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Laparoscopic Pelvic Organ Prolapse Surgery

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This article briefly discusses pelvic organ prolapse, which is treated using a minimally invasive technique.

Written by

Dr. Asma. N

Medically reviewed by

Dr. Arjun Chaudhari

Published At June 5, 2023
Reviewed AtJanuary 29, 2024

Introduction

Pelvic organ prolapse is a condition in which the pelvic organs (area below the abdomen, between hip bones) plunge into or outside the vaginal canal or anus due to weakness in pelvic muscles or ligaments. The pelvic organs include the urethra, cervix, uterus, vagina, rectum, and bladder (frequently involved organ). Pelvic organ prolapse is subcategorized according to the organ of descent. Cystocele (prolapse of the bladder), urethrocele (prolapse of the urethra), uterine prolapse, vaginal vault prolapse, enterocele (small bowel prolapse), and rectocele (rectum prolapse). This prolapse can be treated by surgery with the laparoscopic technique, a minimally invasive technique that reduces recurrence and complication rates.

What Are the Causes of Pelvic Organ Prolapse?

The causes of pelvic organ prolapse include:

  • Vaginal delivery.

  • Obesity.

  • Respiratory problems with a chronic, long-term cough.

  • Constipation.

  • Pelvic organ cancers.

  • Hysterectomy (surgical removal of the uterus).

  • Advancing age.

  • Family history.

  • Increased intrabdominal pressure due to heavy lifting.

  • Chronic cough.

  • Menopause.

  • Hypoestrogenism (low level of estrogen).

What Are the Symptoms of Pelvic Organ Prolapse?

The symptoms of pelvic organ prolapse include:

  • Fullness or pressure in the pelvic area.

  • Feeling "bulging" in the vagina.

  • Leaking of urine and a chronic urge to urinate.

  • Fecal incontinence.

  • Constipation.

  • Loss of bowel control.

  • Spotting or bleeding from the vagina.

  • Lower backache.

  • Painful intercourse.

What Is the Diagnosis of Pelvic Organ Prolapse?

The diagnosis of pelvic organ prolapse includes:

  • The pelvic organ prolapse quantification (POP-Q) system is used to diagnose the degree and location of pelvic floor dysfunction.

  • Bladder function tests (detects the structures around it).

  • Intravenous pyelography (X-ray of the urinary tract that detects kidneys, bladder, and ureters).

  • Voiding cystourethrogram ( X-rays of the bladder and kidneys)

  • Doctors can do computed tomography scans (CT scans), ultrasound, and magnetic resonance imaging scans (MRI scans) of the pelvis.

What Are the Types of Treatment Mode for Pelvic Organ Prolapse?

The treatments types for pelvic organ prolapse include:

  • Physical therapy and Kegel exercises to strengthen the pelvic muscles.

  • Mechanical treatment like pessary (small plastic device) insertion into the vagina that supports the drooping organs.

  • Surgical treatments like laparoscopic, robotic, or open are done to repair or remove the organ. For example, in laparoscopic pelvic floor repair, surgeons reattach the drooping pelvic organs to the floor muscles of the pelvis or the bone using sutures (non-absorbable or permanent) or mesh materials. In addition, laparoscopic procedures, such as sacropexy, lateral suspension, or pectopexy, are popular.

  1. Laparoscopic sacropexy is widely used, in which the uterus (hysterosacropexy), cervix (cervicosacropexy), or vaginal vault (colposacropexy) is fixed to the sacrum (the bony structure that forms the back wall of the pelvis)with polypropylene tape. Hysterosacropexy is indicated in young patients because it does not affect the uterus and the quality of sexual life.

  2. The laparoscopic lateral suspension procedure involves a T-shaped polypropylene mesh fixed to the uterine cervix (lower part of the uterus). Then, its arms of mesh are placed behind the peritoneum (membrane of tissue that covers the pelvic organs).

  3. The laparoscopic pectopexy procedure involves attaching one mesh end to the uterine cervix, whereas its arms are fixed laterally to iliopectineal ligaments (Cooper ligaments). The mesh bypasses structures, such as the ureters and intestines.

What Is the Procedure for Laparoscopic Lateral Suspension?

