Surgical Repair of Pelvic Prolapse 

Symptomatic pelvic relaxation can be surgically corrected, with excellent results.  The  goal of pelvic reconstructive surgery is to restore normal anatomy and function.  In addition to improving cosmetic appearance, pelvic reconstruction strives to cure incontinence and voiding dysfunction, and improve bowel and sexual function. The surgical repair of pelvic relaxation is referred to as pelvic reconstruction. This may involve one or more of the vaginal compartments. Anterior compartment pelvic reconstruction is for repairing a prolapsed bladder; posterior compartment pelvic reconstruction is for repairing a prolapsed rectum; apical compartment pelvic reconstruction is for repairing prolapsed small intestine. The pelvic reconstruction may or may not be augmented with a piece of netting know as mesh. Mesh repairs are used more commonly when one’s native tissues are defective.

Surgical repair of prolapse can often be performed on an outpatient basis. The procedure is performed under either general or regional anesthesia. The anesthesiologist will discuss these options with you to help you determine what type of anesthesia is best for you. The entire procedure is performed with your legs in padded stirrups and is done through the vagina. After completion of the surgery, the vagina will be packed with antibiotic gauze for several hours.

Your normal diet and medications can be resumed immediately. You can resume most of your normal activities as soon as possible. In fact, walking and stair climbing are desirable as rapid return to activities facilitates recovery. You may bathe or shower. Any non-strenuous activity is permissible as long as pain is not experienced. Avoid heavy lifting, strenuous exercise, straining at bowel movements, and sexual intercourse. The operative site may hurt more with excess activities. This should be a signal for you to ease up a bit. Vaginal, pubic, and pelvic soreness are normal for several weeks. Vaginal discharge (often bloody), is also typical for several weeks following surgery and it is therefore recommended that you wear a pad.

Prior to being discharged, you will be given typed instructions and a prescription for antibiotics and a pain medication. It is important to complete the prescription for antibiotics to help avoid a urinary tract or pelvic infection.

 

 

 

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Surgical Repair of Stress Urinary Incontinence (SUI)

 

Sub-urethral Sling.  Stress urinary incontinence (SUI) is an involuntary  spurt-like loss of urine due to a sudden increase in abdominal pressure.It is often provoked by sneezing, coughing, laughing, exercising, changing position, ect. Underlying contributing factors include childbirth (in particular, traumatic vaginal deliberies of large babies), menopause, hysterectomy, aging and any condition causing a chronic increase in abdominal pressure such as cough, asthma, and constiation. SUI is usually due to a combination of intrinsic and extrinsic causes. The intrinsic factor, intrinsic sphincteric deficiency, is a weakness of the urethral sphincter muscles.  The extrinsic factor, urethral hypermobility, is an acquired laxity in the tissue support of the urethra that allows urethral descent with increases in abdominal pressure.

The goal of surgical management of SUI is to provide support to the urethra in order to correct the intrinsic and extrinsic deficiencies. There are many variations on surgical techniques to provide sub-urethral support to sure SUI.  The surgical treatment of SUI has evolved significantly over the past several decades. The current procedure represents an evolution of surgical technique that has merit because of its effectiveness, durability, relative simplicity, and need for only tiny incisions.

A commonly used surgical procedure for repair of SUI is called a “trans-vaginal  suburethral sling”.   Its purpose is to cure SUI. It is also performed in conjunction with cystocele (bladder prolapse) repair to prevent the occurrence of SUI that may be unmasked as a result of the  cystocele repair.  The sling procedure works by providing support and a “backboard” to the urethra such that with “stress” maneuvers such as coughing and sneezing, the urethra can be compressed against  the sling to provide continence. 

Only a small vaginal incision and a tiny pubic or groin incision is needed. The stitches used to repair the vagina and pubic or groin region will dissolve on their own and do not require removal. 

Sub-urethral refers to the placement of the sling beneath the urethra, the tubular channel that leads from the bladder to the urinary opening. The sling is placed underneath the urethra to recreates the “backboard effect.”

Sling refers to the “hammock” that provides urethral support and that allows compression of the urethra with stress maneuvers.

Benefits and Potential Risks of the Sling Procedure

Benefits:

  • 90% cure of stress urinary incontinence.
  • 65% of patients with pre-existing urgency incontinence that accompanies the stress urinary incontinence will have resolution of the urgency incontinence.

Potential Adverse Effects:

  • Failure of the procedure to cure the SUI in 10%.
  • New onset of urgency incontinence in 5-10%. Urgency incontinence is a sudden urge to urinate with the inability to make it to the bathroom on time. If this occurs, it can be treated wtih a bladder relaxant medication.
  • Prolonged time before resumption of spontaneous voiding in 2.5%.
  • Inability to urinate in less than 1% requiring self-catherization or takedown/revision of the sling.
  • Injury to the urethra, bladder, bowel, or vascular structures: extremely rare.
  • Protrusion of sling material: extremely rare.

 

 

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Surgical Repair of Cystocele   (classic Repair)

 

 

 

 

 

 

 

 

 

 

 

Mesh-Augmented Cystocele Repair

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Surgical Repair of Rectocele

 

 

 

 

 

 

 

 

 

Perineal Repair

 

 

 

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Surgical Repair of Enterocele and Vault Prolapse

 

 

 

 

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Surgical Repair of Uterine Prolapse

 

 

If the uterine prolapse is low to moderate grade, consideration for uterine suspension can be made, a procedure in which the uterus is secured to the pelvis in order to prevent its descent. Essentially, a piece of surgical mesh is sutured to the uterine cervix, and the other end of the mesh is attached to one of the hardy pelvic ligaments. This results in the re-establishment of uterine support and a return of the uterus to its normal anatomical position. However, if the uterine prolapse is high grade, hysterectomy is the option of choice. Hysterectomy is the surgical removal of the uterus, a procedure that can often be performed vaginally by your gynecologist. If high grade uterine prolapse coexists with bladder and urethral prolapse, the gynecologist and urologist will collaborate to repair all aspects of the prolapse.

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