Good afternoon, I am Dr. David Cohen, President of the Latin American Association for the Celbic Floor, at least here in South America, I live here in Chile, we are in the afternoon, depending on what region of the United States you are in, it will probably be a good night or an earlier afternoon. I wanted to introduce you to the symposium that was organized Today, this is a symposium organized by the OX, the majority are probably members of the OX, we are and I am the President of the LAB, the Latin American Association and Dr. Víctor Miranda, who is the President of the Scientific Office of the LAB, is accompanying us and Dr. Omar Dueñas will also join us during the presentation, He is a member of the OX and lives in the United States. This forum arose a little from the relationship that is being forged between OX and LAB in these last two years, I want to tell you a little bit about how that came about and then I'm going to present to you what the forum consists of and how it will be carried out. The title of the forum is Surgical Forum, Experience of the States United States and Latin America and I have already introduced you to those who will be today's teachers tonight. I wanted to remind you that if you have any questions, please use the button which is at the bottom of the screen to write your questions, you can write them in Spanish or English so we can answer them and if you need any help OX secretariat can contact the secretariat that is connected during the presentation in the chat directly, in case they need any type of assistance or some more specific response from the OX. So welcome again to this surgical forum and the first thing I am going to do is introduce you a little about what this is. OX-ALAP project. So the first question that I ask myself and that I imagine you ask is what is ALAP? That is a QR code that takes you directly to the ALAP page, in case any of you want to know ALAP. We are a fairly young society, it is a society that has been around for eight years, there are the posters from all the congresses that we have done, we have traveled around all of Latin America, we have gone to Central America, I'll tell you what's coming now. Therefore we are like any society and as I say OX, a society that offers a lot of things, but probably the heart is given for this meeting that we hold once a year, where all the members of ALAP get together and we do a meeting. There are some photos there, we have important guests, there is Víctor Niti, We have the poster from when we were here in Chile, the poster from when we were in Buenos Aires last year, there are images of Colombia that we were previously in 2020, and there you see a photo of the author Elizabeth Miller. Elizabeth Miller is the past president of OX, I had the opportunity to share with her in Buenos Aires almost a year ago, in October of last year, and where together with her we were able to establish a little what we wanted like ALAP and what did you like OX want from us and see how we we can enhance. And now I'm going to tell you a little about what that work we did is and in what we are today. And in the middle, as in all congresses, it is also an opportunity to meet with Friends, there is Dr. Mucelio Lemos, many of you probably know him, There is a past president of the society, our former secretary, therefore we have the opportunity to get together with friends. Apart from the congress, what else do we have? We have a website where we deliver a lot of activities, courses, access to journals, etc., Therefore we have an activity just like you have, activity throughout the year, with webinars, with activities that can be obtained from the website, with access to bibliographic searches, with access to journals and this was probably the main milestone that joined the OX. It is true that last year I had the opportunity to invite Dr. Miller to to attend our congress in Buenos Aires, so that she could hold the first symposium OX-ALAB within the OX congress. It was a very good experience, very very good, I before I had had conversations with some past presidents and with the OX manager who is no longer here working for OX and we always thought what we could do together and one of those things was hold an OX symposium within the OX congress and within that the possibility arose that The Uruguayan Ecology, which is the official magazine of the OX, could also be transformed into the official magazine of our association. And so it is, today and for the next three years, The Uruguayan Ecology is also the official journal of our association, which has us very happy, very proud and we already have a significant and growing number of our partners who They are participating and being partners, sorry, and having membership of the magazine. What other something we also think, just as we invited the OX to the OX congress so that the OX bring teachers to the OX and be able to bring science from a country like the United States to Latin America, and probably many of you who are in this symposium are from Latin America or have roots in Latin America, the idea was to attract top-level science to Latin America because not everyone has the possibility of leaving Latin America for the United States United or towards Europe. And this is how the OX, OX professors have come to our conferences, They come from companies also from Europe and other American companies have also participated with us, but I think the strengthening of ties between our two societies has been very important. And here I can show you an activity that we are going to be developing next next Wednesday in Portland and if I'm not mistaken it will be the first symposium in Spanish and the title is the panorama of urogynecological practice in Latin America, in a symposium in which it will Dr. Víctor Miranda, who is currently traveling to the United States, will participate. There will also be Dr. Abner Santos representing the AP who comes from Guatemala and Dr. Sebastián Pérez Junqueira who comes from Argentina. I am there at the head of the workshop and there you can see a list of all the teachers who are also going to participate in this symposium and are also leaving to be able to present approximately 10 free works that applied to Congress, which are going to be presented in English, during this symposium they will also be able to be presented in Spanish, which will give us We are very happy, very proud, we want to be able to reach Spanish-speaking people in the United States. United and OX and this is a project that really has us very very excited, so as well as the OX board, therefore the exchange of teachers to be able to enhance both congresses is something that is becoming a reality. Here I can show you others activities, there is the surgical forum, we have some regional symposiums that are not the case talk about that, but what is important is that our next congress is going to be held in Panama, in Panama City, between February 21 and 24 and we have some confirmed teachers, You see several names that are known, but in red is the name of Dr. Jennifer Wu, of Dr. Matt Barber and Dr. Omar Dueñas, they are confirmed, they are going to represent from the OX to our congress in Panama, where they are going to develop a symposium at the OX or OX similar with another theme to what we are going