Prolapse 2017-08-08T19:37:22+00:00

PROLAPSE

DEFINITION:

Prolapse is a hernia of the vagina that a woman may feel as a bulge or pressure.

This is referred to in many different ways. Sometimes it is called a “dropped bladder”, “dropped uterus,” “dropped vagina,” or “dropped rectum.” It affects 1 in 10 women.

TYPES OF PROLAPSE

When I have a cystocele, is it the bladder that I am seeing or feeling?

What you see is the vaginal epithelium or the lining. The bladder is the content of the prolapse. In other words, the boggy thing behind the vaginal lining is the bladder.

CYSTOCELE: Dropped bladder

RECTOCELE: Dropped rectum

RECTOCELE: Dropped rectum

Uterine Prolapse

Prolapse of the Uterus

Vaginal Prolapse

Vaginal Prolapse

Find Out How Pelvic Organ Prolapse affects 1 out of every 10 women.

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CAUSE:

Prolapse occurs due to the weakness of the support tissues of the genital organs. These tissues include ligaments, fascia and muscles. There are several factors that increase the likelihood of prolapse such as childbearing, menopause, strenuous activities, chronic cough, constipation, obesity and hysterectomy. In some cases there may be a strong genetic predisposition as her mother or grandmother may also have a history of prolapse.

At the time of a hysterectomy the support tissues at the top of the uterus are cut and this could lead to vaginal wall prolapse subsequently.

PROLAPSE SUCCESS STORY AT AUGM:

PREVENTION OF PROLAPSE

There is no single definitive way of preventing prolapse, as a woman cannot change her genetic profile which influences the strength of her connective tissues. She can, however, make wise choices that influence those risks which are modifiable.

In general, avoiding increased pressure inside the abdomen and on the pelvic floor is wise.  This can be done by:

  • Maintaining a normal weight or losing weight if overweight.  Overweight women are at a significantly increased risk of developing prolapse.

  • Constipation and chronic straining during bowel movement increase a woman’s chance of developing prolapse, especially a rectocele.  A diet with plenty of fiber and fluids, as well as regular exercise is important for maintaining regular bowel function.

  • Seek medical attention to evaluate and treat a chronic cough which increases abdominal and pelvic pressure.

  • Avoid heavy lifting and learn how to lift safely by using leg and arm muscles.

  • Don’t smoke! Smoking affects the strength of the connective tissues.

  • Avoid repetitive strenuous activities. A chronic cough should get checked out. Constipation should be corrected.

  • Learn and perform pelvic floor muscle exercises regularly to improve the strength of the pelvic floor, and limit the likelihood of developing prolapse.

SYMPTOMS OF PROLAPSE

This depends upon which wall of the vagina is affected.

  • If the anterior (front) wall is falling down then the patient has a bladder prolapse or a cystocele and this could lead to a sensation of incomplete bladder emptying accompanied by urgency and frequency.

  • If it is the posterior (back) wall of the vagina then the rectum is bulging into the vagina (rectocele) and this could lead to difficulty evacuating stools with the need to manually splint the vagina in order the empty the bowels.

  • If after a hysterectomy, the vaginal apex (top of the vagina) is falling then there is a small bowel hernia (enterocele) in the prolapse and this could cause low backache.

However, the most common and definitive symptom of a vaginal prolapse is the perception of a vaginal bulge coming at or outside the vagina, something the patient is very aware of and has to keep pushing inside. This is especially noticeable in the standing position.

DID YOU KNOW?

  • For a prolapse to warrant treatment, the patient usually should be able to feel it coming to or outside the vaginal opening.

  • If she cannot feel or see it then the diagnosis may be something else.

COMPLICATIONS DUE TO PROLAPSE

Mild to moderate prolapse does not typically lead to any complications, however, larger prolapses could. The typical problem is ulceration of the exposed vaginal lining mainly due to dryness from exposure to the outside, friction with the clothes and thighs, and venous engorgement just like varicose veins.

Moreover, the underlying prolapsed organ could malfunction. For example, with a large cystocele, the bladder may not empty completely and this could lead to repeated bladder infections with the danger of kidney infections. Moreover, the ureter (tube that travels from the kidney to the bladder) could now get bent or kinked and lead to back pressure and damage to the kidney.

