New Directions in Restoration of Pelvic Structure and Function

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1 2 New Directions in Restoration of Pelvic Structure and Function Peter E. Petros and Bernhard Liedl The fundamental theme of this chapter is that structure and function are intimately related. Abnormal symptoms and prolapse are caused by connective tissue laxity in the vagina or its suspensory ligaments Integral Theory1 (Fig. 2.1). Other than pelvic pain, in some way, all the symptoms concern closure (continence) or opening (emptying) by the muscle forces (arrows). Tissue tension is critical for each of these functions. It follows that, in order to restore function, the surgical technique used must also restore tissue tension. A new tensioned sling technique which fulfills these criteria is presented later in this chapter. The tensioned sling works like the tensioned wires of a suspension bridge. It addresses both prolapse and abnormal symptoms, and has been successfully applied in >2,000 cases since November 2003 for patients with both stress incontinence and major prolapse. There are three zones and nine potential sites of connective tissue damage in the female pelvis (Fig. 2.1). Correct diagnosis of which ligament(s) is damaged is critical, so as to guide accurate repair of such ligament(s). Restore the structure, and you will correct the function. Dynamic Anatomy Organs are suspended by ligaments. Pelvic muscles (arrows, Fig. 2.1) stretch the organs against the ligaments to give them shape and support. By a sequence of coordinated contraction and relaxation, the organs are closed (continence) or are opened out actively (emptying). Lax ligamentous insertion points therefore may cause not only prolapse, but also symptoms of incontinence and abnormal emptying (Fig. 2.1). The Integral System of diagnosis and surgery is based on a three zone classification, containing nine connective tissue structures (Fig. 2.1). P.E. Petros (*) University of Western Australia, Claremont, WA, Australia kvinno@highway1.com.au Pathogenesis of Prolapse and Abnormal Symptoms Abnormal symptoms and prolapse are caused by connective tissue laxity in the vagina or its suspensory ligaments Integral Theory.1 The Causes of Damaged Connective Tissue Childbirth, age, and congenital collagen defects are major causes of uterovaginal prolapse, bladder, and bowel dys function. Structural Effects of Damaged Connective Tissue The circles in Fig. 2.2 represent the baby s head descending down the vagina, stretching the connective tissue supporting structures (ligaments) laterally, thereby causing laxity. Lateral displacement of ligaments and fascia may cause the bladder, uterus, and rectum to herniate through the space to present as cystocoele, uterine prolapse, and rectocoele. The same ligamentous laxity may cause abnormal urinary and bowel symptoms (see Figs. 2.1, ). Minor Damage, Major Symptoms: The Trampoline Analogy The three muscle forces tension the vaginal (trampoline) membrane against the suspensory ligaments (Fig. 2.6) (springs). Like a trampoline, laxity in even one ligament may prevent the vaginal membrane from being tensioned sufficiently to support the stretch receptors (N), and prevent them from activating the micturition reflex at a low bladder volume. The patient perceives this as frequency, urgency, and P. von Theobald et al. (eds.), New Techniques in Genital Prolapse Surgery, DOI: / _2, Springer-Verlag London Limited

2 10 P.E. Petros and B. Liedl Vagina Anterior Middle Posterior PUL Hammock EUL Cystocoele Para-vaginal high cystocoele Enterocoele Uterine prolapse Vaginal vault prolapse PCF CX RING ATFP USL RVF PB Stress incontinence Abnormal emptying Pubourethral ligament (PUL) Hammock External urethral ligament (EUL) Pubocervical fascia (PCF) Arcus tendineus fascia pelvis (ATFP) Cardinal ligament/cervical ring (CL) Frequency and urgency Nocturia Fecal incontinence Pelvic floor laxities which can be repaired Fecal incontinence Uterosacral ligament (USL) Rectovaginal fascia (RVF) Perineal body (PB) Obstr defaec Pelvic pain Fig. 2.1 The pictorial diagnostic algorithm. A summary guide to causation and management of pelvic floor conditions. The area of the symptom rectangles indicates the estimated frequency of symptom causation occurring in each zone. The main connective tissue structures causing symptoms and prolapse in each zone are indicated in red capital letters. There is no correlation between degree of prolapse and symptom severity nocturia. The cause may be ligamentous damage in any of the three zones. This statement can be directly tested by examining a patient with a full bladder. Digital pressure ( simulated operation ) at midurethra controls stress incontinence and often urgency. Gentle digital support anterior to cervix or in the posterior fornix may also control urge symptoms. Vaginal Examination Each zone is examined, in turn, for damage and the results are recorded. Anterior Zone Examination Diagnosis The pictorial diagnostic algorithm (Fig. 2.1) is the key to diagnosis.2 It relates specific symptoms to damaged ligaments in each zone. Accurate assessment of the zone of damage by examination is critical. Often, the final diagnosis can only be made in the operating room. The anterior zone extends from the external urethral meatus to bladder neck. Three structures are tested: the external urethral ligament (EUL), the pubourethral ligament (PUL), and the vaginal hammock. A pouting (open) external urethral meatus generally signals laxity in the EULs, especially if associated with eversion of the urethral mucosa (Fig. 2.7). The test for a damaged PUL