to do now next week at the congress of you there in Portland, and that is wonderful because the symposium that is going to be held in Our congress will of course be in English, but the idea is to have teachers of this caliber, that for Latin America I insist that it is super important, it is to have them sitting down and teaching them to the people of Latin America and the only objective is that the OX, our association, is a little the gateway of knowledge from the first world to Latin America and that we can be the exit door also for knowledge of this region, which I humbly think we have large centers distributed in many countries in the region doing very good medicine and that is the intention to be able to go to show next week, therefore there is the poster of our congress again. Now getting into the matter, I wanted to introduce you to the forum, I want introduce you to the teachers who are going to participate, first of all Dr. Omar Dueñas, he is a clinical scientist who obtained his medical degree from the Benemérita Universidad Autónoma de Puebla, had its residence as ward I at Lebanon Hospital in the Bronx, Albert Einstein College, He is a member of the OX and he graciously had the interest of being able to work on the symposium that We are going to do it in Spanish next week, but also to be able to generate this symposium in Spanish, a way to give it a kick and enthusiasm so that all of you can join us on the next week in Portland. Secondly, first it was the owner of the house, now it is us the guests, Dr. Víctor Miranda, Víctor Miranda is a gynecologist and urogynecologist, he is gynecologist who works at the clinical hospital of the Catholic University of Chile, It is a very very important university hospital here in Chile and then he trained in urogynecology at the University of Toronto and had a master's degree in epidemiology, currently he is the director of department of gynecology at the Pontifical Catholic University of Chile, apart from being a very good friend of mine and you will have the opportunity to listen to him, he is a great great presenter. AND Finally I introduce myself, I am Dr. David Cohen, I am a gynecologist and urogynecologist, currently I also work in a university clinic in Santiago de Chile, which is the clinic of the Universidad de los Andes and I am currently the president of the Latin American Association for the Pelvic Floor, therefore there are the scrolls and the people who are with you today. I'm introducing myself and what are you going to do now, I was going to discuss a little bit of the project to the box, I'm already finishing my presentation so that's already a check and then the Dr. Miranda will be able to present to us the topic of sacrocorporexia and the analysis and has some good videos that you will be able to show us. Thirdly, Dr. Omar Dueñas is going to talk to us about the vaginal techniques of apical suspensions and finally we will be able to have the opportunity to ask questions and answers, to be able to leave a message for home, for everyone you and the idea is to be able to interact during this presentation. Therefore, welcome to this box symposium together with the lab and I leave with you Dr. Víctor Miranda. Thanks a lot, David. Well, thank you very much for the invitation, the truth is that I thank David, a great friend, I hope you enjoy this instance a little, which I think is very valuable, especially considering the future events of our societies together. Well, my idea is to introduce you a little, I think everyone knows what laparoscopic sacrocorporexy is, but I will tell you a little about what been our experience and in our center in Chile and show you some results too. Therefore, the roadmap for this presentation includes some prolapse generalities, surgical options for prolapse management and results in our center, which is in the Catholic University. We know that prolapse is a pathology that affects not only the uterus, the clothed, but also the rectum, causing a series of disorders that affect the quality of life of patients, as you see in this resonance ultrasound in which there is a significant rectal prolapse, there is a significant enterocel, there is also an apical defect and important and is what we have to see in an important group of patients. We know not It's easy to quantify, right? Because? Because many patients arrive with those who have more advanced prolapse, are the ones who consult and many patients with less advanced prolapse do not they consult. What we can know with certainty is that 11% of patients will require some type of prolapse surgery throughout their day and up to 30% will require some reoperation. We know that prolapse, as I told you, not only affects, it is not only the only cause for which patients consult and many times we see that they present with other types of symptoms allergy, what is incontinence, what is urinary incontinence, right? Or the mix of all these types of problems. That is why it is important to approach them in a good way and ideally in a place that has people who have expertise in this regard and hopefully multidisciplinary teams They are like they happen in some centers in Chile in which we have physiotherapists, with urologists, coloproctologists, etc., gynecologists and we work on it. Factors that are well known, right? Obesity, age, eh eh chronic pushing factors such as obesity, such as stupidity, such as smoking, but without a doubt parity is fundamental. The fact of having births and especially births with forceps is essential for uh for this type of problems to occur. And because? Because trauma occurs that specifically damages the support mechanisms in the isopelvic which can be microtrauma. Microtrauma is mainly nerve damage. Yes. Hey, if we do a postpartum electroneography on the patients, we see that sixty percent of patients are going to have a nerve conduction disorder. But there is also the macrotrauma, which is this injury that occurs at the level of damage to the pubic rectal muscle. Here You can see the dynamic resonance where you can see the pubic rectum muscle in a V. Here you can see how a disinception of the muscle occurs from the pubis, right? Eh causing this called abultion of the pubic rectal muscle which can be unilateral or bilateral. AND When this muscle damage occurs, the pelvic organs are only subject to to poor quality to be able to provide support. And the symptoms occur, right? They descend pelvic organs causing disorders like mainly the vaginal lump which is the main cause of consultation, bladder foundation disorders, the rest, which affect the quality of lives of our patients anyway. How are we going to face this? Well, the thesary, the surgical treatment, eh, par excellence, but if the patient is not a good candidate for the use of thesaries, or directly wants surgical treatment, we have to see if the patient is a candidate for reconstructive or obliterative surgery. The obliterative is the closing of the vagina and that is clearly indicated in patients who are not having, are not going to have the ability to be able to uh to be able to undergo reconstructive surgery. Surgery reconstructive surgery can be for vaginal life, because no details go into it, because Dr. Dueñas is going to talk and yes eh or it can be for abdominal life and one can choose