Surgical repaired is indicated only in symptomatic patient. Posterior colpoperineorrhaphy does not cause stress incontinence. Aposition of levator ani infront of rectum has obvious role in rectocele repair but it causes dyspareunia. so it is not routine done by many gynecologist. Site specific repairs should be done but it is illegible in clinical practice. In cystocele, you have to examine for occult stress incontinence, otherwise post operatively patient may complaint it.

Agree with Dr Mondal

If there are no complaints, the operation as far as the patient is concerned is unnecessary

Site specific repair with no vaginal excision is the best type of native tissue repair as it does not shorten the vagina.

Any vaginal repair can unmask USI, but does not actually cause it.

The levator muscles have an important function in regulating bladder and anorectal opening and closure

Stretching a muscle is fundamentally wrong as it diminishes its contractility

It is also painful

At times, patient may come with some other complaint e.g. Menorrhagia and higher degree of vaginal prolapse may be a coincidental finding. Patient's attention is towards the other complaint. Is it OK to do vaginal prolapse repair in such cases after informing the patient about it, along with say NDVH.

Whenever site specific repair is done for bigger vaginal prolapse, some redundant vaginal wall will be left. Shouldn't that be excised?

Should we abandon the traditional anterior and posterior colpoperineorrhaphy in favor of site specific repair in the present era?

Surgical repair is indicated only in symptomatic patients. Rectocele repair does not cause stress urinary incontinence. Even with levator ani approximation, the condition has a tendency to recur, probably because stools are not always kept soft. Mesh insertion has too many serious complications. If a vaginal hysterectomy is done for menorrhagia, the vaginal vault should be sutured to the uterosacral ligaments, to prevent the occurence of an enterocele. This can be simply done by keeping the sutures on the uterosacral ligaments and then, after vaginal hysterectomy tying them together.

I am late to answer. During vaginal hysterectomy due to UV descent, two things has to be done. One is culdeplasty (McCall's) and other is vaginal vault fixation (uterosacral or sacrospinous or sacrococcygeal). Every technique has its individual success rate (sacrococcygeal has least success). McCall's culdeplasty has dual actions such as culdeplasty as well as vault fixation. [Most gynecologist believe that failure to identify or successful repair of enterocele is the main culprit of further vault prolapse.

During site specific repair, excess vaginal wall has to be excised. As for example, due to paravaginal defect, lateral displacement of bladder causes cystocele. You are somehow repairing the paravaginal defect vaginally (such as by mesh) you have to excise the excess vagina.

Another point, what is site specific repair? How will you repair it? How will you differentiate paravaginal defect from transeverse or longitudinal vesicovaginal fascial defect. Has specificity or sensitivity of the clinical tests described in the books?

All the questions are debatable. So we never forget the traditional golden techniques such as anterior, posterior colporrhaphy, perineorrhaphy, culdeplasty, vaginal hysterectomy. During managing a case of prolapse in my institution, I want to share my experience towards my students.

Examine the case. Identify the risk factors. Try to delete them. Diagnose the each abormality (Cystocele, urethocele, UV descent, enterocele, Rectocele, low rectocele or perineal defect). Now during repair, correct all the abnormalities and restore the levels of vaginal support.

Remeber one thing, what is VH with PFR. It is the vaginal hysterectomy with formation of a neovagina (convensional definition).

My suggestion is that please collect the original articles of the conventional techniques (they are available) read them and then collect the recent evidenced based guide lines.

I agree with prof petros, in my pratice only surgery site specific are performed

Defect theory of fascia is totally on assumption.

It is not an assumption.

The TVT is based on creating a neoligament at the site of the pubourethral ligament (PUL)

Repair of PUL and uterosacral ligaments improve prolapse and function.

Petros PE New ambulatory surgical methods using an anatomical classification of urinary dysfunction improve stress, urge, and abnormal emptying. Int J Urogynecology (1997) vol 8, 5: 270-278.

Sekiguchi has shown that repairing Cardinal and Uterosacral ligements restore uterine prolapse, cystocele and bladder function.

Yuki Sekiguchi & Manami Kinjo & Yoshiko Maeda & Yoshinobu Kubota

Reinforcement of suspensory ligaments under local anesthesia cures pelvic organ prolapse: 12-month results. Int Urogynecol J

DOI 10.1007/s00192-013-2281-x

I fully agre with Prabhat. So called "sites" and "compartments" are non-existent in the female human pelvis. A compartment means a four-walled "chamber". I have never seen these human imaginatory "compartments". I fully agree - RCT are necessary. Currently one can call certain urogynaecological procedures industry driven "meshes of the meshes". Regards, Johan (JT) Nel.

There is a misunderstanding here. It is quite correct that the vagina derives its strength from the musculoelastic layer. It is called " fascia", probably wrongly so. I was not talking about compartments. I was talking about specific anatomical structures.

My view is that it is laxity in the suspensory ligaments and the vagina which cause prolapses.

We have found that dislocation of the pubocervical fascia from the cervical ring is an important cause of cystocele (maybe to 80%) and it is correctible with a TFS cardinal ligament sling. Lateral defect cystocele we find is caused by dislocation of the vagina from the ATFP. Uterine prolapse and low rectocele (perineocele)are caused by stretching of uterosacral ligaments and separation of the perineal bodies respectively

All of these structures can be repaired by applying the TVT neoligament principle to 4 ligaments, pubourethral, ATFP, cardinal, uterosacral and perineal body.

Thanks Bakul - you have nicely summarised important facts. Another problem with meshes are their artificial nature - the asscociated complications, including erosion, is just simply too high. Statistics may be misleading in medicine, e. g. if the prevalence of erosion is say 1% - 2%, it may seem low, but for the individual patient it is a 100% serious complication.

Another problem with RCT in surgical disciplines is the varying skills of individual surgeons - to overcome this, the surgeons doing the trial should be crossed-over in the middle of the trial - the latter may be difficult to estimate. This does not apply where two organs in the same patients are evaluated, e.g. the ovaries.

Thanks Dr. Bakul Leuva and Dr. Johan Nel. We are not against latest interventions. We will accept those operation after RCTs are available or other investigators take it seriously, otherwise those techniques (claimed as highly efficacious) will be forgotten.

Thanks Prabhat - your answer is that of a wise man ! Regards.

I also compltely agree with john and prabhat, but the facts said by  dr.Bakul Leuva is very basic in nature to explain the difference of the artificially used mesh and natural action of the ligaments with the elasticity and flexibility.yes after the invention of mesh the use of it has been increased and even the smaller defects are also hyphed.

4/11/2014

Dear Colleagues,

RCT have some disadvantages, since no two groups are exactly the same!

Only symptomatic prolapse shuld be repaired.

Kind regards,

Johan (JT) Nel.