Deciding on the type of surgery to correct pelvic organ prolapse and/or incontinence is one of the most difficult challenges facing the genitourinary and reconstructive pelvic surgeon. Obviously, there is no single operative procedure, nor should there be, that will correct the types of disorders and associated pelvic pathology that the clinician may encounter during a lifetime of surgical experience.
Proper patient selection should be based on thorough history and physical examination, including meticulous neurologic assessment. Urodynamic evaluation is essential to confirm the diagnosis of stress urinary incontinence (SUI), especially when there are mixed symptoms, and is mandatory after previous failed reconstructive surgery. Patients with significant anorectal symptoms, and in particular fecal incontinence and/or rectal prolapse, need thorough investigations, which may include anorectal motility studies, defecography, ultrasound or pudendal terminal motor neuron latency studies prior to the decision for surgical correction.
Conservative options should be offered to all patients prior to surgery. Patients should be involved in the decision making process, and the expectation for short- and long-term recovery and success should be clearly outlined; including the need for a suprapubic catheter, the risk of voiding dysfunction and retention, as well as the risk of failure.
The outcome of pelvic reconstructive surgery can be influenced by several factors including hormone status, presence of fibrosis and scarring from previous infection or surgery, or from radiation exposure, chronic chest disease, smoking, constipation, obesity, habits or hobbies such as weight lifting, and pelvic denervation. The quantitative and qualitative types of collagen may play a factor in pelvic organ prolapse, especially in patients with recurrence of pelvic organ prolapse after previous repair.1
This chapter will present some of the approaches we use to deal with these problems. Because our experience with the laparoscopic abdominal approach to reconstructive pelvic surgery is limited, it will not be discussed in this chapter. Nevertheless, we believe that minimally invasive surgery will play an increasing role in this area, as long as the attending surgeons follow the same anatomical principles and goals as they do with open cases and can produce equivalent long-term results.
