Pelvic Floor Reconstruction

Curriculum in Urology

Pelvic Floor Reconstruction .................................. W. Artibania,*, F. Haabb, P. Hiltonc a

Department of Urology, University of Verona, I-37134 Verona, Italy Tenon Hospital, Paris, France c Royal Victoria In®rmary, Newcastle upon Tyne, UK b

The female pelvic ¯oor consists of a number of individual anatomical structures,

each of which is associated with speci®c functions and dysfunctions (Table 1). Historically, each of these systems has been considered as a separate entity, with urologists concerned only with the bladder and urethra, gynaecologists focusing on the reproductive organs and also, to some extent, urinary incontinence, while colorectal surgeons were dedicated to the posterior compartment. Furthermore the trans-anal perspective of the colorectal surgeon towards the pelvic ¯oor was very different from the trans-vaginal perspective of the urogynaecologist. Increasingly, however, a multi-dimensional approach towards the pelvic ¯oor is being adopted, in which the entire system is viewed as a single entity from both the anatomical and functional perspectives. This can be achieved in a variety of different ways; for example, with a multi-disciplinary team including a urologist, a gynaecologist and a colorectal surgeon. Alternatively, surgeons can develop the relevant skills from all three specialities, in order to become specialist pelvic ¯oor surgeons. Regardless

W. Artibani

Eur Urol 2002;42/1 (Curric Urol 1±11)

Abstract The female pelvic ¯oor is an anatomic and functional complex of three interrelated systemsÐvesico-urethral, genital and ano-rectal. Diseases and interventions affecting any of these compartments also impact on the others, and diagnostic and outcome evaluations cannot be restricted to one system. Instead, the management of pelvic ¯oor disorders demands a multidimensional approach, and pelvic ¯oor reconstruction requires the expertise of a variety of disciplines, including urology, gynaecology, colorectal surgery and physical therapy. Successful outcomes therefore require either multi-disciplinary co-operation or the development of a trans-disciplinary culture. Definitions, multi-dimensional diagnostic and outcome evaluations

Department of Urology, University of Verona, I-37134 Verona, Italy Tel.: ‡39-45-585252; Fax: ‡39-45-8074080.E-mail address: [email protected] (W. Artibani).

1 *

Table 1. The female pelvic floor

2 *

Anatomical structure

Functions

Dysfunctions

Pelvic diaphragm (striated muscle and connective tissue) Lower urinary tract (bladder and urethra) Vagina Colorectal system, anal sphincter

Pelvic organ support

Defective support

Storage and voiding of urine

Urinary incontinence, urinary retention Prolapse, sexual dysfunction Faecal incontinence, constipation

Sex and reproduction Faecal storage and evacuation

of which approach is followed, the urologist should be aware of the structural and functional aspects of the other pelvic ¯oor structures, particularly with respect to the potential impact of urological interventions on these structures. In the past, urologists tended to focus on the structure and function of the urethra without giving suf®cient consideration to the role of the surrounding supportive structures on urinary function and dysfunction. Although it is possible that a condition such as stress urinary incontinence can occur in isolation, in the majority of cases it is a manifestation of more extensive pelvic ¯oor dysfunction. From a pathophysiological perspective, female pelvic ¯oor disorders can arise as a result of a defect of the connective tissues, the muscles or the nerves, and it is now recognised that neuropathy and connective tissue pathology are the main causes of pelvic ¯oor dysfunction. There is a substantial interplay between the musculature and the connective tissue of the pelvic ¯oor. Any muscular weakness can result in stretching and damage to the supportive fascia and ligaments. For example, chronic constipation can lead to pudendal neuropathy with consequent myopathy and connective tissue pathology. As a consequence, genital prolapse is a sign of a disorder of the whole pelvic ¯oor. In accepting that the female pelvic ¯oor is a unity in terms of its anatomy, physiology, disorders, evaluation and treatment it is apparent that any intervention in one compartment causes changes in the other compartments. For example, ventral ®xation of the anterior vaginal wall changes the forces within the pelvic ¯oor, and a study by Stanton and co-workers [1] found that 27% of patients required re-operation for enterocoele or posterior vaginal wall prolapse following Burch colposuspension. Eur Urol 2002;42/1 (Curric Urol 1±11)