3 2 New Directions in Restoration of Pelvic Structure and Function 11 A lax hammock (see Fig. 2.7) is evident on inspection, but it can also be tested by the pinch test; taking a unilateral fold of the hammock with a hemostat. Diminution of urine loss during this test demonstrates the importance of an adequately tight hammock for urethral closure. These maneuvers are an essential part of the vaginal examination (Fig. 2.8). Middle Zone Examination Fig. 2.2 Schematic representation of zones and structures of connective tissue damage at childbirth. (1) PUL pubourethral ligament (stress incontinence), (2) ATFP arcus tendineus fascia pelvis and pubocervical fascia (cystocoele), (3) USL uterosacral ligament (uterine prolapse), (4) Perineal body/rectovaginal fascia (rectocoele) The middle zone extends from bladder neck to the anterior lip of the cervix or hysterectomy scar. It has three connective tissue defects, central, lateral ( paravaginal ), and cardinal ligament/anterior cervical ring defect ( high cystocoele, transverse defect ). A central defect typically is shiny, and blows out on straining. A central cystocoele can be differentiated from a paravaginal defect by placing ring forceps in the lateral sulci to support the ATFP and asking the patient to strain. Often, however, a patient has both central and lateral defects. The cardinal ligaments insert anteriorly into the cervical ring. Tearing of this insertion may dislocate the pubocervical fascia, creating a characteristic lateral extension of the bladder fascia around the cervix (Fig 2.9, arrows). This is known as a high cystocoele or transverse defect and it is often accompanied by a retroverted or prolapsed uterus (Figs and 2.11). Posterior Zone Examination Fig. 2.3 Childbirth. Forcible lateral displacement of hiatal and perineal structures. The A-P diameter of the pelvis is cm. A flexed head measures 9.4 cm, and a deflexed head 11.2 cm. The margin for prevention of damage is low (After Santoro) involves two essential stages. The first is for the patient to demonstrate urine loss in the supine position on coughing. Then, a finger or a hemostat is placed at midurethra on one side and the cough is repeated. Control of urine loss signifies a weak PUL. The posterior zone extends from the cervix/hysterectomy scar to the perineal body. Evidence of a bulge at the apex, vaginal wall, or perineal body should be looked for during straining. Small degrees of prolapse in the apex of the vagina are easily missed. Therefore, when examining in the supine position, always support the lateral sulci of the anterior vaginal wall with ring forceps and ask the patient to strain when examining the posterior zone. Alternatively, examination in the left lateral position may be helpful. The posterior vaginal wall is tested for defects in the rectovaginal fascia (rectocoele) by asking the patient to strain, and also by digital rectal examination. The perineal body and external anal sphincter are tested by digital examination. Major posterior zone defects are frequently accompanied by other defects. For example, the patient (Fig. 2.12) most likely has a cardinal ligament/cervical ring defect, a central cystocoele, lax and separated uterosacral ligaments with an enterocoele, and probably lax rectovaginal fascia (Fig. 2.13).

