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