The Female Pelvic Floor: Function, Dysfunction and Management According to the Integral Theory, 3rd Ed (2011)

This is a third, enriched edition of a textbook based on the theory that revolutionized surgery for female stress urinary incontinence. The concept, developed and presented in the 1990s by Ulmsten and Petros, is known as integral theory and has made a large contribution in considering the organs contained in the pelvis as being part of a single integrated system. As such, the mutual interaction of clinical presentation and surgical repair should be considered. The book is rich in illustrations, including high quality anatomical dissections as well as clear diagrams that help the reader understand better the principles of the integral theory. The included DVD makes the learning process more interactive, and the lectures by Petros explaining his theory with the aid of plastic models, real cases and anatomy specimens complement the text nicely. The book is divided into 7 chapters. The first 3 chapters are dedicated to explaining the integrated view of the anatomy, and the dynamics of pelvic floor function and dysfunction and connective tissue damage. The remaining 4 chapters are dedicated to surgery. The integration proposed by Petros between anatomy and function is interesting and at some points creative. For instance, 1 chapter explains how a lax ligament in a certain location in the pelvic floor can cause multiple pelvic floor dysfunctions. Similarly, in a section regarding simulated operation technique Petros states that functional symptoms such as urgency and urge incontinence can be addressed simply by restoring the anatomy. Unfortunately nothing but the expert opinion of the author is provided. Without more robust neurophysiology and clinical studies the usefulness of the proposed simulated operation and proposed neurological mechanisms of the lower urinary tract seems a bit simplistic and limited. Chapter 4 describes the principles of reconstructive pelvic floor surgery according to the integral theory. At the beginning of the chapter a well-known and frequently used tension-free tape positioned at the mid urethral level is described. The chapter begins with a useful and relevant section discussing the physiology of the healing process and meshes in vaginal surgery. With the recent Food and Drug Administration warnings, every surgeon who is implanting mesh or tape should be fully informed of the possible consequences of the surgery being performed. We must be mindful that if a procedure seems easy, it does not mean that it is also safe. There are no brave surgeons, but only brave patients. In light of using as little mesh as possible the new proposed therapy, the tissue fixation system, moves in the same direction. The major difference compared to the kit meshes for pelvic organ prolapse is that the tissue fixation system is basically tape that is attached with an anchor, thus minimizing the amount of polypropylene used. As stated by Petros, a modern pelvic floor surgeon has to think like an architect (to design the form of the reconstruction) and act like an engineer (to rebuild a pelvic floor that can withstand the forces imposed on it).