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Vaginal Prolapse Repair

Pelvic Organ Prolapse is when one or more parts of the vagina and pelvic organs are bulging to the opening of the vagina or beyond.  A cystocele is when the anterior vaginal wall is prolapsing with the bladder behind it.  The uterus itself can prolapse.  An enterocele is when the apex or top of the vagina is coming down, either behind the cervix in patients that still have a uterus, or just the vagina with intestines behind it in patients that have had a hysterectomy (vaginal vault prolapse).  A rectocele is a bulging of the posterior vaginal wall with the rectum behind it.  Many patients will have more than one part of the vagina bulging and can have a combination of multiple defects. Patients with prolapse may have a variety of symptoms, ranging from just bulging, pressure, and low back pain to increased urinary frequency and urgency, urinary incontinence, voiding difficulty, repeated urinary tract infections and difficulty with bowel evacuation

 

pelvic anatomy cystocele
rectocele enterocele

Figures: A- normal vaginal support, B- cystocele, C-rectocele, D- enterocele/post hysterectomy vaginal vault prolapse

A normal vagina is supported by the levator muscles of the pelvic floor and the endopelvic fascia, which is an intricate natural elastic layer of connective tissue lining the entire pelvic floor. Pelvic organs (bladder, uterine cervix, rectum and vagina) are partially embedded into the endopelvic fascia. Weakening or breaks of the fascia result in the different types of prolapse.  Possible risk factors for pelvic organ prolapse include genetic factors, number of full term pregnancies (particularly vaginal birth), menopause, advancing age, prior pelvic surgery, connective tissue disorders, and factors associated with elevated intra-abdominal pressure such as obesity and chronic constipation with excessive straining. Vaginal repair of pelvic organ prolapse is the most minimally invasive approach for prolapse repair. The goal of prolapse surgery is to repair the anatomic defects in the endopelvic fascia and pelvic floor muscles to restore normal anatomy.

Anterior (Cystocele) repair: The skin of the anterior vaginal wall is opened to expose the layer of endopelvic fascia. The defects in the fascia are repaired, often using a layer of permanent suture followed by a layer of dissolvable suture. If the existing tissue is very thin and weak, we may reinforce the repair with a graft which can be biologic (animal source) or a synthetic mesh. The vaginal skin is then closed with absorbable suture. A pubovaginal sling can also be done with this procedure to correct stress incontinence if needed.

AnteriorCystocele

Posterior (Rectocele) Repair: The skin of the posterior vaginal wall is opened to expose the layer of endopelvic fascia. The defects in the fascia are repaired with suture. If the existing tissue is very thin and weak, we may reinforce the repair with a graft which can be biologic (animal source) or a synthetic mesh. The vaginal skin is then closed with absorbable suture. Often a large rectocele repair will be combined with a uterosacral ligament plication or sacrospinous ligament fixation.   Vaginal Vault (Enterocele) Repair: These are often done in combination with other surgeries such as a vaginal hysterectomy, and anterior/ posterior repair and are used to suspend the top of the vagina to a strong supporting structure which is either the uterosacral ligaments or the Sacrospinous ligament.

PosteriorRectocele

Vaginal Vault (Enterocele) Repair: These are often done in combination with other surgeries such as a vaginal hysterectomy, and anterior/ posterior repair and are used to suspend the top of the vagina to a strong supporting structure which is either the uterosacral ligaments or the Sacrospinous ligament.

Uterosacral Ligament plication:  The uterosacral ligaments are the supporting ligaments that attached the  back of the uterus to the sacrum. This procedure is most often used in combination with a vaginal hysterectomy. Once the uterus (and tubes and  ovaries if indicated) are removed, the top of the vagina is attached to  these ligaments and then the top of the vagina is closed.

ProlapseRepair

Sacrospinous Ligament fixation:  The Sacrospinous ligament is a strong fibrous ligament that runs between the  ischial spines of the pelvic bone to the sacrum. This provides a very strong anchor of support for the top of the vagina. The endopelvic fascia from   either the anterior or posterior vaginal wall can be attached to the   ligament with sutures on both sides. Usually a permanent (nonabsorbable) suture is used.

Pelvis

Vaginal Prolapse Repair:

  • Minimally invasive, no incisions
  • 1-2 days in the hospital, depending on the complexity of the repair
  • Back to most routine activities in 3-4 weeks
  • No strenuous activity for 2-3 months
  • No sexual intercourse for 3 months
  • Recurrent prolapse rate is 20-30%
  • Vaginal Estrogen use before and after surgery is critical if you are postmenopausal, to increase the blood supply and elastin levels in the tissue to facilitate healing.