Similarly, ®xation of the posterior vaginal wall can cause prolapse of the anterior vaginal wall, and a 92% incidence of cystocele has been observed following sacrospinous ligament ®xation [2,3], even though only a minority of women needed a surgical correction. Any surgeon approaching treatment of the pelvic ¯oor must adopt a transdisciplinary approach, with an awareness of the interplay of the three compartments and incorporating aspects of urology, gynaecology and colorectal surgery. Evaluation of the pelvic floor It is mandatory that a thorough transdisciplinary evaluation be performed before commencing any intervention involving the female pelvic ¯oor. The International Continence Society Pelvic Organ Prolapse (ICS POP) Terminology Standardisation [4] recommends that evaluation should include urological, gynaecological, sexual, physiatric, colorectal and quality of life (QoL) perspectives. These recommendations are a tool that can be used to guide trans-disciplinary evaluations in routine clinical practice (Table 2). In addition, a number of other guidelines for evaluation of the female pelvic ¯oor are available, including the American Urological Association Stress Incontinence Guidelines [5] and those of the First International Consultation on Incontinence [6]. Urological evaluation should include detailed questioning of the patient about the presence of any symptoms, as well as completion of a bladder diary and performance of a stress test, while the performance of a pad test is optional. The gynaecological evaluation requires assessment of any local symptoms (Table 2) and a physical examination to determine the extent of any genital prolapse. It is no longer acceptable to grade prolapse using Artibani/Haab/Hilton

Table 2. ICS POP terminology standardisation Urinary symptoms

Stress incontinence Frequency (diurnal and nocturnal) Urgency Urge incontinence Hesitancy Weak or prolonged urinary stream Feeling of incomplete emptying Positional changes to start or complete voiding

Gynaecological/other local symptoms

Vaginal pressure or heaviness Vaginal or perineal pain Sensation or awareness of tissue protrusion from the vagina Low back pain Abdominal pressure or pain Observation or palpation of a mass

Sexual symptoms

Is the patient sexually active? If she is not, why? Does sexual activity include vaginal coitus What is the frequency of vaginal intercourse? Does the patient experience pain with coitus? Is the patient satisfied with her sexual activity? Has there been any change in orgasmic response? Is any incontinence experienced during sexual activity?

Bowel symptoms

Difficulty with defecation Incontinence of flatus Incontinence of liquid stool Incontinence of solid stool Faecal staining of underwear Urgency of defecation Discomfort with defecation Digital manipulation of vagina, perineum or anus to complete evacuation Rectal protrusion during or after defecation

subjective terms, such as `mild', `moderate' or `severe', and an objective system that can be used reproducibly by other clinicians, such as the Baden±Walker or ICS classi®cations, should be used. The Baden±Walker Half-way system is very popular among gynaecologists and is based on the anatomical ®xed points of the ischial spines and the hymenal ring [7]. Using this system, four grades of prolapse are recognised, depending upon the extent of descent (Fig. 1). In addition, this system gives a description of anatomical sites and of clinical conditions, all of which can be graded from 0 to 4 to provide an objective measure of severity. The ICS POP has also published a system for evaluating the extent of pelvic organ prolapse, which is based upon measurements from a series of ®xed points in the anterior vaginal wall, at the level of the vaginal apex in the posterior vaginal wall and of total vaginal length. These measurements can then be used to provide a mathematical expression of the Pelvic Floor Reconstruction

severity of the prolapse by means of a 3  3 grid. Although this system appears more complex than the Baden±Walker system, it is relatively easy to apply in clinical practice, and there is a good level of correspondence between the two systems (Fig. 1). Close questioning of the patient about her sexual activity, including any changes in the pattern of activity (Table 2), is an important part of the pre-treatment evaluation and also of the outcome assessment after any treatment. Evaluation of fascial defects is more problematic. Such defects can affect both the anterior and posterior vaginal walls, occurring either laterally, transversely, distally or centrally. Although evaluation of such defects is dif®cult and subjective it is, nevertheless, important because surgical correction of discrete fascial defects can improve the overall functioning of the pelvic ¯oor. Physiatric assessment of the striated musculature of the pelvic ¯oor is another key element of the trans-disciplinary evaluation. Eur Urol 2002;42/1 (Curric Urol 1±11)

3 *

Fig. 1. The Baden±Walker classification (Half-way system) for female prolapse in comparison with the International Continence Society's system for pelvic organ prolapse (POP). Anatomical site (clinical condition): urethral (urethrocele); vesical (cystocele); uterine or cuff (prolapse); cul-de-sac (culdocele); rectal (rectocele) and perineal (laceration).

