Promontofixation for the treatment of prolapse

Abstract

Genital prolapse is a common problem in women. The wide variety of surgical techniques used to treat this problem demonstrate how difficult it is to manage. Laparoscopic surgery offers a new approach. It allows a good view of the anterior and posterior compartments so that a global approach for the prolapse is possible by the same surgical route. Traditional promontofixation can be combined with a new approach to the posterior compartment. Laparoscopic promontofixation through installation of an intervesicouterine prosthesis for the treatment of hysterocele and cystocele is associated with paravaginal repair of lateral defects and a Burch anterior colposuspension for urinary stress incontinence. When combined with laparoscopic treatment of rectocele by myorrhaphy and reinforcement of the fascia by means of a prosthesis, it provides a complete range of treatment for all types of feminine prolapse. After 20 years of experience through laparotomy, promontofixation using a triangle has been carried out by laparoscopy at the authors' center since 1991 in an attempt to eliminate the cystocele by solidly anchoring the uterus and bladder floor to the promontory. This laparoscopic technique follows the usual steps for pelvic prolapse repair: 1. Total or subtotal hysterectomy or suspension of the uterus is performed in such a way that it returns to normal physiologic position, and a solid subvesical floor is created. 2. The physiologic axis of the vagina is restored by creating a strong, low posterior point of support and by performing culdoplasty. 3. Evident or latent stress incontinence is treated. It would be pointless to treat the hysterocele on its own because, once the prolapse has been cured, the subvesical mass will disappear and allow urinary incontinence to appear. 4. Reconstruction of the posterior rectovaginal support structures seems to be mandatory and is carried out in almost all cases. The first phase of the laparoscopic approach to pelvic prolapse allowed the authors to explore the technical aspects. Several approaches are possible by laparoscopy. Herein, the authors report 8 years of technical research and assessment. This experience confirms the tremendous potential of laparoscopic surgery for the treatment of all aspects of this pathology by the same route. Stress incontinence, cystocele, hysterocele, rectocele, or enterocele can be treated. The operative time is longer than with the open route, and the surgeon must be highly experienced. Based on their experience, the authors are discovering new concepts. More data are required before a conclusion can be drawn concerning this promising new approach.