Pelvic Floor Prolaspe Repair

Laparoscopic surgery can be used to repair prolapsed pelvic floors.

Enterocoele is a herniation, or prolapse, at the top of the vagina.
Rectocoele is a herniation, or prolapse, of the rectum through the back wall of the vagina.
Urethrocoele is a herniation, or prolapse, of the urethra on the lower front wall of the vagina. It can be repaired laparoscopically with a bladder neck suspension.
Cystocele is a herniation, or prolapse, of the bladder through the front wall of the vagina. This is difficult to repair laparoscopically and often need a vaginal approach.

The supporting structures of the posterior vagina can be easily visualised laparoscopically, often in a better way than when a vaginal approach is used so rectocele and enterocoele can be repaired with great precision using a laparoscopic approach.

Sometimes during childbirth the pelvic floor becomes detached at the edges of the bony pelvis. This cannot be easily repaired through the vagina but the area can be been laparoscopically. If the muscle is reattached better success is achieved in some pelvic floor repairs. This detachment is a relatively new concept in pelvic floor surgery and explains why pelvic floor exercise alone may not cure prolapse.

Advantages of laparoscopic pelvic floor repair

Small incisions and less scarring
Better views of the vaginal supports
Gentler handling of the body tissues and organs during the operation
Less blood loss during the operation
Less postoperative pain
Less postoperative narcotic use for pain relief
Shorter hospitalisation
Faster overall recovery with an earlier return to normal activity

Technique for laparoscopic pelvic floor repair

Preoperative preparation involves a shave and a small enema, and you will need to fast for six hours before the operation.

A general anaesthetic is administered.
The laparoscope and other instruments are introduced as described.
The uterus and other pelvic structures are checked.
The area between the vagina and bowel is opened and the bowel is freed from the vagina.
A series of sutures are placed in the vaginal ligaments and the back wall of the vagina to create a column of support.
The side areas of the vagina are opened and the lateral pelvic muscles are sutured if needed.
A bladder neck suspension is often performed.
The wounds are closed.

Recovery after laparoscopic pelvic floor repair

Immediate postoperative recovery involves several days in hospital. Some pain relief is usually required, either injections for tablets. Careful attention will be paid to bowel function and an enema or suppository may be administered. You will come back to the ward with a catheter in your bladder. This will usually be removed the next day.

You will be monitored carefully to make sure passing urine is comfortable and complete. Some patients have trouble emptying their bladder and may need to be taught to self-catheterise. This always sounds very daunting but is easy and patients manage it very well.

The first few days at home should be taken very easily. The patient should have someone to help. Plenty of rest and fluids are advisable. Exercise your calf muscles to prevent clots. Oral pain relief such as Panadeine and Panadol may be needed, especially at night. Avoid constipation. Graded recovery occurs over a few weeks.

Many patients can go back to light work within one to two weeks. Heavy lifting should be avoided. Driving is allowed. No sexual intercourse should take place for six weeks after surgery. Everyone is different and each patient should assess their own recovery rate.

Risks of pelvic floor repair surgery

Infection – Infection rates are low as preventative antibiotics are used at and after the surgery. In hospital rates are 1-2%.

Bleeding – At the time of the operation some blood will be lost. Very rarely this can be serious and require some emergency treatment such as transfusion. No such cases have yet occurred in our unit but the possibility does exist. The operative area is a large potential space and can form a bruise called a haematoma. If large these cause added pain and infection risk. They are uncommon.

Damage to bladder, ureter and bowel – These structures are very close to the vagina and can be damaged. The risks are about 1 in 250-300 cases. Damage detected at the time of surgery is repaired immediately and will often not have serious consequences. A cystocopy will be performed to check for this and minimise any risks. Sometimes the injury can be undetected or developed over several days after surgery e.g. where a burn is made to stop bleeding. A fistula can then develop. This is a connection of bladder, ureter or bowl to skin or vagina. Further surgery will be required to fix this. The risk of this is about 1 in 500 cases.

Deep Venous Thrombosis or Pulmonary Embolus – A clot can form in the leg or pelvic veins and travel to the lungs. The risk of this happening is about 1 in 400-500. This is serious and can rarely be fatal. Tell your doctor if these have happened to you before or if you have a family history. During the surgery a number of precautions are taken to prevent these. Early mobilisation after laparoscopic surgery may also reduce the risk compared to larger incision operations.

Other risks of laparoscopy – As described in the page on Laparoscopic Surgery.

Bowel disturbance is common for a few weeks postoperatively.

Recurrence of the prolapse can occur. All prolapse operations have failure rates over time as the tissues repaired have lost some of their integrity. Failure rates over 10 years may be in the order of 10-30% depending on individual circumstances. Failure rates are higher in obese patients, smokers and patients with chronic respiratory illnesses.

Postoperative bladder instability

There are two sorts of involuntary urine loss – stress incontinence and urge incontinence. Urge incontinence is due to electrical bladder instability with the muscles of the bladder spasming and threatening to empty. Some patients have both sorts in incontinence.

Surgical interference with the bladder commonly causes temporary bladder irritability. This usually settles after 2-6 weeks although occasionally may not. Some patients have their underlying urge incontinence exposed after surgery and then will need tablets to stabilise their bladder and settle the electrical activity.