4 *

This is a special, gravitational musculature with a predominance of slow-twitch ®bres in the levator ani. The pubococcygeal muscles can be assessed using a ®nger to determine symmetry, strength of contractions, endurance and fatigability. One such approach is the PERFECT (Power (P), Endurance (E), number of Repetitions (R) a number of Fast (1 s) contractions (F), Every (E) Contraction (C) is Timed (T)) system, but this has not been widely adopted. A simpler system is to grade maximal contraction on the basis of strength (0 ˆ no contraction to 3 ˆ good contraction), endurance (0 ˆ <2 s to 3 ˆ >9 s) and fatigue (0 ˆ <2 maximal contractions to 3 ˆ >9 maximal contractions). It is important for urologists to gain some awareness of the female pelvic ¯oor from the perspective of the colorectal surgeon. Therefore, the patient should be questioned about the presence of any bowel symptoms (Table 2). For example, close questioning of a patient presenting with stress incontinence will frequently reveal the co-existence of ¯atus incontinence. In addition, a physical examination of the anus should be performed, looking for the presence of conditions such as overt or occult rectal prolapse and haemorrhoids. In certain circumstances, it may also be appropriate to perform Eur Urol 2002;42/1 (Curric Urol 1±11)

procedures such as anoscopy or bowel transit studies. Finally, establishing the impact of the patient's symptoms on her QoL should be used in both the initial evaluation of her condition and also in the assessment of outcome following treatment. A number of generic measures are available to assess the impact of incontinence on QoL, including the sickness Impact Pro®le, the Nottingham Health Pro®le, the Short-form 36, EuroQoL and the Go È teborg Quality of Life Instrument. It is preferable, however, to add one of the speci®c measures developed for use in patients with incontinence, such as the Urogenital Distress Inventory, King's Health Questionnaire, Symptom Severity Index, Bristol Female LUTS, Incontinence Impact Questionnaire, the Symptom Impact Index or the contilife scale [8]. Management of pelvic floor disorders A number of different therapeutic interventions are available for the management of pelvic ¯oor disorders, such as education, life-style changes, oestrogen therapy, pelvic ¯oor exercises and surgery, which may be used either concurrently or sequentially in an integrated approach to treatment. In the same way that multi-dimensional evaluation of the initial dysfunction is Artibani/Haab/Hilton

necessary, the evaluation of treatment outcomes should also be multi-dimensional. Such an evaluation should include the patient's satisfaction with the treatment and her QoL, her continence status, pain status, sexual activity and the presence and severity of any bowel symptoms. It is no longer acceptable to consider that a perfectly continent woman with severe dyspareunia or de novo severe bowel symptoms or de novo genital prolapse has had successful treatment. However, many published studies of treatment outcomes do not include such factors in their evaluations. Surgical treatments for pelvic ¯oor disorders can involve either repair, reconstruction, compensation for or replacement of the dysfunctional tissues, and these procedures can use a vaginal, a suprapubic, a laparoscopic or a mixed approach. Although there has been a trend towards a procedure-oriented approach to surgery (e.g. increasing use of laparoscopy), this does not always deliver the best outcome for the patient. It is important, therefore, to ensure that all surgery is patient-oriented that is, where the primary objective is to provide the best possible outcome for each patient. Abdominal and laparoscopic approaches Urethral hypermobility is the most common cause of stress urinary incontinence in women, and it may be corrected using procedures such as colposuspension or slings to restore urethral support. A less common cause of stress incontinence is a sphincter de®ciency, which may be treated by placement of an arti®cial urinary sphincter. Burch colposuspension The Burch colposuspension is one of the most widely-used procedures to restore urethral support in women. This procedure, which was ®rst described in 1961, involves ®xation of the vagina to Cooper's ligaments to restore support to the bladder neck and proximal urethra. The procedure can be performed using an abdominal Pelvic Floor Reconstruction

