Pelvic Organ Prolapse

Surgery for pelvic organ prolapse involves returning the prolapsed pelvic organ (bowel, bladder, vagina, uterus) to its proper position by restoring pelvic supporting structures. An operation is not always needed, but if your pelvic floor symptoms are severe and disrupting your quality of life, you may want to consider surgery. Several surgical options are available to treat pelvic organ prolapse, and the choice between them depends on the type of prolapse and symptoms involved.

All my pelvic floor operations are now planned using a robotic approach. The advent of robotic-assisted surgery has allowed colorectal surgeons to perform procedures within the narrow confines of the bony pelvis with the precision and extent that is not possible with open or normal keyhole surgery. Using the robotic approach, no bowel needs to be removed and the nerves involved in bowel, bladder and sexual function can be avoided. For these reasons, robotic pelvic floor surgery is now considered a safe and effective way of treating most forms of pelvic organ prolapse, and often its symptoms as well.

Pelvic floor prolapse typically involves more than just one organ, varying degrees of prolapse, and a host of pelvic floor symptoms that vary from person to person, so when it comes to surgery, it is not a case of ‘one size fits all”. Therefore, pelvic prolapse surgery requires detailed planning in advance, and in my practice often involves working hand in glove with a urologist or urogynaecologist to come up with a two-fold plan that will repair the prolapse and deal with as many of its troublesome symptoms as possible at the same time.

Surgical options

The most common pelvic floor procedures I perform in my colorectal practice are sacrocolporectopexy (in women) and a modified Orr-Loygue rectopexy (in women and men). Both of these procedures are more extensive variations of an operation known as ventral mesh rectopexy (VMR), a recently developed procedure used to repair external rectal prolapse, internal rectal prolapse, and rectocoele. The procedure that is right for you is planned in advance after lengthy discussions with you, and where necessary, with other pelvic floor specialists as well, but may sometimes need to be modified when we reach theatre, depending on what we find there.

Ventral mesh rectopexy

VMR entails stitching a mesh* (my preference is polyvinylidene fluoride) to the outer surface of the anterior side of the rectum (the side facing the front). Some of the mesh can also be stitched to the vagina in women. The mesh is then fixed using sutures or surgical tacks to the ligament covering the bone at the back of the pelvis (sacrum). This has the effect of lifting the bowel into its correct position and preventing it slipping downwards again. The risk of a prolapse returning after VMR is very small when it is performed for external prolapse. However, the risk of recurrence increases to 20%–30% if VMR is performed because of an internal prolapse with obstructed defecation syndrome or faecal incontinence.

Sacrocolporectopexy

Sacrocolporectopexy is a modification of the VMR, and is particularly useful in women with a prolapse of the anterior vaginal wall (where the side of the vaginal wall that faces the front has dropped from its normal position) accompanied by elements of external rectal prolapse, internal prolapse (particularly when there is obstructed defaecation syndrome as well), uterine prolapse, cystocele, rectocoele, and/or enterocoele.

Sacrocoloporectopexy differs from the VMR in that it not only corrects internal rectal prolapse but can also help to resolve the vaginal symptoms and sensation of pelvic pressure often described by patients. It provides complete support to the top/front of the vagina, which is the area most likely to prolapse. Sacrocoloporectopexy gives as much importance to repairing the vaginal prolapse, rectocoele and enterocoele as it does to repairing the external or internal rectal prolapse. During the procedure, mesh is stitched not only to the rectum, but also to the pelvic floor, vagina, and uterosacral ligaments to reconstruct the rectovaginal septum, which is the thick sheet of fibrous tissue that, prior to the prolapse, kept the vagina and rectum separated. Long-term cure rates using sacrocolporectopexy for internal and external prolapse are as good as for VMR, and may have the additional benefit of improving the symptoms of vaginal prolapse, enterocoele and rectocoele.

Modified Orr-Loygue rectopexy

Both VMR and sacrocolporectopexy have a success rate of 70%–80% when used to treat the symptoms of internal rectal prolapse. A likely reason for some of the failures is that these two procedures only repair the anterior (front) component of the rectal prolapse and cannot repair a posterior (back) component if one is present. A residual prolapse coming from the posterior of the rectum may cause continued symptoms because it is not held up by the mesh at the front. For this reason, I have developed a modification of a procedure known as the Orr-Loygue mesh rectopexy for patients with symptomatic internal rectal prolapse, where I add mesh at the back of the rectum to mend any remaining posterior prolapse. Using the robotic approach, it is now possible for surgeons to work within the confined space of the pelvis and treat structures that were once too difficult to access without damaging the pelvic nerves lying close by.

Helpful patient information

Pelvic prolapse surgery is done under general anaesthesia, so you will not feel any pain. You will need to fast from midnight on the night before if your surgery is scheduled for the morning, or from 7 am if it scheduled for the afternoon. No special bowel preparation is needed.