The laparoscopic lateral suspension (LLS) represents a simple and effective technique that rarely causes complications. The preoperative procedure involves examining the medical history and performing a physical examination. The indication for LLS is anterior organ prolapse, isolated apex or uterine descent associated with cystocele, and vaginal vault prolapse. When rectocele is the predominant element of pelvic organ prolapse, the LLS technique may not be indicated. The first step of Laparoscopic lateral suspension is performing an anterior cleavage. After that, the vesicovaginal cleavage is carried below the bladder trigone, then a rolled-up mesh (“inverted T” mesh that can be cut from a large titanium-coated polypropylene mesh) is introduced into the abdominal cavity through the optical trocar, arms of the mesh are held with traction forceps (5 mm laparoscopic forceps with claws). And the mesh is fixed by absorbable polyester tackers using Kocher forceps, which helps eliminate the number of sutures. The suspension axis of the uterus should be placed crosswise so that it remains in the center of the pelvis. Skin suspension point is made 5 cm posteriorly to the anterior superior iliac spine, causing the uterus or vaginal vault to return to the middle part of the pelvis. The arm of the inverted T mesh must lay flat without any twist, and the tension of the mesh must be symmetrically adjusted.

How Is the Recovery After the Surgery?

After the procedure, patients should do some simple breathing exercises to prevent respiratory infections by stimulating spirometry devices in which Coughing and deep breathing are done, which helps to prevent pneumonia and other pulmonary complications. Discomfort may be present and require pain medications.

What Are the Advantages of Laparoscopic Pelvic Organ Prolapse Surgery?

The advantages of laparoscopic pelvic organ prolapse surgery are:

  • Shorter hospital stays and fast recovery.

  • Less pain.

  • Minimal blood loss.

  • Minimal scarring.

  • Fewer complications.

  • A better view of the pelvic organs during surgery.

  • Due to better visibility and access, surgery is done better.

  • The recurrence rate is low.

What Are the Complications of Laparoscopic Pelvic Organ Prolapse Surgery?

Laparoscopic sacropexy is associated with a higher incidence of cystocele, tissues around the sacrum that can cause nerve and vessel injuries and defecation disorders. The complications of laparoscopic pelvic organ prolapse surgery include:

  • Laparoscopic lateral suspension of the cervix or vaginal stub may lead to anterior displacement of the vaginal axis, which may cause cystocele and rectocele in the future.

  • It can cause rare injury to the bladder, bowel, blood vessels, and nerves of the pelvis.

  • After the surgery, there may be slight pain in the shoulder because of the carbon dioxide gas used to inflate the abdomen during laparoscopic surgery.

  • Bladder spasm, which will diminish over time.

  • Blood-stained urine for several days may occur after surgery.

  • Damage to the bladder or intestine during surgery.

  • Excessive bleeding.

  • Deep venous thrombosis (a blood clot in a leg vein).

  • Implant complications (damage to pelvic structures caused by vaginal mesh material).

  • Infection.

  • Recurrence of the prolapse.

Conclusion

Pelvic organ prolapse is a serious condition affecting 50 percent of perimenopausal women. This procedure's primary goal should involve restoring normal topography, which leads to normalized pelvic organ function. Therefore, adequate education and training are necessary to achieve better results. Laparoscopic pelvic organ prolapse surgery has advantages of shorter hospital stay, fast recovery, minimal blood loss, and less pain.

Frequently Asked Questions

1.

What Are the Signs and Symptoms of Pelvic Prolapse?

Pelvic prolapse presents with a range of symptoms, such as a persistent sensation of pressure in the pelvic region, a distinct fullness near the vaginal opening, discomfort, and pain in the vaginal area, and urinary issues like involuntary urine leakage and frequent urination. Additionally, individuals with pelvic prolapse may experience difficulties with bowel movements, uneasiness during sexual intimacy, lower back pain, abnormal vaginal bleeding or unusual discharge, and an elevated risk of recurrent urinary tract infections.

2.

How Can One Perform a Self-Examination for Pelvic Organ Prolapse?

Self-examination can be initiated by first washing the hands thoroughly. One can perform this examination while in a squatting position, standing with one foot elevated on a stool, or lying down. To aid in the observation, make use of a mirror. It is essential to ensure the bladder is emptied before you begin. Cough forcefully and pay close attention to any movement of the vaginal wall as it descends from or protrudes out of the vaginal entrance. Apply a firm downward pressure (keeping your pelvic floor relaxed) for six to eight seconds, and closely monitor for any further movement of the vaginal walls. If one detects protrusion of the vaginal wall or cervix, this indicates a definite prolapse.

3.

Is There a Cure for Pelvic Prolapse?

The approach to treating this condition is tailored to the ailment's seriousness and the patient's individual choices. For milder cases, patients can choose Kegel exercises and physical therapy to bolster their pelvic floor muscles. Alternatively, they may explore the use of vaginal pessaries to provide support to prolapsed organs. In more severe scenarios, surgical intervention becomes a viable option. This surgical procedure entails reattaching sagging organs to the pelvic floor with the aid of sutures or mesh materials.