the one we like the most which is the laparoscopic or periodic assisted route. Here we have a uh in which we are uh in the using the mesh in a patient is the anterior surface of the vagina eh we are using a mesh type one made of polypropylene, right? Eh fixing it I fix it by previous and At the back, the straps separately to be able to give a little more tension to the anterior one and less tension to the posterior one to reduce the disorders a little eh insults that can be associated with this type of virulgin. Eh, without a doubt there we both have Mayans, right? One anteriorly, the other posteriorly, there you can see the bladder in the background and um the dissection of the um chromontorium has already been done, here it is, there you can see the dissect the uh the posterior mesh, the anterior mesh, in front, and we're going to set this in anterior longitudinal ligament of the sacrum. I like to set it separately, as I said, with different functions. Here is the anterior longitudinal ligament. There you can see the dissection and putting the point at the level of that one that is like that one, that two is ideal to be able to fix and reduce the risk of in these cases. So, there we are setting the back mesh. They can see with little attention. And then we're going to fix the previous one in the same way and then peritonize the meshes. The truth is that from the point of view of assisting the robot they are the same steps, they do not change anything at all, The only advantage that the robot has is the ease of making the stitches and knots, there is less essential tremor, more ergonomics for the surgeon, but in practice it is the same. We fix the previous mesh, achieving good elevation and then both mallets are peritonized. Why do we like this surgery? Because the truth is that there is enough evidence to show that it is the best surgery for prolapse correction, We have this systematic review of COPRAN that shows that it decreases the recurrence of symptomatic prolapse compared to vaginal life surgery and would also reduce the need for further prolapse surgery compared to vaginal surgery. If we analyze a little this systematic review and meta-analysis, which is a good study, demonstrated that surgery is indeed better than other surgeries in relation to anatomical recurrence of all compartments. And also in relation to the need for reoperation, the same does not happen with the symptoms of recurrence, apparently there is no statistically significant difference between the approaches at this point, and the truth is that it is something that is frequently seen in many studies. Sacropulpopexy therefore, what is concluded in the literature, is that it would be the surgery of choice, in my opinion in prolapses, especially apital, which would have a better result from an objective point of view than vaginal surgery, and not so in terms of symptoms, which would be more or less similar, there would be less need for reoperation, And what yes, we can see that it allows us to have a good correction of all the prolapsed compartments. Let's see how our center is doing, which is the Santiago del Chilo surgery, These are three hundred and three patients that we operate with sacropulpopexy in the parascolite, of which one hundred and eighty had a subcutal stereotomy associated with the body, and one hundred and twenty-three did not end well. The truth is that our symptomatic recurrence rate was around seven point six percent, which is pretty close to what the literature describes, This group of patients were followed for around forty-nine months. When we analyzed the difference a little to see if there was any factor that was associated with recurrence, the truth is that we did not find any important factor, Clearly, patients with prolapses in pediatrics would have a slightly higher chance of receiving treatment than patients with prolapses with a shorter stay, and when we associate it with a dental rectopexy, the truth is that it has gone quite well for us from the point of view that the recurrence of prolapse is lower, This is probably because these are patients who perhaps have less anterior and apical component than the rest of the patients. When we looked at whether associating it with a subcutal stereotomy increased the risk of receiving sacropulpopexy without uterus, The truth is that we did not find any statistically significant difference, nor was it when we analyzed the different types of anchorages to the anterior longitudinal elevation of the sacrum, there was no statistically significant if we used ProTAC or APNIC points or anchors, etc. Therefore, we believe that sacropulpopexy, specifically laparoscopic, For us it would perhaps be the best alternative for prolapse correction, we have good results in our anesthesia center with low infernal complications, and we have good patient follow-up, which allows us to consider this technique as something useful for patients with anterior prolapses, apical or multicompartmental, especially those who do not want obliterative surgery but rather recontrolled surgery. And we are moving to the robot, We have a robot on the new electronic robotic platform called Hugo, which will allow us to present our next technique a little at the WHO. So thank you all very much for your attention. Perfect, thank you very much Víctor, your presentation is very nice, a very clear summary, then at the end we can talk a little with those who are present here if there are questions, or maybe between us with Omar. So Omar has already arrived, I have already introduced them, so Omar, the screen is all yours so you can tell us what you wanted to show us today. How are you? Hello, good afternoon. An apology because I'm still on my way home, I barely left the operating room, I had a complication with a surgery and we were stranded there. So I don't know if you would like to maybe talk a little about the talk you just gave. and it would give me a little bit of time to maybe get home and try to untangle myself so I can put on my presentation. No problem, count on that. I don't know if down here in the questions, there is no question, but Víctor I wanted to take advantage of you to ask a question, First of all, I would like to congratulate you, a center here in Latin America that has brought together more than three hundred patients with follow-up in sacrocorpopexy, I think it's a super interesting number. When you talk about recurrence, what criteria did you use to consider recurrence of prolapse? Yes, look, we have groups, we have various types of, not all patients have quality of life questionnaires applied, but we have a smaller group in which we have validated quality of life questionnaires. Most of the time we have defined it as anatomical recurrence beyond a stage two prolapse. We know that it has been demonstrated that probably the element of interest that we should measure is symptomatology, because we see that at the end of the day it is what is relevant for patients. I think we are moving towards that, We now have an electronic registry that allows us to have more information in relation to the validated quality of life questionnaires, The CellDiscord Distress Inventory and the CellDiscord Impact Questionnaire would allow us to better evaluate how we are doing from that point of view. Perfect. Let's