Laparoscopic surgery for the treatment of urinary incontinence and pelvic organ prolapse is evolving rapidly. There is a desire to achieve the long-term cure rates of traditional open repairs with a less invasive surgical approach. Reported benefits of laparoscopic surgery included shorter hospital stay, less patient discomfort, improved cosmesis, and shorter convalescence. Some surgeons suggest laparoscopy provides improved visualization due to laparoscopic magnification, insufflation effects, and improved hemostasis. This allows for more precise dissection and suture placement. The potential disadvantages of laparoscopy include the cost of laparoscopic equipment, increased operative times, and the technically more demanding nature of the laparoscopic surgery, which results in a more prolonged learning curve.
Genuine stress incontinence (GSI) is defined by the International Continence Society (ICS) as the involuntary loss of urine coincident with increased intra-abdominal pressure, in the absence of a detrusor contraction or an overdistended bladder,1 making the diagnosis of GSI a urodynamic-based diagnosis. The most common cause of GSI is urethral hypermobility where laxity of the pubocervical fascia compromises the normal backboard against which the urethra is compressed during increases in intra-abdominal pressure. GSI can be treated conservatively with medical therapy, pelvic muscle exercises, or a pessary, but many patients progress to surgical therapy.
When considering the anatomy of the repair of pelvic organ support, a surgeon needs to keep in mind the three levels of support of the vagina.2 The upper fourth of the vagina (level 1) is suspended by the cardinal/uterosacral complex; the middle half (level 2) is attached bilaterally to the arcus tendineus fasciae pelvis and the medical aspects of the levator ani muscles; and the lower fourth (level 3) is fused to the pubic symphysis anteriorly and the perineal body posteriorly.