Chapter 1 16 1.3 Surgical treatment Another, yet invasive alternative is surgical repair. The main goals of pelvic floor reconstructive surgery are to restore normal pelvic anatomy, while also eliminating POP symptoms and normalizing bowel, bladder and sexual function. Surgery for prolapse can be performed by either the vaginal or abdominal route, and with insertion of implants or without, i.e. using the patient’s own tissue and sutures (referred to as native tissue repair). The same goes for surgical management of SUI where suspension of the bladder neck or mid-urethra can be done via abdominal route by sutures (e.g. Burch colposuspension) or by vaginal route using synthetic mesh (midurethral sling; MUS) or an autologous sling (fascia lata or rectus sheet). Based on current evidence, both autologous pubovaginal slings and Burch colposuspension have cure rates comparable to those of MUS, but are obviously more morbid with a less beneficial safety profile and more common adverse events such as storage lower urinary tract symptoms following autologous slings, and more mid- or posterior vaginal wall prolapse following Burch.23,24 Surgical treatment options for UUI include neuromodulation and botulinum toxin instillation, however improvement rates do not exceed 70%, and adverse events, including infection and obstructive voiding, are not uncommon.25 Clearly defined guidelines on the surgical treatment of both prolapse and urinary incontinence are lacking. The choice of surgery depends on several factors, including the general health status of the patient, the expertise of the surgeon, the preferences of both patient and surgeon, and, in the case of prolapse, the site and severity of the prolapse. Whereas most patients with symptomatic prolapse can be adequately managed via the vaginal route, correction of apical descent or multi-compartment prolapse, including a so-called level I defect, is, based on current evidence, better treated via the abdominal approach.26 In sacrocolpopexy the vaginal vault and/or cervix is fixed by means of a graft to the anterior longitudinal ligament over the sacrum, as shown in Fig. 6. The technique can be empirically divided in five steps, each of them requiring specific skills to overcome specific challenges. Following the dissection of the promontory, the right paracolic gutter and vaginal vault are dissected. Next the mesh is fixed to the vaginal vault by resorbable sutures and to the promontory, by either sutures or tackers. As a last step the peritoneum is closed, although the necessity of this step is questioned.27 There are numerous reports on the successful outcome of laparoscopic sacrocolpopexy (LSCP), including data from our own group. We first implemented LSCP in our unit in the late 1990s, and earlier reported on short and medium-term outcomes.28,29 Laparoscopic sacrocolpopexy yields excellent objective (97% anatomical cure) and subjective (83% improvement) outcomes, yet at the expense of longer operating times and a steep learning curve (between 30 and 60 cases, depending on what outcome measures are considered).30,31 One potential way to reduce operating time might be decreasing the number of sutures. Some surgeons use fewer sutures without apparent impact on outcomes. The development of alternative, faster mesh fixation methods, including surgical glue, could also help.32 As different approaches to
RkJQdWJsaXNoZXIy MTk4NDMw