Pelvic Reconstructive Surgery (For Prolapse)

Cause / Condition
Prolapse is an all-inclusive term that refers to a protrusion through the vagina that creates an uncomfortable feeling, pressure, or even pain. When there is excessive rubbing of this protruded tissue against underwear, etc., bleeding and ulceration may occur. The specific anatomical defect that gives rise to this protrusion determines the name for the protrusion.

If the support of the bladder is weak and allows its protrusion through the vaginal opening it is called a cystocele. If rectal-fascial support is weakened and the rectal wall is protruding through the vagina it is called a rectocele. Prolapse of the upper wall of the vagina is usually filled with intestine and is called an enterocele. When the uterus protrudes through the vagina its lower end (called the cervix) is what is seen. This is called uterine prolapse. In women who have undergone subtotal hysterectomy the remaining cervix may prolapse, while in women who have undergone total hysterectomy the top of the vagina, called vaginal vault, may invert and prolapse through the vagina. This is called a vaginal vault prolapse.

In addition to protrusion and pressure symptoms, a rectocele may cause difficulty with bowel movement while a cystocele may result in difficulty in initiating urination and a feeling of incomplete afterwards.

Prolapse is directly due to breakage of supporting ligaments (technically called a defect) or breaking or tearing of fascia, which is a layer of unstretchable connective tissue that surrounds all of the vagina and interposes itself between rectum, bowel, and bladder from the vaginal mucosa or epithelium. The predominant cause of this break in the ligaments and fascia is vaginal delivery at childbirth, while other causes like undue sudden exertion, a large uterine tumor pressing down, or excessive coughing might rarely play a role.

Prolapse seems to manifest itself mainly around the menopause, when the withdrawal of estrogen seems to weaken the secondary muscle support that is compensating for the breakages. However, in some cases women can immediately notice the result of childbirth as soon as within two months after delivery. While this acute prolapse after childbearing usually improves with pelvic floor exercises and weight reduction, in some cases surgical repair may be needed.

About the Procedure
An accurate diagnosis of all the defects present is important for appropriate and successful repair. The aim of any surgery is to obtain a cure that will be longstanding. Currently any treatment that achieves a result where 80% of women are still symptom-free after five years would be considered a good result.

There are three basic surgical approaches:

  1. Vaginal Approach: This is the traditional first-line approach for prolapse and may still be the preferred route for elderly and debilitated women. It is difficult to suspend the vagina to a higher level with maintenance of vaginal length by this approach and the recurrence of vault prolapse in the literature is between thirty to fifty percent in five years.
  2. Abdominal Approach by Incision (laparotomy): This approach is often used after repeated failures of vaginal surgery for vault prolapse and a synthetic mesh is usually used to attach the vagina to the front of the sacral bone (sacrocolpopexy). This approach is also used primarily for cystocele cause by lateral defects and the operation is called a paravaginal repair. These techniques tend to lengthen and support the vagina in a more anatomical position and in the literature have higher success rates at five years than the vaginal approach.
  3. The Laparoscopic Approach: This approach reproduces the same surgery as by laparotomy but through tiny incisions with resultant less pain, morbidity, and hospital stay.

For a lateral defect cystocele, the paravaginal repair is performed together with a BURCH suspension of the bladderneck. For a vaginal prolapse with the uterus present, the uterosacral ligaments are shortened by suturing to elevate the vagina and uterus. Enterocele repair is performed by reapproximating the tear in the posterior fascia to this ligamental ring. If the ligaments are of poor quality a synthetic mesh can be used to repair the enterocele as well as to support the vagina to the sacral ligament or to the ligament in front of the sacral body. A relatively new procedure called colposacrorectopexy allows the mesh to be extended downwards to repair a rectocele and vaginal vault prolapse at the same time.

All of these laparoscopic procedures require considerable skill in laparoscopic suturing so that the exact procedure as performed at laparotomy can be replicated. It is acknowledged by all laparoscopists that suturing is the most difficult skill to master and would explain why laparoscopic prolapse surgery is not widely available.

Occasionally a perineoplasty which is performed vaginally may be necessary in order to repair the external musculature of the vagina which has been damaged by childbirth resulting in a “gaping” vaginal opening.

Hysterectomy is not necessary in the treatment of prolapse if the uterus is small. On the other hand, a large bulky uterus will continue to exert pressure on the prolapse repair and will cause a higher failure rate. Under such circumstances a hysterectomy is advised and this would be performed at the same time as the prolapse surgery by laparoscopy. If desired, a subtotal hysterectomy may be performed instead.

Recovery
We perform all prolapse repairs exclusively by laparoscopy, and depending on the extent of the operation, women are discharged within 6 to 48 hours. The majority go home within 23 hours. Most normal activities can be resumed between five to seven days after surgery with the exception that heavy lifting over ten pounds is not permitted for two months. However, return to work is possible between one to three weeks after the procedure, depending on the extent of the procedure and the fitness of the person.

Expectations / Experience
The literature demonstrates better long-term cure of prolapse when the approach is abdominal rather than vaginal. We perform the abdominal operation through the laparoscope, thus achieving the longer lasting repair while avoiding a six-inch or more incision that would normally cause a longer hospital stay and more pain during recuperation. In fact, we now believe that because of the excellent visualization at laparoscopy, a better corrective repair can now be attained at laparoscopy compared to even laparotomy. These surgeries, whether done by laparotomy or laparoscopy, or vaginally, are long surgeries and may take up to five hours.

In the “old days” a quick solution was to do a vaginal hysterectomy and anterior and posterior repair, which is basically tucking the vaginal skin in front and behind. It is well known that this is followed by high rates of vault prolapse and recurrence of cystocele and rectocele.

The modern approach is to identify all the defects preoperatively and at operation, and to treat all the defects. This requires more extensive surgery and thus lengthens the time of surgery, no matter what approach is used.

For the younger woman with cystocele, stress incontinence, vault or uterine prolapse, and rectocele, the appropriate laparoscopic approach will maintain a longer vagina with curative support that will be maintained in over 80% of women five years after surgery.

If a paravaginal repair with BURCH colposuspension has been performed for cystocele and stress incontinence, a bladder catheter will be left in place overnight and removed the following day. Less than 5% of women require a catheter for longer than that. However, when this is necessary, the woman is discharged with a “leg bag” attached to the catheter and she is taught how to drain it periodically. Four days later in the office the catheter will be removed. This occurs in about 5% of cases.

Complications
Complications can occur with any surgery whether vaginal, abdominal, or laparoscopic.

Factor Traditional Laparoscopic
Hospital Stay 1-2 weeks 1-2 days
Pain during recovery Moderate Minimal
Return to work timeframe 4 weeks 1-2 weeks
Cosmetic results 4-5" scar 3 tiny incisions

For more information on laparoscopic pelvic reconstructive surgery contact:

The Milwaukee Institute of Minimally Invasive Surgery
Columbia St. Mary's Hospital Milwaukee
2301 N. Lake Dr.
Milwaukee, WI 53211

(800) 377-2673

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