A large enterocele or small bowel hernia may cause backache. A large rectocele may make bowel movements difficult. Patients get very constipated and have to push back on the vagina to empty their bowels.

MANAGEMENT OF GENITAL ORGAN PROLAPSE

The typical treatment options are:

  1. Surgery
  2. Pessary
  3. Expectant

When should a woman consider treatment for the prolapse?
Treatment of prolapse should be based on the symptoms. In rare cases, severe prolapse can cause urinary retention (inability to empty the bladder) that can progress to kidney damage or infection. When this occurs, prolapse treatment is considered urgent. In most cases, patients should be the ones to decide when to have their prolapse treated – based on the symptoms they are having. A woman should seek treatment whenever her symptoms have a negative impact on her quality of life. Vaginal and uterine prolapse, while common, is not a normal result of childbirth and aging. You do not have to ‘learn to live with it.’

Why should a vaginal prolapse be treated?
The main reason is a bulge that is bothersome due to its presence. In these cases, the bulge is coming outside the vagina and especially becomes prominent when the patient stands up. Though the other associated symptoms such as urgency/frequency, difficulty in emptying the bladder or constipation may be due to the prolapse, it is important to rule out any other causes prior to blaming the bulge.

Should every prolapse case be treated?
This usually depends upon the extent of prolapse and the level of bother to the patient. Typically any prolapse that protrudes out of the vaginal opening is usually bothersome to the patient.  Very large prolapses can lead to functional impairment such as urinary retention and cystitis. It could also kink the ureters and lead to obstructive damage to the kidneys.

SURGICAL TREATMENT FOR PELVIC ORGAN PROLAPSE

What are the principles of prolapse surgery?
1. To restore normal anatomy and function
2. Improve patient’s quality of life including sexual intercourse if desired.

How is this achieved?
This is achieved through reconstruction rather than extirpation (removal of the uterus). The uterus and the vaginal walls are attached to the strong pelvic ligaments and muscles in order to recreate the torn ligaments.

What is the difference between anatomic and functional success?
Anatomic success is when the vagina has been restored to its normal placement as noted by the surgeon on examination. Functional success means that the symptoms that the patient was complaining of such as a bothersome vaginal bulge, difficulty emptying her bladder or bowel and fear to have intercourse are improved by correcting the prolapse.

So, if there is anatomic success, will there also be functional success?
Intuitively it may seem that if the anatomy is corrected then the function also should improve. However, this may not happen. Sometime, anatomic success can also lead to new problems especially if the vagina is made too tight. This is more likely to happen with native (non-mesh) tissue repairs as the vaginal lining is trimmed and this scar tissue could result in a contracted vagina that may lead to pain during intercourse. So, anatomically the vagina may look perfect but functionally the surgery is unsatisfactory as the patient now has pain during intercourse. So a surgeon should always strive towards a functional success and not just anatomic success.

How to make sure that the patient is satisfied after the surgical intervention and experiences functional success?
It is important to understand why she is coming to the office and what her complaints are. We make sure that her complaints are truly due to the prolapse and only then would we embark on a surgical approach. The ultimate goal is to do no harm. In other words, we do not want to simply correct the bulge but her complaints are not relieved and now she has some other problems additionally.

GOALS OF SURGERY:

  • Provide lasting results with none or minimal complications

  • Get the prolapse corrected at the first instance and avoid risk of failure and recurrence

  • Understand the patient’s complaints and address function and not just the anatomy

  • Enroll patients in clinical trials so that we can continue to understand our outcomes and continue to improve

  • Correct the problem without creating any additional problems after surgery

HYSTERECTOMY AND PROLAPSE OF THE UTERUS

Is hysterectomy a treatment for prolapse?
Hysterectomy alone is NOT a treatment for prolapse. In fact women who have had a hysterectomy are at an increased risk for vaginal prolapse. If the uterus is falling down, traditionally most gynecologists and urogynecologists will perform a hysterectomy along with some type of vaginal wall suspension and repair.

