Surgical correction: TVM procedure
Transvaginal extraperitoneal colpopexy (transvaginal mesh) is a technique for the complete repair of damaged pelvic fascia using a synthetic mesh implant. The most versatile and recognized material is the Gynecare Prolift system.
Depending on the location of the anatomical defect, the following reconstruction options are distinguished:
- Anterior compartment reconstruction (cystocele repair using a transobturator approach with fixation of the mesh to parts of the tendinous arch of the pelvic fascia — arcus tendineus);
- Posterior compartment reconstruction (reinforcement of the posterior vaginal wall by passing the mesh implant through the sacrospinous ligaments);
- Complete pelvic floor reconstruction.
The mesh is placed strictly subfascially, perfectly matching the contour of the vaginal tube, eliminates the prolapse, and does not alter the vector of the physiological displacement of the vagina.
Advantages and features of the TVM technique
Modern surgical approaches are characterized by high efficacy and safety. Key advantages of the method include:
- Versatility and broad indications;
- High efficacy in complex, recurrent forms of prolapse in patients with prior surgeries;
- Safety for patients with concomitant extragenital pathology;
- Variable scope of intervention: the procedure can be performed independently with uterine preservation or combined with hysterectomy or cervical amputation.
Outdated surgical methods are rarely used in modern practice—primarily in elderly patients with complete uterine or vaginal vault prolapse, as they frequently lead to recurrences and sexual dysfunction.
Physiology and mechanisms of urinary continence
Normally, urination is controlled by the cerebral cortex, which inhibits the micturition center in the sacral segments of the spinal cord. Complete emptying is achieved through sustained contraction of the detrusor with simultaneous relaxation of the urethra and pelvic floor muscles.
Urinary continence is maintained by two groups of factors:
- External factors: pelvic floor muscles that contract when intra-abdominal pressure rises and compress the urethra. Weakening of the visceral fascia and muscles leads to pathological mobility of the bladder neck.
- Internal factors: the muscular layer and sphincters of the urethra, mucosal folds, and alpha-adrenoceptors. Deficiency develops due to trauma, estrogen deficiency, or innervation disorders.
Types and diagnosis of urinary incontinence
Urinary disorders frequently accompany pelvic organ prolapse. The most common types are:
- Stress urinary incontinence (involuntary urine loss during physical exertion and coughing without urgency);
- Bladder instability (overactive bladder);
- Complex and combined forms.
The prevalence of the condition increases during perimenopause. The objectives of the examination are to determine the type of disorder, assess lower urinary tract function, and select the appropriate correction method. The first stage of examination necessarily includes a gynecological pelvic examination.
Briefly: answers to topical questions
What conservative treatment methods exist for pelvic organ prolapse?
Conservative treatment of pelvic organ prolapse includes the following methods:
- A set of physical exercises to strengthen the pelvic floor muscles (Kegel exercises).
- Physiotherapy exercises.
- Worn pessaries. Supportive pessaries include ring pessaries, Gehrung pessaries, and Hodge pessaries, as well as space-filling pessaries.
Which specific muscles make up the female pelvic floor that provide external continence mechanisms?
The female pelvic floor, which acts as an external continence factor, is conventionally divided into three layers and includes the following muscles:
- Ischiocavernosus muscle (m. ischiocavernosus) — belongs to the superficial layer.
- Bulbospongiosus muscle (m. bulbospongiosus) — located in the superficial layer.
- Superficial transverse perineal muscle (m. transversus perinei superficialis) — runs from the ischial tuberosity to the central tendon.
- Deep transverse perineal muscle (m. transversus perinei profundus) — belongs to the muscles of the urogenital diaphragm (second layer).
- Levator ani muscle (m. levator ani) — forms the deep layer and consists of the pubococcygeus (m. pubococcygeus), iliococcygeus (m. iliococcygeus), and ischiococcygeus (m. ischiococcygeus) muscles.
Class and exam questions
What is a TVM procedure and what material is used for it?
TVM surgery (transvaginal mesh) is a pelvic fascia repair system using a synthetic mesh implant. The Gynecare Prolift system is recognized as the most versatile.
What is the difference between external and internal urinary continence factors?
External factors are represented by the pelvic floor muscles, which compress the urethra during exertion. Internal factors include the urethral muscle layer, sphincters, mucosal folds, and receptor apparatus.
What causes stress urinary incontinence?
The main causes are dislocation and weakening of the ligamentous apparatus of the urethra and urethrovesical segment, as well as urethral sphincter deficiency.
Why are outdated prolapse treatment methods rarely used nowadays?
They frequently lead to disease recurrence and sexual dysfunction; therefore, in modern practice, they are performed extremely rarely and only in advanced age.
What else to study on this topic
- Anatomical structure of the tendinous arch of the pelvic fascia (arcus tendineus)
- Mechanisms of mesh fixation via the sacrospinous ligaments
- The role of alpha-adrenoceptors in the urethral muscle layer
- Pathogenesis of overactive bladder
- All stages of a comprehensive clinical examination of a patient with prolapse
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