Minimal invasive surgery

Prof. Goeschen has been the first surgeon in Europe who performed these new minimal invasive operations for pelvic floor reconstruction. In cooperation with Prof. Petros he created new techniques.

 
The new keyhole techniques reinforce damaged tissue. The principles are:

1. The vagina must have better support for bladder opening and closing. A prolapsed vagina is conceptually like an invagination. Its side walls need to be secured to prevent a further prolapse. 
2. A severely damaged ligament cannot be repaired. New natural ligaments can be created by using precisely positioned artificial tapes. The Intra-Vaginal-Sling plasty (IVS) uses the body’s own wound repair mechanism to create new natural collagenous ligaments at the site of lost or weakened ligaments. The problem of weak and thin vaginal tissue is addressed by avoiding vaginal excision. Excess width is refashioned as length. Double layer "bridge" repairs weakened structures.
 
Although the positive outcome of an operation can never be guaranteed the long-term results of IVS show an overall success-rate of 80 % up to 90 %.

After Prof. Petros in Australia and, in cooperation with him, Prof Goeschen in Germany have developed this new "vaginal keyhole surgery" which sees and repairs the pelvic floor as a functional unit (integral concept), women now have a new hope for improvement of their situation. It is not necessary any longer to accept problems with bladder, pelvic floor and organic related sexual disturbances as beyond repair if they are caused by damaged tissue in the genital tract.

There are further advantages of the Petros/Goeschen method: no vaginal shortening and only small vaginal scars (minimal invasive vaginal surgery). The vagina remains in its normal anatomical position. The attempt to operate all the damaged tissue in one operation did not prove successful. Overcorrections are a possibility. Sometimes it is better to operate in two steps. 

The 2-year and the 4-year follow-up overall cure rate of the Petros/Goeschen procedure is 80 % to 90 %. After 2-year follow-up: for stress incontinence, 88 %, for urinary frequency, 85 %, for nocturia, 80 %, for urge incontinence, 86 %, and for emptying problems, 50 %. Pre- and post-operative urodynamics indicate that detrusor instability is not associated with surgical failure. After 4-year follow-up urine incontinence is cured in 80 % of all patients, the cure-rate for faecal incontinence is 90 %. 

Another advantage of the keyhole surgery (Petros/Goeschen concept) lies in the drastic reduction in post-operative in-patient and out-patient recovery. Using standard traditional operating techniques (either through the abdominal wall or through fairly large vaginal incisions) post-operative in-patient recovery may take up to 10 to 14 days. With the keyhole surgery, post-operative recovery is reduced to 2 to 7 days, depending on general health of the patient. 

All Petros/Goeschen techniques are performed entirely through the vagina, either under general anaesthesia, spinal anaesthesia or local anaesthesia. The type of anaesthetic used is decided after consultation between the specialists and yourself. 


The advantages of the Petros/Goeschen techniques

 
- High, until now unheard-of healing rates, also helps patients who have already   been operated using different techniques
- Minimal post-operative pain
- Urinary catheter after surgery only for some hours
- Small vaginal incisions and wounds
- Short post-operative stay in hospital (2-7 days)
- Quick return to daily life
- Operation is suitable for women of any age
 
Surgical treatment in the anterior Zone

The Anterior Zone extends between the external urethral meatus and bladder neck. The urethral tube lies entirely within the anterior zone. Inability to close off the tube will result in involuntary urine loss. The aims of anterior zone defect repair are to reinforce the ligament and its supporting structures by implanting a tape without constricting the midpart of urethra. This can be done in three ways:


Fig.4 ‘Tension-free’ midurethral sling to reinforce the anterior ligament. The ends are placed suprapubically through the abdominal wall. There is a little chance to perforate the bladder or great blood vessels

 


Fig.5 ‘Tension-free’ midurethral sling to reinforce the anterior ligament. The ends are placed laterally through obturator fossa. This reduces the chance to perforate the bladder or great blood vessels

 