4 12 Fig D ultrasound demonstrates a dramatic widening of the levator hiatus ballooning, in a patient during straining (Valsalva), from 9 cm2 at rest, to 64 cm2 (After Dietz HP. With permission). The arrows define the hiatal space between the pubovesical muscles. This figure is Fig. 2.5 Childbirth. Forcible lateral displacement of uterosacral ligaments (USL), perineal body (PB) and rectovaginal fascia (RVF) by the fetal head (circles) causing connective tissue laxity, and protrusion of enterocoele and rectocoele Surgical Repair of Connective Tissue Structures Reconstructive pelvic floor surgery according to the Integral Theory System differs from conventional surgery.3 1. It has a symptom-based emphasis (the pictorial diagnostic algorithm), which expands the surgical indicators from major prolapse to include cases with major symptoms and only minimal prolapse. The same operations apply for symptoms and prolapse. 2. Special instruments insert polypropylene tapes to reinforce damaged ligaments in three zones of the vagina. 3. It is based on specific surgical principles which minimize risk, pain, and discomfort to the patient. P.E. Petros and B. Liedl consistent with the causation proposed in Figs.2.2 and 2.3: connective tissue damage of the ligaments and fascia binding the hiatal structures causes lateral displacement, laxity, and herniation of these structures Fig. 2.6 Schematic representation of a fetal head pressing into the pelvic brim, against the vagina and its suspensory ligaments, uterosacral (USL), pubourethral (PUL), and arcus tendineus fascia pelvis (ATFP). Even minor damage to the ligaments may cause urgency, as this symptom is neurologically determined To minimize pain Avoid tension when suturing the vagina Avoid vaginal excision Avoid surgery to the perineal skin To avoid urinary retention Avoid tightness in bladder neck area of vagina Avoid indentation of the urethra with a midurethral sling 4. The uterus needs to be conserved wherever possible. It is the central anchoring point for the posterior ligaments, the rectovaginal fascia, and the pubocervical fascia. The descending branch of the uterine artery is a major blood supply for these structures, and should be conserved where possible even if subtotal hysterectomy is performed.

5 2 New Directions in Restoration of Pelvic Structure and Function Fig. 2.7 Lax external urethral ligament (EUL) and hammock. The urethral meatus (M) is lax, and the urethral mucosa is everted. The lateral EUL supports are seen drooping downward (arrows). The hammock is lax and angulated downward 13 Fig. 2.9 Prolapse, third degree, of bladder and uterus. A large central defect extends laterally. Prolapse of bladder around cervix (CX) (curved arrows) is characteristic of Cardinal ligament/cervical ring defect. BN bladder neck PS PCM PUL PUL BLADDER trigone H C LP O LMA Fig. 2.8 Testing for a lax pubourethral ligament.2 Unilateral anchoring at midurethra is the only method possible for diagnosing a damaged pubourethral ligament (PUL). Cessation of urine loss on coughing confirms a lax PUL. Midurethral anchoring restores the closure forces, which narrow the urethra from O (stress incontinence) to C (continence) during coughing, and it also restores the geometry from a funneled to a normal outlet. Taking a fold of vagina H ( pinch test) generally also decreases urine loss Tension-free Slings (with or Without Attached Mesh) These techniques are designed to reinforce damaged ligaments and fascia, and are well covered by other contributors. This chapter concerns New Directions, in particular, tensioned minislings, as applied for prolapse and abnormal symptoms. Fig A ruptured cervical ring r may cause dislocation of PCF (cystocoele). It may loosen the cardinal ligament attachments CL, so that the uterus may retrovert and even prolapse Tensioned Minislings: A Physiological Alternative for Prolapse Repair Minislings mostly avoid the major vascular and nerve complications reported with the retropubic, transobturator, and perineal slings. The tensioned minisling (Fig. 2.14) applies the engineering principles of a suspension bridge the suspensory wires (ligaments) (Fig. 2.14) hold up the suspension bridge (pelvic organs). Lax ligaments cannot support the organs, resulting in prolapse. Unlike large mesh sheets, there is no limitation to backward extension of the organs, because the tapes are transversely sited (Fig. 2.14). There is no invasion of the rectovaginal and vesicovaginal spaces, so scarring, adhesions, and dyspareunia are largely avoided.

6 14 P.E. Petros and B. Liedl Fig Large rectocoele (R), and deficient perineal body (broken lines) revealed by rectal examination. Note scar S from previous surgery for rectocoele Fig Differentiation between central/lateral cystocoele and high cystocoele (cardinal ligament/cervical ring defect) is confirmed if the cystocoele disappears when laterally placed Allis forceps are approximated. Persistence of a bulge indicates the lesion is caused by a rupture/ stretching of the pubocervical fascia (central/lateral defect) Fig Tensioned Polypropylene tapes T bring the laterally displaced ligaments and fascia toward the midline. This tightens the suspensory ligaments like the wires of a suspension bridge, and the tapes create artificial neoligaments to bind the connective tissue structures together during straining (see Fig. 2.4): pubourethral (PUL), uterosacral (USL), cardinal (CL), arcus tendineus fascia pelvis (ATFP), and also, perineal body (PB) Fig Everting fourth degree vault prolapse. X denotes the line of the hysterectomy scar The cathedral ceiling analogy visually explains how tapes (joists) can provide support to a much weaker structures such as damaged vaginal fascia (Fig. 2.15). Symptom Cure Connective tissue must be tensioned to restore muscle function (Fig. 2.6) because a muscle requires a firm insertion point to function optimally. The descriptions below are confined to the TFS (Tissue Fixation System) minisling, as that is the only tensioned sling available today. Short-term results in patients with multiple symptoms and symptom improvement

