ABODOMINAL MESH SACRAL COLPOPEXY SURGERY
WHAT IS A VAULT PROLAPSE?
A prolapse of the vaginal vault. The vault is the name given to the top of the vagina after someone has had a hysterectomy. (The cervix and uterus have been removed). The supports that normally hold up the top of the vagina are weakened and the vault is falling down like a roof caving in. Vaginal vault prolapse is usually not isolated but commonly occurs in combination with other prolapses of the bladder (cystocoele), large bowel (rectocoele) or small bowel (enterocoele). Incontinence of urine is another problem that may commonly co exist. Repair of these may be performed at the same time.
HOW IS IT DIAGNOSED?
By vaginal examination either lying down or in the standing position whilst you push, bear down, or cough.
WHEN SHOULD A VAULT PROLAPSE BE REPAIRED?
When it is causing the patient significant bother and symptoms; enough to accept the risks associated with the surgery to correct it. Usually the top of the vagina needs to have fallen more than halfway down the length of the vagina to cause symptoms. This is classified as a Stage II or more vault prolapse.
WHAT SYMPTOMS MIGHT IT CAUSE?
- A feeling of a lump or pressure in the vagina or a a lump protruding from the vagina. These are the most common symptoms and the ones most likely to be due to the prolapse.
- There are other symptoms that may or may not be due to the to the prolapse
- Pain with intercourse
- Discomfort when walking
- Pelvic pain
- Incontinence (accidental loss) of urine or faeces
- Difficulty emptying the bladder
- Recurrent urine infections.
- When the prolapse is protruding from the vaginal opening the overlying skin can become ulcerated.
- If the vagina falls down and out completely, (complete eversion), it can block off drainage from the kidneys. Although rare, this is a serious and potentially life threatening complication.
WHAT DOES THE OPERATION INVOLVE?
The procedure is usually performed through either an abdominal incision or key hole surgery (laparoscopy or robotic). A piece of synthetic mesh made out of prolene is sewn to the top of the vagina and then to the front of the sacrum. The sacrum is the lower part of the bony spinal column. This then provides a point of attachment for the top of the vagina, suspending it and preventing it from collapsing down again. The procedure takes about 2 hours but may take longer especially if combined with other procedures.
WHAT ARE THE OTHER MANAGEMENT OPTIONS?
- No treatment but, ongoing observation, follow up and exercises (see below).
- Pelvic Floor Exercises - You should learn pelvic floor exercise and optimize your pelvic floor muscle strength prior to surgery. Pelvic floor exercises can improve a prolapse and its symptoms avoiding the need for surgery in some women. Pelvic floor exercises will strengthen your pelvic floor muscles and help protect you against prolapse and stress incontinence for life. Physiotherapists or continence nurses can assist with pelvic floor education and an exercise programme.
- A Ring Pessary – this is a device placed easily into the vagina in the rooms to try to hold the prolapse up. This avoids surgery but it may not work properly, stay in or be comfortable in all patients. It also usually has to be removed for intercourse as well as every 3-6 months for cleaning and vaginal examination. For these reasons it is often not a good long term solution in younger or sexually active patients.
- Sacrospinous colpopexy, uteroscral ligament fixation or iliococcygeus fascia fixation– This procedure is done from below through the vagina and the top of the vagina is stitched to a ligament or fascia in the pelvis. It has lower success rates than the abdominal procedure but it avoids an abdominal incision.
- Ureterosacral ligament fixation with an abdominal approach. This can be via keyhole surgery.
- The Abdominal Sacral Colpopexy is probably the most effective procedure longterm for the correction of a vault prolapse especially for young women who desire a fully active lifestyle and sexuality.[1] It is also a good procedure to maintain maximum vaginal length
WHAT MIGHT BE REQUIRED BEFOREHAND?
- A vaginal examination.
- A urine and blood test.
- An Ultrasound of the pelvis and bladder.
- Fluoroscopic Urodynamic Studies – This test is to check for bladder problems that might occur in conjunction with the prolapse such as the risk of hidden stress incontinence. This is a stress incontinence problem that might only appear after the prolapse is repaired and so if checked for beforehand it can be repaired at the same time.
- A laxative or bowel enema prior to surgery to clear the lower bowel out.
HOW LIKELY IS IT TO WORK? – WHAT IS THE SUCCESS RATE?
- This procedure successfully corrects the vault prolapse in up to > 95% of patients in some studies [2].
- Recurrence of the vault prolapse is low; reports as high as < 3% over 10 years in some studies [3].
- A review paper found 7% of women were still aware of their prolapse after surgery and 4% required repeat prolapse surgery. [9]
- Other prolapses of the bladder or bowel may occur subsequently.
WHAT DOES THE POST OPERATIVE RECOVERY PERIOD INVOLVE?
- The average hospital stay is 4-5 days with open surgery, often shorter with keyhole.
- You will be able to drink fluids as tolerated after the procedure and a diet once bowelactivity returns.
- In theatre a catheter is placed in the bladder, then usually removed after 1- 2 days.
- A pack may be placed in the vagina, then usually removed after 1-2 days.
