A review of the Integral Theory of Pelvic Organ Prolapse and proposed concept of repair: part 2 – the TFS ligament repair

Aim: To demonstrate how TFS site specific repair of the 4 main damaged ligaments (Part 1) restores the anatomy of patients’ with cystocoele, uterine/apical prolapse and high, mid and low rectocoele. Surgery: The surgery is based on the TVT neo-ligament principle, shortening and reinforcing the ligaments: arcus tendineus fascia pelvis (ATFP ) and cardinal (CL) to cure cystocoele; CL and uterosacral (USL) to cure uterine/apical prolapse; USL and perineal body (PB) to cure rectocoele; PUL to cure urinary stress incontinence. There is no vaginal excision. Which ligament to repair is guided by the Pictorial Diagnostic Algorithm, which uses symptoms to identify which ligaments are damaged. Results: The application of TFS for repair of only 4 ligaments has been found to be sufficient for repair of all three prolapses, cystocoele, uterine/apical and rectocoele. The 5th ligament, PUL, is essential for repair of urinary stress incontinence. There seems to be minimal recurrence of the prolapses in the longer term. Data from patients having total repair (all prolapses) indicates there is only a minimal fall in cure rate, from 92% at 12 months to 84% at 48 months. Conclusions: Suturing damaged tissue to damaged tissue creates scar tissue and more damaged tissue. With reference to the suspension bridge analogy, if the tensioning cables (ligaments) have collagenous damage, the collagen must be strengthened by tissue reaction from precisely implanted tapes. The one-way system at the base of the anchors allows the tapes to both shorten and reinforce the damaged ligaments, thus restoring anatomy and function: the directional muscle forces require a firm insertion point (ligament) to contract efficiently, according to Gordon’s Law.