Integral System Surgical Techniques

Surgical Repair of Connective Tissue Structures

Reconstructive pelvic floor surgery according to the Integral System differs from conventional surgery in four ways:

1. It is minimally invasive (day-care).

2. It is based on specific surgical principles which minimize risk, pain and discomfort to the patient.

3. It takes an holistic approach to pelvic floor dysfunction by isolating the contribution(s) of each zone of the vagina to dysfunction.

4. It has a symptom-based emphasis (the Pictorial Diagnostic Algorithm) which expands the surgical indicators to include cases with major symptoms and only minimal prolapse.

In keeping with the overall framework of the Integral System, the surgical techniques are organised by zone. The zones consist of nine key structures which potentially need repair in pelvic reconstructive surgery (fig 1-10).

The 5 main structures which require repair with a tape are outlined in bold

Anterior zone
1 = external urethral ligament (EUL)
2 = pubourethral ligament (PUL)
3 = suburethral vagina (hammock)

Middle zone
4 = arcus tendineus fascia pelvis (ATFP)
5 = pubocervical fascia (PCF)
6 = anterior cervical ring/cardinal ligament (CL) ZCE = excess tightness, usually scar tissue below bladder neck (‘tethered vagina’)

Posterior zone
7 = uterosacral ligament (USL)
8 = rectovaginal fascia (RVF)
9 = perineal body (PB).

Using a special delivery system, polypropylene tapes are inserted as an anterior sling at midurethra, a posterior sling in the position of the USLs, and other positions according to which structure in which zone has been damaged Cystocoele Repair Tapes are inserted in positions ‘4’ to repair lateral and central defects, and ‘6’ to repair transverse defect (high cystocoele/anterior cervical ring).

Rectocoele repair

The whole posterior vaginal wall is supported by repairing the uterosacral ligaments ('7) and perineal body ('9').

Non-Surgical Repair

Pelvic Floor Rehabilitation according to the Integral System

The Integral System for pelvic floor rehabilitation (PFR) differs from traditional methods in four major ways:

1. It addresses symptoms of urgency, nocturia, frequency, abnormal emptying and pelvic pain in addition to stress incontinence
2. It introduces two new techniques , squatting and reverse pushdown exercises so as to strengthen the 3 directional muscle forces.
3. It combines electrotherapy, hormones, fast and slow twitch exercises.
4. It is designed to seamlessly fit into a patient’s daily routine.

The regime consists of four visits in three months. The Pictorial Diagnostic Algorithm (fig 1-11) guides diagnosis of anatomical defects in the anterior, middle and posterior zones of the vagina. Hormone replacement therapy (HRT) is administered to thicken epithelium and prevent collagen loss. Electrotherapy is given for 20 minutes a day for the first four weeks to improve neuromuscular transmission. The patients do slow twitch muscle exercises - squatting or sitting on a rubber ‘fit’ ball - for a total of 20 minutes per day.

First Visit

The patient is instructed in a Kegel exercise routine, two lots of twelve, three times per day. The exercises are performed in bed, face downwards, morning and night with legs apart, according to the methods of Bo (1990). The remaining 24 squeezes are performed at lunchtime or during visits to the toilet. It is helpful for the patient to visualise squeezing the sides of a lemon inwards, or to pretend she is cutting off her urine stream. Endocavity electrical stimulation of 20 minutes per day is prescribed for four weeks. With any anterior zone defect, the probe is placed just inside the introitus on alternate days and in the posterior fornix every other day. The aim is to strengthen both PCM and LP. With pure posterior zone defects, the probe is placed in the posterior fornix only. Squatting or sitting on a ‘fit ball’ for a total of 20 minutes per day if possible is encouraged as a universal slow-twitch exercise. The aim is to integrate this activity into the patient’s daily routine. For instance, the patient is encouraged to substitute squatting for bending at all times. If a patient has arthritis, she may sit on the end of a chair with legs apart or on a fitball. Compliance is vastly improved by explaining the principles behind the exercises, and encouraging patients to plan and record their daily routine.

Second Visit

In patients without a cystocoele, a reverse downward thrust is taught on the second visit. The patient presses upwards with the probe or a finger placed approximately 2 cm inwards from the introitus, and strains downwards. The downward thrust is now alternated with the Kegel squeezes, each three times per day. The downward-acting exercises strengthen the fast twitch fibres of all three directional muscle forces.

Third Visit

The attendant checks the patient compliance (diary), discusses how she has incorporated the programme into her daily routine, and reinforces the aims and principles of the programme.

At the three month review (fourth visit), in consultation with the patient, a decision is made whether to proceed to surgery, or continue with Maintenance PFR.

Maintenance PFR

By the end of three months, it is assumed that the patients have incorporated the exercises into their normal routine. Squeezing is alternated with the downward thrust, a total of six sets of 12 exercises per day. Squatting is by now an acquired habit. Electrotherapy is performed five days per month. The patient is advised to continue this routine for the rest of her life.

Comments

Almost 70% of patients who completed the treatment seemed unwilling to perform the reverse pushdown exercises. Squatting, Kegel and electrotherapy were well received.

Results of the First study (Petros & Skilling, 2001)

Sixty patients completed the study. Improvement was defined as >50% improvement in their symptoms (see Table 1).

Results of the Second Study (Skilling, PM and Petros PE (2004)

Of 147 patients (mean age 52.5years), 53% completed the programme. Median QOL improvement reported was 66%, mean cough stress test urine loss reduced from 2.2 gm (range 0-20.3 gm) to 0.2 gm (range 0-1.4 gm), p=<0.005 and 24 hour pad urine loss from a mean of 3.7 mg (range 0-21.8 mg) to a mean of 0.76 mg (range 0-9.3 gm), p=<0.005.

Frequency, nocturia were significantly improved (p=<0.005). Residual urine reduced from mean 202 ml to mean 71 ml(p=<0.005) (See Table 2 for improvement in individual symptoms).