7 2 New Directions in Restoration of Pelvic Structure and Function 15 (PCM) Fig The cathedral ceiling structural analogy a new direction for prolapse repair. Direct reinforcement of the ligaments, as in Fig. 2.14, provides sufficient strength for prolapse repair, without the requirement for large mesh Anchor were as follows: SI (89%) fecal incontinence (n = 33), 88%, stress incontinence (n = 43), 89%, urgency and nocturia (n = 50), 80%.4 Fig Anatomical position of the Tissue Fixation System (TFS) anchor. The midurethral tape is anchored into the inferior surface of the pelvic floor muscles. The prepubic (external ligament) TFS tape is positioned between the muscle layer and tissue covering the anterior surface of the pubic bone Tensioned Midurethral TFS Minisling: Repair of the Pubourethral Ligament Indications Stress incontinence (SI) or mixed incontinence. The dissection is almost identical to a tension-free tape sling a midline incision, dissection of urethra from vagina, penetration of the perineal membrane (urogenital diaphragm). The applicator is placed into the dissected space. The TFS anchor is released and the tape tightened over an18g Foley catheter until it touches the urethra without indenting it. The free ends are trimmed. The vaginal hammock fascia and the external ligamentous attachment of the external urethral meatus are then tightened with 2 0 Vicryl sutures. No cystoscopy is required. The cure rate at 3 years is equivalent to tensionfree midurethral tape operations5 (Fig. 2.16). Tensioned Pre-pubic TFS Minisling: Repair of the External Urethral Ligament Indications Continued urine leakage after cure of stress incontinence with a midurethral sling The patient complains of leakage on sudden movement, often associated with a feeling of a bubble escaping. There is usually no SI. Measured leakage may be large, but is reduced by 50 70% by insertion of a menstrual tampon. The operation is identical to a midurethral sling, except that that channel is made anteriorly, between the anterior surface of the pubic bone and the muscle layers. Tensioned TFS Mini U Sling Repairs Central and Lateral Pubocervical Fascia and ATFP Indications Cystocoele caused by a central/lateral (paravaginal) defect. The surgical principle underpinning this operation is to mimic the ATFP and to provide a transverse neofascial beam to reinforce the damaged central pubocervical fascial defect. In patients with an intact uterus and no previous surgery, the dissection can be made via a transverse cm incision at the vesical fold. The bladder is dissected off the vaginal wall and cervix. Under tension, a channel is made below the pubic ramus, extending onto the medial aspect of the obturator fossa, in the position of the ATFP insertion (Fig. 2.17). The applicator is inserted, the anchor released and the tape tightened until a resistance is felt. The vagina is sutured without tissue

