Prolapse surgery is based on pelvic floor anatomy
- the support mechanisms in the anterior, middle and posterior compartment
- the upper vagina is horizontal and rests upon the levator plate
Pelvic floor anatomy
- the anatomy of the levator ani muscles
- the role of the muscles, innervation and of the ligaments
Pelvic floor prolapse and/or urinary incontinence is frequent in over 10% of older women
This is caused by damage during delivery of the support system, i.e. rupture of ligaments or attachments together with weakening of the support system by age or collagen decrease, such as menopause without hormone replacement. Prevention, therefore, is hormone replacement therapy.
Being mainly a mechanical problem therapy will be mainly the repair of the support system (vaginal or laparoscopic surgery, by site-specific repair or mesh repair.) and, when needed, muscle training
Our strategic choices for prolapse surgery
In older women with health problems, vaginal surgery under local or epidural anaesthesia is preferable i.e.vaginal hysterectomy, and/or vaginal wall repair and TOT for urinary incontinence
In all other women
- For Stress urinary incontinence without a cystocele (bladder descent) is, a TOT (trans obturator tape) the method of choice, with excellent results in over 90%. If this fails (10%), a laparoscopic Burch should b considered (A TVT as a first intervention has only historical significance. It was a major step forward 10 years ago, but TOT has the same results and fewer complications.)
- For an isolated (large) cystocele with or without stress incontinence, An anterior mesh repair is preferred for a pure mid-line defect, For the more frequent lateral defect without major descent of the uterus, a vaginal mesh repair or a promontofixation with subtotal hysterectomy or a vaginal hysterectomy (with 30% recurrences) the methods of choice. A paravaginal repair with a laparoscopic Burch is rather historical.
- For an isolated rectocele with or without enterocoele. For a low defect only, we prefer a vaginal colporrhaphy posterior and perineal body repair. For larger defects, we prefer to start with a laparoscopy and to decide during laparoscopy whether to perform a high McCall procedure with a levator plasty or a promontofixation
Combined defects with uterine prolapse and cystocele, and rectocele require choices which, unfortunately, vary with the skills of the surgeon rather than with the quality of results.
- a vaginal hysterectomy + colporaphia anterior and posterior is the “classic” approach, with a high recurrence rate of around 20% to 30%. This is not surprising since this type of surgery does not repair the defect.
- a subtotal laparoscopic hysterectomy + a promontofixation has excellent Long term results and has become the method of choice. However, it requires a surgeon with the skills to do this in less than 3 hours.
- a sequential treatment starts with a vaginal hysterectomy and colporaphia. In those with 20-30% recurrences, a laparoscopic promontofixation is performed
Our attitude: We personally prefer option 2 since it requires only 1 surgery.
Site-specific repairs
Para-vaginal defect and Burch are site-specific repairs since a prolapse of the bladder is 95% caused by a detachment of the suspension from the bone. This has been replaced by a promontofixation
Levator plasty - High Mc Call - Colposuspension repairs a posterior descent and prolapse of the vaginal cuff. Although a promontofixation is superior, the mesh discussion has emphasised clinical judgement .
- –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 promontory when uterosacral ligaments are defective.
Urinary incontinence
Two types: Stress incontinence is a loss of drops of urine when walking, coughing, or laughing. This is a mechanical problem caused by a bladder descent or insufficient support of the bladder neck. Urgency is coming too late, and losing of a lot of urine, an over-active bladder with many causes
Predisposing factors are those of prolapse of the anterior vaginal wall., i.e. vaginal deliveries and a decreased quality of the support without hormone replacement
The diagnosis is mainly clinical. The clinical exam gives information on vaginal descent and the quality of the pelvic floor muscles. The usefulness of urodynamic exams is controversial and limited, except for very rare diseases of bladder neck incontinence. colpo-cysto-defecography is experimental or unclear without any clinically proven usefulness. Also, ultrasound is still unclear whether useful
Treatment of stress urinary incontinence is surgery. Without cystocele (anterior vaginal wall prolapse) is a TOT treatment of choice. TVT is outdated as first-line therapy. With severe anterior vaginal wall descent: is a vaginal mesh with a TOT the best strategy. For urinary incontinence with anterior vaginal wall descent and descent of the uterus, is promontofixation the method of choice. A simultaneous TOT should not be performed because of the risk of over-correction and urinary retention. The major complication is mesh erosion.
Meshes for prolapse surgery and urinary incontinence in gynaecology
Why a mesh? Pelvic floor prolapse is a mechanical problem caused by insufficiently solid support tissues or by a tear of the support tissue A decrease in the quality of the support tissue should be treated by reinforcement with a mesh
Which mesh? Pros and cons? Prolypropylene meshes with large holes and light weight are standard. We do not use organic meshes since rather experimental. 
However, meshes are not without complications, such as mesh erosion in 5 to 7% of vaginal meshes. Other intra-abdominal complications as bowel obstructions, are rare.
What to do, and who should do it?
Recent concerns 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 is 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 present at meetings. The skills themselves are never assessed. This is another nice example that video registration should be mandatory.
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