- It is usual to have some wound pain post-operatively but this mainly resolves by 6 weeks. Usually this is controlled with paracetamol. You can take up to 2 paracetamol every 4 hours to 6 hours (maximum 8 per day). Some patients describe occasional discomfort from their abdominal wounds for up to 12 months following surgery.
- It is usual following surgery to have some spotting, bleeding or discharge from the vagina. This usually stops by about 4 weeks. You should wait 6 weeks and until after your post operative follow up visit before having sexual intercourse. Then proceed as comfortable. Other important instructions for when you go home.
- It takes about 4-6 weeks to return to normal activity.
- It is important to avoid any straining, heavy lifting or strenuous activity for up to 12 weeks as this could break the mesh repair.
WHAT ARE THE POTENTIAL RISKS AND COMPLICATIONS?
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
- Urine infection or fever post surgery.
- Some patients can develop an ileus. This is a delay in the return of normal bowel activity after surgery. It is treated by fasting and resting the gut. It is more common in patients when many bowel adhesions are found at the time of surgery requiring division before placing the mesh.
- Significant Bleeding requiring blood transfusion 1.2 -2.6% [4]
- Urinary retention – inability to pass urine requiring a catheter 3.5-25% [3]
- infection of the abdominal wounds.
- Mesh infection or Mesh erosion into vagina occur in 2.6 - 9% [2] [5]. Mesh erosion into bowel is rare. Mesh erosion or infection requires further surgery to remove the mesh but this doesn’t always result in prolapse recurrence. [1] [2].
- Bowel obstruction or constipation can occur. This can be from the mesh being too tight and may require surgery to attempt to correct it [6].
- Bowel perforation is rare.
- Stress urinary incontinence can occur as a new symptom. Urodynamic studies prior to surgery try to predict this although it is not always possible.
- Urgency to pass urine.
- Vaginal narrowing or shortening can result in dyspareunia; pain or other difficulty with intercourse. These problems could require further surgery to rectify including removal of part or all of the mesh. Abdominal sacral colpopexy is the best operation for vaginal vault prolapse to maintain vaginal length and sexual activity [7].
- Infection of the bony sacrum has been reported but is extremely rare. [8]
There are other more general risks related to surgery and anaesthesia;
- General medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses; 2-5%. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke).
- There is a small risk of death; about 5 in 10,000.
- Injury to the bladder, urethra or ureter is uncommon.
- Bowel, nerve or vascular injuries are rare.
- There is a small risk of urine infection, wound infection, wound breakdown, haematoma (collection of blood) or seroma (collection of fluid) post-operatively; 5-10%.
- Other rare complications include a significant pelvic haematoma (collection of blood), infection or abscess, a urinary fistula (leak).
- Pain from the mesh or scarring.
- Some of these complications require further surgery to correct.
Post-operative follow-up.
You will be given a follow up appointment.
- If you experience any of the following problems after discharge you should seek medical attention;
- Severe pain not controlled with pain killers
- Bleeding
- Wound problems – infection or breakdown
- Or any other significant trouble.
If at any stage your prolapse returns you should arrange a review visit.
References
1. Winters, J.C., R.D. Cespedes, and R. Vanlangendonck, Abdominal sacral colpopexy and abdominal enterocele
repair in the management of vaginal vault prolapse. Urology, 2000. 56(6 Suppl 1): p. 55-63.
2. Lindeque, B.G. and W.S. Nel, Sacrocolpopexy--a report on 262 consecutive operations. S Afr Med J, 2002. 92(12): p.
982-5.
3. Lefranc, J.P., et al., Longterm followup of posthysterectomy vaginal vault prolapse abdominal repair: a report of 85
cases. J Am Coll Surg, 2002. 195(3): p. 352-8.
4. Timmons, M.C., M.F. Kohler, and W.A. Addison, Thumbtack use for control of presacral bleeding, with description of
an instrument for thumbtack application. Obstet Gynecol, 1991. 78(2): p. 313-5.
5. Iglesia, C.B., D.E. Fenner, and L. Brubaker, The use of mesh in gynecologic surgery. Int Urogynecol J Pelvic Floor
Dysfunct, 1997. 8(2): p. 105-15.
6. Baessler, K. and B. Schuessler, Abdominal sacrocolpopexy and anatomy and function of the posterior compartment.
Obstet Gynecol, 2001. 97(5 Pt 1): p. 678-84.
7. Given, F.T., Jr., et al., Vaginal length and sexual function after colpopexy for complete uterovaginal eversion
Thumbtack use for control of presacral bleeding, with description of an instrument for thumbtack application. Am J
Obstet Gynecol, 1993. 169(2 Pt 1): p. 284-7; discussion 287-8.
8. Weidner, A.C., et al., Sacral osteomyelitis: an unusual complication of abdominal sacral colpopexy. Obstet Gynecol,
1997. 90(4 Pt 2): p. 689-91.
9. Maher, C., et al., Surgery for women with apical vaginal prolapse. Cochrane Database of Systematic Reviews 2016, Issue 10.
Version: V3, July 2017
