Prolapse surgery and urinary incontinence in gynecology.
Pelvic Floor anatomy
Essential concepts to understand pelvic floor are
- the support mechanism in the anterior, middle and posterior compartment
- the upper vagina is horizontal and rests upon the levator plate
- the anatomy of the levator ani muscles
- the role of the muscles, innervation and of the ligaments
Pathology, aetiology and treatment of prolapse and urinary incontinence
Pelvic floor prolapse and/or urinary incontinence is a frequent pathology occurring in over 10% of women older than 80 years. The causes are
- damage during delivery including an innervation damage. Innervation damage will weaken the muscle and cause extra stress to the ligament support system.
- damage of the support system i.e. rupture of ligaments or attachments (repair := site specific repair)
- weakening of the support system by age or collagen decrease e.g. by menopause or congenital collagen pathology.
Prevention of pelvic floor prolapse and/or urinary incontinence is hormone replacement therapy.
Therapy of pelvic floor prolapse and/or urinary incontinence consist of a combination of
- muscle training
- replacing /repairing the support system
- by vaginal or laparoscopic surgery,
- by site specific repair or mesh repair.
Surgical therapy of pelvic floor prolapse and/or urinary incontinence
Until 10-15 years ago repair was performed by vaginal surgery. Since laparoscopic surgery a spectrum of therapeutic possibilities exist with specific pro’s and con’s.
- Vaginal Surgery consisted of , vaginal Hysterectomy with if necessary Colporaphia anterior and/or Colporaphia posterior and repair of perineal body. This is the traditional approach with unfortunately 20-30% recurrence rate.
- Laparoscopic surgery has taken advantage of the newer concepts of anatomy and introduced the site specific repair such as high McCall, paravaginal defect etc.
- In parallel mesh repair was introduced i.e. mainly the promontofixation.
- Vaginal mesh repair as initially TVT and then replaced by TOT revolutionised stress urinary incontinence surgery.
Surgical strategy of pelvic floor prolapse and/or urinary incontinence
Few randomised studies exist and choices are often base upon the surgical skills of the surgeon. Indeed those are equally skilled in all types or surgery are rare, vaginal surgery being basic training whereas promotofixation already is level 2 endoscopy.
Facts upon which strategic choices are based.
- the repair of the perineal body can only be performed by vaginal surgery
- Vaginal surgery is associated with a high recurrence rate up to 30%
- Vaginal meshes are associated with 5 to 10% mesh erosions, which is a disturbing complications.
- A subtotal vaginal hysterectomy together with a promotofixation requires a skilled and fast surgeon to do this in less than 3 hours.
- a promontofixation should not be performed when the vagina is opened
- The discussion between ‘site specific repair’ (popular in the USA) and mesh surgery, (mainly developed in France) : long term results of meshes are better, but it is equally clear that meshes are a problem in case of complications (eg an infection ) or during subsequent surgery. For the recent FDA advice on mesh surgery
Preoperative exams ?
- Urodynamic tests ? Although popular, they have little impact upon the choice of surgical technique.
- Imaging : as ultrasound and dynamic MRI. This are research instruments with today little proven clinical value.
Strategic choices of pelvic floor prolapse and/or urinary incontinence surgery
In older women with health problems vaginal surgery should be considered since this can be done under local or epidural anesthesia i.e. traditional vaginal surgery as vaginal hysterectomy and / or vaginal wall repair and TOT for urinary incontinence
In all other women
Stress urinary incontinence without a cystocoele (bladder descent)
- a TOT (transobturator tape) is the method of choice with excellent results in over 90%.
- If surgery fails (10%) a laparoscopic Burch procedure is performed. (A TVT as first intervention has only historical significance. It was a major step forward 10 years ago, but TOT has the same results and less complications.)
An isolated (large) cystocoele with or without stress incontinence.
- When caused by a a mid-line defect of the pubovesical fascia which is a rare pathology, a total anterior mesh repair is preferred.
- A lateral defect of the pubovesical fascia (a paravaginal defect) without a descent of the uterus.
- a paravaginal repair together with a laparoscopic Burch if necessary.
- a vaginal mesh repair and eventually a TOT is technically easier but associated with some 10% mesh erosions.
An isolated rectocoele - enterocoele :
- for a low defect only we prefer a vaginal colporaphia posterior and perineal body repair since this generally is sufficient and the most easy surgery.
- for a larger defect we prefer to start with a laparoscopy and to decide during laparoscopy about the type of surgery. ie
- either a high McCall procedure with or without a levator plasty. The advantage is that no mesh is used and that this can be combined with a colporaphia posterior.
- or to perform a mesh repair using the uterosacrals for suspension if present. Otherwise the mesh is fixed to the promontory (less physiologic) if the uterosacrals are absent or defect. In this case vaginal surgery is performed later if necessary.
A Pure vaginal cuff prolapse is rare. If it occurs a posterior mesh repair + repair of the “pericervical fascia” ie attachment to the pubo-pelvic fascia + repair of a paravaginal defect for the larger ones.
Most frequent are combined defects such as a uterine prolapse with cystocoele and rectocoele.
solution 1 : a vaginal hysterectomy + colporaphia anterior and posterior. This is the “classic” approach. The drawback is a relatively high recurrence rate around 20% to 30%. This is not surprising since this type of surgery can difficultly correct a paravaginal defect (which is much more frequent than a mid-line defect) whereas a levator plasty is limited to the lower part of the vagina and a suspension with uterosacral repair is more difficult.
solution 2 : a subtotal laparoscopic hysterectomy + a promontofixation . A consensus has developed that this technique does not require an associated paravaginal repair. Long term results are excellent. This has become the method of choice if the surgeon has the necessary skills. Not that many are able to perform this surgery in less than 3 hours.
solution 3 : a sequential treatment : start with a vaginal hysterectomy (+ a colporaphia anterior and posterior)knowing that there will be 20-30% recurrences and do a laparoscopic promontofixation if the prolapse recurs.
