Prolapse Surgery
Surgery to correct prolapse varies considerably depending on the type of prolapse and patient individual characteristics. As described in previous pages, prolapse can present in different ways depending on which areas are affected and there isn’t a “one size fits all” operation. In addition, the pelvic floor can be approached either from the vagina or the abdomen with different surgical techniques.
Here is a description of the most common procedures which can be combined depending on which anatomical areas need to be treated.
SURGICAL MANAGEMENT OF ANTERIOR VAGINAL WALL AND BLADDER PROLAPSE
In women who present with what is called an anterior central vaginal defect, where the bladder protrudes down in the middle of the vagina the most common operation is an Anterior Vaginal Repair.
The purpose of the anterior vaginal repair, or anterior colporrhaphy, is to reinforce the vaginal fascia (layer of supporting tissue) that overlies the bladder to reduce the bladder and anterior vaginal wall bulge.
The vaginal skin is incised in the midline and dissected away from the bladder and underlying fascia. Several layers of interrupted delayed absorbable sutures are placed laterally on the pubocervical fascia reducing the defect and building support. Excess vaginal skin can be trimmed and the vagina is then sutured with absorbable sutures.
Paravaginal or lateral defects can be repaired from the vagina or from the abdomen. In the latter case, the preference is for a laparoscopy (keyhole surgery).
In this procedure, rather than creating support in the midline below the bladder, the aim is to suture the lateral portions of the vagina to its usual place of attachment over the pelvic floor muscles (obturator internus and pubococcygeus muscles and fascia at the level of the arcus tendineus fascia pelvis).
SURGICAL MANAGEMENT OF POSTERIOR VAGINAL WALL AND RECTAL PROLAPSE
A posterior vaginal wall prolapse, usually a rectocoele (protrusion of the rectum at the back of the vagina) is surgically treated with a Posterior vaginal repair or Posterior colporrhaphy.
The surgery is done through a transvaginal approach.
The vaginal skin is incised in the midline and dissected away from the rectum. Several layers of interrupted delayed absorbable sutures are placed over the rectovaginal fascia reducing the protrusion and supporting the rectum in its original position.
The procedure also includes a posterior Colpoperineorrhaphy where the perineal muscles (levator ani muscles) are approximated with sutures to reinforce the perineum and help support the rectum.
Excess vaginal skin can be trimmed and the vagina is then sutured with absorbable sutures to conclude the operation.
SURGICAL MANAGEMENT OF APICAL VAGINAL PROLAPSE AND UTERINE PROLAPSE
Apical compartment or vaginal vault prolapse can happen in women who still have the uterus as well as in women who already had a hysterectomy.
In women who still have the uterus, a Hysterectomy may be part of the surgery to treat the prolapse. A hysterectomy is not always necessary and women who want to preserve the uterus are able to do so in most cases. It is important to have a proper evaluation and a discussion with the treating surgeon.
If a hysterectomy is required, it can be performed in conjunction with the prolapse surgery by any of the routes described below.
The Apical compartment of the vagina can be approached surgically form the vagina or from the abdomen.
VAGINAL APPROACH
There are a few different techniques for the surgical treatment of uterine and apical vaginal prolapse. They all aim to use the ligaments which usually provide support to the pelvic floor to restore the anatomy and position of the prolapsed pelvic organs.
The two most common vaginal procedures are:
- Fixation to the sacrospinous ligaments.
There are 2 sacrospinous ligaments on each side of the pelvis. They are thin, but very strong ligaments found deep in the pelvis between the ischial spine (a bone prominence of the pelvic bone) and the lateral side of the sacrum behind the coccygeus muscle.
The ligament is approached through a vaginal incision as the one made for a posterior vaginal repair. The surgeon dissects the space around the rectum to reach the ligament. A suture is then passed through the ligament and through the top of the vagina. Once the knot is tied, the vagina is moved upwards to try and restore its original position. The procedure can be done through one (unilateral) or both (bilateral) ligaments.
- Uterosacral ligament suspension
There are a few variants of surgical procedures that use the uterosacral ligaments (2 fibrous structures that connect the back of the uterus near the cervix to the middle of the sacral bone). The most common ones are McCall culdoplasty and high Uterosacral ligament suspension. The approach is from the posterior aspect of the vagina behind the cervix. Once the vagina is incised, sutures are placed to incorporate the ligaments themselves, the posterior vaginal vault and the endopelvic fascia. Tying the sutures reduces the length of the ligaments, closes the gap behind the uterus and brings the apex of the vagina upwards into the pelvis.
