Pelvic Prolapse Repair

Pelvic prolapse results from decreased support of the urethra, bladder, vagina, uterus, and/or rectum. If surgery is necessary to correct the prolapse, sutures are placed to strengthen and repair the supporting tissue of these structures. Frequently, various mesh or graft materials are used to improve the quality of the pelvic prolapse repair. In reality, the procedure(s) is a type of hernia repair. The repair may be done vaginally (no abdominal incisions), laparoscopically (so-called laser surgery), or at laparotomy through a large abdominal incision.

Vaginal repair of pelvic prolapse is usually performed under general anesthesia. The procedures are called anterior repair for bladder and urethral support and  posterior repair for rectal support (or A&P repairs for both). An enterocele repair (repair a hernia at the top of the vagina) may also be done at the same time. If urinary incontinence is a problem, many physicians recommend other procedures along with the vaginal repairs. The suburethral sling and laparoscopic Burch both give good long-term results in treating urinary incontinence. Hysterectomy may or may not be needed and is usually done separately from the prolapse repair. Various procedures are used to strengthen the support the vagina when this structure is involved in the prolapse (sacrospinous ligament fixation, paravaginal repair).

Due to significant damage to the supporting tissues of the pelvis, it is sometimes appropriate to use materials (grafts or mesh) to strengthen the repair. Common materials include various synthetic materials (currently polypropylene) and acellular collagen matrix (highly purified dermal tissue from pigs or cattle). Because the synthetic mesh generally gives a longer lasting repair, this is the material Dr. Biggerstaff most often uses.

The graft material is placed between the anterior vaginal wall and the overlying bladder for an anterior repair, between the posterior vaginal wall and the rectum for a posterior repair, and over the weakness in the top of the vagina for an enterocele repair. The graft material may be held in place with sutures or by the friction created by long extension strap-like arms of the graft material weaved through the pelvis. If the extension strap-like arm technique is used, you will have 2 tiny incisions on your bottom lateral to the vagina and 2 tiny incisions on your buttocks for the anterior repair. There are 2 tiny incisions on your buttocks for the posterior repair. These tiny incisions are in addition to the incision(s) inside the vagina.

 

This drawing shows the blue mesh of an anterior repair. It should be noted that the mesh I am currently using is called Exair by Coloplast®. Click on the image for a larger view.

Cystocele Repair

This drawing shows the blue mesh of a posterior repair. I am currently using Exair mesh by Coloplast®. Click on the image for a larger view.

Rectocele Repair

What About Mesh?

Marketing by attorneys has brought attention to possible complications of mesh use. Some ads ask if “have you been treated with defective mesh?” In reality, some mesh has been taken off of the market not due to being defective but due to a rule from the FDA (Food and Drug Administration) that requires companies that manufacture mesh to document effectiveness and safety. That sounds reasonable but cost the companies millions of dollars to comply with the rule. Some company boards made a business decision to withdraw production of the products rather than spending large amounts of money to comply with the rule.

Many physicians get a much longer lasting of the repair success using mesh than when the same surgery is done simply with suture without mesh. The downside of using mesh is the small risk of mesh erosion into the vagina. Mesh erosion can cause discharge, bleeding, pain, or infection. My mesh erosion rate is less than 5%. If mesh erosion occurs, the mesh may be left in place, removed in the office, or removed in the operating room. If my wife needed prolapse repair, I would want it done by an experienced surgeon using mesh.

Most patients spend one night in the hospital. Expect recovery to normal activity (except for intercourse) to take 2-4 weeks unless your physician advises differently. The main discomfort associated with this type of surgery is usually rectal pressure. You may be advised to refrain from lifting heavy objects and straining for 6 to 12 weeks to allow for complete healing.

All surgical procedures present some risks. Although rare, complications associated with these procedures may include injury to blood vessels of the pelvis, nerve damage, difficulty urinating, bladder or bowel injury, and erosion of the mesh (mesh is exposed in the vaginal canal or adjacent structures).

It is important to note that using a combination of both surgical and non-surgical treatments will give you the best long-term results in treating pelvic prolapse. If it applies to you, a combination of losing weight, stopping smoking, taking estrogen replacement, performing Kegel’s exercise, and having a surgical repair will work better than having surgery alone.

Sacral Colpopexy

Laparoscopic Prolapse Repair  – The sacral colpopexy is a surgical procedure that involves attaching one end of a synthetic mesh to the top of the vagina and the other end to the sacral promontory (upper part of the tail bone or lower part of the spine). The procedure is one of the better ways to treat vaginal vault prolapse. With vaginal vault prolapse, the structures that are attached to the vagina and hold it in place have torn loose to varying degrees. This problem with pelvic support looks somewhat like grabbing the toe of a sock from the inside and turning the sock partially, or completely, inside out.
Frequently, an enterocele (hernia at the top of the vagina) is present along with the vaginal vault prolapse. A hernia is caused by a defect or hole in a strong, canvas-like tissue called fascia. The mesh used with the sacral colpopexy is an effective way to repair the defect in the tissue of the top of the vagina (enterocele). Several other types of defects in pelvic support may also be present and should be corrected at the same surgery.

Laparotomy vs. Laparoscopy

Very few gynecologists perform sacral colpopexy at laparotomy, and even fewer at laparoscopy. The main concern many physicians have with this particular surgical procedure is the many vital structures immediately surrounding, and in, the small area of the sacral promontory. Within an area 2-3 inches square are located major blood vessels, the ureter, and intestine. With training, experience, and meticulous surgical technique, the risk of complication is small.
In order to safely perform laparoscopic sacral colpopexy, the surgeon must have extensive experience performing difficult cases at laproscopy, must know the laparoscopic anatomy, and must be skilled at laparoscopic suturing. The major advantage of performing the sacral colpopexy at laparoscopy is a significant reduction in post operative recovery time and pain – because it is done through small incisions rather than a large incision required at laparotomy.

 

 

The information provided by Advanced Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes only. As each woman is unique, do not rely on this information for diagnosis and treatment. We cannot guarantee the accuracy of the content and advise that you see a qualified Health Care Professional for individual needs and care.

 

 Advanced Healthcare for Women
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Telephone 912-355-7717
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gyndoc@bellsouth.net