**5. The evolution of pelvic reconstruction surgeries**

The surgical treatment for pelvic organ prolapse can be categorized into obliterative and reconstructive procedures. Reconstructive surgery for treating prolapse aims to correct the prolapsed vagina, preserve (or improve) vaginal sexual function and relieve the associated pelvic symptoms. Reconstructive surgery can be performed by either the transabdominal or vaginal route. Currently, several common approaches for correcting apex or uterovaginal prolapse include abdominal sacral colpopexy, abdominal sacral cervicopexy, McCall culdoplasty, high uterosacral ligament suspension, and vaginal sacrospinous ligament suspension. Anterior and posterior colporrhaphy in combination with central plication of the fibromuscular layer of the vaginal wall are still popular techniques for correcting anterior and posterior vaginal wall prolapse (Jelovsek et al., 2007; Gomelsky et al., 2011). Paravaginal defect repair, a side-specific repair of the vaginal wall to make a reproximation of vaginal tissue that has been torn from its lateral attachment to the arcus tendineous fascia pelvis or arcus tendineous levator ani, has also been advocated by some physicians for treating anterior vaginal wall prolapse (Mallipeddi PK et al., 2001; Young et al. 2001).

In the past two decades, the efficacy of anterior colporrhaphy, associated with central plication of the pubourethral ligament or fibromuscular layers of the vaginal wall for treating urinary incontinence or anterior vaginal wall prolapse, has been controversial. Beck et al. reported the cure rate for treating 194 patients increased from 75 to 94% when a Kelly-Kennedy technique was modified to include a vaginal retropubic urethropexy (Beck et al., 1991). Jarvis's review revealed a cure rate of around 60% using anterior colporrhaphy for stress urinary incontinence (Jarvis., 1994). It has been reported that only 30 to 46% of patients experience satisfactory or optimal anatomic results with standard anterior or ultralateral anterior colporrhaphy for the treatment of anterior vaginal wall prolapse (Weber et al., 2001). However, for this group the clinically relevant definitions of success were defined as (1) no prolapse beyond the hymen, (2) the absence of prolapse symptoms (visual

Suburethral Slingplasty Using a Self-Fashioned Mesh

for Treating Urinary Incontinence and Anterior Vaginal Wall Prolapse 223

wall prolapse (Maher et al. 2010). The high failure rates of pelvic reconstructive procedures for anterior compartment prolapse might be a result of a decrease in the muscularis of the prolapsed vaginal tissues which impair vaginal tone and contractility (Boreham et al., 2002). Alterations in collagen, elastin, and proteoglycan proteins of the extracellular matrix within the pelvic-support ligaments and vaginal tissue might also contribute to or be associated

In order to reduce the high failure rate of anterior vaginal wall repair, we developed a tension free vaginal tape, using self-fashioned Gynemesh, for treating urodynamic stress incontinence and anterior vaginal wall prolapse, concomitantly. The rationale behind our suburethral slingplasty is using tension-free mesh for augmenting and enforcing the supporting layer of the urethra and bladder to treat stress urinary incontinence and anterior vaginal wall prolapse concomitantly. This procedure has provided a relatively high success rate in curing urinary incontinence (continence was 80%, improvement was 17%) and reduced the rate of recurrence of anterior vaginal wall prolapse (none with recurrent prolapse greater than stage II). As well, there was a more acceptable rate of mesh erosion

The basis of the current procedure is to place a tension-free and customized mesh underneath the proximal urethra and bladder to act as a supporting suburethral hammock to reinforce the anterior vaginal wall while undergoing pelvic reconstructive operations. The self-fashioned mesh may augment the supporting and suspension effects against an increase in mechanical forces of daily activities and gravity. Concurrently, the mesh patch may also act as a frame for inducing fibroblasts in fibrogenesis during healing (Hung et al. 2010).

The self-fashioned mesh is a polypropylene mesh from Gynemesh PS (10 cm in width and 15 cm in length; 300 USD a piece; Gynecare, Ethicon inc., Somerville, NJ, USA)(Su et al. 2009). The mesh is trimmed in the shape of a body with a pair of arms (shown in Figure 1)

Fig. 1. The mesh is trimmed in the shape of a body with a pair of arms (B) from a Gynemesh

with causes of pelvic organ prolapse or recurrence (Connell KA., 2011).

(6%) when combined with other pelvic reconstructive procedures.

**8. Surgical technique** 

PS (A)

**8.1 Preparation of self-fashioned mesh** 

analog scale ≦2), and (3) the absence of re-treatment. There was a higher success rate for treating anterior vaginal wall prolapse with anterior colporrhaphy (Chmielewski et al., 2011). In the past, the discrepancy in success rates of anterior colporrhaphy for the treatment of anterior vaginal wall prolapse can be attributed to varying definitions of success. As we know, a higher success rate is associated with a higher complication rate for the treatment of pelvic organ prolapse. Physicians should base the definition of success on patient perceptions and satisfaction according to clinically relevant definitions of success rather than on physicians' perceptions of success.

The use of mesh has also become common practice in pelvic reconstructive procedures in recent decades. An increasing number of commercial kits have been designed for sitespecific defect repair or total mesh-augmented vaginal repairs to reinforce the supportive function of the vagina. Recent literature demonstrates that graft-augmented repairs seem to have a high success rate and conventional standard repairs (no mesh augmentation) have relatively high recurrence rates. However, potentially high success rates resulting from use of mesh products are accompanied by a high complication rate. Complications or sideeffects associated with vaginal mesh include mesh erosion or extrusion, infection, pain, and dyspareunia (Baessler et al. 2006; Maher and Baessler 2006; Natale et al., 2006; Wu MP, 2008; Jelovsek et al. 2007; Gomelsky et al., 2011). Therefore, researchers from the Third International Consultation on Incontinence concluded that because of mesh's high potential morbidity, mesh placed transvaginally should only be used in well-designed clinical trials and not in general practice until more data is available (Brubaker et al. 2005).
