Who is uterine prolapse surgery recommended for? Vaginal repair, sacrocolpopexy, removing or preserving the uterus, mesh, preparation, risks and recovery.
Uterine prolapse surgery is the general name for surgical procedures that aim to support again the prolapsed uterus or, if the uterus has been removed before, the upper end of the vagina (the vaginal vault). Surgery is considered when the symptoms bother you; the route and method are chosen together with your doctor according to the site of the prolapse and your situation. The information below offers a general framework; it does not replace the individual assessment made for you.
Who is uterine prolapse surgery considered for?
Surgery is considered if the prolapse symptoms disturb your daily life, if you have not benefited enough from non-surgical approaches such as a pessary or pelvic floor muscle training, or if you do not want these approaches. What the symptoms are, the stages of prolapse and the non-surgical options are a separate subject; the decision for surgery is made after this assessment.
How is the surgical route chosen, and what is the aim?
In choosing the surgical route (vaginal or through the abdomen), the area in which the prolapse lies, your state of health and your expectations about sexual life play a part. The aim of the operation is to suspend the uppermost part of the vagina (the apical region) from the sound tissues of the pelvis. If there is also prolapse of the front or back wall, repair of these areas can be added to the same operation. If you plan a pregnancy, the timing of the operation and whether the uterus will be preserved are discussed separately with your doctor.
What options are there in apical prolapse surgery?
Which operation suits you varies from person to person. The options are broadly divided according to three questions: vaginal or through the abdomen; your own tissue or a mesh for support; whether the uterus will be removed or preserved.
How is vaginal tissue repair performed?
In these methods no incision is made in the abdominal wall, and your own connective tissue is used. In sacrospinous ligament fixation, the upper end of the vagina is attached with stitches to a strong ligament at the side of the pelvis; this supports the upper vagina and preserves vaginal length. In uterosacral ligament suspension, the vaginal vault is hung upward by being tied to the uterosacral ligaments that pass behind the uterus. These two suspension methods show similar effectiveness and a similar side-effect profile.
What is sacrocolpopexy, which is performed through the abdomen?
In sacrocolpopexy, the vaginal vault (or the cervix if the uterus is preserved; in this case the procedure is called sacrohysteropexy) is attached with a thin mesh strip to the ligament in front of the bone in the lower back, the sacrum. The procedure can be performed by the laparoscopic, robotic or open route. No clear difference has been shown between these routes of access; the choice is made according to the doctor's assessment and your situation.
In people whose uterus has been removed before and who have developed prolapse of the vaginal vault, sacral colpopexy has been found to be associated with lower rates than vaginal procedures in outcomes such as awareness of prolapse, repeat surgery for prolapse and prolapse on examination. However, the reliability of these data varies from very low to moderate.
Should the uterus be removed or preserved?
In prolapse the uterus can be removed (hysterectomy) or preserved. Removing the uterus alone does not support the upper end of the vagina; it is recommended that apical support is also provided during or after hysterectomy. Approaches that preserve the uterus are also among the options. When surgery that preserves the uterus is compared with adding a suspension to vaginal hysterectomy, no clear conclusion can be drawn from the available data. Whether there is a separate problem in the uterus that needs treatment, and your preference, influence this decision.
What is an obliterative operation, which closes the vagina?
There are also procedures in which the vagina is partly or completely closed (colpocleisis). Vaginal sexual intercourse is not possible after these procedures; for this reason they can be considered in people who have no expectation of sexual intercourse, and the decision is made after a detailed discussion.
What are the benefits and risks of using mesh?
The mesh discussion involves two separate questions, and the two should not be confused.
The first is repair of the vaginal wall (front or back) with a mesh placed through the vagina. The data show that a permanent mesh placed by this route can bring benefit in some outcomes, but is associated with bladder injury, new urinary incontinence and the mesh coming through the tissue to the outside; because of this balance of benefit and risk, the value of permanent transvaginal mesh in a first operation is found to be limited. Guidelines on this subject also do not open these mesh repairs to routine use, and consider them applicable only within a research arrangement. This assessment belongs to wall repair; it does not cover apical sacrocolpopexy.
The second is the mesh strip placed from inside the abdomen in sacrocolpopexy. This is a different procedure; no direct inference can be drawn for it from the data on vaginal wall mesh. In sacrocolpopexy too, there is a possibility of the mesh becoming exposed and of an additional procedure being needed; if mesh is to be used, its possible benefit and risks should be discussed with you in detail before the operation.
How do you prepare for the operation?
Planning starts with an examination that shows at which level the prolapse is greatest (uterus, vault, front or back wall) and whether there is an accompanying urinary or bowel problem; your doctor requests tests if they think it necessary. If the uterus will be preserved, the suitability of the cervix and the lining of the uterus is also reviewed. Having had an abdominal or pelvic operation before, your chronic illnesses and the medicines you take regularly influence the choice, particularly of methods performed through the abdomen such as sacrocolpopexy. The team will explain to you, in writing or verbally, the restriction on eating and drinking before the operation, whether medicines are to be continued and, if needed, bowel preparation. The measures to be taken against the risk of clots in the leg veins are determined separately according to your level of risk.