approach by means of a transverse or mid-line incision. More recently, a laparoscopic approach has also been described [9], which provides the opportunity to perform a para-vaginal repair, by ®xing the fascia to the arcus tendineus. The laparoscopic Burch colposuspension can be performed using either an extraperitoneal or trans-peritoneal approach, but the latter provides greater visibility and working space as well as the opportunity to perform concomitant procedures. The effectiveness of the Burch colposuspension is well established, with a number of studies showing that it associated with long-term success rates ranging from 85% to 90%. An important prognostic factor for a successful outcome is the urethral closure pressure (UCP), and studies have shown that patients who had a pre-operative maximal UCP < 20 cm water had a lower success rate compared with patients with a maximal UCP > 20 cm water [10,11]. Similar continence rates of approximately 80 90% have been reported following laparoscopic Burch procedures, but the mean operation time is typically longer (up to 190 minutes) when this approach is used. Very few studies have directly compared outcomes following open and laparoscopic Burch colposuspension. However, Burton [12] compared the two techniques in a prospective, randomised study and found superior outcomes on both the pad test and number of leaks per day in patients who underwent open surgery. Another study by Carey et al. [13] found that laparoscopic surgery was associated with a longer operation time and a lower cure rate than open surgery, but that the blood loss was less with the laparoscopic procedure. Complications of the open Burch procedure include intraoperative complications (3 6% incidence; e.g. bleeding and bladder injury), postoperative detrusor instability (7 28%), voiding problems (6 20%), enterocoele (3 17%), pelvic pain and ureteral obstruction (0.5 1%). Complication rates for laparoscopic surgery have been reported as mortality of 0.5 2 per 10,000 cases, vascular injury (0.64%), and injury to the bowel (0.27%) or the bladder (1%) during trocar placement [14]. Eur Urol 2002;42/1 (Curric Urol 1±11)

5 *

Slings The approach for sling placement can be either abdominal, vaginal or a combination of these two approaches. There have been very few reports of laparoscopic sling surgery. The material used to form the sling may be autologous (e.g. rectus fascia or fascia lata), heterologous (e.g. cadaveric pericardium) or synthetic (e.g. PTFE, silicone, polypropylene). However, synthetic slings are associated with a relatively high complication rate due to the development of erosions (up to 20% in the ®rst year after surgery). In addition, one of the major problems of sling placement surgery is that there is currently no objective method for determining optimum sling tension. Cure rates with slings placed using the abdominal approach range between 78% and 90%. However, the success declines markedly in patients who have undergone previous surgery for the treatment of stress incontinence [15]. Complications such as voiding disturbances, de novo detrusor instability and urinary retention are relatively frequent. The most common reason for such complications is excessive tension on the sling. A study of cure rates in patients with persistent urethral hypermobility following sling placement found that patients with a completely ®xed urethra had lower cure rates for stress incontinence than those in whom some hypermobility remained [16]. In patients with a totally ®xed urethra, the incidence of de novo detrusor instability was increased, probably as result of bladder outlet obstruction. In such patients, placement of an arti®cial urinary sphincter (AUS) may be appropriate.

6 *

Artificial urinary sphincter The placement of an AUS is one option that should be considered in the presence of stress urinary incontinence due to severe intrinsic sphincteric de®ciency following correction of urethral hypermobility. In women, the cuff is placed at the level of the bladder neck, and the control mechanism is positioned in the labia majora of the vagina. A recent study of 207 patients with mean follow-up of 3.9 years found that the Eur Urol 2002;42/1 (Curric Urol 1±11)

success rate for AUS was 82%, with an explantation rate of 5.9% [17]. Reasons for explantation included infection, erosion and urethral atrophy. The most important prognostic factor was injury to the bladder or vagina during surgery, and the risk of such injury was directly correlated with the number of surgical procedures prior to AUS implantation. Other complications include mechanical failure (e.g. cuff leakage and pump or tubing problems), although these have been less frequent in recent years due to modi®cations, and detrusor instability, albeit at a lower incidence than after sling placement. Sacrocolpopexy Sacrocolpopexy is the most common procedure for prolapse repair using an abdominal approach, and it can also be performed laparoscopically. The advantages of open surgery are that it is a wellestablished procedure that is easy and reproducible with a standardised followup. However, laparotomy is necessary and vaginal myorrhaphy is often necessary to correct a rectocele. In contrast, no incision is required for laparoscopy, and a posterior myorrhaphy is not normally necessary as the posterior mesh can be placed at the level of the levator ani. Laparoscopy also provides the potential to use to tension-free vaginal tape (TVT) to correct stress incontinence as a concomitant procedure. However, the laparoscopic procedure is complex and lengthy, it is very dif®cult to adjust the tension of the tape in cases of large prolapse. A retrospective analysis of 77 patients who underwent laparoscopic sacrocolpopexy found that there were six conversions to laparotomy, the operating time ranged from 180 to 292 minutes, and complications included one rectal injury, two bladder injuries, three re-operations for haematoma and one rejection of the mesh [18]. In addition, one re-operation was required for grade 3 cystocele. It should be noted that complications seen after open sacrocolpopexy, such as bleeding, bladder injury, infection, and small bowel obstruction may also occur after laparoscopic surgery. Artibani/Haab/Hilton

