Anterior and posterior intravaginal slingplasty (TVS)

Abstract

Genuine stress urinary incontinence (SUI) is the involuntary loss of urine associated with activities that increase abdominal pressure such as coughing, laughing, lifting, sneezing, and physical exertion. It is usually associated with an increase in mobility of the neck of the bladder. Increased mobility of the bladderand urethra is called a cystocele and sufferers perceive that their "bladder is falling out". This mobility compromises the function of the bladder to store urine and causes the involuntary loss of urine with maneuvers such as lifting, laughing and staining down. Most procedures to correct SUI are designed to "tack" the bladder and urethra into a more normal anatomic position. The hope is that by correcting the anatomy, normal bladder function will be restored. Keyhole surgery techniques for vaginal prolepse and female incontinence are based on the Integral Theory of Female Incontinence. This theory states that both urinary dysfunction and vaginal prolapse have a common origin, i.e., laxity in the vagina or its supporting ligaments, A classification of laxity in 3 zones of the vagina guides both surgical treatment and new pelvic floor rehabilitation methods. The operations work by strengthening ligaments and connective tissue laxity in the 3 zones. Longer term surgical cure rates for stress incontinence of 85-94% have been reported in multicentre studies. Tension — free Vaginal Tape (TVT) or Anterior Intravaginal Slingplasry (Anterior IVS) device is intended to be used as a pubourethral sling for the treatment of SUI for female urinary incontinence resulting from urethral hypermobiliry and/ or intrinsic sphincter deficiency. This occurs because the pubo-urethral ligament, which attaches the urethra to the pubic bone, becomes stretched and loose due to childbirth and age. It cannot counteract the backward pull of the pelvic muscles, which open or funnel the urethra with coughing or straining, and this leads to stress incontinence. In addition the looseness of "the urethral supports can lead to premature activation of the micturition reflex, causing frequency and urgency of urine. This procedure is minimally invasive. The devise is positioned close to the urethra, with no increased tension on the vaginal wall and no elevation of the urethra. The tape provides a sling under the urethra and does not pull or lift the urethra from its anatomical position. NX/hen at rest, the urethra is in its normal position. When stressed, the devise provides tension - free support of the inner urethra and bladder neck in the correctional position. In essence, a polypropylene tape is inserted under the urethra and bought out through a small 1 cm incision above the pubic bone on each side. There is a fibrous reaction around the tape, which acts as an artificial ligament to strengthen and replace the weakened ligament. The vagina is then attached to the pelvic muscles. Patients have less postoperative pain than with the more invasive procedures and may return home the same day. Complications are rare, but it must be understood and accepted that these can occur. The complications that can occur include infection of the urine or wound, haemorrhage, injury to Bladder. Posterior TVS is performed to correct an enterocoele, which forms after hysterectomy. The ligaments are weakened and a hernia forms at the site where the uterus was removed, pushed down by the bowel above and it protrudes through the vagina. To repair this defect, a tape is passed from near the coccyx bone, up past the rectum to the site of the enterocoele, and then passed down through the other side. This tape is attached to the remains of the weakened pelvic ligaments and vagina. A fibrous reaction occurs around the tape, to strengthen and replace the weakened ligament. The results of any operation cannot be guaranteed, and it is possible for the condition to recur at a later date. However, unlike other vaginal repair operations, there should be a cure of the prolapse without shortening the vagina or making it too tight and thus causing pain with intercourse. Complications are rare but may occur. The complications that can occur are infection of the wound requiring antibiotics, (however a pelvic abscess could develop, requiring drainage), haemorrhage, injury to Rectum, and rejection of the tape.