Pelvic Organ Prolapse
There are a variety of treatment options for women suffering from pelvic organ prolapse. Some treatments offer temporary relief whereas others are long-term solutions that are effective and have low risks associated with them. As with any treatment options, patients should be aware of all of the options and should understand the costs and benefits of the treatments. Patients should be prepared to ask questions of their physicans to gain an understanding of the recommended procedure as well as the surgeon’s expertise.
Vaginal Pessary
A Vaginal Pessary is a flexible device made of silicone that is worn in the vagina and provides support for prolapsing organs. Pessary may be a good option for patients who do not want to undergo surgery or can be used as a temporary measure in anticipation for surgery. This device must be removed and cleaned with soap and water periodically. Sexually active women must learn to remove and insert the pessary on their own.
Vaginal Anterior and Posterior Repair (A&P repair)
The Anterior and Posterior (A&P) repair is a surgical procedure that is used to treat bladder (anterior repair) and rectum (posterior repair) prolapse. This procedure involves removal of a portion of the vaginal wall that is then sewn back together to achieve reduction in the prolapsed and help push the pelvic organs into their normal position. Sometimes mesh material is used to provide additional support.
Although A&P repair is the most common procedure performed by general gynecologists, it has many disadvantages. This procedure is associated with a failure rate (recurrence of prolapse) of 30-50% at two years after surgery. It can also cause significant dyspareunia (pain during intercourse) because of narrowing of the vaginal canal. Vaginal mesh placement at the time of the procedure is associated with a significant risk of mesh erosion which is when the mesh causes ulceration in the vaginal wall and causes pain. Another disadvantage of this procedure is that it does not treat the uterine or vaginal apex prolapse that is often present in patients with bladder and rectum prolapse.
Vaginal Suspension
Vaginal suspension procedures include sacrospinous fixation and uterosacral fixation. Uterosacral fixation involves suturing the uterosacral ligament to the top of the vagina. In sacrospinous fixation, the top of the vagina is attached to the sacrospinous ligament with sutures. Both of these procedures are associated with a high failure rate most likely because they utilize the already loosened ligaments to attempt to hold the vagina in its proper position.
Laparoscopic Sacrocolpopexy
Laparoscopic Sacrocolpopexy with A&P repair with mesh is a procedure used by WSC physicians to treat patients with pelvic organ prolapse. This is the gold standard procedure for treatment of prolapsed and is far superior to the procedures described above. This procedure provides patients with long lasting results without risk of mesh erosion, without high risk of failure, and without risk of painful intercourse. The entire procedure is performed laparoscopically without any alteration to the anatomy of the vagina. The mesh is placed through the abdominal cavity which avoids the problems associated with vaginal procedures. During this procedure the top of the vagina (vaginal apex), bladder and rectum are suspended which treats all aspects of pelvic prolapsed at the same time.
Laparoscopic Sacrocolpopexy is a complex procedure requiring a high level of surgical skill. Some physicians perform abdominal or open sacrocolpopexy which requires a much larger incision and consequently a longer recovery period. Robotic Sacrocolpopexy is an alternative to open surgery. However, this procedure is extremely lengthy which leads to higher cost due to the longer operating room time as well as potential health risks associated with prolonged exposure to general anesthesia. Robotic Sacrocolpopexy offers no advantage to Laparoscopic Sacrocolpopexy performed by a highly trained surgeon.
Comparison
Laparoscopic Sacrocolpopexy versus Open Suspension
| Laparoscopic Sacrocolpopexy | Open Suspension | |
|---|---|---|
| Discharge Home | Less than 24 hours | 3 – 5 days |
| Recovery Time | 2 weeks or less | 6 – 8 weeks |
| Incision Size | 4 - 1/4 inch | 8 – 10 inches, vertical or horizontal |
| Pain Tolerance | Very good to good. Mild to mod pain the first several days. | Fair to poor secondary to increased incision size |
| Blood Control | Excellent | Good |
| Procedure Time | 2 to 2.5 hours | 1.5 to 2 hours |
| Complications | Minimal secondary to small incisions, minimal pain, rapid discharge from hospital, immediately ambulatory. | Incision: increased incidence of wound breakdown and infection, incisional pain, pain with breathing. Ambulation: difficulty ambulating with increased incidence of clot in legs and lungs due to venous stasis. Increased incidence of stroke and MI due to venous stasis and stress/pain, lung collapse and pneumonia, increased risk of hospital acquired infection (MRSA) secondary to prolonged hospital stay. Increased risk of adhesion formation as compared to laparoscopy. |