Pelvic prolapse surgery is performed as a minimally invasive (robotic) procedure. The operation is done using instruments inserted through five small cuts (about 1–1.5 cm long), one above the navel (belly button) and four other small cuts on both sides of your lower abdomen; one for the camera, three for robotic instruments, and one for the surgical assistant to assist with the passing of sutures and equipment as required. A small video camera is passed through one of the cuts so that the inside of the abdomen can be seen on a TV monitor, and surgical tools are used to perform the operation itself. Carbon dioxide gas is used to slowly inflate the abdomen and give a clearer view of the rectum and surrounding structures.

There are many delicate structures in the pelvic floor that need to be protected, and this is achieved by precision surgery. The blood vessels to these organs are sealed and cut by special surgical instruments so the amount of blood loss is minimal.

As a last step, the wounds are closed with dissolvable stitches, and surgical glue is applied to make the wounds watertight. Pelvic prolapse procedures take 2-4 hours to perform, depending on complexity, patient factors, and if the surgery needs to be performed jointly with other pelvic floor specialists.

You will be given a long-acting antibiotic in the anaesthetic room and an injection of local anaesthetic before you leave the operating theatre. Women also receive a vaginal pack before being taken from theatre.

After your operation

After your surgery, you will be taken to the recovery area and then to the ward. When you wake up, you will have an intravenous infusion tube in your arm to give you fluids and any necessary drugs and a catheter in your bladder to drain urine. These tubes are removed after 24 hours. If a vaginal pack was inserted during surgery, it will be removed at the same time. Supplementary oxygen is given by nasal prongs. Antibiotics are generally not necessary after pelvic prolapse surgery.

Some discomfort is common after this type of surgery when your local anaesthetic wears off. The anaesthetist will decide on the method of postoperative pain relief that is best for you. Intravenous analgesia is rarely needed after robotic surgery. Oral painkillers are all that is necessary in most patients.

You can eat and drink as you wish after the operation, and if there is no problem with drinking, the drip providing fluid will be stopped. Some patients feel a little nauseous after eating and drinking soon after their surgery. In these patients, we wait a little longer before introducing food and fluid and keep the fluid drip going. You will be mobilised on the day following your surgery. The stay in hospital after pelvic prolapse surgery is around 1–2 days.

You will not be able to drive when you are discharged from hospital, so it is important to arrange a friend or relative to take you home. When patients can resume driving after this type of surgery is determined on a case-by-case basis. This is usually 2 weeks, but will be discussed with you after your surgery. Most people need longer before they can safely, forcefully, and quickly press the emergency footbrake to avoid a potential incident whilst driving. Please let your insurance company know when you have been given the all-clear to resume driving.

Analgesia and laxatives will be given to you to take home. It is common not to have a bowel movement for up to 5 days after pelvic floor surgery. However, it is very important to avoid constipation and straining in the first few weeks after surgery, so laxatives may need to be continued for up to 6 weeks after you go home.

When you get home

Many people feel tired and weak after major surgery of this type, and full recovery may take up to one month. When you get home, you will need someone to help with meals, housework, and shopping. For the first week or two you may tire easily, so try to alternate short periods of light activity and rest in bed, taking care not to spend too much time lying down because of the risk of developing a blood clot in your legs (deep venous thrombosis).

Most people can return to work 2–4 weeks after pelvic floor surgery, providing that their job does not involve heavy manual labour. However, It is essential that you do not lift anything heavy, such as children, groceries or washing, or do strenuous work like digging the garden or lawn mowing until you have been cleared by me to do so, which may take up to 6 weeks. As a rough guide, do not lift anything heavier than a full kettle during this time. You should also abstain from sexual intercourse for at least 6 weeks.

A follow-up appointment in the clinic will be arranged for 1–2 weeks after your surgery to check your surgical wounds and discuss further management if necessary. If you have any questions or concerns about your surgery, please contact my office.

*Surgical mesh has been the subject of much media coverage. However, there is a lot of confusion around this. The mesh products associated with failed procedures and increased rates of infection were materials that were poorly designed and poorly engineered, and were used by some surgeons in the pelvis when they were not intended for this type of surgery. I use synthetic meshes and to a lesser degree biological meshes. A synthetic mesh is a sterile woven material made of plastic. This type of mesh does not dissolve, and the specific type of synthetic mesh used needs to be carefully chosen for each patient and procedure, and takes into account multiple aspects of the mesh itself. Correct use of synthetic mesh results in a very low risk of infection, and it has been used safely in pelvic prolapse surgery for over 10 years. I place mesh in the pelvis through sterile keyhole instruments, so it never comes into contact with skin or the lining of the vagina, which are potential sources of infection. Even mesh placed through the vagina has a mesh infection rate of only 1%. The mesh I have chosen through intensive research has a published infection rate of only 0.3%.