Fig.6 ‘Tension-free’ midurethral sling to reinforce the anterior ligament. The ends are placed into the tissue close to the pubic bone. There is nearly no chance to perforate the bladder and great blood vessels

Surgical treatment in the Middle Zone

The middle zone extends between bladder neck and the cervix or hysterectomy scar. The anterior vaginal wall in the middle zone is supported by a thin fascia. The bladder base sits on this membrane. Herniations caused by lax or ruptured connective tissue in this thin membrane lead to a cystocoele (Fig.7)) or laterally to a paravaginal defect (Fig.8)). Many patients were found to have both defects. These defects are not easy to repair using traditional techniques, as up to one third may recur.

Direct repair cannot adequately restore stretched damaged tissue. Thus the vaginal wall needs to be supported by slings or meshes. The “U-sling” (Fig.9),  “transverse sling” (Fig.10) or “mesh support” (Fig.11) operation reinforces both the lateral and midline defects simultaneously using tapes or a meshes. 

Fig.7 Midline Defect = Cystocoele                                                     

Fig.8  Lateral Defect

  Fig.9 strong repair with U-sling or         

Fig.10 transverse slings or             


Fig.11 mesh-support

Surgical treatmentof Scar tissue in the Middle Zone = Tethered Vagina

The ‘tethered vagina syndrome’ is an entirely iatrogenic condition that is caused by scar-induced tightness in the area of the urethral tube and the bladder neck due to multiple previous vaginal operations. The classical symptom is commencement of uncontrolled urine leakage as soon as the patient’s foot touches the floor, indeed, often commencing as the patient rolls over to get out of bed.

Due to multiple previous vaginal operations the bladder acts like a watering can: In the supine position  urine is stored in the bladder. While standing up the patient presents an uncontrolled bladder emptying immediately on getting out of bed.  


Fig.12 Resting in supine position
The bladder acts like a storage

Fig.13 Standing up causes a massive urine loss.

In these cases it is essential to dissect the vagina from the bladder neck and urethra, and then to free all scar tissue from urethra and bladder neck to restore the elasticity. In order to prevent a recurrence fresh vaginal tissue must be brought to the bladder neck area of vagina. 

Fig.14 Restoration of elasticity after removing the scar tissue
and covering the defect with a muscle-skin-flap

Surgical treatment in the posterior Zone

Weakened ligaments in the posterior Zone causes the uterus or after hysterectomy the upper vagina to descend into the vaginal cavity with the result of an uterine/vaginal prolapse. It is clear that as well as a posterior sling, approximation of the sidewall is also needed to support the apical repair as well as lengthen the vagina.

Fig.15  strong posterior repair with sling or                  

Fig.16  mesh


- The importance of preserving the uterus

The uterus is located in the centre of the pelvic floor. It is surrounded by important nerves, blood vessels, connective tissue, and muscles. Within the complex architecture of the pelvic floor the uterus acts like the keystone of an arch, being an important insertion point for posterior ligaments and the downward muscle. Removal of the uterus may cause a point of weakness in the posterior ligaments predisposing to prolapse of the vagina. This, in turn, may cause bladder problems in 18 % of patients who have had a hysterectomy.

Fig.17 a+b The uterus, the central anchoring point of the pelvic floor, acts like the keystone of a roof

For the above reasons we try to conserve a healthy uterus whenever possible. A hysterectomy using the procedure of Petros/Goeschen is rarely necessary. Pregnancy after keyhole approach is still possible. However, we recommend then that delivery should take place by Caesarean section. 

Fig.18 Hysterectomy may weaken the fascial side-wall support and the ligaments by removing a major part of its blood supply. Conservation of the uterus is important in the long-term prevention of vaginal prolapse and incontinence

 

Back to your daily life

Keyhole surgery is designed for patients to return to home, work, and normal activities as soon as possible. On day after discharge from hospital, you can usually drive your car, cook, go shopping and look after your children. However, in some patients, recovery may take longer.