Why is hysterectomy not a treatment for prolapse?
In cases of uterine prolapse, the uterus is in fact the victim or the consequence of the prolapse rather than the cause. Removing the uterus does not solve the problem as the support tissues are still weak and the vagina will subsequently fall down. Therefore the main treatment should be to reconnect to the strong tissues of the pelvis and fix the torn connective (support) tissues of the pelvis.

If a hysterectomy is done for other reasons besides prolapse, does this increase the risk of prolapse?
When a hysterectomy is performed the support ligaments are cut in order to remove the uterus. This weakens the vaginal wall supports and could result in vaginal prolapse.

Do you perform a hysterectomy for uterine prolapse at AUGM?
We do not perform a hysterectomy. Our surgical technique allows us to perform a uterine-sparing and uterine preservation surgery. This allows us to retain the entire vaginal depth. The cervix may also have a role in sexual function. Besides, a hysterectomy is associated with its own risks and complications especially bladder, bowel and ureteral injuries. We attach the uterus to the strong ligaments of the pelvis at the time of the vaginal augmentation surgery.

DID YOU KNOW?

  • A hysterectomy alone should never be performed for uterine prolapse.

  • Hysterectomy CAUSES prolapse

  • Despite this, 60% of patients with prolapse still undergo a hysterectomy without any additional repair!

PROLAPSE SURGERY: WHAT IS THE BEST ROUTE

What are the benefits of vaginal over a laparoscopic or open abdominal approach?
It is a matter of gaining access to the prolapse. For laparoscopy as in laparotomy (opening the abdomen), one has to enter the belly cavity. This may be a problem in morbidly obese patients or those with prior belly surgeries who may have significant scarring and adhesions in the belly cavity. Finally a laparoscopic approach in an elderly patient who is put in a steep Trendelenburg (head low) position could lead to heart/lung compromise.

With the vaginal approach, the surgical field is entered without any obstacles and an experienced surgeon can get the case completed even before the robot can be connected (docked) or the abdomen opened.

Unquestionably the vaginal route is the most preferred route as it is associated with minimal postoperative pain and the recovery is very speedy.

Why is it then that more surgeries are NOT done by the vaginal route?
This is mainly due to lack of training and experience on part of the surgeon. The American College of Ob Gyn (ACOG) is striving to increase the use of vaginal surgery as it clearly recognizes that this is a much safer route for the patients.

Does the robotic approach have any better outcomes?
Robot is another method to access the belly cavity and is not a surgery in itself.  Robotic laparoscopic surgery is not cost effective as compared to a non-robotic laparoscopic surgery.  The vaginal route is not only the simplest but also the least expensive.

Moreover, approaching the vagina from the vagina itself makes the most sense.

DID YOU KNOW?

  • NINOS: No Incision Natural Orifice Surgery

  • We perform the surgery completely vaginally without any outside incisions.

  • The recovery is faster, pain is lesser and healing is quicker.

PROLAPSE SURGERY: NATIVE TISSUE OR MESH SUPPORT

What is non mesh or native tissue repair for prolapse?
This is a surgery done using the patient’s own connective tissues. If the bladder is falling down then the fascial (native) tissue under the bladder is stitched together. With a rectocele or rectal prolapse into the vagina, the fascia between the rectum and the vagina is tightened and repaired.

Unfortunately, in patients with large vaginal prolapse, the supportive tissue becomes extremely sparse and weak and the risk of recurrence (failure) is very high. This has been especially seen in patients with large cystoceles where the risk of recurrence could be as high as 60%.

Does the prolapse surgery involve patient’s own (native) tissue or is some type of mesh augmentation necessary?
This depends upon the patient’s anatomy, extent of the prolapse, prior prolapse repairs, overall health, current medical conditions, her desire to retain sexual function and the experience and training of her surgeon. Every woman’s situation is different.  There is no single operation that is right for every patient. Patients with large prolapses and recurrences after a prior repair failure essentially have very weak tissues and using the patient’s own tissues risks a high failure rate. Patients with smaller degrees of first-time prolapse may be managed without a mesh. Our goal is to provide the patient the best success possible at the first intervention.

