Surgical Options
Vaginal Repair Surgery
The vagina is a musculo-elastic tube made up of three layers - skin, muscularis and fascia. The vaginal tube is suspended from the pelvic ligaments above (Level 1 support) and adherent to the ligaments and fascia on each side (Level 2 support).
The "vaginal tube" can be damaged in two ways. Firstly a disruption defect or tear is a damaged area in the fascia or wall of the tube. Disruption can be repaired by suturing the tissues together or by making a patch with a piece of mesh.
The second type of damage is a "Detachment" where the tube has been torn away from where it was hanging down from the ligaments attached to the bony pelvis. Detachment can only be repaired by reattachment.
A number of techniques are used in Pelvic Reconstructive Surgery to restore normality to the pelvic anatomy. These techniques follow basic principles:
1.
A prolapsed vagina is like an intussusception. If the upper vagina is not
attached it can fall into the lower vagina which might still be attached. The apex and side walls need to be
"reattached" or secured to prevent further prolapse.
2.
A severely damaged ligament may not be repairable. Artificial ligaments
are created by precisely positioned tapes or slings which trick the body's wound repair
mechanism into creating collagenous neo-ligaments.
3. The problem of weak vaginal tissues is addressed by avoiding vaginal excision. Excess width is refashioned as length. Double layer "bridge" repairs, polypropylene mesh or biological prostheses can be used to reinforce weakened structures and correct the disruption of the tissues.
4.
Postoperative pain is minimised by avoiding surgery at the introital skin
and avoiding excessive tightness during resuturing of ligaments and vaginal
epithelium. There should be no tension at all in the surgery.
Like bowel, vagina has a visceral nerve supply. Pain is elicited by
compression not cutting or pricking.
5. Postoperative retention of urine can be caused by excessive tightness of the vagina preventing funnelling of the urethra. This can also be avoided by ensuring there is no tension in the repair.
Anterior and Posterior Repair (Colporrhaphy)
The traditional repair operation fails to address the underlying anatomical defect. Colporrhaphy involves tightening the vagina sideways by cutting away some skin and sewing the skin and muscle defect back together in an effort to provide support. Often it is done in conjunction with a hysterectomy. Pulling things together sideways does little to lift them up and the results of traditional repair procedures, especially in the anterior compartment, are poor. In the posterior vagina a repair usually involves pulling the muscles together in the lower vagina to tighten the opening and this also causes pain. After two or three failed repairs the chances of a good functional result are reduced even when using a mesh to rebuild the fascia.
Fortunately skin flap and other Plastic Surgery grafting procedures do offer salvation to women who have suffered terrible loss of vaginal epithelium but the surgery is time consuming and difficult with a significant risk of failure.
Bridge Repairs
This
is an alternative to the traditional repair. Bridge
repairs enable the vagina to be tightened without shortening or excising tissue.
Skin is recycled rather than removed and used like a piece of mesh to repair a
disruption defect. Sexual function may be improved and a seam of tissue provides extra support in
the midline where the pelvic fascia is often at its weakest. A bridge repair
should only be considered where the is adequate excess skin to use in the
fascial repair and the defect is not very large. These operations are especially
helpful in women who do not have a severe prolapse but are suffering from
vaginal looseness or laxity. These repairs can be
performed anteriorly and posteriorly and are indicated on the pelvic anatomy
diagram below:
Vaginal Paravaginal Repairs (Lateral Fornix Repairs)
The vaginal hammock is reattached to the lateral "white line" of the pelvic muscle to correct a specific defect and restore support.
Paravaginal repairs may be able to be further strengthened and by reinforcement with biological mesh to promote tissue remodelling and rehabilitation of the native tissues. This type of operation is technically difficult and there is a significant risk of bleeding and needing a blood transfusion.
Manchester Repairs and Posterior Fornix Repair
Weakness in the cardinal ligaments and uterosacral ligaments can lead to the posterior Fornix Syndrome which is characterised by incomplete bladder emptying, frequency, nocturia (getting up at night) and pelvic pain. When the ligaments at the back of the bladder are weakened or destroyed the bladder will fall forwards and may become unstable. Nerve fibres are activated and sensory or motor urgency can result. Traditional and laparoscopic surgical procedures that tighten the front ligaments will only exacerbate the support problem posteriorly and leave the patient unable to pass urine or subject to recurrent cystitis.
