A low cost artisan tension-free tape technique cures pelvic organ prolapse and stress urinary incontinence - proof of concept

Abstract

Introduction: The primary cause of pelvic organ prolapse (POP) is weak cardinal/uterosacral (CL/USL) ligaments and for stress urinary incontinence, weak pubourethral ligaments (PUL).

Material and methods: A 1 cm wide tape cut from a mesh sheet was applied tension-free to reinforce already plicated CL/USLs for cure of prolapse and directly to PUL for cure of stress urinary incontinence (SUI). 40 tapes were inserted, 10 midurethrally for SUI and 30 for 2^nd/3^rd degree prolapse: 15 to uterosacral ligaments and 15 to cardinal ligaments.

Results: At 12 months follow-up there was 72% cure for POP, 70% for SUI and improvement in urge/nocturia symptoms in 82% of patients.At 36 months 8/15 patients were evaluated. Anatomic cure for POP III was 2/4, for POP I-II 6/6.

Conclusions: Though a 'proof of concept' study, our results may be sufficient to provide, in time, an alternative individual pathway for surgeons wishing to provide more certainty to a prolapse repair than 'native tissue' for an individual patient. The method questions whether expensive mesh kits are really necessary: our data though small, actually part of a learning curve, was within 15 percentage points of more sophisticated, more expensive tensioned slings. Intraoperative complications were low with no tape erosions seen at 12 months. Further validation with larger prospective and comparative trials is required.

Keywords: Integral Theory; artisan tape; midurethral sling; native tissue repair; pelvic organ prolapse; tension-free tape.

Figure 1

Both CL and USL are elongated in uterine prolapse. It is self-evident that loose cardinal (CL) and uterosacral (USL) ligaments (DeLancey level 1 supports) and their fascia attachments F will elongate to cause uterine prolapse, with structural supports restored only by shortening and strengthening.

Figure 2

Artisan tape used for cure of SUI. Upper figure: Repair of the pubourethral ligament. Schematic view from above. The artisan tape is inserted via a single suburethral incision. The tape is inserted with a Crile forceps below the symphysis via a tunnel made through the perineal membrane as per the TVT. Lower figure: Schematic view looking into the vagina. With an 18 Fr catheter in situ, and using a 2-0 vicryl suture, the external urethral ligament (EUL) lateral to the urethra is located; the suture is placed into the vaginal fascia (f) on one side, then into (f) on the contralateral side, then into the contralateral EUL and tied loosely.

Figure 3

Cardinal ligament/pubocervical fascia repair by tension-free tape. Schematic 3D view of the uterus, vagina and cardinal ligaments (CL). CLs are shown torn from their attachment to the anterior cervical ring and prolapsed down the side of the cervix. The pubocervical fascia (PCF) of the vagina is shown torn from the cardinal ligaments and the cervical ring. The CLs are sutured back onto the cervical ring ‘S’ and the tape is inserted tension-free via tunnels made along the anatomical line of the CLs.

Figure 4

Uterosacral ligament/rectovaginal fascia repair by tension-free tape. Schematic view looking into the vagina. A and B = uterosacral ligaments (USL); A 5 cm long transverse full thickness incision is made between A and B, 3–4 cm below the cervix (CX) and opened out. USLs (A&B) are approximated. Following this, the tape (T) is inserted tension-free along the length of the USLs.