Future directions There is some evidence that a concomitant procedure to correct stress incontinence at the same time as prolapse surgery could be bene®cial in some patients. However, it will be necessary to develop some predictive measures to identify those patients who are likely to bene®t from such surgery. Similarly, guidelines are needed to identify those patients in whom concomitant hysterectomy is indicated, and also those in whom posterior repairs may be appropriate. Finally, there is a need for prospective comparisons between laparoscopic and open procedures, and also between laparoscopic and vaginal approaches. Vaginal and combined approaches The overall objective of pelvic ¯oor reconstruction should be to correct or prevent prolapse and urinary or faecal incontinence, whilst preserving sexual function. In many cases, this is likely to involve correcting prolapse and preventing the development of incontinence secondary to surgery; alternatively, it may mean correcting incontinence whilst preventing the subsequent development of prolapse. Thirdly, it may mean the concurrent correction of both prolapse and incontinence. Studies performed in the USA have found that by 80 years of age 11% of women will have had surgery for either prolapse or urinary incontinence [19]. Furthermore, 1% of the population will undergo three or more operations to correct pelvic ¯oor dysfunction throughout their lifetime. Similarly, a large prospective study performed in the UK found that the admission rate for prolapse surgery was 2.04/1000 woman years [20]. From an epidemiological point of view, parity showed the strongest association with prolapse surgery, whereas social class, contraception, height and smoking showed no association. Although the number of admissions for prolapse surgery was higher in women who had undergone hysterectomy (3.6/1000 woman years), this association was almost entirely due to women undergoing hysterectomy for prolapse Pelvic Floor Reconstruction

(15.8/1000 woman years); those undergoing hysterectomy for other reasons had only a small increase in risk of subsequent prolapse surgery (2.9/1000 woman years). Vaginal approach versus abdominal approach versus laparoscopic approach The vaginal approach to the pelvic ¯oor is associated with less pain, less visible scarring, more rapid mobilisation, shorter hospitalisation and a shorter convalescence compared with the abdominal approach, and so is likely to be preferred by the patient. However, from the surgeon's perspective, the abdominal approach gives better access to the surgical ®eld. The laparoscopic approach has advantages for the patient, in terms of limited scarring, and also for the surgeon by providing optimal access to the pelvic organs, but it generally requires longer operation times than the other approaches and data on long-term outcomes are limited. Ultimately, the choice of approach for any indication should be guided by the objective of providing the greatest long-term success with the lowest risk of complications. At present, however, there are very little data from comparative studies on which to base such decisions. The vaginal approach can be used for procedures to repair a prolapse affecting any of the three compartments of the pelvic ¯oor, as well as for procedures to correct incontinence (Table 3). Colporrhaphy Anterior colporrhaphy has traditionally been the most commonly performed procedure by gynaecologists to treat both prolapse and urinary incontinence. An increasing body of evidence suggests, however, that it is not the most effective procedure to treat either condition, and it is also associated with a relatively high rate of complications. Thus, the overall average cure rate for stress incontinence is only approximately 50%, while an average of 18% of continent women undergoing colporrhaphy for prolapse develop stress incontinence after surgery. Consequently, it has been suggested that women with occult abnormalities of urinary function Eur Urol 2002;42/1 (Curric Urol 1±11)

7 *

Table 3. Vaginal and combined approaches to the female pelvic floor Vaginal approach

Combined approach

Prolapse

Continence

Anterior compartment

Anterior colporrhaphy Mesh repair Para-vaginal repair

Bladder neck buttress Needle suspension Tension-free vaginal tape

Middle compartment

Vaginal hysterectomy

Sacrocolpopexy with mesh colporrhaphy

Enterocoele repair Sacrospinous fixation Iliococcygeal hitch Posterior compartment

