Pelvic Prolapse Repairs

iStock 000009790955SmallThere are many treatments for pelvic floor prolapse. The surgical options performed in our office ASC or as an outpatient surgery at the hospital are as follows:

Repairing Anterior and Posterior Prolapses

If a patient is still sexually active, or still desires to keep the ability to have sexual intercourse, which most patients do, then the goal is to reconstruct the supports to the vagina in such a way that the supports are maximized, while still allowing normal sexual activity to occur after healing is complete. These have been called anterior repairs, if they involve repairing the anterior compartment, posterior repairs if they involve repairing the posterior compartment, or anterior and posterior (A&P) repairs if they involve repairing both. The repairs are most often done vaginally, but occasionally done laparoscopically via the abdomen.

Using the Patient’s Own Supports

Traditionally, surgical prolapse repairs have involved making an incision inside the vagina, along the anterior and or the posterior walls, depending on the problem, finding the torn fascial edges and bringing the natural tissue together again. If no tear is evident, just weak tissue, then the surgical techniques are used that bring the weak and stretched tissue closer together. These kind of repairs have about a 60% long term success rate, which means they have a 40% change of failing and needing to be redone. In the anterior compartment, either a vaginal or paravaginal repair is used to re-establish the supports at each level of the anterior defect along the vagina.

Using Collagen (biologic grafts)

Reinforcing the repair with bovine or porcine collagen may add to the longevity and overall success of the repair, particularly if it is a moderate to severe prolapse, or a recurrence. In addition, because of the technique used, it can easily repair both midline and lateral cystoceles, and can be used as an apical support as well. In the posterior compartment, the effect is smoother and more like the original support of the vagina. Using collagen mesh on the posterior wall results in less of a "bumpy" feel to the back wall of the vagina than using a traditional repair. Possibly this results in less risk of pain with intercourse after the procedure. Both biologic grafts and synthetic meshes have advantages over using the patient's natural tissue in terms of longevity of the repair. In Dr. Ravasia's opinion, the collagen leaves the vagina with a more natural and less leathery consistency than synthetic methods. It is also much less likely to erode and be extruded by the body than a synthetic mesh. Most repairs done with collagen last at least 10 years. Longer data is not available. The instrument used to place collagen sheets can be done with a device called a Capio that reduces the length of the vaginal incision that need to be made, so the technique is minimally invasive and can fairly easily be done in the outpatient setting. This is another advantage to using biologic grafts over simple repairs with the patient's own tissue.

Using Synthetic Mesh

There are a variety of proprietary synthetic meshes (simple synthetic meshes and complex kits) that have flooded the market in the last few years, that can be placed easily and with minimally invasive techniques. Synthetic meshes serve the same purpose as collagen reinforcement, but likely last longer (although they are all fairly new developments, so those long term studies aren't completed). Mesh erosions and exposures (ie mesh that works its way to the surface of the vagina over time), are one of the complications that are considerably more common with synthetic meshes than with collagen biologic grafts. Erosions are believed to be the body attempting to reject the mesh There are surgical techniques that minimize this risk but none that eliminate it. Dyspareunia (pain with intercourse) seems to be more common with synthetic mesh than with biologic grafts, although this may be related to technique as well. In general, the risk of exposure or erosion after using a synthetic mesh is 5-10% and the risk of new onset of pain with intercourse is 15 to 17% with synthetic mesh.

Repairing Apical Prolapse

These can be done by securing the top of the vagina to the anterior or posterior sheet of collagen or mesh, or securing it directly to the sacrospinous ligaments, or to the sacrum itself. Depending on the technique used, it can be done vaginally or laparoscopically. There are also pelvic repair kits designed specifically to support and reinforce apical problems. When collagen or synthetic mesh is used, there is less of a need to proceed automatically to a hysterectomy, unless there are other compelling reasons to remove the uterus. Traditionally the uterus has been removed (vaginal hysterectomy) if it is prolapsing, but with the advent of collagen reinforcement and synthetic mesh support, this may no longer be necessary.

Enteroceles have traditionally been repaired with a technique called "high ligation" that involved entering the sac containing the bowel and tying it off at a high point, then reinforcing the supports below it, usually by bringing the uterosacral ligaments together in the midline (culdoplasty). However, with the advent of biologic grafting and synthetic mesh, these are usually reduced fairly easily without actually entering the sac that contains the bowel.

What are the complications of pelvic floor reconstructions for prolapse?

As with any surgery, there is always a risk of bleeding, infection, injury to surrounding organs, anesthetic risk, risk of clots. These are fairly unusual but can happen, and can prolong recovery and necessitate another surgery sometimes. Unique to the use of synthetic mesh supports is the advent of mesh exposures and erosions. More serious complications have been associated with synthetic mesh kits (such as necrotizing fasciits, and perirectal hematomas) than have been reported with traditional techniques, with or without biologic grafting. It is possible that synthetic mesh will result in better long term outcomes than traditional techniques, but we don't know that yet. In the meantime, they do appear to be associated with more complications. Dyspareunia (pain with intercourse) as a direct result of the surgery, or from pelvic floor spasm secondary to pelvic surgery, occurs in about 5% of people with traditional repairs and is usually temporary and resolves in a few months, although it can be permanent. It appears that this risk is more common (15 to 17%) when synthetic mesh is used.

So which should I choose?

It really depends on many factors, and you should turn to your provider to help guide you through your options. At Women's Health Connection, we have extensive experience with pelvic floor reconstruction, and will help guide you through the maze of options.

How long is the hospital stay?

Most of these repairs can be done as outpatient procedures at this point.

How long is the recovery?

Generally, with a simple anterior repair, the recovery can be as little as a week. However most women need 3 weeks, and sometimes more, off work. The discomfort is deep in the pelvis and even sitting for prolonged times can be challenging during the recovery. Usually by 6 weeks, the repair looks normal, but it can take 2-3 months to feel normal. Most women who make the decision to undergo a pelvic floor reconstruction are happy about the choice, but it is not without some surgical risk, so it should be reserved for those with significant prolapse and symptoms.

What can I do and not do during the recovery?

You should rest, drink plenty of fluid, use pain medications as necessary, keep your stool soft (use a bowel routine), use a peri-bottle if necessary when emptying your bladder. Using a donut cushion for sitting can help in the first few weeks. Ice packs to the perineum, 10 minutes, 4 times daily, can help take down swelling.

You can begin a walking routine, and should, just as soon as you are feeling ready. You should be trying to go for at least 10 minute walks a few times a day during the first several days of recovery. This helps prevent leg clots.

You should avoid sex until the repair has healed, usually for 2-3 months. Expect some discomfort the first few times that you have intercourse, and proceed gently and cautiously if this occurs. Listen to your body.

In Summary…

In summary, the best treatment of pelvic floor therapy is to prevent it in the first place, and if it does occur, to begin treatment conservatively. When surgery is necessary, it is Dr. Ravasia's practice to use traditional repair methods, reinforced with biologic grafts if the prolapse is severe or recurrent, rather than surgical synthetic mesh kits, although the mesh kits may have a role to play in certain patients.