Procedure Prolapse Repair
WHAT ARE THE SURGICAL TREATMENTS FOR PELVIC ORGAN PROLAPSE?
The choice of the procedure for pelvic organ prolapse depends on the degree/grade and location of prolapse.
- Cystocele or anterior repair refers to the repair of the bladder prolapse. This repair can be performed through a vaginal approach and involves the reconstruction of the vaginal wall and tissue between the bladder and the vagina. This can be done with or without the use of synthetic mesh.
- Rectocele or posterior repair refers to the repair of rectum prolapse. This repair can be performed through a vaginal approach and involves the reconstruction of the vaginal wall and tissue between the rectum and the vagina. This can be done with or without the use of synthetic mesh.
- Apical repair refers to the repair of uterine prolapse, or prolapse of the top (apex) of the vagina. The most commonly performed techniques for apical prolapse require hysterectomy, because the apex is elevated and the vaginal cuff is fixed to a supporting ligament.
The two most common techniques are sacrospinous ligament suspension (SSLS) and sacrocolpopexy (abdominal or laparoscopic).
- Sacrospinous ligament suspension (SSLS) is performed through a vaginal approach.
During this procedure, the uterus is removed and the vaginal apex is fixed to the sacrospinous ligament with a non-absorbable suture. Two years after this procedure is conducted, recurrence rate of prolapse is approximately 15 percent. This approach has a short recovery time (five to seven days) and can be performed at the time of rectocele and cystocele repair.
- Sacral colpopexy is the fixation of the vaginal apex or the cervix to the anterior longitudinal ligament of the sacrum, using a synthetic mesh graft. Sacral colpopexy procedures require the use of synthetic mesh and are considered more effective in the treatment of apical prolapse than SSLS. Two years after this procedure is conducted, the recurrence rate of prolapse is approximately five percent. The reported rate of mesh-related complications is approximately three percent. As SSLS, sacral colpopexy requires the removal of the uterus. Cystocele and rectocele repair can be performed at the same time. There are three approaches to sacral colpopexy: open abdominal, robotic, and laparoscopic. The laparoscopic approach is superior to the abdominal and robotic approach because of the shorter recovery time and less post-operative pain.
- Abdominal Sacral Colpopexy: This approach requires a large abdominal incision and is not preferred due to longer recovery and pain, as compared to robotic and laparoscopic approaches. Very few surgeons are performing sacral colpopexy via this approach because of the great disadvantages to the patient.
- Robotic Sacral Colpopexy: This approach requires five incisions placed in an arc in the middle of the abdomen. The surgeon remotely controls the robotic arms that use the instruments to grasp and cut tissue. This approach is better than abdominal in that it uses small incisions, allowing for less pain and a quicker recovery. The operative time, however, can be very long, especially when performed by a less experienced surgeon. This means that the patient is under general anesthesia for four hours and sometimes even longer. There is no advantage to the patient to have robotic over laparoscopic sacral colpopexy.
- Laparoscopic Sacral Colpopexy: This preferred approach uses smaller and fewer incisions compared to abdominal and robotic approaches. The incisions are cosmetically placed and are barely noticeable when healed. The recovery time, operative time, and overall patient satisfaction is also better, when compared to abdominal and robotic approaches. The patient is able to leave the hospital the same day and the recovery is generally seven to 10 days.
Questions to Consider
WHY IS SYNTHETIC MESH SOMETIMES USED DURING BLADDER AND RECTUM PROLAPSE REPAIR?
Cystocele and rectocele repairs are performed through a vaginal approach. During the repair, a large segment of mesh is placed between the bladder and vagina for cystocele repair and between the rectum and the vagina for rectocele repair.
Transvaginal mesh placement has primarily been associated with improved short-term outcomes for the repair of bladder prolapse, as compared with procedures without the use of mesh.
Synthetic mesh was thought to provide better support and have lower recurrence rates of prolapse, as compared to procedures performed without the use of mesh.
WHAT ARE THE RISKS ASSOCIATED WITH USING SYNTHETIC MESH DURING CYSTOCELE AND RECTOCELE REPAIR?
Concerns have been raised regarding the safety of transvaginal placement of reconstructive synthetic materials. The most common complication of transvaginal mesh placement is mesh erosion, which is usually treated successfully with mesh excision. The rate of mesh erosion has been shown to be as high as 30 percent. Most patients with mesh erosion do not have symptoms.
The most important issue of concern regarding transvaginal mesh is the development of severe pelvic pain and pain with intercourse in a subset of patients. In contrast to mesh erosion, multiple surgical procedures are often required and pain may persist even with the removal of mesh.
Due to the potential negative long-term effects, our surgeons do not use synthetic mesh during cystocele and rectocele repair.
WHAT IS THE FDA WARNING REGARDING THE USE OF TRANSVAGINAL MESH?
The FDA has issued several documents regarding the use of reconstructive materials for female pelvic floor surgery. The conclusions to date have been that transvaginal placement of these materials are of uncertain efficacy and are associated with safety risks. In contrast, use of synthetic mesh for sacral colpopexy (for apical prolapse repair) or for full-length retropubic or transobturator midurethral slings (for incontinence treatment) was considered safe and effective.
I HAVE URINARY INCONTINENCE. CAN THIS BE FIXED DURING PROLAPSE REPAIR?
Anti-incontinence surgery is often performed during the prolapse repair. Women with symptoms of both prolapse and stress incontinence are treated with a combined prolapse repair and continence procedure (urethral sling).
IS URETHRAL SLING NECESSARY DURING PROLAPSE REPAIR IF I DO NOT HAVE SYMPTOMS OF INCONTINENCE?
For women with advanced prolapse, there is a high likelihood that they will develop stress incontinence (SUI) post-operatively. These women will benefit from a concomitant continence procedure (urethral sling) at the time of prolapse repair. Pre-operative urodynamic testing can be performed to determine whether a urethral sling will be necessary. However, even with normal testing (no incontinence), approximately 40 percent of patients will have symptoms of urinary incontinence after prolapse repair surgery. Patients, who choose not to undergo a sling procedure, may have it performed at a later time if incontinence symptoms develop after the prolapse repair surgery.
In the case of pelvic organ prolapse, you have a wide range of treatment options and you want to be sure you are making the best possible decision for your case. It takes well educated and empathetic surgeons to help you through the process.
All of our surgeons are:
- Fellowship-trained in Minimally Invasive Surgery or Gynecologic Oncology;
- 100 percent focused on GYN surgery;
- Do not perform Obstetrics – no distractions from the main focus;
We have a high volume of patients, making for a high level of experience; and we do not perform open or robotic procedures.
Our surgeons are true specialists, not generalists.
Know your options. There is nothing more important than being well-informed about your options and what they entail. CIGC® surgeons do their best to assess your individual case and recommend the best possible treatment options. Since there are many different types of possible treatments, we want to offer our patients peace of mind in the form of an understanding of your condition, your options, and your recovery.
Our methods are safe and effective. It is normal to be apprehensive about certain treatments for pelvic organ prolapse, including the use of transvaginal mesh, because the FDA has decided that reconstructive materials are of uncertain efficacy and are associated with safety risks. We would be happy to answer any further questions and discuss any potential risks with you, so that you feel as comfortable as possible before and after your surgery.
Hear it from our customers. Our patients share their experience with CIGC.
Be your own best advocate. When deciding which surgeon treats your pelvic organ prolapse, choose the minimally invasive GYN experts.
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