Aging, childbirth, prior surgeries and genetics all can cause the various organs of a woman’s pelvis to descend resulting in discomfort as well as functional impairment. Treatment options are dependent on the location and extent of the descent as well as a person’s individual sense of bother and can range from non-surgical to surgical reconstruction. Often times Prolapse and incontinence are present in the same patient and these issues can often be addressed in a single operative setting if appropriate.
Cystocele (Dropped Bladder)
This is the most common type of prolapse and occurs when the wall separating the vagina and bladder weakens allowing the bladder to relax against the vaginal wall causing a bulge in the anterior or top wall of the bladder. This may lead to discomfort especially after standing for a long time or during physical activities such as hiking or golf. Cystoceles can also result in difficulty emptying the bladder and in some circumstances predispose a patient to urinary tract infection. This condition can be treated conservatively using a pessary device to hold the bladder in the correct position; however in patients who are not interested in the maintenance of such a device, surgical options are available and can be discussed in detail. These surgeries are almost always outpatient with the patient able to return to work soon after surgery with minimal discomfort or bleeding. Additionally, most patients do not require a urinary catheter following surgery.
Rectocele (Dropped Rectum)
In the same way that the wall separating the vagina and bladder can weaken, so can the separation between the rectum and the vagina. This results in relaxation and bulging of the rectum against the posterior or bottom facing wall of the bladder. This may also lead to discomfort after standing for long periods of time, during periods of exertion or during intercourse. Rectoceles are often known to cause difficulty with evacuating the bowels and an especially symptomatic patient may find that she actually needs to push against the skin of the vagina or perineum in order to help guide the stool out and more efficiently empty the bowels. As with the bladder, minimally symptomatic patients may observe this issue or opt for a pessary device. However, those who are more symptomatic or have more dramatic prolapse often require surgical intervention. These surgeries are performed on an outpatient basis as well, with most patients not requiring a urinary catheter following surgery.
For women that have had a hysterectomy, apical prolapse refers to the descent of the very tip of the vagina, the portion that was once in contact with the cervix. For women who have not had a hysterectomy, apical prolapse refers to descent of the uterus itself. In women who have had either a cystocele repair, rectocele repair or both in the past, with recurrence of the bulges and discomfort a few years later, apical prolapsed is often the culprit. Support of the vaginal apex is the keystone of any successful reconstruction. However, this type of repair is also the most surgically complex and demanding, often times requiring additional surgical training to perform. Vaginal apex repairs rely on finding suitable tissues in the abdomen or pelvis to anchor the tissue to. Such tissues include ligaments and bony structures and can be accessed vaginally, abdominally or laparoscopic/robotically
Uterine prolpase has traditionally been treated with a hysterectomy followed by vaginal vault suspension by any of the aforementioned techniques. However recent studies have revealed that women do not need to have a hysterectomy when otherwise healthy and this is often in keeping with their personal philosophies. Due to our advanced training, we are able to offer uterus sparing vault suspension (hysteropexy) in addition to the more traditional operations making all options available to our patients.
Alaska Urology is able to offer everything from open abdominal repairs to minimally invasive robotic type repairs because of the trained physicians in the group.
One of the most significant surgical advances in Urology and Gynecology in the past generation has been the development and perfection of robot-assisted laparoscopic surgery. By using advanced robotic technology to magnify and refine a surgeon’s motions, complex surgical procedures can now be done through incisions the size of keyholes. This has led to a clear benefit to patients, with decreased hospital stays and quicker recovery due to the decrease in morbidity caused by larger abdominal incisions. The predominant robotic system used throughout the United States is the da Vinci® Surgical System. The surgeons of Alaska Urology have had extensive training and experience with this system and are able to offer robotic-assisted surgery to their patients.
Robotic surgery has made vaginal vault suspension a much less morbid procedure. Whereas previously a 10-15 cm incision would be required on the abdomen to provide enough visualization to perform surgery, we are now able to perform an identical procedure through 4 or 5 keyhole incisions on the abdomen.
A few modifications to this technique are employed to provide uterine-sparing surgery depending on the wishes of the patient and their medical history. Following robotic surgery, patients of all ages are able to go home within 24 hours of entering the hospital, usually without a urinary catheter, walking under their own power.