References
  1. Glazener CMA, Breeman S, Elders A, Hemming C, Cooper KG, Freeman RM, et al. (for the PROSPECT study group) Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT) LANCET 2016 Published Online December 20, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31596-3
  2. Baroness Cumberlage Report. The Independent Medicines and Medical Devices Safety Review Written Evidence Clinicians, Academics and Other Individuals – Pelvic Mesh Published December 2018.
  3. Donald, A. Journ. Obstet. and Gynaecol. Brit. Emp., March, 1908.
  4. Fothergill WE. Pathology & the operative treatment of displacements of the pelvic viscera. Journal of Obstets & Gynaecol of the British Empire, 1907) 13:410-419.
  5. Buchman, M. I. (1953). Blood loss during gynecological operations Amer. J. Obstet. Gynec., 65, 53.
  6. Petros PE. Severe chronic pelvic pain in women may be caused by ligamentous laxity in the posterior fornix of the vagina. Aust NZ J Obstet Gynaecol. 1996;36(3):351-354.
  7. Yamada H. Aging rate for the strength of human organs and tissues. Strength of Biological Materials, Williams & Wilkins Co, Balt. (Ed) Evans FG. (1970); 272-280.
  8. Liedl B, Inoue H, Sekiguchi Y, Gold D, Wagenlehner F, Haverfield M, Petros P. Update of the Integral Theory and system for management of pelvic floor dysfunction in females. Eur J Urol. EURSUP-738. http://dx.doi.org/10.1016/j.eursup.2017.01.001
  9. Williams G Browning A Petros PE The integral theory and its tethered vagina syndrome visited: vaginal scarring may cause massive urinary incontinence BJU Int 2018 Oct;122(4):532-534. doi: 10.1111/bju.14218. Epub 2018 Apr 23.
  10. Shkarupa D, Zaytseva A, Kubin N, Kovalev G, Shapovalova E. Native tissue repair of cardinal/uterosacral ligaments cures overactive bladder and prolapse, but only in pre-menopausal women. Cent European J Urol. 2021;74:372–378.
  11. Petros PE, Development of the midurethral sling for stress urinary incontinence, Doctor of Surgery Thesis 1999, University of Western Australia.
Fig1. Vaginal incisions for classical and minimally invasive Manchester operations. Note the classical Manchester takes the incision to within 1.5cm of the urethra “U” and around cervix “CX”. The minimal vertical incision method is always 1cm below bladder neck, in order to avoid “tethered vagina syndrome”. A=anus.
Fig2 Anatomy of uterine prolapse
Uterosacral (USL) and cardinal (CL) ligaments overstretched at childbirth or weakened by collagen loss after the menopause cannot support the uterus, so it prolapses. Clearly both CL and USL need to repaired during reconstructive surgery.
Fig3 Identifying and suturing laterally displaced cardinal ligaments.
Left figure Displaced cardinal ligament’s (CL) The dilatation by the head to 10 cm has fractured the CL’s attachment to the cervix and displaced it laterally. Also torn is the pubocervical facsia (PCF) attachment of vagina to CL. The vagina now rotates downwards like a trapdoor to cause cystocele (“transverse defect”). The sutures “S” re-attach CL to the cervix.
Right figure Identifying a dislocated CL. The cervix (CX) is pulled to the right to show the vagina on the lateral wall of CX
Fig4. CL dislocation with prior hysterectomy. Broken lines =hysterectomy scar, identified by “dimples”. E= enterocele; Arrow indicates the bulge of the dislocated cardinal ligament (CL).
Fig5 Approximation of uterosacral ligaments (USL). Schematic view into the vagina. A transverse incision (broken red lines) is made at the apex of the enterocele or 4cm below the cervix or hysterectomy scar. The incision is opened out (broken diamond-shaped lines) and USLs are located A strong needle with No2 polyester suture is inserted laterally to at least 1cm depth, taking a segment of tissue. This suture is held and another suture is inserted. The sutures are approximated. USL=uterosacral ligament.
Fig6 Central cystocele is shiny and usually accompanies a transverse defect cystocele. Broken lines with arrows indicate ruptured and prolapsed cardinal ligaments. BN=bladder neck. CX=cervix.
Fig7 Re-attachment of dislocated vaginal epithelium to underlying fascia with continuous or interrupted fascial attachment suture. Excess vaginal tissue was shrunken by suturing the vaginal epithelium onto the deep fascial layer. With each suture, the fore and middle fingers are placed around the descending suture, to push down the vaginal epithelium into the fascia.