We personally prefer option 2 since it requires only 1 surgery.
This, however, might be a slightly biased position because our laparoscopic surgical skills. Moreover today, given the median laparoscopic surgical skills of the gynecologists, option 3 definitively will have to be applied for many years to come.
Increases with age up to 85%
Types of urinary incontinence
- Stress incontinence : loss of drops of urine when walking, coughing, laughing. This is a mechanical problem caused by a bladder descent or insufficient support of the bladder neck.
- Urgency : coming too late -losing of a lot of urine - an over-active bladder can have several causes
Predisposing factors for urinary incontinence
Urinary incontinence is generally associated with a pelvic floor descent of the anterior compartment, ie a descent of the anterior vaginal wall.
Predisposing factors are vaginal deliveries, or a decreased strength of the support tissue as occurs with age, especially when no hormone replacement has been taken or in association with specific congenital diseases
Exams : the diagnosis of urinary incontinence is mainly clinical
- The clinical exam gives information of the degree of vaginal descent and of the quality of the pelvic floor muscles.
- Urodynamic exam : the usefulness is very limited except for very rare diseases of bladder neck incontinence
- colpocystodefecography : only experimental without any clinically proven usefulness. Does not change the surgical strategy.
- ultrasound : still experimental
Treatment of urinary incontinence is surgery except for pure urgency incontinence.
Urinary incontinence without cystocoele (anterior vaginal wall prolapse)
TOT is the treatment of choice because of the high success rate of over 90% and because it is technically a short and simple intervention which eventually can be performed under local anaesthesia. TVT is outdated as first line therapy.
When this treatment fails a TVT can be considered.
Urinary incontinence with anterior vaginal wall descent.
A vaginal mesh with a TOT seems today the best strategy preferable to a laparoscopic Burch with a paravaginal defect repair or .
Urinary incontinence with anterior vaginal wall descent and descent of the uterus.
A promontofixation is the method of choice.
A simultaneous TOT should not be performed because of the risk or over correction and urinary retention.
If this treatment does not correct the urinary incontinence, a TOT should be performed in a second intervention.
The major complication is a mesh erosion.
Meshes for prolapse surgery and urinary incontinence in gynecology
What is a mesh
Pelvic floor prolapse is a mechanical problem caused by insufficiently solid support tissues or by a tear of the support tissue from its attachment to the bone. Hence it increases with age (wrinkles also are caused by a decrease in collagen quality) and after delivery.
A tear of the attachment to the bone is logically treated by reattachment : ie a site specific repair
A decrease in quality of the support tissue should be treated by reinforcement with a foreign substance ie a mesh
Which mesh ?
Many types of meshes exist. This variety is mainly caused by commercial arguments and much less by scientific arguments.
Prolypropylene meshes are the way to go, provided the pore size is large, and that light weight is better.
Organic meshes today should not be used unless experimentally.
Results are often slightly better with a mesh while recurrences are less.
In addition a site specific repair cannot correct insufficient strength of the support tissues
Drawback of meshes
The main concern is a mesh erosion : this occurs in 5 to 7% of vaginal meshes and can be very difficult to correct.
Other intra-abdominal complications as bowel obstructions are extremely rare
When later another is intervention is needed the presence of a mesh will make this intervention more difficult.
What to do and who should do it ?
In younger women with good quality of collagen a site specific repair is preferable
When the quality of collagen is less a mesh is preferable.
The main problem however is the skill of the surgeon : meshes apparently seem easy surgery and are performed by many.
Meshes require however a very skilled surgeon in order to minimize complications.
Obviously surgeons not skilled to do laparoscopic interventions, will not offer site specific repair and will overuse vaginal meshes.
Recent concern on the use of meshes and FDA recommendations
In the October 2012 newsletter of the Australian endoscopy society recent concerns on the use of meshes are discussed together with the FDA recommendations concerning training.
The key issue however is not addressed : the main problem are the surgeons not the meshes. FDA recommends obtaining knowledge and training in vaginal and vaginal mesh surgery.
- what is missing is that unless the surgeon is equally skilled in laparoscopic surgery and promontofixation, it is unlikely that a fair balance of vaginal versus laparoscopic surgery will be offered to the patient. In addition
- what is missing is that evidence of knowledge and training is limited to presence at meetings. The skills itself are never assessed. This is another nice example that video-registration should be mandatory.
Laparoscopic surgery for Urinary incontinence and prolapse in gynecology
Para-vaginal defect and Burch
A prolapse of the bladder is in 95% caused by a detachment of the suspension from the bone. This creates a para-vaginal defect which can be corrected site specifically laparoscopically. Only few gynecologists are skilled in this intervention, which in over 90% can be replaced with a colpo-promonto-fixation.
Levator plasty - High Mc Call - Colposuspension
In order to correct an important posterior descent and or a prolapse of the vaginal cuff a posterior repair is performed. When the defect is more severe, surgical repair will be more extensive. The surgical procedure therefore will vary from a McCall only to a sacrocolposuspension.
- –a high McCall :(= shortening of uterosacral ligaments)
- -………………..+ a levator plasty (repair of the defect between the levator ani muscle)
- -……………………………………….+ a mesh attached to the uterosacral ligaments
- -……………………………………….+ a mesh attached to the promontorium when uterosacral ligaments are defective.