Vaginal Surgery for pelvic floor disorders
Pelvic descent and stress urinary incontinence are often but not always associated. Surgery intends to correct both. Management has changed dramatically over the last years. Sinse 2005 I adhere to the following guidelines and principles. Randomised controlled trials are still lacking, but this is not surprising since surgery has been continuously evolving, and since few surgeons are equally good in all techniques.
1. Site specific repair ie repair of what is deficient without overcorrection
2. The most appropriate technique should be used. This can be laparoscopic or vaginal. according to pathology, not to the surgeons preference.
3. The combination of open vagina and mesh use should be avoided.
4. A 2 step approach can be preferable instead of overtreating in one procedure
Traditional surgery for pelvic descent
Colporaphia anterior and Kelly plication : indicated for cystocoele caused by a midline defect. This technique is quesionable for treating a paravaginal defect for which I prefer a laparoscopic paravaginal repair. This is the most frequently performed procedure when a vaginal prolaps exist. Since the recurrence rate is high, and since most women have a paravaginal and not a midline defect, I have replaced this procedure by a laparoscopic paravaginal repair in most women (unless in association with a vaginal hysterectomy)
Colporaphia posterior and perineal body repair : is indicated for rectocoele. For more severe cases eg when associated with an enterocoele this surgery is complimentary to a laparoscopic posterior compartment repair. Since a mesh is contra-indicated in association with vaginal surgery, the laparoscopic intervention can sometimes be scheduled as a second intervention.
Classic Vaginal Hysterectomy and vault suspension.
Richter is the fixation of the vaginal vault to the spine ligament. Today this surgery is replaced by a laparoscopic mesh repair or promontofixation, unless health concerns with anaesthesia and laparoscopy are present
Traditional vaginal surgery still is the most widely used and is the preferred method for mainstream gynaecology. Briefly, a vaginal descent of uterus, bladder or rectum is treated by vaginal correction by removal of the uterus, and by repairing the bladder and the rectal descent.
Vaginal surgery unfortunately can difficultly correct a paravaginal defect, and whereas ideal for a low rectal prolaps, it is less indicated for a high rectal prolaps/enterocoele.
Laproscopic surgery could replace a vaginal hysterectomy+bladder repair+rectum repair. Unfortunately this surgery requires a very fast and skilled endoscopic surgeon to perform this operation in less than 150 minutes. Moreover a subtotal hysterectomy should be performed in order to permit the use of a mesh if necessary.
The alternative is to perform a classic vaginal surgery in if a recurrence occurs (some 30%) a laparoscopic correction is performed during a second intervention .
Newer vaginal MESH techniques
De transobturator tape is the most recent treatment of isolated stress urinary incontinence. The results were demenostrated to be comparable to the TVT
Principle : support of the mid-urethra (similar to the TVT)
- virtually risk free in comparison with TOT
- does not hamper subsequent surgery if necessary
- skin incision over foramen obturatorius .
- can be done onder local anaesthesia
- hospitalisation : day surgery, eventually 1 day.
The TVT was introduced before the TOT for isolated stress urinary incontinence. Large series with excellent results have been performed.
Since the TOT gives similar results, since the TVT is associated with a much higher incidence of surgical complications, and since in the absence of success (some 10%) a laparoscopic Burch is more difficult, for me the TVT mainly has historical merit. It has been replaced entirely by the TOT
Prolift or other vatiants of total vaginal MESH repair