**7.5 Surgical therapy: cystocele and descent of vaginal stump or uterus**

The therapy of the cystocele is complex. Vaginal, abdominal and laparoscopic approaches are possible. The choice of the procedure ultimately also depends on the patient's wishes and on whether and which other compartments are affected by a descent.

The German Deszensus guideline confirms that anterior vaginoplasty is a good option in patients who have not previously been operated on, especially with simultaneous apical fixation [9]. According to the Cochrane Review of 2016 and other systematic reviews, mesh augmentation in the anterior compartment is superior to surgery with autologous tissue, i.e. anterior vaginoplasty [12]. A wide variety of meshes are available on the market. Which is possibly better than another cannot be described with the available data, since no comparative studies are available. However, patients did not benefit from using biological materials [11].

In the past, hysterectomy was usually a key part of a descensus-, but also often of incontinence surgery. Vaginal hysterectomy with anterior and posterior colporrhaphy was the most frequently chosen operation. If incontinence was in the foreground or a vaginal approach seemed impossible, abdominal hysterectomy with retropubic colposuspension (with several procedures as according to Marshall-Marchetti-Kranz, Hirsch, Burch, Stanton, Cowan etc.) can be considered. With the introduction of alloplastic implants and the triumph of laparoscopy, the spectrum expanded considerably. The possibility of combining the procedures in different ways makes it increasingly difficult for the surgeon to select the correct procedure [11].

For primary surgery of a cystocele, especially if there is a central defect (pulsation cystocele), conventional anterior colporrhaphy with median fascia lift is still the most suitable procedure. According to the German Deszensus guidelines, however, if there are pronounced stages of prolapse or the desire for improved stability, a primary mesh implantation can be considered. This also applies to patients with a high surgical risk who want to avoid another operation for a relapse. In the case of recurrence of the cystocele, stabilization by using a mesh is recommended. It becomes more difficult with paravaginal defects (traction cystocele). In conventional surgery, there is only the paravaginal repair according to Richardson with attachment of the endopelvic fascia to the tendon arch, which can usually be done through retropubic access, but also vaginally. However, the success rates of this procedure were not convincing. The reason for this is the lack of stabilization of the apex (level 1) and the upper third of the vagina. Still, with increasing use of sacrocolopexy, paravaginal repair is gaining in importance. The stability is achieved by fixation of the apex (cervix or vaginal end) by the mesh fixed on the sacrum/ promontory. The correction of the cystocele, which is not always sufficient, can be improved by lateral fixation. This combination is more complex, but is preferable to a vaginal mesh, especially for younger patients. For older patients with a pronounced lateral defect, treatment with a vaginal mesh-supported plastic is very effective [11]. Whereas in the past the focus was on treating cystoceles and rectoceles, the focus of the descensus surgery has nowadays shifted towards stabilization in level 1. Fixing the cervix or the vaginal stump after hysterectomy brings better results, not only for level 1, but also for the cystocele. A cystocele correction with or without mesh shows fewer recurrences if the apex is fixed at the same time. Several methods are available today for this purpose. Sacrospinal fixation of the vaginal stump (several modifications according to Amreich and Richter) has become established for the vaginal access. Today, this procedure is also performed while preserving the uterus with fixation of the cervix to the sacrospinal ligament. The sacrospinal fixation in the original technique or with a band system can

*Pelvic Floor Disorders in Females: An Overview on Diagnostics and Therapy DOI: http://dx.doi.org/10.5772/intechopen.101260*

be performed with the uterus in place or with a hysterectomy primarily or in the event of a relapse. It can be easily combined with conventional colporrhaphy. The abdominal or laparoscopic approach has proven to be a further approach for level 1 fixation [11].

After being informed by the surgeon, the patient has the right to participate in the choice of the surgical procedure. Some want good stability, so that a mesh can be implanted, while others do not want one for fear of alloplastic implants. Likewise, many strictly reject a hysterectomy, others wish it because of existing pathology. The indication is becoming more and more complex due to the multitude of options available. The advantage, however, is that you can offer an operation concept that is individually tailored to the patient and the present findings [11].

#### **7.6 Surgical therapy: urinary incontinence**

Surgical therapy is highly effective in stress incontinence with placement of mid-urethral slings being the first line option. Retropubic and transobturator pathways are possible. The treatment of urgency incontinence is more complex. Neuromodulation is one possibility, if pharmacotherapy is not effective for urgency incontinence. Another possible treatment option is the intravesical injection of botulinumtoxin A, which usually lasts up to 12 months and can be repeated, if necessary [10].
