Zusammenfassung
Senkungen nehmen demographisch bedingt zu. Steigende soziokulturelle Ansprüche der Frauen erfordern effektivere Behandlungen mit erfolgssicheren Methoden. Bei kritischen Indikationsstellungen und exakten Operationstechniken haben sich bei Senkungen und Beckenbodeninsuffizienzen netzbasierte pelvine Plastiken den konventionellen Verfahren wegen guter Langzeiterfolge und nur geringen Rezidivraten als überlegen erwiesen. Bei systematischer Therapieplanung sollte man spezifische Regeln und Schrittfolgen einhalten. Also: „Implantiere so wenig Netz wie möglich und nur so viel Netz wie unbedingt nötig!“ Grundsätzlich sollte der implantierende Operateur auch zum Explantieren befähigt sein! Man wähle zum Eingriff einen vaginalen, abdominalen oder laparoskopischen befundgerechten Zugang, um den Aktionsraum so zu bemessen, dass eingriffsbedingte Kollateralschäden vermieden werden. Instrumentelle Nahttechniken und Operationsroboter sind bei beengten Zugängen und Aktionsräumen vorteilhaft. Bei apikalen direkten Fixationen ist die therapeutisch relevante Zielgröße der Elevationswinkel der Vagina. Bewährte anatomische Fixationspunkte sind vorzuziehen. Eine risikolose Distanz der Implantate zu vulnerablem Gewebe ist zu wahren. Autochtone bindegewebige Strukturen sind zu erhalten, zu stärken und zu rekonstruieren, um gestörte Funktionen zu restituieren. Netzbasierte Deszensuskorrekturen sind bei Rezidiven, bei Primärsituationen, bei kombinierten Defekten im vorderen Kompartiment, bei Zentraldefekten multimorbider und älterer Patientinnen und v. a. zum Organerhalt indiziert. Praktische Fähigkeiten zu hochspezialisierten netzbasierten Eingriffen sowie effektive Techniken zum Komplikationsmanagement sollten in interdisziplinären Spezialistenkursen fallbezogen vermittelt werden.
Abstract
There has been an overall increase in pelvic organ prolapse due to demographic changes (increased life expectancy). Increasing sociocultural demands of women require treatments that are more effective with methods that are more successful. In the treatment of pelvic floor insufficiency and uterovaginal prolapse, pelvic floor reconstructions with mesh implants have proven to be superior to conventional methods such as the classic colporrhaphy, reconstructions with biomaterial, and native tissue repair in appropriately selected patients and when applying exact operation techniques, especially because of good long-term results and low recurrence rates. When making a systematic therapy plan, one should adhere to certain steps, for example, a pelvic floor reconstruction should be undertaken before performing the corrective procedure for incontinence. The approach, if vaginal, laparoscopic, or abdominal should be chosen wisely, taking into consideration the required space of action, in such a way that none or only minimal collateral damage related to the operation occurs. The use of instrumental suturing techniques and operation robots are advantageous in the case of difficult approaches and limited anatomical spaces. In principle, the surgeon who implants meshes should be able to explant them! The surgical concept of mesh-related interventions in the pelvis must meet established rules. “Implant as little mesh as possible and only as much suitable (!) mesh as absolutely necessary!” In the case of apical direct fixations, a therapeutically relevant target variable is the elevation angle of vagina (EAV). Established anatomical fixation points are preferable. A safe distance between implants and vulnerable tissue is to be maintained. Mesh-based prolapse repairs are indicated in recurrences, in primary situations, in combined defects of the anterior compartment, in central defects of multimorbid and elderly patients, and above all, when organ preservation is wanted. Native connective tissue structures are to be preserved, strengthened and reconstructed to restore altered functions. Practical skills for highly specialized mesh-based operations as well as effective techniques for complication management should be taught in interdisciplinary specialist courses.
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J. Neymeyer, D.-E. Moldovan, K. Kornienko, K. Miller und A. Weichert geben an, dass kein Interessenkonflikt besteht.
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Neymeyer, J., Moldovan, DE., Kornienko, K. et al. Implantate bei Genitalprolaps. Urologe 56, 1576–1582 (2017). https://doi.org/10.1007/s00120-017-0540-z
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DOI: https://doi.org/10.1007/s00120-017-0540-z