Ann-Sophie Page

Chapter 4.1 54 INTRODUCTION Urinary incontinence (UI) and pelvic organ prolapse (POP) are prevalent (3-60% and 24.5-64.7%, respectively) and bothersome conditions, seriously affecting the quality of life.39,98-100 A close association between both conditions has been reported earlier.10 Prolapse repair has been reported to result in the resolution of UI symptoms.11,12 Therefore, anatomical aspects may play a role in the aetiology of urinary incontinence. There are several anatomical theories supporting this finding, which remain in constant evolution due to the advances in clinical experience, surgical correction, and evolution in clinical imaging.101 The Integral theory holds that lax ligaments may result in apical prolapse and urinary incontinence.13,102 Therefore, the clinical association between apical prolapse and urge urinary incontinence (UUI) might be caused by malfunctioning uterosacral ligaments (USL). Current treatment options for UUI and mixed urinary incontinence (MUI) (pelvic floor exercises (PFE) and medical treatment) are limited by their small short-term efficacy and low compliance.103 In addition, medical treatment for UUI and MUI entails considerable costs and side effects. Therefore, further exploration of the potential benefits and safety profiles of these surgical alternatives is to be considered. Cervicosacropexy (CESA) or vaginosacropexy (VASA) might restore apical prolapse while using a relatively low load of permanent graft material compared to other procedures for correcting vault prolapse. Laparoscopic sacrocolpopexy (LSCP) is currently the gold standard for apical prolapse repair and involves suspension of the vault by meshes.104 These may lead to graft related complications, which may be, in part, due to the mesh type or the amount of foreign material used. In CESA or VASA, site-specific defect repair requires less mesh. Second, the alloplastic material chosen, by its biomechanical characteristics, may minimize graft-related complications. Polyvinylidene fluoride (PVDF) is known to have better textile and biological properties than polypropylene.105 Jäger et al. were the first to report on a well-standardized surgical procedure to treat UUI and MUI by replacing both USL with PVDF tapes of identical length (Dynamesh CESA:8.8 cm, Dynamesh VASA:9.3 cm, FEG Textiltechnik mbH, Aachen, Germany)106. It is known that the mean length of the USL is 8.7cm (95% CI 7.5 to 10.0).101 These tapes are sutured to the prevertebral fascial layer in front of S1/S2 sacral vertebrae and on the opposite side at the insertion of the USL at the cervix (CESA) or, after previous hysterectomy, at the edges of the vaginal vault (VASA) by non-absorbable sutures.107,108 Several single center uncontrolled studies report promising results in treating UUI and MUI by CESA or VASA.37,107-111 To date, only one randomised controlled trial (RCT) has been performed and supports these findings.106 We systematically reviewed the literature on the efficacy and safety of this innovative yet standardised surgical procedure as a potential alternative treatment for women with mixed or urge urinary incontinence and/or apical prolapse.

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