see, there is a question here. What criteria do you use to select the patient between sacrocolpopexy or vaginal suspension surgery? Linda Lin asks. Normally, when we are going to undergo reconstructive surgery on a patient, If the patient probably has a prolapse, is young, is sexually harassed, I refer her, has few risk factors for surgery In robotic paroscopy, I prefer abdominal surgery. If the patient has any problems wearing tights, o you do not want to wear meshes, probably you are an older patient or you have many abdominal surgeries, who would prefer an extraperitoneal approach, probably my option would be an application to the sacrophinous. It has a higher, slightly higher recurrence rate, especially from the point of view of the need for rotations, a little more dyspareunia than abdominal sacrocolpopexy, but it is also a very good alternative, especially in patients who want to avoid the abdominal route or they don't want to wear tights. Yes, I wanted to complement a little, I agree with you, I think that in young women, usually, in very active women, athletes and everything, I believe that with the evidence that there is for the risk of waste, at least anatomically, I believe that sacrocolpopexy is also the choice, I don't have much doubt. When one begins to have doubts, they are in patients over 60 or 65 years old, who are less active patients, who are more obese, who live more of a home life, or who have other additional pathologies, often the morbidity of sacrocolpopexy It is not given by surgery, but rather it is given by pre-existence and its pre-existing pathologies. Obesity, hypertension, smoking, diabetes, Many times patients can have complications secondary to this. In fact, there is a big, big review out there, what is it called, colpocleisis, with more than 500 patients, where complications secondary to surgery were practically none, and all those patients who became complicated or died, were patients who died from pneumonia, from upper urinary tract infections, from pulmonary thromboembolism. Therefore, it is the group of older patients where one says that the vaginal route will have less invasion. One could add to the vaginal route not only the sacrospinous, but also the utero-sacral ligaments, with a high utero-sacral or with a modified high utero-sacral, which is also a very, very good technique. I can also contribute, Víctor, is that next week I am going to show there in Portland a little about the current situation of abdominal surgery in Latin America, and it's probably a little different than what happens in the United States, where access to laparoscopic training seems to be much broader. In Latin America we are still very behind. Víctor works in a top-level center here in Chile, where he has access to paroscopy, he has access to the robot, but that is not what happens transversally in Latin America. In Chile we have many centers like this, but there are many other centers where sacrocorpopexy surgeries continue to be done open. Therefore, there is the discussion whether it is really worth doing an open sacrocorpopexy. Much more morbidity, of course. That's where morbidity increases. I would tell you that an additional thing from there would be to also add as far as one has to remove the uterus for some condition as well. There, clearly, a sacrocorpopexy cannot be performed. associated with a total stereotomy due to the risk of exclusion of Mayans. For example, if the patient had atypical cordular hypoplasia, If the patient had a history of cervical pathology, in which the cervix had to be removed, probably the vaginal route. associated with a high application, uterus-sacral, or self-sacral application is the most appropriate for that patient, perhaps assuming a little more risk of residue, but that's it. There is also a question regarding... The truth is that in general it is not necessary. There are patients for whom one could reduce the hiatus through a perineoplasty, if it is with a very large hiatus, but in general it is not necessary to do a vaginal plasty associated with a sacrocorpopexy, especially if one achieves a good descent or a good dissection to place the sleeves sufficiently below, both anteriorly and posteriorly. It's a good comment, Víctor, because for many of the people who do sacrocorpopexy, the technique is not so standardized. You see things, but they are not so standardized. There are many people who put the mesh only on the dome, others who lower the mesh halfway through the vagina. For me, personally, what I do, at least posteriorly, is to go down to the levators ani, and I anchor myself at the level of the rectal foam bilaterally, at least posterior, and anterior, probably down to about 2.5 or 3 centimeters from the urethra, from the urethral mead. Therefore, in this type of patient, I believe that if one wanted to perform a vaginal surgery, you would probably find with the mesh or you are at risk of encountering the mesh. So, if you anchor the mesh higher, I think that in those patients it could have a place. posterior repair of the vagina. Of course, I would tell you that in patients who, for example, have previous hyperectomies, dissection of the dressing is often very difficult. It is very difficult to find the map and be at risk of entering. There perhaps one could reach a safe place, saying, you know we are going to attack, anchor the mesh and perhaps correct a little vaginally, including the risk of having to open the dress and having to put the mesh in with an associated cystotomy. In these patients we often find the appropriate plane. Other times it is simple, but there perhaps one evaluates risk versus benefit. In patients with whom a hyperectomy is associated, cycal descent is generally quite appropriate, as you mention. In fact, the cycal lesions that I have had at least have been in hyperectomized patients. Where it is most difficult, again in the webinar, In the symposium that we are going to have next week, we are going to talk, it is going to be a very technical symposium, where we are going to talk about technical aspects, and there we will be able to discuss the tips and tricks of the different surgeries and we will be able to compare what one does, what another does, but actually entering and recognizing the dome and dissecting the bladder in hyperectomized patients, I would say that it is a key and risk point during surgery. Look, here's another question, he says, it seems to me, in your case, Víctor, I can answer later, that they use the Boston mesh, the Absilon. Have you ever used ultralight mesh? Why yes or why not? The truth is that the mesh size was 11 million, which we were occupying. The truth is that I believe that there is no difference between meshes being type 1 polyprothylene mesh. There are some who like to use a little mix of polyprotylene mesh with migril, But if it is Ulcaprox, which is used a lot by folocroptols, but the truth is that there is not much difference, I believe that it being type 1 polyprotylene mesh, Macropore, it should be fine. Yes, I agree with you, Víctor, what I do not use is the White Mesh, because the White Mesh forces you to calibrate the mesh below according to the calibration of the dome. Being White Mesh, then, I do the same as Victor, I carve an anterior mesh and a posterior mesh, I carve the