4.

What Constitutes the Most Effective Treatment for Prolapse?

Determining the most suitable treatment hinges on various factors, including the condition's severity, the patient's overall health, and their personal choices. In milder cases of prolapse, the most effective approach often involves lifestyle adjustments, Kegel exercises, and the use of pessaries. However, as the severity of the condition escalates, healthcare providers may consider vaginal or abdominal repairs. Additionally, minimally invasive laparoscopic procedures are an option, known for their quicker recovery times.

5.

Can Pelvic Prolapse Resolve on Its Own Without Medical Intervention?

In mild instances, prolapse may naturally improve without the need for medical intervention. These cases can often be effectively managed through lifestyle adjustments, including weight management and pelvic floor exercises. However, in severe cases, spontaneous resolution is unlikely, and other interventions become necessary. These interventions may involve the use of vaginal pessaries or surgical measures, such as reconstructive surgery, aimed at restoring the organs to their original positions.

6.

Is Pelvic Prolapse a Permanent Condition?

Pelvic prolapse isn't always a permanent condition, yet it can become chronic in certain individuals. The prognosis of this condition hinges on various factors, including its severity and the effectiveness of the chosen treatment and lifestyle adjustments. In mild cases, conservative treatments can effectively manage the condition, alleviating symptoms and offering long-term relief. Maintaining a healthy weight, refraining from heavy lifting, and incorporating pelvic floor exercises can help prevent recurrence. However, in severe cases, surgical procedures become the definitive solution.

7.

Does Pelvic Prolapse Have the Potential to Completely Recover?

Pelvic organ prolapse involves the protrusion of pelvic organs into the vaginal canal. Managing its symptoms and achieving a complete cure is indeed possible. However, the journey to recovery and long-term results is influenced by the condition's severity, with milder cases often responding well to conservative treatments like pelvic floor exercises, pessary use, and weight management. Age and overall health also play a role in treatment success, as younger individuals tend to exhibit more positive responses. Hormone replacement therapy (HRT) might be employed to enhance tissue health, although it may not guarantee a full recovery.

8.

How Severe Is Pelvic Prolapse as a Medical Condition?

Pelvic organ prolapse, while not life-threatening, can lead to discomfort and inconvenience. It may result in pelvic pain, a sense of fullness in the pelvic region, the perception of a vaginal bulge, urinary leakage, loss of bowel control, vaginal spotting, lower backache, and painful intercourse. Mild cases can often be effectively managed using conservative treatments. However, in severe cases, the condition can significantly impact one's quality of life and necessitate surgical intervention.

9.

What Are the Permanent Solutions for Addressing Prolapse?

The most lasting solutions typically involve surgical interventions. Various surgical procedures, including laparoscopic, robotic, or open approaches, are performed to repair or remove the affected organs. Surgeons employ sutures or mesh to reposition the sagging organs back to their proper place. Laparoscopic techniques such as sacropexy (where the drooping organs are anchored to the sacrum bone), lateral suspension (involving a T-shaped polypropylene mesh fixed to the lower part of the uterus), or pectopexy (utilizing one mesh end attached to the uterine cervix, with its arms secured laterally to iliopectineal ligaments) have gained popularity for this purpose.

10.

Can Regular Walking Help Improve Pelvic Prolapse?

Indeed, regular walking can contribute to the amelioration of pelvic prolapse. Walking serves to enhance general physical fitness, which can be advantageous for the pelvic floor muscles. The consistent, rhythmic motion associated with walking aids in improving muscle tone and coordination within the pelvic floor. Moreover, it has the potential to enhance bowel regularity and alleviate issues related to constipation. Walking also promotes improved blood circulation throughout the body while simultaneously reducing stress levels.

11.

Can Prolapse Return to Its Normal State?

Absolutely, a prolapse can revert to its normal state. In milder cases, the prolapse can be restored to its usual condition through conservative measures like weight management, pelvic floor exercises, regular walking, and the use of vaginal pessaries. Conversely, in severe cases, surgical intervention becomes necessary. This surgical procedure aims to reposition the pelvic organs to their typical state, facilitating the prolapse's return to its normal condition.

12.

At What Age Is Pelvic Organ Prolapse More Commonly Experienced?

Pelvic organ prolapse predominantly affects older women, where pelvic organs like the uterus, bladder, or rectum deviate from their usual positions and protrude into the vaginal canal. This condition is experienced by approximately 37 percent of women aged 60 to 80.
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Dr. Arjun Chaudhari
Dr. Arjun Chaudhari

Obstetrics and Gynecology

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