Does traditional vaginal surgery without the use of a mesh have lesser risks and complications than mesh surgery?
Essentially the dissection that is involved in mesh and non-mesh surgeries is very similar. Complications due to bleeding, hematoma (blood collection under the vagina), infection, scar tissue formation, pelvic pain, injury to the neighboring organs could happen with any type of surgery whether the mesh is used or not. In other words, complications occur due to the surgical procedure itself rather than the mesh material.

VAGINAL MESH SURGERY – WHAT ARE THE FACTS

What is the mesh made up of?
It is a weave of monofilament polypropylene (Prolene). Prolene is a permanent thread that has been used in surgery since the 1960s. The newer mesh used in vaginal surgery is light weight and macroporous (wide gaps in the mesh design) so that the body defense cells (macrophages) can pass through the large pores of the mesh in the presence of an infection and get it under control.

What is vaginal mesh surgery?
This is a surgery that involves correcting the prolapse by interposing a mesh as a scaffold to support the weakened connective tissue. The mesh then acts as a trampoline as it attaches to the strong muscles of the pelvis while supporting the pelvic organs such as the bladder, uterus/vagina and the rectum.

In what cases would you perform vaginal mesh surgery?
Our intention during any surgical intervention is to provide the patient with the best chance of success and to avoid coming back to the operating room neither for a complication nor for a failure. Also, we look at not just the anatomic success but also functional success— what was bothering her and what was her complaint.

Each prolapse case is individually assessed based upon several factors. Typically, vaginal mesh augmentation is performed for previously repaired prolapses that have failed or large primary prolapses where there is significant weakness of the natural tissues noted and the risk of future failure (recurrence) is high.

What about cases where the uterus is also falling out (uterine prolapse)?
Native tissue surgery is ineffective for supporting prolapsed uterus with failure rates as high as 75%. Thus, in these cases a hysterectomy is needed.

With vaginal mesh surgery, we can provide robust support to the uterus and anchor it to the strong ligaments and muscles of the pelvis and thereby avoid a hysterectomy. This is called vaginal mesh hysteropexy.

If the uterus is falling out and the patient is postmenopausal, why not just do a hysterectomy? What is gained by leaving the uterus behind?
In patients with prolapse, the uterus is merely a passenger and a “victim” of the prolapse and not the cause. In most cases the uterus is very tiny. By re-supporting it to the pelvic supports, the entire depth of the vagina is preserved and also the cervix may have a role in sexual function. More importantly, why do an unnecessary operation with its added risks and complications not to mention increased costs by the surgeon, hospital and the pathologist.

How is the vaginal mesh used?
After making an incision, the vagina is opened up like a window and the mesh is then placed between the bladder and the vagina in the front and the rectum and the vagina at the back. The mesh is secured to the top of the vagina or the uterus. It is attached to the deeper and stronger ligaments of the pelvis to restore the pelvic supports. There are no outside incisions as the entire procedure is done from inside the vagina. Once the mesh is attached, the vagina is closed with minimal or no trimming of the vaginal lining. This restores the entire depth of the vagina. In other words, the falling uterus and vagina are turned from outside to back in. The mesh acts like a hammock on which the pelvic organs now rest.

SAFETY OF VAGINAL MESH SURGERY

Is mesh safe?
The polypropylene mesh is inert and does not shrink, contract, break down, degrade or change shape. Mesh surgery, like any other vaginal surgery has its inherent risks of complications. However, when performed by an experienced surgeon, the risks/complications are very low and the success very high. Therefore, the risk benefit ratio is very favorable when done by an experienced surgeon AND for the correct indication.

Does mesh cause cancer?
No. Mesh does not cause cancer. Polypropylene mesh has been used extensively over the past 50 years and there has been no known case of cancer.

DID YOU KNOW?

Vaginal mesh surgery, if done by an EXPERIENCED SURGEON for the CORRECT INDICATION and in the APPROPRIATE PATIENT produces excellent results with minimal complications.

Once implanted, can the mesh be felt by the patient or her partner?
The mesh resides under the vaginal epithelium. Hence, once the vagina heals, the mesh can neither be seen nor felt by the patient or her partner.

Does the mesh migrate or move after it is placed?
Within a few weeks, there is scar tissue formation. Once this happens, the mesh stays where it was implanted and does not move.