mesh, I anchor it well down, I sew it together, but I go up with only one arm, so it is a technique that one says, well, it is not so standardized. What mesh do I occupy today? I have used Ultralight, I have used Ultapro, I have used Johnson, I have used Maya, Macropore Monofilament. Today I am working for a company that is a Argentine company that has products of the highest quality, which is from Promedon. Because I like That Maya much? Because it is Macroporo and because it has, it has very little memory. So the beauty of having a short memory is that one can fold the Maya forward in the vagina. backwards and the Maya does not return and technically allows me to anchor the Maya more easily and not get it into the surgical field. But that is a matter of taste and training, but I think there is no big difference in long-term results. Yes, there is a difference when using biological implants. The results are not good and If Maya made of polypropylene should be used because when using what is called a biological implant, corpse phase or whatever, the results are much poorer. Swine, they are very poor results, there is more waste. Look, there is a very interesting question, if there is a bladder injury, Does the surgery continue? Yes, I follow it, I try, I do, I repair the gallbladder and I try to put the Maya as far away as possible. It is very controversial, never, at least, fortunately few injuries that I have had, but I have had, without a doubt, I have continued with the surgery and I have had no problems, I haven't had fistulas or anything, but I have tried to put the Maya away and put, put in a little, several, two or three planes of suture of the bladder and try to move the Maya away from the injury bladder and have it in place for a couple of days. And the infections with Maya, tell me. Yes Yes, No, I wanted to reaffirm that a little, when you review a little what is published, what has been reported, is that, basically, repairing the bladder, hopefully in two planes, trying to remove the Maya de la, of the bladder, but the idea is to leave a very well repaired bladder, ideally in two planes or three planes if possible, and do not abandon the surgery, unless it is a really serious injury extensive, or that it approaches the ureteral meatuses, or that it reaches the trigone, there one has to think about it several times if you are going to want to put a Maya, because if not you can have a very serious complication. Where it is clear that the procedure should be abandoned if one has a rectal injury. You have to abandon the procedure, end it there, repair the rectum, call the surgeon, at least we call digestive surgeons or rectal surgeons, and eventually end the surgery there, or go to an alternative vaginal route and discontinue vaginally. I think Omar is, he is ready, but there is one last question that I would like to answer from there. Yes, from condissection. Yes, I have had dysitis, and the truth is that it was necessary in that patient, When managing diacet, always suspect dysitis in a postacropotency patient who has fever or low back pain. That said, every patient with fever and low back pain must order laboratory tests to see if there is any elevation in inflammatory parameters and eventually an MRI to see the presence of dysitis. One can try medical management with antibiotics, certainly, just removing the implant if it is one there is a larger disc compromise, or the antibiotics are not enough to be able to reduce inflammatory parameters of pain. I have had to remove it and have had to remove it in Maya, a product of dysitis, fortunately the patient evolved well after that. Yes, I have not had infections, fortunately, knock on wood, I will probably get it one day. have, but I would say that of course, the great fear that one has is dysitis or osteomyelitis, and I think that the way to avoid it when you see the anatomy figures, etc., what you want is to anchor yourself to the anterior longitudinal ligament, it is a ligament that It is quite superficial, but when one passes the point, one feels as if the point is slipping over the surface where one puts the point. If one wants to go deeper and one insists on putting a very deep point, usually one feels that it hits the bone or eventually it could be getting inside the disc, then you have to be careful that the point slips very gently as if one were passing the point over butter to avoid getting into the disc and increase the risk of the complication of dysitis, which is one of the fears that one has as a major complication in this type of surgery. I think that later we can continue, and Omar I think that is installed, thank you all for the questions, it is very very interesting and come on Omar, we want to listen to you. Now, can you hear me? Perfect, we heard you very well. Very well thank you. So what I am going to be presenting is a a little different, right, what is the correction through the transvaginal technique and the reason for which we sometimes have, now the different techniques, both abdominal and transvaginal is because we must precisely perform a surgery that is in accordance to the needs of our patients, then not all prolapses are the same and definitely Just as you mentioned, right, not all patients are the same, at least we are. What we see every day here are patients who have a fairly high body mass index and therefore So, well, many times that transabdominal surgery is definitely much more complex, definitely the use of the robot or some other type of technology can help us, however We must also have some other type of alternatives. As for what the patients, well, also not all patients are the same in the aspect of the group of age, as we see here on the right side, we have patients who are younger, such as you mentioned, it's probably younger athletic patients, it's probably those in which it would be recommended to do a procedure with a sacrocorpopexy or those patients of middle age group after advanced age or those precisely who are later of 70 years or depending on the status of those patients as well, because we definitely have We have to offer them other types of alternatives compared to abdominal surgery, especially paroscopy. It's so good, for example here the American Society of Urology in the In 2020, he released this flowchart and released a standardization of everything that is the various techniques that can be offered to patients in terms of procedures. obliterative or reconstructive. And as we can see, even though we can lump them into certain groups, we can see that well, we can address prolapse both vaginal and abdominal type and within vaginal techniques since there are many types of variations, especially currently with uterine preservation, which is a topic in vogue at least here, it is something that has definitely changed a lot in terms of what we offer you to the patients. And well, today we are going to be talking at least about my topic of what it is. the correction of the apical prolapse, that means that we would be focused on the correction of the level 1 from Delancy and well, the techniques that we can offer our patients, right? That is the suspension to the sacrospinous ligament. The suspension technique to the sacrospinous ligament was originally described around the 1950s by Amrich and was modified