Discussion
Ligaments for structure, vagina for function The differential
biomechanics of ligaments (structure) and vagina (function) endorse the
intuition of Fothergill in making CL and USL repair key parts of his
operation. Tissue biomechanics explain poor results for prolapse with
vaginal repair only [1]. Ligaments 300 mg/mm2[7] are the main structural support of the uterus while the more
elastic vagina 60mg/mm2, transmits the muscle forces
to close and open the urethra, and to stretch the vagina to control the
afferent impulses from the urothelial stretch receptors [8].
Vaginal conservation The vagina is an organ. Once its
collagen and elastin are excised, they cannot be regenerated. Rather
than excision, excess vaginal tissue can be easily re-assigned, fig7.
The cut edge of epithelium is brought down onto the fascia below, in
effect, compressing the loose tissue. Within a few weeks the component
collagen and glycosaminoglycans which constitute the structural elements
of the vagina re-order the tension within the vaginal tissue, so by 6
weeks review, vaginal appearance appears normal. Excision and scarring
may fibrose the vagina sufficiently to cause the “Tethered Vagina
Syndrome” (TVS) [9], which may cause massive urine loss,
characteristically on getting out of bed in the morning. TVS can only be
repaired by a skin graft to the vagina.
Minimizing excision of tissues reduces bleeding. By conserving
vagina, not hiding potential bleeding points on the cervix behind
Sturmdorf sutures, not transecting CL, many potential bleeding points
are avoided.
Native ligament repair does not work well after the menopauseShkarupa et al. published native ligament repair data for CL/USL much as
described here, in two cohorts, premenopausal and postmenopausal
[10]. By 18 months, good results for cure of prolapse, OAB (urge,
frequency, nocturia) were obtained at 3,6,12,18 months, Table 1, but
only for the premenopausal cohort. A massive stepwise deterioration in
symptoms and prolapse occurred by18 months, Table1. The authors
concluded that the cause for the rapid deterioration was collagen
breakdown in the ligaments [10]. They recommended cardinal/USL
slings in postmenopausal women.
Use of No2 polyester . The midurethral sling’s success in curing
stress urinary incontinence is based on harnessing the collagenopoietic
effect of an implanted polypropylene tape to structurally reinforce
weakened pubourethral ligament [11]. The collagen created, collagen
I, has a breaking strain of 18,000 lbs / sq inch[11]. It follows,
not much collagen is required to reinforce a ligament 0.5-0.7mm in
diameter. Our aim in using a thick No2 polyester suture was to create
new collagen to reinforce the native tissue ligament repair.
Conclusions The minimally invasive repair faithfully follows
the Fothergill principle of ligament repair, suitably modified to
conserve tissue, reduce bleeding and hopefully, to provide longer term
cure.
Contributions Surgery VIDEOS PP RH XS. Planning PP RH XS
Analysing PP RH XS WJL Writing PP RH XS
Conflict of interest NIL for any author.
Ethics Not applicable. These are standard hospital operations
for all authors.
Funding NIL