Tethered vagina syndrome: massive urine loss caused by bladder neck scarring cured by skin graft.

The bladder neck area of the vagina is known as the "zone of critical elasticity" (ZCE). Adequate vaginal elasticity at ZCE is required for the oppositely-acting muscles to independently close the distal urethra and bladder neck. Scarring at ZCE "tethers" the more powerful posterior muscles to the anterior muscles and the bladder neck is forcibly pulled open, resulting in massive urine loss. This condition is known as "tethered vagina syndrome" (TVS). In developed countries, the main cause of TVS is iatrogenic. Vaginal repairs, vaginal mesh, may cause scarring at ZCE and this directly links the oppositely-acting muscle forces. Over-elevated Burch colposuspensions may stretch the ZCE to the point where its elasticity is lost so the muscles can no longer function independently. The treatment is to dissect the vagina clear of the scarring and to insert a skin graft to the bladder neck to restore ZCE elasticity. In developing countries, extensive trauma to the vagina and bladder from obstructed childbirth can cause obstetric fistulas. In up to 40-50% of these women, there is ongoing massive urine loss after the fistula has been successfully closed. Performing a prophylactical skin graft during fistula closure if there is vaginal tissue deficit is proving to be revolutionary. In women with Goh type 4 fistula (n=45), 46% were cured (full dryness) against an expected 19%. The same operation can produce equally dramatic cures in women who continue to leak urine after successful fistula repair.

Tension-free artisan tape: a low-cost option for cure of pelvic organ prolapse and stress incontinence.

The Lancet PROSPECT Trial has shown that vaginal repair has dismal cure rates of some 20% at 12 months. Meanwhile 10-year data from collagen creating ligament repair methods (implanted mini-sling tapes), with no vaginal excision, report very high, long-term cure rates. The reason for conserving the vagina, is that the vagina's main function is to transmit the muscle forces for external urethral closure or opening. Ligaments provide the main structural support for the organs, much like a suspension bridge. Collagen is the key structural component of the ligaments which structurally support the organs. However, collagen breaks down after the menopause and is excreted as hydroxyproline. If sufficient collagen breaks down, the ligaments weaken, and this explains the 80% failure rates for native ligament in the Lancet PROSPECT Trial. Whereas satisfactory results for pelvic organ prolapse (POP) and symptoms have been obtained with native ligament repair in premenopausal women, it has been shown that collagen-creating ligament repair method, for example, precisely inserted tapes, is required in older women. Tension-free" artisan tapes work in the same way as commercial tape kits which have been used to cure stress urinary incontinence (SUI) and POP. The "tension-free" artisan tape results for POP at three years were encouraging, but were applied only in a small number of cases. Very recently, long-term (5.7 years) tension-free artisan tape data has become available from artisan SUI surgery. Results from 93 women using an artisan transobturator tape (TOT) achieved a cure rate of 91.3% at a mean of 5.7 years postoperatively. The only significant complication was a 4.3% erosion rate. The implications are that tension-free artisan tape for POP is also likely to be long-lasting. Another implication is the cost, which, for each tape, is a few Euros. The low cost allows the artisan method to be applied even in the poorest nations.

Cure of Underactive and Overactive Bladder Symptoms in Women by 1,671 Apical Sling Operations Gives Fresh Insights into Pathogenesis and Need for Definition Change.

INTRODUCTION: To check evidence that symptoms identical with those constituting "underactive bladder" (UAB) and "overactive bladder" (OAB) are caused by apical prolapse and cured by repair thereof. MATERIAL AND METHODS: After repair of apical prolapse by mesh tape reinforcement of lax uterosacral ligaments (USL) data form 1,671 women were retrospectively examined to determine the presence of OAB and UAB symptoms and to check, how many were cured surgically. Thereby 3 different techniques were performed: elevate (n = 277), "Posterior IVS" (n = 1,049), and TFS cardinal (CL)/USL (n = 345). RESULTS: Symptoms identical with those comprising UAB and OAB were cured in up to 80% of cases following surgical repair of the CL/USL complex. CONCLUSIONS: These symptoms may be consistent with symptoms of the posterior fornix syndrome, which comprises 4 main symptoms: micturition difficulties, urge/frequency, nocturia, chronic pelvic pain, all consequent on USL laxity. Surgical cure of OAB and UAB is inconsistent with existing definitions, which imply pathogenesis of the detrusor muscle itself. A reconsideration and reformulation of existing definitions may be required. Altering UAB definition to "bladder emptying difficulties" and return to former definitions for OAB such as "detrusor" or "bladder instability" may help to restore compatibility with surgical cure of these conditions.