8 *

Posterior colporrhaphy Mesh repair Levatorplasty Trans-anal repair

may have them unmasked by surgery. One study found that, among women presenting with utero-vaginal prolapse, fewer than half showed a normal pattern of activity when urodynamic studies were undertaken with the prolapse reduced by ring pessary, and 35% showed signs of genuine stress incontinence, even though they were free from urinary symptoms [21]. Other studies have indicated an incidence of `occult stress incontinence' between 28% and 100% (mean 55%). It is important, therefore, to consider the possibility of occult urinary dysfunction when making decisions relating to surgical procedures. Posterior colporrhaphy is also associated with a high rate of post-operative complications, and it has been found that up to 30% of women will never have sexual intercourse again after posterior colporrhaphy. A recent study of 231 women who underwent repair of rectocele found that symptoms of incomplete bowel emptying, constipation faecal incontinence and sexual dysfunction were all more common after surgery than before the procedure [22]. It is apparent, therefore, that although colporrhaphy may be effective from the surgeon's perspective, in that it repairs the anatomical defect of the pelvic ¯oor, it may not provide the patient with the desired symptomatic improvement. Furthermore, there is considerable evidence to indicate that in some cases the procedure itself may precipitate the onset of de novo symptoms. Eur Urol 2002;42/1 (Curric Urol 1±11)

Sling procedures

Sphincter reconstruction Artificial or neosphincter

Para-vaginal repair As an alternative to colporrhaphy, paravaginal repair using an abdominal approach may be used for the treatment of prolapse, although this procedure is more commonly used in North America than in Europe. In this technique, which was ®rst described by Richardson in 1976, the para-vaginal fascia is re-attached to the arcus tendineus, thereby restoring support to the vagina [23]. It does, however, rely upon the ability of the surgeon to identify discrete defects within the endopelvic fascia. Several series have shown cure rates of 85 95% for prolapse corrected by para-vaginal repair using the abdominal approach, but the cure rates for stress incontinence are lower (72 79%). Mesh repairs Modi®cation of the standard sacrocolpopexy procedure by extending the mesh from the vault down the posterior vaginal wall to the perineal level may be an effective treatment for both vault prolapse and also rectocele (Fig. 2). Modi®cation of colporrhaphy by the introduction of mesh either posteriorly or anteriorly may also improve the success rates for correction of rectocele and cystocele, respectively. The use of synthetic meshes for gynaecological surgery provides several advantages. They avoid the need for harvesting fascial tissue and the materials used are potentially stronger than autogenic tissues, thereby simplifying the procedure and reducing operation time. In addition, their Artibani/Haab/Hilton

Fig. 2. Modified sacrocolpopexy, extending the mesh from the vault down the posterior vaginal wall to the perineal level.

use helps to reduce post-operative discomfort and wound complications. Nevertheless, the use of synthetic materials is associated with some complications, and some of the older materials, such as Te¯on and Silastic, have removal rates of up to 25% due to sling erosion or infection. Newer materials such as Marlex, however, appear to be associated with lower rates of erosion and infection. In a study of 24 patients with recurrent cystocele following two or more previous procedures, 12 patients treated by standard colporrhaphy had four recurrences by 2-year post-operation, whereas 12 patients in whom the colporrhaphy was reinforced with mesh had no recurrences, but there were three cases of mesh erosion [24]. In another study of 78 patients with grade 2 cystocele who had an anterior `tensionfree' mesh repair, 100% were anatomically normal at a mean follow-up of 12 months [25]. Although the data are still limited, they suggest that the introduction of a synthetic mesh may improve the outcome of other colporrhaphy procedures. Sacrospinous fixation Sacrospinous ®xation involves ®xing the vault onto the medial portion of the sacrospinous ligament, and is an effective treatment for vault and utero-vaginal prolapse. Pelvic Floor Reconstruction

There are considerable data to show the effectiveness of this procedure. From a total of 1602 patients from 23 series with follow-up of up to 10 years, there was a 92% cure rate for vault prolapse. However, 21% of patients developed a cystocele post-operatively, although many were asymptomatic, and 7% had de novo stress incontinence. Although it has been suggested that sacrospinous ®xation might be a cause of cystocele, other studies have found no evidence to support this hypothesis, suggesting instead that those women who develop a cystocele post-surgery had a pre-existing weakness affecting the anterior compartment. Smilen et al. found 11.7% of patients undergoing anterior repair with sacrospinous ®xation developed cystocele, compared to 9.4% following anterior repair alone, while 17.8% of patients following other repair procedures with sacrospinous ®xation developed cystocele, compared with 17.9% where other repairs were carried out in isolation [26]. Neither difference was signi®cant. Other common complications of sacrospinous ®xation include haemorrhage, particularly from the inferior gluteal artery, and buttock pain, which is possibly due to traction on nerves within the sacrospinous ligament, and usually resolves within a few days. Eur Urol 2002;42/1 (Curric Urol 1±11)

