Anatomical steps in the conceptualisation of the urethral ligament plication(ULP),a tape-free operation for stress urinary incontinence(SUI)cure

INTRODUCTION It is not sufficient to describe an anatomical structure.An answer is required to the question,‘what is it for'.Salvador Gil-Vernet(1892-1987)was a famous Spanish anatomist and urologist and Nobel Prize nominee.The anatomical structure in question is the role of the pubourethral ligament(PUL)in the cure of stress urinary incontinence(SUI).The 1990 Integral Theory,on which the tension-free vaginal tape(TVT)operation is based,described two separate closure mechanisms for the urethra,both reliant on the PUL,distally and at the bladder neck,with the bladder neck the most important.

Minimally invasive Fothergill-Manchester operation with connective tissue conservation

Poor cure rates for prolapse repair reported by the PROSPECT TRIAL1 and total mesh bans after the Cumberlage Report,2 leave few options for vaginal surgery for urogynecologists worldwide.One remaining option,the Fothergill-Manchester Repair began as a modification of the Donald operation.3 Fothergill emphasized the role of cardinal ligament(CL)and uterosacral(USL)ligaments in uterine prolapse repair.4 The classical Manchester operation involves full thickness inverted V-shaped vaginal excisions(Fig.1).The cervix is dilated and if elongated,it is amputated.CLs are severed and sutured to the anterior part of cervix.USLs may also be severed.Sturmdorf sutures bring vaginal flaps into the cervical canal.Vagina is repaired.The operation can be traumatic,some even reported a large quantity blood loss as high as 850 ml,5 possibly related to severing of CLs which contains uterine artery branches and also,failure of Sturmdorf sutures to control bleeding from cervical amputation.

Pathogenesis of overactive bladder and surgical treatment according to the Integral Theory Paradigm

Overactive bladder(OAB is a definition by the International Continence Society(ICS).It comprises three symptoms,urge,frequency and nocturia.OAB is a major problem for up to 30%of women,more so for elderly women.OAB is generally assumed to be a paradigm,but it cannot meet the criteria of a paradigm,as its causation is said to be"idiopathic"(unknown)and is said to have no known treatment.In 1993,it was demonstrated that the sequence of events in urodynamically diagnosed detrusor overactivity(now"DO")was identical with what occurred in normal micturition,which led to the conclusion that frequency,urgency,nocturia were in effect,an uncontrolled but otherwise normal micturition.Data from a 1997 experiment indicated the control mechanism of the bladder was binary,either closed or open,regulated by a peripheral musculoligamentous system under cortical control.The Integral Theory paradigm's view of OAB is based on and is compatible with,ICS definitions and descriptions.The Integral Theory paradigm(ITP)views OAB pathogenesis as anatomical,caused by defects anywhere along the control mechanism pathway,but mainly damage in its weakest link,collagen defects in the peripheral musculoligamentous system.Specific tests to prove causation consist of mechanically supporting suspensory ligaments,pubourethral ligament(PUL)or uterosacral ligament(USL),"simulated operations";PUL support prevents urine loss on coughing;USL support by inserting the lower blade of a bivalve speculum into the vagina diminishes urge and pain.The ITP specifies treatment of correctible causes:squatting-based exercises to strengthen the reflex pelvic muscles,ligament repair by plication for premenopausal women,slings for postmenopausal women.