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No of words Text 396
Dear Dr. Aris Papageorghiou,
Re (1) Fayyad AM, Hasan MR. Novel technique of laparoscopic mid-urethral
autologous rectus fascial sling for stress urinary incontinence. BJOG.
2024 Nov;131(12):1587-1590. doi: 10.1111/1471-0528.17877. Epub 2024 May
29. PMID: 38812080.
The ban on large vaginal mesh implants unfortunately took with it the
midurethral sling (MUS). Unlike mesh sheets, horizontally-positioned
tapes, did not have the crippling pain complications from vaginal mesh
scar tissue compressing nerves. British women now have few equivalents
to MUS for their SUI (stress urinary incontinence). In the midst of this
gloom, “Necessity, the mother of invention” inspires human
creativity to provide solutions.
I write as the codeveloper of the MUS and the Integral Theory of Female
Urinary Incontinence (IT) (2), to congratulate the authors on their
skilful, innovative, well-engineered, laparoscopic fascial sling
operation (1), which they based on the same IT anatomical principles
behind the MUS (2).
The aim is to provide further information on the IT as a practical guide
for addressing pelvic floor symptoms besides SUI.
The 1990 IT stated (2), “Symptoms of stress and urge, mainly
derive, for different reasons, from laxity in the vagina or its
supporting ligaments, a consequence of altered collagen/elastin” (2).
Underlying (2) was the discovery that bladder function was not from the
bladder itself, but from outside it: 3 cortically directed pelvic floor
muscles contracted against suspensory ligaments to close urethra
(continence), open it (micturition) and stretch vagina like a trampoline
to prevent bladder-base stretch receptors from activating micturition at
low bladder volumes (urgency, urge incontinence). Collagen deficiency in
such ligaments would weaken the muscle forces to cause prolapse and
symptom dysfunctions, Figure1.
It was repeatedly observed that repair of uterosacral ligament (USL) for
uterine prolapse, also gave high rates of cure for urge, frequency,
nocturia, abnormal emptying and chronic pelvic pain and bowel
dysfunctions (3-7).
The IT is agnostic about whether pelvic ligaments causing pelvic
symptoms are repaired abdominally or vaginally. BJOG readers interested
in exploring recent advances in etiopathogenesis of
bladder/bowel/pain/prolapse dysfunctions and recent advances in surgical
technique can do so at a recent IT Update (20 papers,45 authors, 60
videos). https://atm.amegroups.org/issue/view/1400 New surgical
methods described therein include collagenopoietic wide bore polyester
suture techniques to plicate (and add collagen) to ligaments weakened by
childbirth and age without the need for tapes. The Fayyad paper (1) has
opened a door for an entirely new direction for laparoscopic surgery.
Expert laparoscopists can easily adapt the new vaginal techniques
described in the IT Update to reproduce the impressive symptom cure
results recorded for bladder/bowel/ chronic pelvic pain/ prolapse from
the now banned uterosacral slings (3-7).
.