8 16 Fig U sling. View into the anterior vaginal wall. Vagina (V) is dissected off the bladder wall, and stretched laterally. The TFS tape is anchored (A) medial to the obturator fossa (OF) muscles, toward the arcus tendineus fascia pelvis (ATFP) excision. In patients with previous hysterectomy or previous vaginal repair, an inverted T incision is made to ensure adequate dissection and reduce the risk of bladder perforation. P.E. Petros and B. Liedl Fig Cervical ring/cardinal ligament repair, sagittal view. The tape is placed along the anterior lip of cervix and extends along the cardinal ligament. On tightening, the cervix is pulled back, and the uterus anteverts Cervical Ring Transverse Defect (High Cystocoele) Repair Indications Cystocoele caused by an anterior cervical ring/cardinal ligament defect, especially if associated with urgency and abnormal emptying symptoms. This is a common lesion, especially after hysterectomy, which necessarily dislocates the attached cervical ring and attached fascia. A cm horizontal incision is made in the vesical fold 1cm above the hysterectomy scar, or above the cervix. The bladder is dissected clear of the vagina and cervix. A channel is made along the cardinal ligament to just beyond the lateral sulcus. The dissection plane is about 2 cm above the ischial spine. The TFS applicator is inserted, the anchors released, and tape tightened until a resistance is felt. A high initial cure rate at 9 months has been achieved for TFS cystocoele repair5 (Fig. 2.18). The Posterior TFS Sling Indications Uterine/apical prolapse, enterocoele: In patients with significant Posterior Fornix Syndrome symptoms (nocturia, pelvic pain, urgency, abnormal bladder emptying, Fig. 2.1), Fig Posterior TFS. Perspective: View from above. The tape is placed along the exact position of the uterosacral ligament (USL). The arrows indicate how the remnants of USL are approximated during tightening, closing the enterocoele this operation is performed even with minimal prolapse. The results at 3 years (unpublished data) are equivalent to more invasive procedures. The posterior TFS sling is similar to the McCall operation insofar as it anchors the apical fascia into the uterosacral ligaments (USL). A full thickness, cm transverse or longitudinal incision is made in the vaginal apex. The uterosacral ligaments (USL) or their remnants are identified and grasped with Allis forceps. If an enterocoele is present it is reduced. Fine dissecting scissors create a 4 5 cm space just lateral to the USLs for the instrument. The anchors are ejected, and the tape tightened. Tightening the tape approximates the uterosacral ligaments and closes the enterocoele (Fig. 2.19).

9 2 New Directions in Restoration of Pelvic Structure and Function 17 tape is set and tightened. This brings each perineal body toward the midline and adequately closes a low and midrectocoele. Limitations of Minisling Surgery Whereas a midurethral sling operation is significantly simpler than the retropubic or transobturator method, a good working knowledge of the site of the pelvic ligaments is required for prolapse surgery. Accurate anchor placement in the position of damaged ligaments is required for tensioned slings to work. Organ damage to date has been minimal. Potential Longer-Term Complications of Minisling Surgery Fig Approximation of laterally displaced perineal body and RVF. Inferiorly, the TFS strongly approximates the laterally displaced perineal body (PB), and with it, rectovaginal fascia (RVF). Superiorly, the posterior sling approximates the laterally displaced uteroscral ligaments and attached fascia, at the same time closing the enterocoele Posterior TFS Sling at the Time of Vaginal Hysterectomy Vaginal vault prolapse is a major long-term complication of hysterectomy. Posterior TFS sling during vaginal hysterectomy is simple, takes only a few minutes to perform, yet provides strong vaginal vault support at 12 month review (Petros and Richardson, unpublished data). Perineal Body TFS Sling A stretched perineal body is the condition where the perineal body (PB) has been stretched thinly across the lower part of the anus. During surgical reconstruction a transverse incision just inside the muco-cutaneous junction vastly facilitates access to the laterally placed intact parts of the perineal body. Using dissecting scissors, and controlled by rectal examination, a channel is made vertically into the body of each perineal body to just beyond the insertion of deep transverses perinea to the inferior pubic ramus (Fig. 2.20). The The main complications are erosion, and change in the structural balance of the three zones. The more significant complication is the development of de novo prolapse and symptoms in other compartments weeks or months after surgery, because structural reinforcement in one zone may divert the pelvic muscle forces to other subclinically weakened zones. Failure to cure may be due to wrong diagnosis, decompensation of other connective tissue structures caused by the intervention itself, or surgical failure of the operation itself. Repetition of the preoperative protocol, diagnosis of the zone and structure(s) (Fig. 2.1) that have been damaged, cough and 24-h pad tests to assess seriousness of the problem, are the key elements in the decision tree for management. References 1. Petros PE, Ulmsten U. An integral theory of female urinary incontinence. Acta Obstet Gynecol Scand. 1990;69(suppl 153): Petros PE. Diagnosis. In: Petros PE, ed. The Female Pelvic FloorFunction, Dysfunction and Management According to the Integral Theory. 2nd ed. Heidelberg: Springer; 2006: Petros PE. Surgery. In: Petros PE, ed. The Female Pelvic FloorFunction, Dysfunction and Management According to the Integral Theory. 2nd ed. Heidelberg: Springer; 2006: Abendstein B, Petros PE, Richardson PA. Ligamentous repair using the Tissue Fixation System confirms a causal link between damaged suspensory ligaments and urinary and fecal incontinence. J Pelviperineol. 2008;27: Petros PE, Richardson PA. Midurethral Tissue Fixation System (TFS) sling for cure of stress incontinence 3 year results. Int J Urogyne. 2008;19:

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