In this procedure a wedge of cervix can be removed and this tightens the cardinal and uterosacral ligaments which are also plicated together to recreate the support at the back of the vagina..
If the tissues are absent or damaged so as to make this type of surgery impossible then a posterior vaginal sling can be used to do the same job, that is, reconnect the back support of the bladder and vagina to the tailbone.
Laparoscopic Pelvic Floor Repair
Laparoscopic surgery is an amazing science that has revolutionised many areas in gynaecology. Unfortunately it is not necessarily the best option for Pelvic Reconstruction for two reasons. Firstly, laparoscopy enables a surgeon to do traditional surgery through a very small incision. Both traditional and laparoscopic surgery for prolapse repair involves muscle plication and in particular sewing the levator muscles together in the posterior vaginal wall.
Secondly, laparoscopy can also be used to place mesh in the pelvis. This is an excellent way of reattaching the upper vagina but unfortunately it is not possible to place mesh under the bladder or adjacent to the lower rectum and anus using the laparoscope from above. Rather, it is better to place the mesh vaginally so as to provide complete support of the pelvis from one side to the other. Vaginal placement of mesh also makes it unnecessary to enter the abdominal cavity and reduces the risk of any associated visceral or vascular damage. As a result in recent years many laparoscopic surgeons have decided to retrain as vaginal surgeons.
Sacral Suspension
This procedure involves reattachment with mesh of the upper vagina to the sacrum. It can be done via an abdominal incision or with the laparoscope. There are added risks of entering the abdomen and damage to the abdominal organs. This method does not address lower vaginal prolapse (rectocoele, cystocoele or urethrocoele) and these problems may need to be fixed vaginally at the same time.
In view of the fact that strong reliable methods of apical reattachment can be performed using minimally invasive vaginal surgery techniques few patients need this extra risk or morbidity.
Colpocleisis
This procedure involves sewing the vagina closed to provide support for a completely collapse vagina. It is often recommended for elderly or frail patients where more extensive surgery might be risky. Colpocleisis is rarely indicated in modern practice. The same result can be achieved with double bridge repairs without closing the vagina and making it impossible to check the upper vagina and monitor for cancer or other problems. Patients with normal mobile complain of pelvic discomfort and bladder/bowel dysfunction after this procedure and little can be done for any problems other than to undo the procedure and assess the situation.
Using Mesh and Biological Materials
New techniques have been developed over the last 10 years where damaged tissues are replaced rather than repaired. Better materials have been developed which reduce complications and enable the anatomy to be restored without the shortening or narrowing of the vagina that follows excessive scar formation.
Dr Farnsworth began using polypropylene mesh to recreate ligaments and fascial layers in Pelvic Reconstructive Surgery in 1997. Initially patients were offered this option when traditional surgery techniques had failed. In reality, patients with previous surgery who have lost significant amounts of vaginal tissue are probably the worst group to implant mesh. Outcomes were carefully documented and have been presented to International Conferences since 2002. In 2006 and 2007 Dr Farnsworth presented his technique at Training Workshops as part of the International Continence Society Annual Scientific Meeting in Christchurch, New Zealand and the International Urogynaecology Meeting in Cancun, Mexico.
Dr Farnsworth has developed a technique in which the Midvaginal hammock is replaced with a sheet of low density wide weave polypropylene mesh.
The mesh is attached in the anterior (A), lateral (L) and posterior (P) directions.
Around the world surgeons are abandoning traditional and laparoscopic techniques as the concept of "replace with new" rather than try and repair gains acceptance. This has been made possible by the development of a host of new mesh products and implantable prostheses over the last few years.
Click here to explore your options for Repair of Prolapse using Mesh
Major
Prolapse - Total Pelvic Reconstruction
In some patients there has been such complete damage to the pelvic support mechanism that there is complete eversion of the genital tract with the vagina, and possibly the uterus now located outside the body. This can cause terrible discomfort for patients as well as significant bladder and bowel dysfunction. Using a combination of minimally invasive techniques a total reconstruction can now be performed with a very low risk of failure and a significantly reduced risk of complications.