by Richter in '68 and as we can see the references, there was a technique that was in fact it originated in Germany and was then dispersed to the rest of the world. They have There have been various modifications, for example, one that is carried out a lot here in the United States is the four walls technique, which was also proposed by Dr. Delancy's group in Michigan. However, this four-wall technique is usually only for patients who have an advanced prolapse, stage 3 or stage 4. However, something we can see is Well, at least I trained in both the United States and Mexico and I remember some of them. the sacrospinous procedures that we performed, there were still no capture devices and had to do a fairly extensive dissection, as this article shows, where at least There are three people with the valves retracting the rectum, retracting what is the bladder and in turn also the vaginal wall to finally be able to expose that sacrospinous ligament and definitely well after that address it with some suture, either in the needle holder or in this case with the Deschamps needle. And one of the things we can see here, right, is the significant amount of bleeds and if we think that this photograph eye for an article, we can know that many Sometimes, well, bleeding can be really important and it's definitely something to worry about. the evolution of how we have placed that advanced sacrospinous ligament suture. In this case, well, we can see in the lower right corner what is the mile needle that practically already It is obsolete at least here and well the capture devices such as the capio or currently on anchor devices is what is really in vogue topic. As for what the advantages and disadvantages are, well, at least I consider this to be a really surgery with the capture devices, a very quick surgery. Unlike the approach intraperitoneal by a sacrocorpopexy, we know that this takes a little more time and usually if these patients have not had or even if they have had an abdominal procedure or pelvic, which is the chiorectal fosse is usually preserved and dissections usually do not involve encountering much scar tissue. The disadvantages, well, definitely the deviation of the angle of the vagina although there are some types of techniques such as We are going to comment on how this can be preserved and also the other thing that we have to take into account. Consideration that this procedure is probably not as durable as a sacrocorpopexy with the use of mesh. As for anatomy, well, one of the things we must to remember is what the safety zone is, that safety zone that is approximately 2.5 centimeters from what the Asian thorn is. On the right side is one of the images of 3D reconstruction of angiography tomography scans from a study we carried out in 2015 and published in 17 in which the path of what the pudendal artery is and how it is shown We can see, well, especially with capture devices and not anchoring devices, there is that possibility many times of being able to come across, especially the inferior gluteal artery, although it also We can grab the nerve roots of S3 and wow, if we stick a little closer to the spine, the coccylic nerve, levator ani, however, definitely the use of these devices capture I think it is something that has definitely revolutionized in our case at least this type of transvaginal surgery. As for anterior or posterior dissection, it is something that, well, at At least there is some divergence, right? There are schools that like the previous dissection, I Personally, I am more traditional, I like the posterior dissection although many times it is agreed to the type of prolapse that these patients have. If they have a previous significant prolapse and do not They have a lot of posterior prolapse. I usually do the anterior approach, although as we can see here in this article by Dr. Cozant, on the left side, if that previous dissection is performed You probably have to do a much larger dissection to reach that ligament. sacrospinous compared to if we performed the surgery through the procedure and the posterior approach. Another thing that is important to know here is, well, there are certain variations such as placing bilateral sutures. Traditionally ligaments, sacrospinous suspension sutures are performed on the patient's right side because the left side There is a risk of running into the rectum and an injury to the sigmoid or the rectum as such, Although we return to the same thing with the capture devices, I feel that that is something really queer. However, well, those people who perform bilateral procedures There is always the risk of further recurrence of the previous type. And so, well, at least that's why transvaginal meshes appeared trying to precisely offer The best of both worlds, right? In this case an approach to the sacrospinous ligament and that could be bilateral and in turn use a prosthetic material that will increase the duration of this type of prolapse repair. However, as we know here in the United States United States, really, as of 2019, the use of transvaginal meshes has been withdrawn and they are only used under research protocols, although really for the moment There are not many schools or places or centers carrying out this type of procedures since We consider here that there is little probability that at least the transvaginal mesh will resurface here with us. In this case, well, also another of the things that is offered in this type of definitive approaches that can be offered to patients with hysteropexy with mesh, which is quite fortunate and above all reduces the risk of mesh extrusion. Currently, well, what we can offer patients is the use of prosthetic material, On the left side we can see what is cadaveric facialata or on the right side we can see what It is dermis. Probably this type of procedure with this type of prosthetic material is not so Durable like mesh, however, it is the alternative we have. Some other types of more modern devices, for example, in this case there are darts that are actually fired directly through the vagina and no longer has to perform a dissection on what is the anterior or posterior wall of the vagina. It's a little bit, at the beginning when I performed these procedures, it's a little scary because we really don't know what's behind it, However, the device is actually calibrated to offer low penetration, however, it is something that many centers are not yet doing, but at least it is, let's say, another procedure that can be offered. I have performed at least 15 procedures with this device and wow, we have not had any complications and what I can say is how Regarding the duration of the procedure, it is less than an hour to perform the procedure in its entirety, including perhaps a sling and an anterior and posterior repair. However, This procedure is only for patients who are going to have a hysteropexy performed. As for what muscle suspension is and what it demands, well, it really is a technique. which is rarely used, it is usually performed in patients who have a short vagina and that sacrospinous ligament cannot be reached. I mention it as such because, well, There are some authors who still continue to use it, however, I think that really only in a few Sometimes, perhaps patients who are not sexually active and patients