9 *

In order to reduce the possibility of complications associated with sacrospinous ®xation, some authors have suggested an anterior approach to the sacrospinous ligament, and others have advocated a modi®ed procedure in which the vault is suspended anteriorly to the ischial spineÐ the so-called iliococcygeus hitch. This is presumed to produce a lower risk of damage to the pudendal neurovascular bundle. The cure rates following iliococcygeus hitch have been generally comparable with those following sacrospinous ®xation in most series. In one case control series, however, whilst success was comparable, the recovery was longer and patient satisfaction lower, following the pre-spinous procedure [27]. TVT Although there is considerable experience with TVT in the treatment of isolated prolapse or stress incontinence, to date only two small studies have looked at the use of TVT in patients with both stress incontinence and prolapse. In the ®rst study of 12 patients, which used TVT in combination with tension-free mesh repair, there was a 75% cure rate at 20 months, with three patients having an asymptomatic cystocele [28]. In a second study of elderly patients (65±91 years of age) in whom general anaesthesia was contraindicated, and who underwent either colpocleisis or colporrhaphy with TVT under local anaesthesia, all patients were discharged within 24 hours and operations were considered to be successful [29]. In one series of 50 women treated by TVT concurrently with various prolapse procedures, the subjective and objective cure rate from incontinence was 81% and for prolapse was 86% (Hilton, unpublished data).

10 *

Abdominal or vaginal approach? There have been few direct comparisons of the abdominal versus the vaginal approach for the repair of pelvic ¯oor disorders. However, one randomised study which compared bilateral sacrospinous ligament ®xation plus para-vaginal repair with sacrocolpopexy plus para-vaginal repair found that although morbidity, complicaEur Urol 2002;42/1 (Curric Urol 1±11)

tions and length of hospital stay were comparable for the two procedures, optimal effectiveness was achieved in 29% of patients who had surgery using the vaginal approach and in 58% of patients who underwent the abdominal procedure [30]. Furthermore, the re-operation rates were 33% for patients in the vaginal group and 16% for the abdominal group, and the authors concluded that surgery by the abdominal route was more effective. Similarly, a number of studies of surgery for stress incontinence have found better outcomes following abdominal procedures. For patients with isolated defects of the pelvic ¯oor, such as stress incontinence or prolapse, the evidence suggests that the abdominal approach is associated with better outcomes. However, as discussed previously, the majority of patients have a combination of problems and there is currently very little data regarding the best procedure for the treatment of combined incontinence and prolapse. Conclusions In contrast to the traditional view of the female pelvic ¯oor, in which each compartment was considered to be an independent entity to be managed by different surgical specialities, there is increasing recognition that in terms of function and, more particularly dysfunction, it should be considered as single structure. Consequently, there is a need for urologists, gynaecologists and coloproctologists to familiarise themselves with all three compartments. It is also essential that all patients with any dysfunction of the pelvic ¯oor should undergo a thorough trans-disciplinary evaluation before any intervention, to ensure that repair of a defect of one compartment does not unmask or precipitate a defect in another (e.g. development of cystocele or stress incontinence following repair of vault prolapse). Finally, there is an urgent need for direct comparative studies of the different surgical approaches to the pelvic ¯oor, to enable identi®cation of the most appropriate procedure for the correction of the various defects. Artibani/Haab/Hilton

