New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge and abnormal emptying

Abstract

The aim of the study was to introduce an anatomical classification for the management of urinary dysfunction based on the Integral Theory, a new connective tissue theory for female incontinence. Eighty-five unselected patients, aged 27-83 years, 12 with pure stress symptoms and 73 with mixed incontinence symptoms, were classified as having laxity in the anterior, middle or posterior zones of the vagina, using specific symptoms, signs and urodynamic parameters summarized in a pictorial algorithm. Special ambulatory surgical techniques, which included the creation of neoligaments, repaired specific connective tissue defects in the anterior (intravaginal slingplasty (IVS), n = 85), middle (cystocele repair, n = 6), or posterior zones (uterine prolapse repair, n = 31, or infracoccygeal sacropexy, n = 33). Almost all patients were discharged within 24 hours of surgery, without postoperative catheterization, returning to fairly normal activities within 7-14 days. At (mean) 21-month follow-up cure rates were: stress incontinence 88% (n = 85), frequency 85% (n = 42), nocturia 80% (n = 30), urge incontinence 86% (n = 74), emptying symptoms 50% (n = 65). Mean objective urine loss (cough stress test) was reduced from 8.9 g preoperatively to 0.3 g postoperatively, and mean residual urine >50 ml from 110 ml to 63 ml, P = <0.02. Pre- and postoperative urodynamics indicated that detrusor instability was not associated with surgical failure. Two new directions, based on the Integral Theory, are presented for the management of female urinary dysfunction, an anatomical classification which delineates three zones of vaginal damage, and a series of ambulatory surgical operations which repair these defects. The operations are fairly simple, safe, effective and easily learnt by any practising gynecologist.

Posterior intravaginal slingplasty for vault and uterovaginal prolapse: an initial experience

“…Pelvic muscles play an important part in bladder symptoms; pelvic muscle support of the bladder base and the stretch receptors control symptoms of frequency, urgency, and nocturia. Previous studies have reported a high concomitant cure rate for bladder symptoms [2]. This study confirms previous reports of high rates of improvement in symptoms of prolapse, urgency, nocturia, pelvic pain, and difficulty voiding [6].…”

“…This procedure provides reconstruction at the three levels of connective tissue support [2]. The tape, by anchoring the apex of the prolapsed vault, supports and restores the cardinal/uterosacral ligament complex.…”

“…The infracoccygeal sacropexy, also known as the intravaginal slingplasty (IVS), is a new minimally invasive procedure introduced by Petros in 1997 to correct vault prolapses [2].…”

Should surgeons continue to implant mesh sheets behind the vagina?

“…The public outcry against vaginal mesh has a valid scientific basis: the collagenous scarring that mesh creates is appropriate for nonelastic ligaments; it is contraindicated for an elastic vagina [2,3]. Ensuring any form of repair that maintains lifetime tissue elasticity is possibly crucial to success.…”

“…Major improvements in tape technology have revolutionized surgical repair of POP. These methods apply the discrete ligament repair principles so successful for the MUS [2,3] combined with site-specific repair of pubocervical, rectovaginal fascia, and extraurethral ligaments, without vaginal excision.…”