Surgical Strategy and results
Facts upon which choices of surgical technique are based
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1. Traditional vaginal surgery versus laparoscopic surgery. Vaginal surgery is probably the easiest, and less invasive technique but is surgically limited. Laparoscopic approach is much more performant but requires an experienced laparoscopic surgeon.
2. With or without meshes ? The use of meshes have been debated over the last decade. The mesh has the advantage of being more solid with better results over longer periods, but has the disadvantage of being more complication prone eg mesh erosions. In addition when an infection occurs this can be very serious while a second intervention after mesh surgery can be very difficult. This resulted in 2 opposing vieuws, the site specific repair (and no meshes) versus almost systematic use of meshes. The former has been the USA principle whereas the latter has been the French attitude
3. Meshes are associated with a risk of some 10% of mesh erosions when the vagina has been opened.
4. More recent mesh surgery for total vaginal repair has been developed and the debate continues between those who prefer laparoscopic surgery to avoid the risk of mesh erosions , those who prefer to take the risk and do systematic vaginal mesh repairs.
What is our position, taking into account surgery, complications and results
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In older women with other health problems vaginal surgery that can be done under local or epidural anaesthesia should be considered ie
- traditional vaginal surgery as vaginal hysterectomy and / or vaginal wall repair : the choice to a large part depends on the technical skills of the surgeon since this will influence duration of surgery which then varies from 1.5 hours to more than 3 hours .
- TOT for urinary incontinence
In all other women
1. Stress urinary incontinence without cystocoele (bladder descent) : a TOT (transobturator tape). This is the least invasive procedure virtually without risks, it will not compromise any future surgery and the results are excellent in over 90%. If surgery fails (in some 10%) a laparoscopic Burch procedure.
Discussion :
We consider TVT as having only historical sifgnificance. The development of the TVT has been a major step forward some 10 years ago, but since TOT has the same results and less complications this has become the ppreferred technique .
When a TOT fails it is preferable to do a Buch since it has another access route. To do a TVT for TOT failures is for us a second choice mainly performed when the surgeon is not familiar with laparoscopic Burch procedures
2. A n isolated (large) cystocoele with or without stress incontinence.
- When caused by a a midline defect of the pubovesical fascia a vaginal colporaphia anterior should be performed. This however is a rare pathology and it is unclear whether the associated stress incontinence should be treated traditionally with Kelly points), or by a TOT, or whether a total anterior mesh repair should be preferred.
- A lateral defect of the pubovesical fascia from the white line and from the pericervical rim ie a paravaginal defect is by far the most common pathology.
Facts : solid data do not exist.
a paravaginal repair is appealing since it is typical ’site specific’ surgery that specifically cures the defect. Simultaneously a laparoscopic Burch can be performed if necessary. The major problem of this approach is that it requires a good endoscopic surgeon of level 2.
a vaginal mesh repair is technically easier but associated with some 10% mesh erosions. – this compises a TOT when necessary.
Our Interpretation
We prefer to do a paravaginal repair and a Burch if necessary, in order to avoid mesh erosions. Moreover when necessary, ie the 10% failures , a vaginal repair remains possible.
3. An isolated rectocoele – enterocoele : the choice of procedure is not that easy since some (combination of interventions should be avoided. It is contra-indicated to combine laparoscopic surgery with a vaginal (mesh) repair. Alternatively the repair of the perineal body can only be performed by vaginal surgery.
Our Interpretation
- for a low defect only we prefer a vaginal colporaphia posterior and perineal body repair since this is sufficient and the most easy surgery.
- for a larger defect we prefer to start with a laparoscopy and to decide during laparoscopy about the type of surgery. ie
either 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 Pure vaginal cuff prolaps is rare. If it occurs 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. Most frequent are combined defects such as a uterine prolaps with cystocoele and rectocoele.
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 can difficultly 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 subtotal laparoscopic hysterectomy + a promontofixation . A consensus has developed that this technique does not require an associated paravaginal repair. Long term results are excellent. This has become the method of choice if the surgeon has the necessary skills. Not that many are able to perform this surgery in less than 3 hours.
solution 3 : a sequential treatment : start with a vaginal hysterectomy (+ a colporaphia anterior and posterior)knowing that there will be 20-30% recurrences and do a laparoscopicpromontofixation if the prolaps recurs.
Our attitude
We personally prefer option 2 since it requires only 1 surgery.
This, however, might be a slightly biased position because our laparoscopical surgical skills. Moreover today, given the medain laparoscopic surgical skills of the gynaecologists, option 3 defintively will have to be applied for many years to come.