References [1] Wiskind AK, Creighton SM, Stanton SL. The incidence of genital prolapse after the Burch colposuspension. Am J Obstet Gynecol 1992;167:399±404. [2] Shull BL, Capen CV, Riggs MW, Kuehl TJ. Preoperative and post-operative analysis of site-speci®c pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 1992;166:1764±8. [3] Holley RL, Varner RE, Gleason BP, Apffel LA, Scott S. Recurrent pelvic support defects after sacrospinous ligament ®xation for vaginal vault prolapse. J Am Coll Surg 1995;180:444±8. [4] Bump R, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic ¯oor dysfunction. Am J Obstet Gynecol 1996;175:10±7. [5] Leach GE, Dmochowski RR, Appell RA, Blaivas JG, Hadley HR, Luber KM, et al. Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 1997;158:875±80. [6] Scienti®c Committee of the First International Consultation on Incontinence. Assessment and treatment of urinary incontinence. Lancet. 2000;355:2153±8. [7] Baden WF, Walker TA. Physical diagnosis in the evaluation of vaginal relaxation. Clin Obstet Gynecol 1972;15:1055±69. [8] Richard F, Haab F, Amarenco G, Ballanger P. Development and validation of a new speci®c questionnaire to assess women's health related quality of life (HRQL) in urinary incontinence. Eur Urol 1999;35(Suppl 2):71. [9] Vancaillie TG, Schuessler W. Laparoscopic bladderneck suspension. J Laparoendosc Surg 1991;1:169±73. [10] Koonings PP, Bergman A, Ballard CA. Low urethral pressure and stress urinary incontinence in women risk factor for failed retropubic surgical procedure. Urology 1990;36:245±8. [11] Lebret T, Yonneau L, Chartier Kastler E, Conort P, Barrou B, Haertig A, et al. Isolated Burch type indirect colposuspension of the bladder for the treatment of stress urinary incontinence in women: Long term results. Prog Urol 1997;7:426±32. [12] Burton G. A ®ve year prospective randomised urodynamics study comparing open and laparoscopic colposuspension. Neurourol Urodyn 1999;18:295±6. [13] Carey M, Rosamilia G, Maher C, Cornish A, Murray C, Ugoni A, et al. Laparoscopic versus open colposuspension: A prospective multi-centre randomised single blind comparison. Neurourol Urodyn 2000;19:389±91. [14] Capelouto CC, Kavoussi LR. Complications of laparoscopic surgery. Urology 1993;42:2±12. [15] Muller SC, Steinbach F, Maurer FM, Melchior SW, Stein R, Hohenfellner R. Long-term results of fascial sling procedure. Int Urogynecol J 1993;4:199±203.

[16] Kreder KJ, Austin JC. Treatment of stress urinary incontinence in women with urethral hypermobility and intrinsic sphincteric de®ciency. J Urol 1996;156: 1995±8. [17] Costa P, Mottet N, Rabut B, Thuret R, Ben Naoum K, Wagner L. The use of an arti®cial urinary sphincter in women with type III incontinence and a negative Marshall test. J Urol 2001;165:1172±6. [18] Cosson M, Bogaert E, Narducci F, Querleu D, Crepin G. Laparoscopic sacral colpopexy: Short-term results and complications in 83 patients. J Gynecol Obstet Biol Reprod (Paris) 2000;29:746±50. [19] Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 1997;l89:501±6. [20] Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: Observations from the Oxford Family Planning Association study. Br J Obstet Gynaecol 1997;104:579±85. [21] Smirni E, Gasson J, Hilton P, Brown K. Occult abnormalities of lower urinary tract function in utero-vaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2000;11(Suppl 1):S60. [22] Khan MA, Stanton SL. Posterior colporrhaphy: Its effects on bowel and sexual function. Br J Obstet Gynaecol 1997;104:82±6. [23] Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126: 568±73. [24] Julian TM. The ef®cacy of Marlex mesh in the repair of severe, recurrent vaginal prolapse of the anterior midvaginal wall. Am J Obstet Gynecol 1996;175:1472±5. [25] Cervigni M, Natale F, ContiPuoger C, Panei M, Cucchi A. Tension-free cystocele repairÐPreliminary experience. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(Suppl 1):S10. [26] Smilen SW, Saini J, Wallach SJ, Porges RF, Varner RE. The risk of cystocele after sacrospinous ligament ®xation. Am J Obstet Gynecol 1998;179:1465±72. [27] Maher CF, Murray MP, Dwyer PL. Prespinous versus sacrospinous ®xation for vault and marked uterovaginal prolapseÐA case control study. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(Suppl 1):S8. [28] Migliari R, De Angelis M, Madeddu G, Verdacchi T. Tension-free vaginal mesh repair for anterior vaginal wall prolapse. Eur Urol 2000;38:151±5. [29] Moore RD, Speights S, Miklos JR. Surgical treatment of stress urinary incontinence and severe pelvic organ relaxation in the medically compromised elderly patient using local anesthesia. Obstet Gynecol 2000;95:S56. [30] Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: A prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol 1996;175:1418±21.

11 * Pelvic Floor Reconstruction

Eur Urol 2002;42/1 (Curric Urol 1±11)