In a total reconstruction the vaginal integrity is restored by replacing fascial layers with a mesh or biological prosthesis and reconstructing ligaments using polypropylene mesh tapes, placed in position without tension.
Read about patient experiences with Total Pelvic Reconstruction of Major Vaginal Prolapse
Hysterectomy
Many patients ay they have been told that a hysterectomy is the best treatment for prolapse in conjunction with a traditional repair. There is no doubt that most patients will achieve a satisfactory outcome with this procedure but removing the uterus does compromise support mechanisms and blood supply in the upper vagina.
Role
of the Uterus in the Pelvic Support Mechanism
The uterus is important in supporting the pelvis and more than 20% of patients who have a hysterectomy will suffer bladder or bowel problems subsequently. A number of techniques are now available to help women solve problems without undergoing a hysterectomy and preserve their original anatomy.
Read
about Alternatives to Hysterectomy
What is Available if You have already had a Hysterectomy
New procedures are now available where the ligaments supporting the bladder are strengthened using artificial neo-ligaments formed around a polypropylene tape inserted through the skin using a needle. These procedures can be Day Surgery Operations in some cases. One such operation is the Posterior Intravaginal Sling which restores anatomy to normal and is helpful in reducing symptoms due to weakness in the posterior ligaments.
Read what Dr Farnsworth's Patients have said about the Posterior Intravaginal Sling Procedure
What about Incontinence ?
Incontinence is a problem related to prolapse. Sometimes repairing a prolapse can reveal that there is also a leakage problem which can be frustrating and embarrassing. A number of Day Surgery treatments now exist for Urinary Incontinence. The critical thing is to make the correct diagnosis and use the right treatment for the problem.
Read more about Urinary Incontinence
Why does Repair Surgery Sometimes Fail ?
Failure of surgery occurs for a number of reasons but the two common reasons are inadequate healing and poor tissues. These may be exacerbated by excessive physical activity or surgical repair attempting to heal under tension.
These problems are much more severe in traditional and laparoscopic pelvic surgery where is no prosthesis present to provide initial support. When a prosthesis is used it is necessary to wait until the tape or mesh has been adequately integrated into the tissues but in the long-term the ongoing reaction of the body to the prosthesis maintains the strength of the repair. It is important to allow adequate time for collagen cross bonding to occur which will strengthen a healing wound.
Often failure will occur because another part of the pelvic support system has collapsed. This is not really a failure but is just as depressing for the patient and means that further surgery will be required.
Sometimes tissue damage especially from previous surgery is so great that the only option is to introduce new material to correct the damage in the form of a biological or synthetic prosthesis.
What Happens If I Have the Wrong Operation ?
Some incontinence and prolapse procedures act by tightening or elevating the anterior ligaments of the bladder. These include the colposuspension, Stamey Procedure, and anterior colporrhaphy. These procedures may result in obstruction and poor urinary outflow, especially if the main problem is actually one of posterior support to the bladder.( Imagine if the front rope of your tent has been tightened too much and some one cuts the back rope - the tent will fall over ! This is very painful, especially if you are in the tent at the time.) In some cases it is necessary to undo a previous operation before correcting the underlying defect.
It is critical that problems in the posterior support mechanisms be assessed prior to surgery or any of these anterior procedures may lead to pain, urinary infection, incomplete emptying and possibly the need for permanent catheterisation.
Untreated constipation and obstructive defaecation can result in severe damage to the healing pelvis after any operation. It is essential that postoperative protocols include steps to avoid constipation and other acute factors such as vomiting or coughing.
Dr Farnsworth has been performing anterior, posterior and midvaginal repair procedures for several years. Detailed information regarding Repairs with Mesh are provided in a webpage devoted to surgery with mesh.
When to Operate ?
Patients often find it difficult to decide when to undergo surgery. Often they will realise they have a prolapse but have minimal trouble or bother from it. If your prolapse is not causing you any problems it is probably best to leave it alone. Any minor complication of surgery will render you worse off and make you regret undergoing the surgery. Instead, concentrate on using conservative techniques to strengthen your support mechanism and avoid having an operation as long as possible.
Click here to decide who is the best surgeon to do your operation.
Click here to help you decide whether to undergo surgery.