Whether local oestrogen will be used before or after the operation in the post-menopausal period is a separate decision for the doctor.
How do the day of the operation and the first days go?
The type of anaesthetic is decided by the anaesthetic and surgical team according to the surgical route. The duration of the operation and the hospital stay depend on the chosen method and on any additional procedures done together. After the operation you may have a urinary catheter in place; when the catheter is removed, and the monitoring of your passing urine afterwards, depend on the doctor's instructions. Pain relief, moving early and taking fluids are part of the care in the first days. The operation is performed by Assoc. Prof. Dr. Nurettin Türktekin at Memorial Şişli Hospital.
What are recovery and return to daily life like?
In the first days there may be tiredness, a feeling that the bladder is not emptying fully when you pass urine, a pulling sensation in the buttock or groin, mild cramp in the lower abdomen and light spotting or brown discharge.
Because the suspended vaginal vault can be strained by pushing, teams often emphasise making arrangements that soften the stool and being careful when lifting. When you can return to walking, sport, work and sexual intercourse, and your follow-up schedule, vary with the surgical route and how quickly you recover, and are given to you in writing by the team that performs the operation.
What are the risks, and how likely is the prolapse to come back?
In apical support operations, setting the anaesthetic risks aside, the following can be encountered:
- Bleeding and infection
- Injury to the bladder, ureter or bowel
- Temporary difficulty passing urine; in some people, new urinary incontinence
- Constipation and a change in bowel habit
- Pain or discomfort during sexual intercourse
- Clot formation in the leg veins
- In methods that use mesh, the mesh becoming exposed and an additional procedure being needed
- The prolapse reappearing in the same place or in a different area
No method guarantees that prolapse will not happen again. The likelihood of recurrence varies with the person, the stage of the prolapse and the chosen method. Your personal level of risk is assessed together with your doctor at the pre-operative consultation.
Frequently Asked Questions
Can I have surgery directly without trying a pessary or exercise?
Yes, they do not necessarily have to have been tried first. Surgery is considered if the prolapse symptoms disturb your daily life, if you have not benefited enough from non-surgical approaches such as a pessary or pelvic floor muscle training, or if you do not want these approaches.
Can I have prolapse surgery without my uterus being removed?
Yes. In prolapse the uterus can be removed (hysterectomy) or preserved; approaches that preserve the uterus are also among the options. Whether there is a separate problem in the uterus that needs treatment, and your preference, influence this decision.
Is mesh always used in prolapse surgery?
No. The use of mesh varies with the situation and should be treated as two separate subjects: because of the balance of benefit and risk, the value of a permanent mesh placed through the vaginal wall in a first operation is found to be limited, and guidelines do not open it to routine use. The mesh strip placed from inside the abdomen in sacrocolpopexy is a different procedure; if it is to be used, its possible benefit and risks should be discussed with you in detail before the operation.
By which routes can sacrocolpopexy be performed?
Sacrocolpopexy can be performed by the laparoscopic, robotic or open route. No clear difference has been shown between these routes of access; the choice is made according to the doctor's assessment and your situation.
Does prolapse come back after the operation?
No method guarantees that prolapse will not happen again. The likelihood of recurrence varies with the person, the stage of the prolapse and the chosen method; your personal level of risk is assessed together with your doctor at the pre-operative consultation.
What is assessed at the first check after the operation?
At the check you are generally asked about, and examined for, wound healing, passing urine and bowel function, and whether your prolapse complaint continues. The timing of the check varies with the surgical route; your doctor will give you the schedule.
Does prolapse surgery affect sexual life?
The effect varies from person to person and no definite generalisation can be made. There may be pain or discomfort during intercourse after the operation. The doctor who sees the healing at the follow-up examination tells you when to return to intercourse. Because your expectations about sexual life can change the method that will be chosen, it is sensible to state them clearly at the first consultation.
Is pain in the buttock or leg expected after sacrospinous fixation?
In this method the stitches are placed in a ligament deep in the buttock, so there may be temporary pain in the buttock or leg. If the pain is getting steadily worse or does not respond to painkillers, let your doctor know.
When can I return to walking, work or sexual intercourse after the operation?
This varies with the surgical route and how quickly you recover; the team that performs the operation will give it to you in writing.
What should I pay attention to about bowel movements after the operation?
Because the suspended vaginal vault can be strained by pushing, it is recommended that you make arrangements that soften the stool and are careful when lifting; teams often emphasise this.
What information is it useful to bring to the pre-operative consultation?
How long you have had the prolapse and your urinary or bowel complaints, the non-surgical methods you have tried, the medicines you take regularly, the operations you have had, your pregnancy plans and your expectations about sexual life all influence the choice of method. Bringing these in writing makes the consultation easier.
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