Does the mesh shrink inside the vagina?
The mesh does not shrink. The tissues around the mesh can shrink as part of scar tissue formation. However, this process can happen whether a mesh is used or not.

Does the mesh cause a lot of scarring? Will it get infected over time as it is a foreign body? Will my body ever reject the mesh? Does the mesh degrade?
Scarring can happen with any type of vaginal surgery and is not unique to mesh. The mesh is macroporous i.e. the mesh pores are wide and therefore the risk of infection is very low. The material has been used extensively and there have been no cases of rejection.

Does mesh cause pain?
Mesh by itself does not cause pain. Any surgery in the vagina can cause scar tissue formation and has the risk of vaginal/pelvic pain. This is not unique to the mesh. In fact, with native (non-mesh) vaginal repairs, the vaginal epithelium is trimmed and a hysterectomy is performed. This in fact could result in shortening of the vagina and pain during intercourse.

With mesh surgery, the vaginal epithelium is not trimmed and we leave the uterus in place. Hence, the entire vaginal caliber is maintained and the vagina is simply reverted back to where it belongs.

If a mesh complication were to happen, does the mesh have to be removed in its entirety?
This is very rare. I have never had to remove a mesh in its entirety. However, if this is required for some rare reason, yes, it could be removed.

Are there any complications unique to the use of mesh in the vagina?
Mesh surgery essentially involves a similar dissection to non-mesh surgery. Complications can happen with either type of surgery as it is usually a factor of dissection and understanding the underlying anatomy. With mesh surgery, the mesh exposure in the vagina is a unique finding where the mesh can now be seen in the vaginal cavity. This is not due to an intrinsic problem with the mesh but is a consequence of healing of the vaginal incision. Every surgeon has experienced a belly incision breakdown. However, if there is a mesh at the base of the wound then it may not heal back up.

Even though this is considered to be a complication of the mesh, it is actually a complication of poor wound healing than the mesh itself. The mesh itself does not actively protrude through the vaginal wall.

So, if there is a mesh exposure in the vagina, does this need to be surgically corrected?
This depends upon the patient’s symptoms. If she has no complaints and neither she nor her partner, are affected by this then it could be left alone. The exposed mesh does not get infected and can be very much be managed expectantly.

On the other hand, if her partner can feel it during intercourse or if she notices vaginal spotting or discharge then the exposed mesh may have to be trimmed. Based upon accessibility, this could be done in the office or under sedation in the operating room.

ADS ON TV BY LAWYERS WHAT ARE THE FACTS

Vaginal mesh is seen all over the TV in the form of ads from the attorneys. What are the facts?
The FDA stated that vaginal mesh complications are not rare. However, it is not correct to simply blame the mesh. There are so many factors that need to be taken into consideration when deciding the correct management approach. In other words, not all patients are suited for mesh surgery and mesh surgery works best in some others.

Is there any truth or validity to the ads seen on TV against mesh?
In a way the ads have some relevance as these mesh surgeries were being done by surgeons with limited experience and knowledge of this field.  The ads have helped in that the “recreational” surgeon doing these cases maybe once every few months, has stopped doing them altogether.

Vaginal mesh surgery when done by an experienced surgeon and for the correct patient is very successful with low risk of complications. This is what our results have shown.

Why do we see so many advertisements on TV about mesh from lawyers?
Mesh surgery is not easy. It is not the mesh itself but the actual surgical dissection and technique which is complex. It requires a certain skill set. It should be done by surgeons who do this all the time and more importantly, follow their patients to see how they do over time. Hence if done by a novice or inexperienced surgeon complications could occur.

What is so complex about vaginal mesh surgeries?
It demands a detailed awareness of the pelvic anatomy especially when seen from the bottom up, in reverse. Also, a lot of surgical work is done through small spaces and mostly by feel. Hence, proper dissection, understanding of altered anatomy from prolapse and surgeon experience is crucial. The learning curve for this surgery is steep and difficult. More importantly, the surgeon needs to keep his/her skills up by doing a fair number of cases per month.

So, if it is someone like you with a very high skill set and experience, can one avoid complications?
No surgery is free of complications. Our experience and skill level helps minimize this to very low and acceptable numbers. We follow our patients and our complication rate is very low as stated later on.