who decline to do a colpoclesis, they are probably the ones that I would perform this type of procedure. And finally, well, we have what is the suspension of the utero-sacral ligaments, which would be another of the apical suspension procedures. This type of technique, the technique varies a lot depending on the type of school and the perspectives historical. If we go back in history, in 1927 it began to be described that these ligaments utero-sacral bones could be used as apical support, but it was not until 1957 that McColl described his technique for obliterating the cul-de-sac with non-absorbable sutures. used silk. And well, this suture, this type of technique has been modified, for example, in this case it is not really a technique in drawing as such described by McColl, this is a technique by Mayo McColl, in which the utero-sacral ligaments are taken, returned and the sutures usually They are of the absorbable type, those that are externalized and go more or less as they look. There are others techniques and variants, as is the case of this one that I am showing here, in which purse-type sutures, in which the peritoneum is incorporated and the ligaments are incorporated utero-sacral, with the final goal precisely of avoiding what is an entero-cele and finally taking the utero-sacral at the end and perform a suspension similar to the one I put in the previous slide. Finally, this technique underwent modifications until finally, around 2000-2008, Bob Schull performed this type of high utero-sacral ligament suspension. Let us remember that The definition as such of suspension to the high utero-sacral ligaments is when it is performed by above the siatic spines. Traditionally a Mayo McColl suspension is used at the level of the Asian thorn and yet in this type of variant by Bob Schull he recommended place three sutures on each side and the sutures at least one below the Asian spine, level of the Asian spine and one centimeter above the Asian spine. However we know For reasons of anatomical relationships, the higher the suspension, the lower the risk that we could bend the ureter. Some of the new variants and For example, this is something that I do, which in the last three years we have done a lot here in our center, which is suspension using the V-notes technique, which is the transvaginal laparoscopic technique. This technique, well, what it offers us, as we can see in the slide in this patient once she had a hysterectomy is at least the comfort for us to be able to see with the camera and we really see how I placed the suture and for those who still have doubts about whether the uterosacral ligaments really they exist or not, right, by paying attention we can see here that this really exists band of fibrous tissue that probably represents the uterosacral ligament but What we really like about this type of technique is above all that we can visualize the ureter well. If we see it here just below the ovary we can have a lot of control at the moment that we are placing the sutures and it is something that, as I have just mentioned, We have accomplished quite a bit here. Last year we presented our case series with 64 patients and in none of the patients was the ureter used in what was the procedure of I see that we have a very good visualization and well we are accumulating a series of cases and we have a multicenter study that we are doing probably for next year We will be publishing a little more about this technique. And there are also others variants, for example, this is hysteropexy, this is from Dr. Lowenstein in Israel in which performed this type of approach at the bottom of the sacrum and in which he performed a suspension to the uterosacral ligaments, placed three bicryl type sutures on each side and finally anchors the sutures to what would be the bottom of the sacrum and the cervix and well it is something that you If you have the intention, you can in fact the article is open and you can consult the reference on video is quite interesting. And well, the evidence that shows us the truth that many times it exists that debate between the suspension of the uterosacral ligaments and what the spinous sacral ligament is, something that we can see and that unfortunately we see that lately we do not There has been a lot of background in those randomized clinical studies in what is reconstructive pelvic surgery, however we have the best study where precisely investigated these two techniques and we really see that there were no statistically differences significant between both groups when the two-year follow-up was carried out, as I put it here There is still another article where there were even fewer patients who followed up but still no statistically significant differences were found. Thus, when we have patients and they can be offered one technique against another, we can to say that to a certain extent there is a degree of equivalence in this type of techniques. Of course there is still no information about what binodes are or the use of material prosthetic like those biological agents, however it is something that is definitely missing more studies. And well, sorry for the speed with which I presented this, however we were a little late. If you have any questions or comments, we are happy to answer them. We are here to answer your questions. Thank you Omar for your presentation, it was a very good summary of the vaginal techniques. I tell you that Dr. Miranda, Víctor, had to take the plane because he is now flying to the United States, So I was at the airport, so just as Omar came running and dressed for surgery, Victor had his suitcases on his shoulders, so he is now flying to Portland. Thank you, I wanted to ask you a question about the suspension of sacrospinatus, what are you using? Are you using the harpoons? Are you preferring to pass, what is it called, the suture, with these devices that capture the suture? What are you occupying? First question and second question, which is one of the things that worries me. I am a surgeon and I trained in a vaginal center here in Chile and then I was at the Cleveland Clinic in Florida also doing reconstructive vaginal surgery and now over the years I have started laparoscopy, I believe that a pelvic surgeon has to have the ability to have the adaptability to operate above or below, but the concern I have is that when you are faced with these prolápsedos, these large antero-apical prolápsedos, I think yo that using the sacrospinous or using utero-sacral, the apical suspension is very good and the big problem is the repair of the anterior compartment, because if there is no fascia and we do not have prosthetic material, what can we do? In exceptional cases, mesh can be used anteriorly or vaginally, but I I personally am not using it because of everything we all know and you in the United States have probably a ban on using it. So the question, what do you think of this second question? How do you resolve that situation when you go vaginally and what anchoring mechanism are you using? for sacrospinous? They are good questions. We, wow, at least I trained using the system Capio capture system, for many years we used it and in the last two years we changed to harpoons. The harpoons, well, apart from the fact that at least here in terms of cost the institution