Background: Diseases of the female pelvic floor, ranging from genital descensus to prolapse, are benign conditions that increase with advancing age and can lead to a reduction in quality of life that requires treatment. The topic of this review concerns the historical development of preventive and therapeutic surgical options in the management of pelvic organ prolapse.
Method: Selective literature research of reviews, original papers, (German / European) guidelines and current textbooks based on personal experience and perspectives.
Results: The incidence of prolapse disorders will probably double by the year of 2050. As a result of increasing life expectancy, the treatment mandate is progressively focused on a collective of older and vulnerable patients. Modern preventive strategy concerns a better obstetric care for vaginal delivery, which is certainly the dominant risk factor for subsequent prolapse. In addition to the routine use of epidural anesthesia, the restrictive use of operative vaginal deliveries and avoidance of protracted labor, careful consideration should be given to particular situations in which primary caesarean section may be preferred as mode of birth.
Until the end of the last century, the most frequent surgical treatment performed for genital prolapse disorders was vaginal hysterectomy with colporrhaphy. In the last 30 years, surgical methods that preserve the uterus have become established. Surgical laparoscopy has enabled abdominal access into pelvic floor with diverse technical advantages. The new insight is that Level I fixation significantly enhances the success rate of surgical procedures targeting the anterior vaginal wall. Further optimization of postoperative stability has been achieved using transvaginal alloplastic implants in the anterior compartment. However, their use was later banned in most countries due to a considerable rate of complications. This fact has prompted a renewed focus on classic, well-established surgical techniques that do not involve alloplastic materials.
Uncommonly utilized procedures for anatomical reconstruction include the laparoscopic uterosacral ligament suspension and the vaginal modified Manchester procedure with amputation of the cervix. The surgical management of total prolapse in elderly, frail women with co-morbidities poses a significant challenge. In such cases, the primary focus is on resolving the functionality, while genital anatomical reconstruction becomes a secondary consideration. Occlusion of the vaginal canal through surgical procedures such as the LeFort colpocleisis or the modified Labhardt operation can offer relatively simple, low-risk solutions that are indeed very effective in cases of advanced prolapse. A great number of patients treated with these techniques are very satisfied with the procedure, mainly due to the improvement of intestinal and bladder functions. Few women express regret about undergoing this operation, as the loss of the ability to engage sexual intercourse is not a major concern in this collective.
Conclusion: Progress in the prevention and intervention of pelvic floor disorders continue to advance steadily. However, not every innovation proves successful in the long term. In this respect, the further development of surgical methods for extreme cases that rely on traditional prolapse surgery is not a mere historical oddity but an essential part of an effective treatment concept in the 21st century.