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When nonsurgical treatment for pelvic organ prolapse is unsuccessful in alleviating symptoms, or when a woman desires a surgical option for repair, the choices may sometimes be overwhelming. Depending upon the consultation, all options may not be discussed in detail, which may lead to frustration or regret later. Understanding the surgical options available to treat pelvic organ prolapse, the pros, cons, risks and benefits, is crucial, in my opinion, before making a decision regarding surgical repair.
There are several types of procedures available to treat pelvic prolapse. When selecting a repair, all areas of weakness in the pelvic floor must be evaluated and accounted for before surgery is planned. Everyone is different, but there are some typical scenarios that should be considered prior to surgery. First, it is rare to have an isolated defect. In other words, a cystocele (prolapsed bladder) rarely occurs without concomitant prolapse of the uterus or vaginal apex (the top of the vagina). Isolated rectoceles are a bit more common than isolated cystoceles. Uterine prolapse is also rarely an isolated finding, but is usually accompanied by a rectocele, cystocele, or both. Sometimes, uterine prolapse may primarily involve a very long, prolapsed cervix with a milder degree of actual uterine prolapse. When evaluating for prolapse problems, it is critical to stage each aspect of the pelvic floor prolapse before recommending a repair. It is very rare to have a cystocele and rectocele without a clinically significant degree of uterine prolapse. I have frequently seen women who present for consultation due to a failure of prolapse repair, only to discover that they underwent a cystocele and rectocele repair vaginally (anterior/posterior colporrhaphy, in medical parlance) without addressing apical (top of the vagina or uterine) prolapse.
Procedures available to treat prolapse, from lowest failure rate to highest:
Le Fort or modified Le Fort colpocleisis:
This procedure involves creating a barrier within the vagina which prevents tissues or organs from bulging out of the vaginal opening. Because it creates a barrier, it is NOT appropriate for anyone who wishes to be able to have vaginal penetration (eg: intercourse) after the surgery. The failure rate is approximately 1 percent, but because it permanently prevents vaginal access is not acceptable for many women. However, because it can be done relatively quickly with lower complication risks than other procedures, it may be a procedure of choice for someone very debilitated or at very high risk for surgical complications. Risks may include infection, bleeding, damage to rectum, bladder, ureters, need for reoperation or more extensive surgery. Also, because the uterus and cervix cannot be accessed after this procedure, it precludes future pap smears or vaginally obtained biopsies of the uterine lining.
This procedure can be done with a regular abdominal incision, via laparoscopy (channels placed through very small incisions the size of a pinkie finger in the abdomen) or robotically (a special form of laparoscopy). The failure rate is estimated to be between 5 and 10 percent. It can correct combined prolapse of the apex, anterior and posterior side of the vagina (bladder and rectal side). It typically involves transabdominal placement of a specialized hernia mesh shaped like the letter, “Y”. Traditionally, it involved use of a strong tissue (fascia) harvested from another part of the woman’s body, and currently in some cases similar tissue harvested from a cadaver is used. Studies have thus far suggested that the mesh graft has a lower failure rate in this procedure. Although there have been legitimate concerns raised about the use of transvaginally placed mesh, the risk of a mesh-related complication with this type of procedure is much lower (generally around 3% for the most commonly done procedure). When performed via a minimally invasive approach (laparoscopically or robotically) it usually involves about a day in the hospital and 2-4 weeks of recovery time, with some restrictions on activity lasting longer. It is considered the “Gold Standard” procedure for repairs of pelvic organ prolapse. Risks include infection, bleeding, scarring, damage to bowel or bladder, ureters, major blood vessels, nerves, pain, new onset urinary leakage symptoms, mesh-related complications (when used, 3% if cervix left in place). Failures, when they occur, are most often involving the rectal side of the vagina.
Sacrospinous Ligament Fixation:
Usually done with a vaginal hysterectomy if the uterus is in place, it involves a vaginal approach, attaching the top of the vagina to ligaments deep in the pelvis to support the upper vagina. It is usually done along with anterior and/or posterior repair (colporrhaphy), to support the bladder (anterior) and rectum (posterior) side of the vagina. The failure rate is estimated at 15-25 percent, depending upon what else is done and the specific nature of the problem. It may be better when the primary defect is on the rectal side of the vagina and involves the uterus or top of the vagina, because it supports the rectal side more. It is more prone to an anterior (bladder side) failure. Complication risks are similar to sacrocolpopexy.
Uterosacral ligament suspension:
Usually done with a vaginal hysterectomy if the uterus is in place, it involves a vaginal approach, but also may include a laparoscopic approach. It is well suited to lesser degrees of prolapse and particularly if there is a very long cervix, with the ligaments remaining relatively strong. The failure rate may range from 10-30 percent, depending upon the specific situation in which it is used. It generally provides the most anatomically correct support of the top of the vagina. Complication risks are similar to sacrocolpopexy.
A vaginal repair to replace the bladder side of the vagina into its proper position. Although there may be specific circumstances where this is appropriate as a single procedure, generally it is rare to have an isolated prolapse of the bladder side of the vagina. Failure rate when done alone is approximately 30%. Risks are similar to other procedures already listed.
A vaginal repair to replace the rectal side of the vagina into its proper position. Although it is more common to have an isolated prolapse on the rectal side, it is vital to carefully evaluate the other areas to confirm that there is no prolapse or weakening in those areas. Failure rate when done alone also approaches 30%. Risks are similar to other procedures already listed.
Regarding transvaginally placed meshes for prolapse repair: The FDA warning regarding this practice has been published elsewhere. Data have shown that the failure rate of vaginally performed procedures using mesh is not significantly different from vaginal repairs done without mesh, but risks of mesh-related complications may range between 15-20%. Another blog entry will address mesh use for pelvic organ prolapse in greater detail.
Each of these procedures has merit for specific individual cases. In addition, each surgeon will have different comfort levels with the various procedures. If you are contemplating prolapse surgery, it is important to discuss the options and determine with your surgeon which procedure would be the best fit for you. If you would like more information please call the office at 561-701-2841 to schedule an appointment with Dr. Kiley