PELVIC ORGAN PROLAPSE

PELVIC ORGAN PROLAPSE

Pelvic organ prolapse is a condition where the uterus herniates out of the vagina. As it descends, it pulls along part of the vaginal wall and the adjacent structures including the urinary bladder and the rectum. Prolapse occurs because of a defect or weakness in the ligaments that support the uterus.

Although vaginal surgery and repair was preferred in older women, laparoscopic surgery has become the route of choice today. This is because vaginal repair utilizes already damaged tissue to repair the prolapse and, hence, the chance of failure of surgery and recurrence of prolapse over the long term is significantly higher.

The following laparoscopic surgeries can be done for pelvic organ prolapse:

  • Laparoscopic sacral colpopexy: Following hysterectomy (removal of the uterus), the upper part of the vagina (vault) can descend down and come outside because of lack of or gradual weakening of its supporting ligaments. This is called vault prolapse. This can lead to symptoms such as repeated vaginal infections & discharge, difficulty in passing urine and constipation. Sometimes the intestines can get entrapped in the herniated vaginal ring leading to intestinal obstruction. Laparoscopic sacral colpopexy is, today, the gold standard for repair (not prevention) of vault prolapse. This involves use of a soft specialized prolene mesh which is fixed to the entire vaginal vault and pulled back to get attached to the upper part of the sacrum (sacral promontory). Additional stuctures such as the ligaments (uterosacral ligaments) and muscles (levator ani) of the pelvic floor can be fixed to the mesh to strengthen the support. Care has to be taken not to entrap the large intestine or the ureter in the mesh.
  • Laparoscopic sacral colpohysteropexy: In women who desire their uteri (avoid hysterectomy) and suffer from prolapse, laparoscopic sacral colpohysteropexy is the procedure of choice. This involves fixing the mesh to the uterus by encircling the cervix and pulling it backwards to fix to the sacral promontory.
  • Uterosacral ligament plication: to reduce the risk of a vault prolapse following a laparoscopic hysterectomy, the uterosacral ligaments (running from the vagina to the sacrum) can be shortened by a series of running sutures and fixed to the upper part of the vagina.

Culdoplasty: In those women who have a deep space between the rectum and the vagina (pouch of Douglas), there is an increased risk of herniation of intestines in that space (enterocoele). This can be prevented by taking helical sutures in the pouch of Douglas to obliterate this space.

NEWER VAGINAL PROCEDURES FOR REPAIR OF PELVIC ORGAN PROLAPSE

In women who are high risk for laparoscopic repair (heart or lung disease), the following procedures can be performed to treat and prevent vault prolapse:

  • Mesh repair: Following removal of the uterus or which performing vaginal surgery for vault prolapse, a soft prolene mesh is placed all around the vagina in the space below it. This is fixed to various ligaments and fascia along the side wide of the pelvis.
  • Paravaginal repair: A thick band of condensed tissue runs along the side wall of the pelvis (arcus tendinous fasciae pelvis). To strengthen the vaginal repair of vault prolapse, either the mesh or the tissue around the bladder and vagina is fixed to the arcus tendinus fasciae pelvis with permanent sutures.
  • Sacrospinous colpopexy: This involves fixing of the vaginal vault to thesacrospinous ligament (a band of tissue running behind the vagina from the side wall of the pelvis to the sacrum).

These are specialized procedures requiring specialized skiils, training and expertise.

Advantages of laparoscopic repair of prolapse include:

  • Avoidance of risks of open surgery including infection, pain, adhesions and hernia at the abdominal scar
  • Cosmetically superior
  • Excellent long term results with extremely low risk of recurrence of prolapse
  • Anatomically better and correct support