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Considering pelvic organ prolapse surgery? Read this first

Pelvic support defects and organ prolapse are common conditions for women as they age, but many women won’t discuss their symptoms – not even with their doctors. In the United States 24% of women have Pelvic Organ Prolapse (POP) where one or more organs in the pelvis, such as the uterus, bladder or rectum, have shifted downward after the pelvic floor wall was injured or weakened.

The risk of prolapse increases with age. It occurs predominantly in perimenopausal and postmenopausal women; however, symptoms can occur at any age. It is most common with women of Hispanic and Anglo backgrounds. Risk factors include multiple vaginal childbirths, prolonged labor, and instrumented delivery. Other causes include chronic cough, hereditary connective tissue weakness, radiation treatment, surgery and obesity.

Symptoms of pelvic prolapse:

  • Sensation of a bulge or a ‘ball’ at the vaginal opening
  • Pelvic Pain or Pressure
  • Urinary frequency or inability to completely empty bladder
  • Constipation or inability to completely evacuate bowel
  • Loss of control of bowel movements
  • Pain during sexual intercourse or loss of sexual sensation
  • Vaginal Bleeding
  • Urinary incontinence

Treatment options include conservative therapy with pelvic floor exercises or fitting for a pessary, a removable support device. If symptoms are not relieved by these therapies, there are minimally invasive surgical options to correct the issue.

When you should consult a specialist in urogynecology

It is estimated that 11% to 19% of women will undergo surgery for POP by the age of 85. If you are experiencing symptoms of pelvic floor disorders you should talk with your doctor to learn about your options for restoring your quality of life and avoiding medical complications such as bladder infections and kidney disease.

“There are a lot of people that are not getting the treatment that they need,” said Dr. Richard Farnam, director of the Texas Urogynecology and Laser Surgery Center. “They don’t want to talk about it.”

The evaluation of prolapse requires a comprehensive approach based on a detailed patient history, physical examination and some testing. All the different treatment options should be explained, including non-surgical treatments, pessary, and mesh and non-mesh surgeries.

Board-certified urogynecologists see and treat pelvic floor disorders with greater frequency than non-
specialists, which is shown to result in the highest chance of long-term success.

You should see a specialist:

  •  If you are told there is nothing that can be done.
  •  If you are told there is only one treatment. A specialist will talk with you about all of your options.
  •  If you’ve had a prior surgery that failed.
  •  If you have severe symptoms (prolapse beyond the opening of the vagina).
  •  If your doctor performs less than 30 prolapse surgeries per year. 
  • If you are uncomfortable talking with your doctor.

Guidelines for choosing a surgeon

The gold standard in pelvic support surgery is sacrocolpopexy, a complex, but effective technique for repairing organ prolapse. Sacrocolpopexy is performed either through an abdominal incision (open surgery) or with a laparoscope or using a minimally invasive surgical robot.

In order to improve long-term outcomes and patient safety for the sacrocolpopexy procedure, the American Urogynecologic Society (AUGS) in March 2103 released new guidelines for credentialing physicians which emphasized that “surgically complex procedures require a balance of knowledge, surgical skill and experience as well as appropriate ongoing surgical volume.”

AUGS guidelines say sacrocolpopexy should be performed by surgeons:

  • with board certification or active candidacy for board certification in obstetrics and gynecology or urology.
  • who perform a minimum of 30 prolapse procedures each year, with at least 5 being sacrocolpopexy.

Improving outcomes in surgery for Pelvic Organ Prolapse

Sacrocolpopexy is a procedure to give support to the vagina or uterus to correct pelvic prolapse. The procedure has been performed since 1957 with variations on technique to improve patient safety and long-term outcomes.

In its advanced form, the first laparoscopic sacrocolpopexy was performed in 1991. Today, surgeons are able to use minimally invasive robotic surgery that offers quicker recovery times and less blood loss than abdominal (open) surgery.

A prolapse may occur in the front wall of the vagina (anterior compartment), back wall of the vagina (posterior compartment), the uterus or the top of the vagina (apical compartment). In its Pelvic Guide for Women, the International Urogynecological Association illustrates how each of these appears, as well as when women have prolapse in more than one compartment.

“Most of the time when surgeons do repairs they just fix the front and the back and they don’t fix the top. And for that reason, prolapse recurrence rates are very high. As high as 30 percent,” Dr. Farnam said, explaining that apical prolapse repair involves suturing the vagina to a strong ligament in the pelvis.

“You have to do advanced surgical training to become proficient at repairing the apical compartment and allowing for a higher success rate.”

The importance of standards

In an attempt to simplify treatment of Pelvic Organ Prolapse, transvaginal prolapse mesh devices were introduced in 2005. But complaints about poor outcomes and short-term failure rates attributed to a lack of consistency in standards for the mesh kits led the FDA to recommend healthcare providers undergo specialized training and thoroughly inform patients seeking treatment for pelvic organ prolapse about the benefits and risks of all potential treatment options.

In a July 2011 statement, the American Urogynecologic Society clarified that the FDA report “pertains to the transvaginal placement of synthetic mesh for treatment of pelvic organ prolapse. The conclusions and recommendations of the report do not apply to the use of synthetic mesh for treatment of stress urinary incontinence or abdominal or laparoscopic repair of pelvic organ prolapse (i.e. sacrocolpopexy) where the benefits of mesh are more clearly delineated and the risks are less.”

The benefits of successful surgery

“The most common comment we get is that women feel like they got their lives back,” Farnam said. “Their lives are no longer dictated by the pain or the bulge or the embarrassment caused by prolapsed organs.”

2012 study comparing abdominal (open) versus robotic-assisted sacrocolpopexy found that while both had a similar clinical outcome, robotic surgery was less expensive and resulted in a shorter hospital stay.

“It’s a matter of choice,” Farnam said, explaining that some women prefer the convenience and cosmetic advantage of minimally invasive surgery.

“Patients are amazed that they only have a little incision, that they’re in the hospital less than a day and that they’re doing most normal activities within a week.”