**2. Pelvic organ prolapse and stress urinary incontinence share similar risk factors**

It has been noted that better pelvic-floor muscle function is associated with less severe prolapse and urinary symptoms. Poor pelvic floor muscle function is one of the inciting or contributory factors in the development of prolapse (Borello-France et al., 2007). Consistent tension from increased intra-abdominal pressure, loss of muscular support for pelvic organs, wideness of genital hiatus, and stretched or torn connective tissue might lead to prolapse (Wei and DeLancey, 2004). Furthermore, intermittent mechanical forces imposed on the prolapsed vaginal tissues or denervation of the vaginal tissues during vaginal delivery might cause decreased content of differentiated smooth muscle in the vaginal wall

Suburethral Slingplasty Using a Self-Fashioned Mesh

still need to be solved.

for Treating Urinary Incontinence and Anterior Vaginal Wall Prolapse 221

Raz…), bladder neck suspension and/or colposuspension to the conventional pubovaginal sling. Retropubic Burch colposuspension was considered the gold standard and the most popular anti-incontinence operation by 1995 (Jarvis, 1994). In recent decades, newer tensionfree, patch and prosthetic tapes with minimal invasive procedures have been used such as the tension-free vaginal tape (TVT) procedure which is based on the integral theory and was introduced by Petros and Ulmsten (1993). The treatment outcomes seem promising (Wu et al., 2008). The use of macroporous monofilament mesh has become a popular treatment in anti-incontinence surgery. However, long-term complications of these synthetic materials

The goals of these procedures for achieving continence have shifted from suburethral fascia plication (Kelly procedure), lifting the urethra up to a higher retropubic position (MMK), elevating the bladder neck to enhance pressure transmission ratio (colposuspension), to stabilizing the bladder neck or proximal urethra to increase urethral closure pressure (sling operation). Now, the popular minimal invasive procedures, based on the integral theory (Petros and Ulmsten 1993), are trying to create a dynamic kinking of the mid-urethra at the level of the high pressure zone in the urethral pressure profile or in the urethral knee angle

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

(terminology used in sonographic findings) (Wu et al., 2008; Lo et al., 2004).

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

of women with pelvic organ prolapse. The pathogenesis of pelvic organ prolapse is not completely understood. The development of pelvic organ prolapse may be multi-factorial. Vaginal childbirth, advancing age, and increasing body mass index are the most consistent risk factors of pelvic organ prolapse (Jelovsek et al., 2007). Other factors such as prolonged second stage of labor, constipation, chronic cough previous to pelvic surgery, and increased intra-abdominal pressure caused by heavy lifting have also been reported in association with the occurrence of stress urinary incontinence and pelvic organ prolapse (Dietz, 2008). The weakness in the supportive layer of the urethra and a lax anterior vaginal wall which results in stress urinary incontinence and/or pelvic organ prolapse seems to be caused by a "multiple-hit" mechanism.
