The aims of surgery for pelvic organ prolapse are to:
- Correct the anatomical abnormality caused by the prolapse
- Get rid of the sensation of a vaginal bulge or lump
- Improve bladder function if it was affected by the prolapse
- Improve bowel function if it was affected by the prolapse
- Maintain or improve sexual function if it was affected by the prolapse
What factors determine the choice of surgery in treating Prolapse?
Many factors are taken into account when counselling a woman about surgery for her pelvic organ prolapse. These include her:
- Desire for further children
- Desire to retain the uterus
- Urinary symptoms
- Sexual activity
- Type of prolapse (i.e. which organ/s are involved – bladder, bowel, uterus or vaginal vault)
- Grade of prolapse (i.e. its severity)
- Previous surgery performed:
- For prolapse
- Other abdominal or vaginal surgery
- Personal preference
What types of surgery are available to treat Pelvic Organ Prolapse?
There are many different options available to treat pelvic organ prolapse. The best way to treat one woman’s prolapse is not necessarily the best way to fix another woman’s prolapse.
The many options available for treatment of prolapse mean that there is not a “right” or “wrong” choice for each woman. The decisions are often complex because the prolapse can involve many compartments or sections of the vagina and cause many symptoms.
Some of the surgical approaches to treating vaginal prolapse include (but are not limited to):
- Vaginal surgery (performed through cuts in the vagina which are not visible externally) such as:
- Anterior repair – which corrects a cystocele
- Posterior repair- which corrects a rectocele
- Vaginal suspension surgery which corrects prolapse of the uterus or top of the vagina (“vaginal vault”) after hysterectomy including:
- Sacrospinous suspension
- Uterosacral ligament suspension
- Manchester repair
- Vaginal hysterectomy
- Combinations of the above types of surgery when prolapse exists in more than one area within the vagina
- Abdominal surgery such as:
- Abdominal sacrocolpopexy
- To suspend the top of the vaginal vault
- Operations to suspend the uterus
- Abdominal surgery can be performed as open surgery (with a cut in the abdomen) or as laparoscopic surgery (keyhole surgery with minimal abdominal incisions).
- Vaginal or abdominal surgery can be combined with the use of grafts which are materials used to reinforce the prolapse repair in order to try and reduce the rate of prolapse recurring.
More specific and detailed information regarding the different types of prolapse surgery will be provided by Dr McKertich on an individual basis after a full assessment.
Patient information regarding specific prolapse surgeries is available from IUGA (the International Urogynaecological Association):
What are the possible complications of Prolapse Surgery?
Unfortunately there is no such thing as a perfect operation and understandably one of the main risks in reconstructive surgery such as prolapse surgery is that the prolapse can recur. Surgery unfortunately cannot change the damage that has already been done to the nerves, muscles and supporting tissues in the pelvic floor. The aim of surgery is to correct the anatomical abnormality caused by the prolapse and hence to improve the symptoms related to the prolapse.
With all surgery there are potential risks and complications related to the anaesthetic, infection and bleeding.
Specific risks associated with prolapse surgery include:
- Damage to nearby organs which depends on the site of prolapse operation for example:
- The bladder
- The ureters (the tubes draining the urine from the kidneys to the bladder)
- The bowel including the rectum
- New or persistent urinary symptoms after surgery including:
- Difficulties with incomplete bladder emptying
- Stress urinary incontinence
- Pain related to sexual intercourse and/ or pelvic pain
- Recurrence of prolapse
- Prolapse recurrence is highest for cystocele (or bladder prolapse) and lower for other sites such as rectocele.
- Between 15 to 30% of women will develop recurrent bladder prolapse after surgery.
- In most cases this is a partial recurrence of the prolapse that often requires no treatment, pessary use or surgery that is less extensive than the original surgery.
- Up to 30% of women may require a repeat prolapse repair later in life.
- Specific complications related to the use of graft material (SEE BELOW)
Why is recurrence of Prolapse a potential problem after Prolapse surgery?
Prolapse surgery is reconstructive surgery but unfortunately the factors that make a woman prone to the prolapse in the first place are not corrected by current surgical techniques including:
- Reduced pelvic floor muscle floor function
- Nerve damage in the pelvis
- Weakness of the pelvic floor connective tissues related to pregnancy, childbirth, ageing and genetically determined factors
The ongoing pressures on the pelvic floor from gravity and daily activities places ongoing stress on prolapse repairs. The presence of ongoing predisposing factors to prolapse after surgery (e.g. being overweight, chronic cough, chronic heavy lifting and high impact activity) also increases the likelihood that prolapse may recur. As a result some women can have a persistence or recurrence of their prolapse after surgery.
What are “Grafts” to repair Prolapse?
Grafts are a foreign material used at the time of prolapse surgery to reinforce the repair and a woman’s own natural tissues in an effort to try and reduce the rate of prolapse recurring.
Prolapse recurrence rates are higher when the prolapse:
- Involves the front wall of the vagina (cystocele)
- Is a recurrent prolapse (i.e. the woman has already had a previous repair for the prolapse)
- Is associated with persistence of risk factors for prolapse such as obesity, chronic coughing, constipation and heavy lifting
Grafts can be made of a range of different material such as:
- Biological grafts which are derived from humans or animals
- Most biological grafts are reabsorbed slowly over 6 to 9 months during which time it is hoped that the woman’s own body produces new support tissue.
- Synthetic absorbable grafts
- Made from synthetic material that dissolve slowly over time and are not permanent.
- Synthetic non- absorbable grafts
- Made from synthetic mesh material.
- This is permanent material that is similar to the material used in mesh hernia repairs to reduce recurrent abdominal wall hernias.
- Synthetic mesh contains many holes or gaps in the material to allow a woman’s own tissues to grow into the mesh that then acts as a supportive framework for the repair.
- Some complications of grafts are more common with synthetic non-absorbable mesh – SEE BELOW
Potential complications related to Synthetic Non-Absorbable Mesh Repairs of Prolapse
Unfortunately there is no such thing as a perfect mesh. The perfect mesh would reinforce the repair, not be associated with infection, would reduce the rate of prolapse recurrence and not be associated with any shrinkage that could result in vaginal narrowing, shortening or pain. Such a mesh is unfortunately yet to be designed.
Potential complications related to use of permanent (non-absorbable) synthetic mesh in prolapse repair include:
- Mesh infection
- Mesh exposure (also called “erosion”) in the vagina
- This may cause no symptoms
- Mesh exposure can cause symptoms of
- Vaginal discharge or bleeding
- Pain related to intercourse for either partner
- Studies have shown a 5 to 10% risk of mesh erosion or infection that may require removal of part of the mesh at a later time when mesh is used in vaginal prolapse repair.
- Buttock or groin pain
- Depending on the type and location of mesh usage
- Chronic vaginal pain and painful intercourse
- Related to mesh shrinkage, erosion, inflammation and or infection
- The incidence of this complication is low and it can unfortunately occur after mesh surgery as well as after traditional prolapse surgery.
- Rarely – mesh erosion into surrounding structures (such as bladder or bowel)
- Need for further surgery to correct possible complications
There are many controversies related to the usage of mesh in prolapse repairs that result in different opinions about which women are candidates for mesh repairs and which types of prolapse mesh should be used. There is no consensus currently about when mesh should be used in prolapse repair.