ABDOMINAL APPROACH
The pelvis can be reached from the abdomen using a laparotomy (open surgery), laparoscopy or robotic surgery. Nowadays, the preference is for minimally invasive techniques, i.e., laparoscopy or robotic surgery.
Again, there are many options which can vary depending on the type and degree of prolapse, and also surgeon’s preference and type of surgical equipment.
Women with previous hysterectomy
Laparoscopic (Robotic) Sacrocolpopexy
This is the most common operation performed with access from the abdomen for women who do not have the uterus and present with apical prolapse or prolapse of the top part of the vagina.
After entering the abdomen through small laparoscopic incisions and inserting a camera to be able to see inside the abdomen and pelvis, the surgeon dissects the vagina from the bladder anteriorly and the rectum posteriorly.
A graft fashioned in a Y shape is then sutured to the anterior and posterior aspects of the vagina.
The surgeon then opens the membrane that covers the sacral bone and exposed the promontory which is the uppermost part of the sacrum below the lumbar spine. The graft is the sutured to ligaments over the bone providing support and aiming to bring the top of the vagina to its natural elevated position.
Women who still have the uterus
A few options are available and the main decisions to be made are whether to remove or preserve the uterus and whether to use a synthetic graft or not.
If a hysterectomy is indicated, some of the possible operations are:
Laparoscopic (robotic) hysterectomy + uterosacral ligament suspension
This procedure does not use synthetic grafts (mesh). Once the uterus is removed with a standard laparoscopic hysterectomy, the top of the vagina is sutured to the uterosacral ligaments to provide support and keep it in position.
Laparoscopic (robotic) hysterectomy + Sacrocolpopexy
This operation is similar to the sacro-colpopexy. The hysterectomy can be total, where the cervix is removed and the mesh is sutured to the top of the vagina and to the ligaments over the sacral promontory, or subtotal where the body of the uterus is removed and the cervix is preserved and used to place the vaginal portion of the mesh.
If the uterus is preserved, the main option is a Sacro-hysteropexy.
The mesh is passed and sutured around the lower portion of the uterus and then sutured to the sacral promontory in the same manner as with the sacro-colpopexy.
Obliterative procedures
These procedures reduce the prolapse by producing surgical occlusion of the vagina. It can be done fairly quickly and sometimes under local anaesthesia. Candidates for the surgery are women who no longer engage in sexual activity and who do not tolerate a prolonged general anaesthetic.
Partial colpocleisis (LeFort procedure)
The LeFort colpocleisis is indicated for women who still have the uterus. A segment of the anterior and posterior vaginal skin is removed. The remaining vagina is then sutured with lateral inverting sutures which progressively invert the vagina reducing the prolapse. This also creates lateral channels to drain any uterine or cervical discharge.
A perineorrhaphy is also usually performed to approximate the muscles of the perineum in order to support the inverted vagina and help prevent pelvic organ prolapse recurrence.
Total colpocleisis
Total colpocleisis procedures are performed for patients with post hysterectomy vaginal vault prolapse. The vaginal skin is incised, prolapsed organs are reduced and the vaginal skin is then sutured. The aim is to reduce the prolapse and suture the vagina close to prevent recurrences.
Preoperative Care
In most patients, surgery for pelvic organ prolapse repair is an elective procedure. This means that there is no urgency to have the operation and steps can be taken to try to optimise the outcome.
The main components are:
· Thorough discussion about:
-the specific condition and type of prolapse
-main symptoms troubling the woman and the effect that the operation may have, i.e., pelvic pain, sexual problems, bowel and bladder function.
-options for treatment including non-surgical measures
-expectations about outcomes
-risks of the surgery
-possibility of incomplete reduction of the prolapse and/or recurrence in the future
· Optimisation of other medical conditions such as Hypertension, Diabetes and heart disease. These may require laboratory tests and review of medications.
· Investigation of other gynaecological issues such as screening for cervical and endometrial cancer. These may require a cervical screening test and possibly an ultrasound and endometrial curettage.
Postoperative Care
It is important to recover well from prolapse surgery and wait for the healing of operated tissues before resuming physical exercise, heavy lifting and other strenuous activities. On the other hand, becoming mobile and resuming day to day activity soon is encouraged.
This document provides a week by week guide to post-operative care and recovery: Prolapse surgery post-operative instructions