was one of the first to approached us and said they could save a little money because it was cheaper and definitely After talking with some other colleagues, we have definitely seen that it is much more fast. There are times when with the other capture device it sometimes scares us a little more especially because of the mechanism in which it is performed, well, the suture goes from top to bottom and the penetration is sometimes difficult to regulate and with harpoons we have done quite well during this years. We have had no complications and at least there is, for example, the advantage that we can change the suture. If I perform a hysteropexy I usually change the suture and use a permanent suture. I like to use the vorotex and anchor it in the cervix, but if the patient has vaginal vault prolapse I usually use the PDS. That's about it which is the first question. As for the second question, yes, definitely the compartment previous definitely has its challenges, as they will say here. The four walls technique It can definitely be a good option, especially in those patients who have a prolapse advanced, since a diamond-type incision is usually made in the vaginal vault, so when the sutures are passed the vault literally piles up, clumps together, then the risk of anterior compartment prolapse decreases. However, it is definitely something that, even though there are certain studies that say that for the function Sexuality does not affect, I personally do not perform it on a patient who is going to be sexually active. The other option we have is currently using prosthetic material, we use it in select cases and what we do is precisely, in fact I am going to do a presentation there in Ox, we cut what is that prosthetic material very similar to transvaginal mesh kits, many times we still have a very similar needle to what the Monarch transocturator is to pass the sutures there and anchor them to the ligament sacrospinous and well, we don't really have the result throughout because there are no studies, true, but we think this is probably better than a native fabric, however, well, There is really that doubt in the long term whether it will be superior or not. That's very interesting because If you check and I commented on it a little before, I don't know if you managed to hear it, when you do an abdominal repair with biological materials, the results are worse and poor when compared to synthetic materials. As you have, here in Chile we do not have biological materials for prolapse repair, yes we have synthetic materials, here in Chile the regulation is quite free, but at least in Chile we have, we look a lot at what It happens in the United States, so I would say that there is no center, dare I say it, There is almost no center in Chile that is using mesh vaginally, exceptionally in the posterior compartment, and what is being used are mini apical meshes to suspend to the uterus or vaginal vault, there are some kits out there or you can cut meshes and anchor bilaterally to the sacrospinous bones, but one would think that if the results are worse using biological material abdominally, perhaps vaginally as well. The results may not be so good, but you have to give it a little time. There is a question there, but the other thing I wanted to ask you is regarding the complication, I also think, I agree with you, that I take care of the harpoons, the capio seems to me that the risk is to pass by and take posterior structures, the Pudendal Artery, the Pudendal Nerve, even the Asiatic Nerve, but the big doubt that I have, I don't do many sacrospinous, the big doubt and problem that I I see that the great complication that sacrospinous surgery has, apart from having a big accident vascular or whatever in the area, is the entrapment of some nerve fiber of the levator muscle anus or something, and of course, a capio, a structure that transfixes can be removed, but the harpoon cannot be removed. take out. Have you had any patients with pain who wanted to remove the harpoon? Because it is not a minor issue. Definitely not, so far we have not had anyone who has had that problem, but I think most of them, in fact, did a long-term, relatively long-term study term, by Catherine Matthews, which was a clinical study, they used a capio against the wide Shure, and saw that there were no differences in terms of short-term pain and long-term pain. term, at the one-year follow-up, they really did not have any patients who, well, were very few patients, there were 48 patients, but they did not see any patient having long-term problems term. Yes, there is that doubt, right? Once you put the harpoon in, that harpoon stays there forever, and I definitely think that most of the pain you have in the sacrospinous ligament It is probably due to the trapping of those muscle fibers and oxygen, and especially the passage suturing with a capture device compared to the harpoon. However, yes, I am I totally agree that there will always be that theoretical risk that if one penetrates with the harpoon a nerve or a structure that generates pain, it is probably going to be something very difficult to treat, definitely. Quick, here they tell us that the anterior or posterior approach. I personally prefer the posterior approach, however, it can be done both anterior and posterior types with harpoons. A little more difficult, and there is some data and people who have debated, perhaps, the angle in which the ligament with the anterior approach. However, I don't see any problem with that. Look, Omario, I appreciate your presentation. We would love to continue talking, but next time This week we will have the opportunity to all be together in Portland. I hope that the attendees of today are there, and those who are not there or those who go, we are going to have the opportunity, we are going to being together, we will be able to discuss this in more depth, more technical aspects. So I, at least, on behalf of ALAP, I am tremendously grateful for having this space, both in this webinar that arose from your idea, Omar was the one who motivated us to do this webinar in Spanish, and also the opportunity to be in Portland, showing a little what we do from here, from this end of the world. So, Omario, I leave it to you to finish, because this is an activity organized by the OX, we are the guests, so I'll leave it to you to finish the webinar. Thank you very much, to Otherwise, thank you very much for your collaboration. I think it's something interesting that finally OX is seeing that there are many people who speak Spanish in the United States, but also outside the United States, and that there is that interest in collaborating, right? Yes in Asia, in Europe it is done, I believe that Latin America and the rest of America can definitely do great things, and well, invite you all to the OX Congress, and we hope that at some point future, this, we can continue with this type of collaborations, and have guests, both from Latin America like OX, who speak Spanish, and that this type of webinars can be held. Thank you very much, then, thank you all and a hug from a distance. Thank you, see you soon, see you later.

symposium

OX

LAB

surgical technique

sacrocolpopexy

prolapse

Latin American Center for Pelvic Surgery

vaginal techniques

apical suspensions

capture devices