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The word vagina , derived from the Latin word for “sheath,” describes the hollow fibromuscular sheath extending from the vestibule to the cervix. The walls of the vagina are in apposition except at the apex where it is held open by the cervix ( 1 ). Vaginograms from normal women show that the vagina takes a slightly S-shaped course, curving at the perineum and cervix with a horizontal plane over the levator plate. Vaginal dimensions based on vaginal casts and radiographic studies show five different vaginal shapes (Figure 1.1) with dimensions ranging from 8.4 to 11.3 cm in length and 2.1 to 5.0 cm in diameter ( 2 , 3 ). The anterior vaginal wall is shorter than the posterior wall given the differences in forniceal length. The anterior vaginal length is approximately 6 to 9 cm in comparison to the posterior vaginal length of 8 to 12 cm ( 4 ).

Because the prevalence of pelvic floor disorders increases with age, the changing demographics of the world’s population will result in even more affected women. For example, based on projections from the United States Census Bureau, the number of American women aged 60 and over will almost double between 2000 and 2030. Even absolute population numbers do not fully reflect the real and growing burden of pelvic floor disorders on women as they age. Luber et al ( 1 ) estimated that the demand for health care services related to pelvic floor disorders will increase at twice the rate of the population itself.

Urinary incontinence is a benign disease; however, its impact on the patient’s quality of life (QoL) is tremendous. The incontinent patient is, most of the time, embarrassed and ashamed, even avoids speaking to her family and friends about her problem. She prefers to isolate herself from some activities that she knows trigger incontinence. She is fearful of being ostracized if discovered.

There is currently no consensus on how much evaluation is required or needed when surgically managing women with pelvic organ prolapse. However, most would agree that optimal treatment is contingent upon a thorough assessment of historical and physical exam findings and an understanding of the relationshipbetween pelvic prolapse and coexisting functional derangements. This assessment very commonly requires ancillary testing in the hope of objectifying the cause of the associated functional derangements (Figure 4.1).

Fecal continence is a complex function with multiple factors contributing to normal continence: anatomic integrity, function, innervation, compliance, capacity, sensation, and stool characteristics. The evaluation of fecal incontinence can also be complex, with a variety of investigations aimed at the different components of continence. A thorough evaluation is necessary to identify the type of incontinence and its etiology so that the correct treatment can be selected.

Electrodiagnostic testing of the pelvic floor is becoming increasingly common in clinical pelvic medicine and pelvic floor research. Along with history, physical exam, and urodynamics, neurophysiologic testing can help in the diagnosis of certain pelvic floor disorders and to determine if a central or peripheral neurologic problems exists. Electrodiagnostic testing is also emerging in studies investigating the etiology of pelvic floor disorders. Therefore, a basic understanding of the principles and techniques used in electrodiagnostic medicine are essential for reconstructive pelvic surgeons.

Standard treatment for stress urinary incontinence (SUI) in women has evolved over the last few decades. The development of effective surgical modalities and the recent explosion in the availability of minimally invasive treatment options have altered the playing field, and have provided a wider range of treatment options for women with SUI. With these alternatives come the opportunity and the responsibility to assess how successful these treatments are. The areaof outcome assessment itself has evolved over the last several years, becoming more structured in the approach to defining treatment success. This process is particularly important for treatments aimed at SUI, where an improvement in the quality of life is the ultimate goal, and for which success can be defined in a number of different ways. Indeed, it may be impossible to identify a single parameter that can be used to define success in every patient undergoing treatment for SUI. This chapter explores current methods to analyze outcome of SUI treatment.

Ideally, the choice of surgery for stress urinary incontinence should be determined by the underlying pathophysiology. Generally, the diagnosis is refined to either urethral hypermobility (UHM) or intrinsic sphincteric dysfunction (ISD) based on history, questionnaires, physical exam, and various special tests including assessment of urethral mobility (Q-tip test or lateral cystogram), stress test, pad test, and video or nonvideo urodynamic studies. Unfortunately, there is no gold standard test or algorithm to allow diagnostic precision in every case, and the diagnosis is usually arrived at based on various combinations of the above investigations along with clinical acumen and experience. Nonetheless, the importance of arriving at the correct diagnosis lies in its role in determining the appropriate surgical intervention. Although this principle of practice has been challenged more and more in recent years ( 1 , 2 ), traditionally, UHM is treated with one of the bladder neck suspensions (BNSs) and ISD with one of the sling procedures, urethral bulking agents, or artificial urinary sphincter. For UHM, once the diagnosis is made, one must decide on the appropriate BNS, for which there exist two main types based on surgical approach: retropubic or transvaginal. Differences in efficacy aside, the decision to proceed with one approach or the other should be driven by any associated pathology requiring concomitant surgical repair. For example, if concomitant vaginal repair of a symptomatic rectocele is undertaken, then a transvaginal anti-incontinence procedure is appropriate. Conversely, if an abdominal hysterectomy is required, then a retropubic approach is logical.

Surgical management of stress urinary incontinence (SUI) has evolved over the last 20 years. Numerous procedures have been introduced and modifications to established procedures have been reported in the literature. Our understanding of the female continence mechanism has evolved as well. Currently, female SUI is attributed to urethral hypermobility, intrinsic sphincteric deficiency (ISD), or a combination of both conditions. This chapter focuses on the surgical management of SUI due to ISD.

The tension-free vaginal tape (TVT) Gynecare was first described in 1996 by Ulmsten ( 1 ) as a minimally invasive procedure to treat female stress urinary incontinence (SUI). This technique quickly gained a major place in incontinence surgery in Europe and is now being used more and more in North America. Prior to TVT, the gold standard technique to treat SUI was the Burch procedure. Several randomized controlled trials have compared the efficacy and safety of TVT and the Burch procedure. These studies demonstrated that TVT had a lower morbidity and an equal or superior efficacy (on midterm follow-up), justifying the widespread use of this technique ( 2 ). The long-term results (5-year outcome) of the procedure are also known (82% to 85% of patients are cured), and they justify the use of this technique ( 3 , 4 ). However, there are concerns regarding its operative safety. A Finnish series ( 5 ) of 1455 women treated for SUI demonstrated few vascular injuries (venous lacerations were the most frequent injury reported),whereas Zilbert and Farrell ( 6 ) reported a case of right external iliac artery injury. In addition, two deaths due to serious vascular injuries have been reported to the manufacturers ( 7 ). Three bowel perforations have also been reported ( 8 ). Postoperative voiding difficulties such as transient urine retention are present in 8% to 17%, and urgency in 5% to 15%. Most of these complications seem to be related to the penetration of the retropubic space. Keeping the principle of a minimally invasive procedure to reinforce the structures supporting the urethra, E. Delorme introduced a procedure that would avoid these complications. In 2001, the transobturator procedure was described, in which the tape is inserted through the obturator foramen from outside to inside (in extenso from the thigh folds to underneath the urethra) ( 9 ). Even though the transobturator out-in TVT technique is claimed to be a safe procedure, it may cause urethra and bladder injuries (Figure 10.1). In 2003, De Leval ( 10 ) described a novel surgical technique that allows the passage of a tape through the obturator foramens, from inside to outside, with the use of newly designed surgical instruments. This technique avoids damage to the urethra and bladder and, for this reason, makes cystoscopy unnecessary. However, the long-term safety of this type of tape is not known, particularly in relation to changes in the synthetic material and changes in bladder and urethral functioning caused by the tape, such as voiding disorders and bladder overactivity.