Then there are a lot of factors involved, not just the mesh, right?
That is correct. We call them: the patient factors, the surgeon factor and the material factors. Finally, the interplay of all these together determines the outcome.  For example, if the patient is morbidly obese, an uncontrolled diabetic, or a smoker then her healing would be impaired.

I understand what you just said, however, when you see the ads on TV repeatedly, one cannot help but get spooked…
We understand that. However, ultimately you have to go by the true facts. We at AUGM can provide these to you as we are continuously doing clinical trials and are familiar with our outcomes.

I cannot vouch for other surgeons and their outcomes or complications. We can give you our facts and the data that we have collected from our surgeries. So when you see the ads, you must understand that yes, some of this information is true but you have to put in the right context:

  1. Who is YOUR surgeon?
  2. What is OUR experience?
  3. Why are we recommending the procedure in your case?
  4. What are the risks of failure if mesh is not used?
  5. What are the risks/benefits based upon our experience in your specific case

DID YOU KNOW?

TV ads by lawyers do not tell the true story. Slings have been found to be safe by almost all medical societies unlike what the lawyers claim in their ads on TV.

OUR SCIENTIFIC PUBLICATIONS ON VAGINAL MESH SURGERY AT AUGM

We have an extensive experience with vaginal mesh and vaginal augmentation surgery for both prolapse and urinary incontinence. Dr Khandwala has been performing mesh prolapse cases since 1997 when the abdominal sacrocolpopexy was the predominant route. Since 2003, he has been using vaginal augmentation surgery for prolapse.

Dr Khandwala has done over 1000 cases of vaginal prolapse mesh cases and has one of the largest series in the world. More importantly we track our outcomes and analyze our data to see where we are and how we need to continue to improve.

1. Prolift study:

a. First vaginal mesh compact kit
b. Retrospective study of 315 cases of Prolift surgery from June 2005 to March 2009
c. Our anatomic success was 93.4% overall and 97.8% for the treated compartment.
d. The mean blood loss for all patients (n=315) was 106.7 mL.
e. The incidence of mesh exposure in this series was 6.6% (n=21).

2. Prolift + M study:

a. Prospective study in 157 consecutive subjects from April 2009 -November 2010.
b. Anatomic success was noted in 94.0% cases.
c. There were no intraoperative injuries.
d. Average hospital stay was 1.2 days; essentially overnight.
e. The mean blood loss was 106.1 mL. No subjects required blood transfusion.
f. There were no cases of postoperative hematoma.
g. 2% had vaginal mesh exposure lower than the 15% quoted in the literature.
h. There were no cases of mesh erosions into the urethra, bladder, or the rectum.
i. De novo dyspareunia (pain during sex) was noted in 6%) of 50. The typically quoted dyspareunia rate for mesh prolapse surgeries reported by other groups has been between 14.5 -36.1%.

3. Vaginal mesh hysteropexy study: Up to 40% of women undergoing hysterectomy subsequently present with vaginal vault prolapse.Vaginal mesh hysteropexy (saving the uterus at surgery) was performed at our center in 77 subjects who met the inclusion criteria from the time period 11/06/2008 to 02/23/2011.
The anatomic success, postoperative POP-Q Stage ≤ II was noted in 91% patients.

This is in contrast to native tissue repairs where Lin et al52 reported a FAILURE  rate of 75% for stage III or IV prolapse and also found that ALL subjects with a preoperative prolapse stage IV had recurrent apical prolapse after a native tissue repair. Based on their data, they advise against performing a sacrospinous non mesh hysteropexy in case of a stage III or IV uterine descent. In our study, with an overall success score of 85.7%, more patients with larger prolapse (stage IV) were successes than failures.

4. Large series of Prolift+M

a. Retrospective study in the first 250 consecutive cases of pelvic organ prolapse managed from September 2008 to November 2010.
b. Our composite success score was 89.2%.
c. Pure anatomic success was 94.1%.
d. Mean intra-operative blood loss was 109.28 mL.
e. There were no erosions into the bladder or the bowel. There were no injuries.

