Surgical Strategy

Principles

For pelvic floor repair we use the following principles.

1. Site specific repair i.e. repair of the defect only

2. Restrictive use of a mesh i.e. when necessary only. A mesh by definition carries a little risk of complications such as infection, of mesh erosion and more complicated subsequent surgery when necessary.

3. The use of a mesh when the vaginal wall is opened should be avoided.

Practically  

1. A stress urinary incontinence without cystocoele (bladder descent) : a TOT (transobturator tape).   The reasons for this choice are :(1)  it is the least invasive procedure virtually without risks. (2) it will not compromise any future surgery (3) the results seem comparable to the TVT, which therefore is no longer used.

If the surgery fails to cure the stress urinary incontinence (some 10%) a laparoscopic Burch procedure is performed.

2. A (large) cystocoele with or without stress incontinence.

- caused by a a midline defect of the pubovesical fascia is  an indication for a vaginal colporaphia anterior. Stress incontinence is treated simultaneously (Kelly points) but the reported long term results are not very good. It is unclear whether this is true or whether many women with a paravaginal defect had been included.

- caused by a a lateral defect of the pubovesical fascia or a paravaginal defect is an indication for a laparoscopic paravaginal defect repair.Simultaneoulsy a Burch can be performed for stress incontinence.

3. A rectocoele - enterocoele : the choice of procedure is not always easy since some are mutually exclusive

- a low defect only can be repaired by a vaginal colporaphia posterior and perineal body repair.

- for a larger defect we start with a laparoscopic posterior repair.  After inspection of the defect it is decided which type of surgery will be performed

either to perform 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 promontorium (less physiologic) if the uterosacrals are absent or defect. In this case vaginal surgery is performed later if necessary.

4. A vaginal cuff prolaps : a posterior mesh repair + repair of the "pericervical fascia" ie attachment to the pubopelvic fascia +  repair of a paravaginal defect for the larger ones.

5. Combined defect such as a uterine prolaps with cystocoele and rectocoele. No ideal solution is available

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  cannot correct  a paravaginal defect (which is much more frequent than a midline defect) whereas a  levatorplasty is limited to the lower part of the vagina and a suspension with uterosacral repair is more difficult.  

solution 2 : a laparoscopic hysterectomy + a paravaginal defect repair + a posterior repair. The disadvantage is that a mesh is relatively contra-indicated since the vagina has to be opened. This has been reported to increase complications as a mesh erosion form 0.5% to more than 5%. Variability of surgical techniques and expertise however cast doubt on these figures. The most important reason why this procedure is not so popular is that in order to perform this combined procedure in less than 2.5 hours the surgeon has to be fast and very experienced. Otherwise the procedure can become very long. 

solution 3 : sequential treatment : a vaginal hysterectomy + a colporaphia anterior and posterior  followed by a laparoscopic repair if a recurrence of prolaps occurs.

Website: http://www.gynsurgery.org