Parulekar SV

Genital prolapse was known to Hippocrates and Galen, in whose writings it finds a place. The exact pathophysiology of the condition was not known then. But it was known that it caused a significant deterioration of the quality of life. Hence attempts were made to repair it. The earliest attempts were simple. Pessaries were used as trusses to control the symptoms of prolapse in the middle of the nineteenth century. Earliest surgical attempts included suturing the opposite side labia together in the midline, and removing a part of the vagina to narrow its width. First operation on the anterior vaginal wall was done by Heming in 1831. Modern techniques of colporrhaphy were being used and reported in the early part of the 20th century. Howard Kelly from Baltimore promoted the plication of pubovesicocervical fascia in the midline for repair of a cystocele. It was assumed that endopelvic fascial support structures got damaged during childbirth causing vaginal wall prolapse. Kelly’s plication of the fascia was based on that concept. This concept remained strong almost throughout the 20th century. A major breakthrough came with identification and classification of fascial defects as proximal, distal, central, and lateral by Richardson et al from Georgia. It was found that the endopelvic fascia invested and supported all the pelvic organs. It connected the pelvic organs to the retropubic fascia, fascia on the lateral pelvic walls (obturator fascia, in which a condensation was present to form the arcus tendineus fasciae pelvis), and pelvic floor (formed by the levatores ani). It was condensed to form uterosacral and cardinal ligaments which were connected to the pericervical ring. DeLancey further showed that the proximal one third of the vagina was suspended by the uterosacral ligaments, the middle one third was supported by lateral attachments to the pelvic side wall at the arcus tendineus fasciae pelvis and the distal one third of the anterior vagina was fused with the urogenital diaphragm. Damage to the fascial attachments to the middle one third of vagina resulted in paravaginal defects. Damage to the fascial attachments between the vagina and the uterosacral-cardinal ligament complexes resulted in central transverse defects. These concepts have become very important in site-specific repairs. It is now found that the plication procedure for repair of a cystocele bunches the endopelvic connective tissue in the midline, which places more stress on paravaginal defects by pulling the detached edge of the fascia away from the pelvic side wall and aggravates the prolapse. As a result, the failure rates are unacceptably high, and there are functional disturbances of micturition too. In more recent times, owing to perhaps a desire to keep doing something new or perhaps due to a marketing strategy of manufacturers of synthetic meshes, there has been growing interest in using meshes under the vagina to provide support to it. Subsequently there have been reports of mesh erosion and other problems and a trend towards not using meshes. Perhaps litigations by patients discouraged doctors. Manufacturers inserted a statement warning about the complications of meshes and asking the doctors to use the product at their own discretion. Perhaps it removed the responsibility from them to the doctors, which discouraged the use of meshes even further. In the meantime, we have been using site specific repair with excellent results and did not have to resort to the use of meshes. In this issue of the journal, we have a report of an innovative operation in which the uterosacral ligament pedicles were placed under the bladder base to support it. If one thinks about it, one realizes it is one form of a site specific repair, since the end result is bladder fascia being attached to the uterosacral ligaments. I hope the readers benefit from this article and enjoy this issue like the previous ones.