5. Exair mesh surgery 1 year follow up, 2016:

a. Transvaginal Exair mesh was performed in 80 subjects for pelvic organ prolapse.
b. 86% had large stage III or stage IV prolapse
c. Our composite success score was 93%.
d. The hysteropexy (uterine preservation) success was 92%
e. Mean intra-operative blood loss was 181 mL.
f. There were no organ injuries.
g. There were no cases of de novo dyspareunia (pain during sex), vaginal wall retraction, voiding dysfunction or de novo incontinence.

6. Restorelle mesh hysteropexy study (2017)

This is an ongoing study to assess the role of Vaginal mesh (Restorelle) for the management of large uterine prolapse. The aim is to see if a hysterectomy can be completely avoided for prolapse management. The subsequent aim is to teach other doctors our technique so that this can be studied at different sites across the country.

7. Postoperative pain management after vaginal mesh surgery (2017)

This study is being done using a special anesthetic technique done by the surgeon (Dr Khandwala) in order to reduce the need for pain medications after surgery. The goal is to make the surgery almost pain-free so that the patients can start bladder function right away and hopefully be discharged home sooner.

SUMMARY OF OUR RESULTS:

  1. Very high success: over 90%
  2. Very low risk of failures that require further surgery: <5%
  3. No intraoperative injuries
  4. Very low risk of postoperative complications: MINOR: 5%, MAJOR: 0%
  5. Quick recovery: most patients (95%) go home the next day after surgery

DID YOU KNOW?

Dr. Khandwala has done over 1,000 vaginal mesh surgeries and his risk of complications is <5% overall with no major complications.Our success for prolapse correction is over 90%.

FDA ADVISORY REGARDING MESH USE IN THE VAGINA

FDA in June 2011 stated that mesh complications are NOT RARE. They suggest that the patient should ask their surgeon questions as to their experience and alternative options. Below are some of the questions and Dr. Khandwala (AUGM) answers.

Are you planning to use mesh?
AUGM: Our decision to use mesh for a surgical intervention is based upon each individual case. Based upon history, prior surgery, patient beliefs, desire to save the uterus, sexual function etc, we come up with what is the best treatment for the patient (outlined earlier).

Why do you think I am a good candidate for mesh surgery? Why is surgical mesh chosen in my case?
AUGM: We decide based upon a comprehensive medical and surgical history and also the patient’s tissue supports and assessment of vaginal wall anatomy. If it seems that all these factors indicate that vaginal mesh would provide the best chance of success then that is what would be recommended. We typically use mesh when it seems that the fascial (tissue) defects are significant and there is a higher chance of failure if native (your own) tissue repair is performed. This is usually the case especially if this is a recurrent prolapse.

What are the alternatives to transvaginal mesh?
 AUGM: As stated earlier, the treatment options are expectant, pessary, native tissue and mesh surgery.

What are the pros and cons of using a mesh? How likely is it that my surgery could be performed without the use of mesh?
AUGM: Vaginal mesh surgery has been performed in several thousand patients. There have been several studies that show that vaginal mesh surgery is associated with very good results with minimal risk of complications provided it is done by an experienced surgeon and for the correct indication. The major advantage of vaginal mesh is that there would be a lower risk of recurrence or failures. Nonetheless, not all prolapse patients need mesh interposition. The treatment is decided on a case by case basis. The only unique complications seen with the use of mesh is mesh exposure and this happens due to poor tissue healing under the mesh and not due to the mesh itself. All other complications seen with prolapse surgery such as pelvic pain, pain during intercourse, infection, injury can also occur with native tissue (non-mesh) repair.

What is your experience with vaginal mesh surgery?
AUGM: We have done over 1000 cases of vaginal mesh surgery and have been doing this since 2005. We have published our results in peer-reviewed scientific journals. Please refer to page 15 for our results.

What can I expect to feel after surgery and for how long?
AUGM: Postoperative course is outlined in the brochure provided to you. This is similar to the traditional vaginal surgeries for prolapse. Anything that is done uniquely in your case such as postoperative vaginal support device placement will be discussed with you.

