPO-UTERINE VESSELS
 SURGICAL MANEUVERS: RESECTION OF INVADED AREA AND PLACENTA

CIRCULAR CUT OF INVADED UTERUS IS

PERFORMED

ALL INVADED TISSUES WITH THE ENTIRE PLACENTA
IS REMOVED IN ONE PIECE

UTERINE CAVITY IS CLEANED
HEMOSTASIS IS ALREADY CHECKED
 SURGICAL MANUVERS: PLASTIC PROCEDURE

FIRST LINE SUTURE IS PERFORMED WITH 5-7 U

MATRESS STITCHES

THICKNESS DIFFERENCES BETWEEN UPPER AND
LOWER BORDERS IS RECTIFIED

ININTERRUPTED SECOND LINE SUTURE IS
PERFORMED

BLADDER MUSCULAR LAYER IS REINFORCED
 PATIENTS WITH DIAGNOSIS OF AIP: 2004/2016: 452

409 SCHEDULLED

474: DIAGNOSIS BY US, DOPPLER, OR MRI

65 EMERGENCY

126 WITHOUT INVASION CRITERIA

348 PATIENTS WITH CLINICAL AND SURGICAL CRITERIA. POSSITIVE US, MRI AND PATHOLOGICAL ANALYSIS

12
 SURGICAL RESULTS: 348 FULL CONTROLLED PATIENTS

TYPE 0 (FALSE AIP): PROTUSION THOUGHT UTERINE SCAR DEHISCENCE, NO NEWLY-FORMED VESSELS


TYPE 1 (CLASSIC AIP): INVASION OF SUPERIOR BLADDER + NEWLY-FORMED VESSELS

TYPE 2 (PARAMETRIAL INVASION): INVASION OF LATERAL SIDE OF THE UTERUS

TYPE 3 (TRIGON-CERVICAL INVASION): INVASION OF POSTERO-INFERIOR BLADDER

TYPE 4 (MASSIVE FIBROUS INVOLVEMENT): INVASION OF LOWER BLADDER +INTENSIVE FIBROSIS

SURGICAL CLASSIFICATION ACCORDING TOPOGRAPHY

14
 SURGICAL RESULTS: 348 FULL CONTROLLED PATIENTS

TYPE 1: 248 PATIENTS UTERINE CONSERVATION IN 202 81,45% ESTIMATED BLEEDING 500-1500 ML

TYPE 2: 44 PATIENTS UTERINE CONSERVATION IN 21 47,72% ESTIMATED BLEEDING 500-1500 ML

TYPE 3: 23 PATIENTS UTERINE CONSERVATION IN 5 21,% ESTIMATED BLEEDING 500-2500 ML

TYPE 4: 11 PATIENTS UTERINE CONSERVATION IN 0 0% ESTIMATED BLEEDING 1000-2500 ML

 SURGICAL RESULTS: 348 FULL CONTROLLED PATIENTS

UTERUS WAS CONSERVATED IN 228/348 (69,9%) CASES OF PAS (GLOBAL RATE)

HYSTERECTOMY: 98 CASES: IN 93 BY MASSIVE DESTRUCTION; IN 6 BY UNSOLVED DIC

LOWER PARAMETRIAL INVASION AND TRIGONAL BLADDER = LOWEST RATE OF CONSERVATION

 SURGICAL RESULTS: 348 FULL CONTROLLED PATIENTS

BLADDER INJURY: 46 PATIENTS (ADHESIONS OR TISSUE THINNING)

4 URETER LIGATURES: EXTENSIVE PARAMETRIAL INVASION URETERAL CATHETERIZATION NOT POSSIBLE

SUBSEQUENT BLEEDING, ILEOUS, URINARY RETENTION WERE 2% OF POSTOPERATIVE COMPLICATIONS

 SIGNIFICATIVE TRAINING

ACCURATE KNOWLEDGE OF UTERINE BLOOD ANASTOMOTIC SYSTEM

SUPERVISED TRANING: 1) BLADDER DISSECTION; 2) OPENING FASCIAS

PRECISE AWARENESS OF BLOOD SUPPLY BY TOPOGHAPIC AREAS

RETROSPECTIVE CASE DISCUSSION: HITS AND MISSES

 SUMMARY

SELECTIVE DEVASCULARIZATION RESECTION RECONSTRUCTION

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 CONCLUSIONS

UP TO 80% OF THE UTERUS COULD BE PRESERVED USING SIMPLE AND INEXPENSIVE TECHNIQUES

USE OF CUSTOM-MADE HEMOSTASIS IS A HIGHLY EFFICIENT METHOD TO PERFORM THE HEMOSTASIS

INTRASURGICAL STRATIFICATION ALLOW TO MAKE A PRECISE DIAGNOSIS,

AND COULD MODIFY THE SURGICAL STRATEGY