What side effects should I report after surgery?
AUGM: This has been mentioned in detail in our handout provided to you. Essentially anything that does not feel right should be reported. Please follow our detailed postoperative instructions.

If there is a complication, will you take care of it?
AUGM: Yes. We will take care of it and depending upon the extent of the complication we may involve an ancillary service and co-manage the problem.

If I have a complication related to the surgical mesh, how likely is it that the surgical mesh could be removed and what could be the consequences?
AUGM:  To date, we have never removed a mesh in its entirety and we have done over 1000 cases by now. This is already good news. However, for some reason if the mesh has to be removed, we could remove this mostly vaginally.

If a surgical mesh is to be used, is there patient information that comes with the product and can I have a copy?
AUGM: This is included in your peri-operative packet. It relates to the particular mesh that we use called the Restorelle. Besides our exhaustive book on prolapse you will also be handed the pamphlet from Coloplast (company) about the Restorelle mesh that we will be using.

After the surgery, what does the FDA recommend?
1. Come for assessment at least annually. We at AUGM have a set protocol and would like to see you within the time frame of your visit. If you do not come we will call you to remind you. We care about you!
2. Inform your doctor if you have any problems. If you have any questions, do not hesitate to call us.

DID YOU KNOW?

TV ads by lawyers do not tell the true story. Slings have been found to be safe by almost all medical societies unlike what the lawyers claim in their ads on TV.

EXPECTANT MANAGEMENT:

Not all prolapse cases need to be treated. In women who have mild prolapse OR are not bothered by the bulge, expectant management with every 6 monthly examinations may be appropriate.

AT AUGM, we want every woman to get her freedom back.

pain during sex

PELVIC FLOOR THERAPY:

This involves strengthening the pelvic muscles by using an electrical stimulation device. This is done in the office without anesthesia and takes about 40 minutes to perform and is done once a week for 4-6 weeks. It is best done in:

  • In patients with mild prolapse, this may retard the progression of prolapse
  • Ancillary symptoms such as urgency may also improve with pelvic floor therapy
  • Postoperatively after the surgery, it strengthens the pelvic muscles and thereby would help with the surgical repair also

PESSARY MANAGEMENT

What is the role of a pessary?
A pessary is a silicone device that sits inside the vagina and keeps the prolapse from falling out. Though it does not correct the underlying defect, it “hides” the bulge inside. Although indicated for any patient with prolapse, it is typically beneficial for patients who are high risk for surgery.

Does the pessary have any complications?
Pessaries can also have complications. The ring pessary, which is typically used, has fewer complications, but can result in erosions of the vaginal walls, foul-smelling vaginal discharge, vaginal spotting and urinary leakage. It is not uncommon for the pessary to be periodically left out due the foul-smelling discharge or vaginal wall erosions from the constant rubbing against the vaginal epithelium.

The Gel-horn pessary has a higher risk of complications as the stem of the pessary could cut through the vaginal walls and perforate the neighboring organs such as the bladder or the rectum causing a fistula. Though this is rare, it could be a life-threatening complication of the pessary.

Is the pessary well-tolerated by the patients?
In most cases at least there is some degree of vaginal discharge which can become a nuisance for the patients. This is especially the case in postmenopausal women who have vaginal atrophy (thinning) to begin with. Pessaries should be removed and cleaned on a regular basis.

What are the long term implications of a pessary?
Pessaries have to be managed on an ongoing basis for the rest of the patient’s life. At any time, if it is left out, the prolapse will come back. Over time it may become increasingly difficult for the patient to come into the doctor’s office 4 times a year for pessary cleaning and management. This should also be taken into consideration when recommending a pessary.

Can the patient have intercourse with the pessary in place?
This is possible but difficult with the ring pessary and impossible with some other types of pessaries. Hence sexually active women have to remove the pessary prior to intercourse.

Other surgeries:

  • Colpocleisis: This is done in women who do not desire sexual function and have significant medical comorbidities. This procedure is done vaginally and involves closing off the vagina.
  • Sacrocolpopexy: This involves attaching the vagina to the tail bone (sacrum). This is done through the belly.

DID YOU KNOW?

A pessary also can cause complications which in some cases could be worse than surgery especially if there is a bladder or bowel perforation from the pessary device.