Cosmetic/Pelvic Repair Surgery at Total Care for Women by James J. Purdy MD FACOG

Gyn-Urologic reconstruction at Total Care for Women

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Pelvic relaxation is condition of weakness in the supporting structures of the female pelvis, this condition causes descent (prolapse) of one or more of the pelvic organs through the vagina. These pelvic organs include the uterus, top of the vagina, vagina or vaginal cuff, bladder and rectum. The pelvic floor is weakened by the passage of the urethra, vagina and rectum through this urogenital diaphragm. Various factors throughout a female's life weaken this connective tissue and cause it to rupture in various places . The result is a gradual or sudden herniation of pelvic organs..

Causes of pelvic relaxation:

Trauma incurred during the birthing process, particularly with large babies or after a difficult labor and delivery, is one of the main causes of the muscle weakness that leads to uterine prolapse. Reduced muscle tone from aging, as well as lowered amounts of circulating estrogen after menopause, may also form contributing factors in pelvic organ prolapses. In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity.

Genetics also may play a role; women of Northern European descent experience a higher incidence of uterine prolapse than do women of Asian and African heritage. ²

Finally, increased intra-abdominal pressure, stemming from such diverse conditions as obesity, chronic lung disease and asthma, can be contributing factors in uterine prolapse.

Risk Factors

One or more pregnancies and vaginal births
Giving birth to a large baby
Increasing age
Frequent heavy lifting
Chronic coughing
Frequent straining during bowel movements

Statistics

In the U.S., pelvic support defects are relatively common and increase with age. One study of more than 16,000 patients found the rate of uterine prolapse to be 14.2%. The mean age at time of surgery for pelvic organ prolapse was 54.6 years.

U.S. studies have found Hispanic race to be correlated with prolapse. By contrast, African Americans had the lowest risk of uterine prolapse. These findings were independent of parity, age, and body habitus, suggesting a genetic component to prolapse.

Anatomy

Normal Female Pelvis The urethra and bladder are located in front of the vagina, the cervix and uterus at the upper portion of the vagina forming the top or apex. The rectum is behind and below the vagina. When prolapse develops from failure of the supporting tissues to keep these structures in place, one or a combination of abnormalities may occur: the urethra and bladder may descend into the vaginal canal from the front wall (urethrocele or cystocele), the cervix and uterus may descend down the vaginal canal from the top (uterine prolapse), and the rectum may ascend into the vagina from the back wall (rectocele). The forces of the lower abdomen may push behind the uterus or the vaginal apex (if the uterus and cervix has been removed) and dissect downward and create a hernia sac between the vagina and the rectum (enterocele). This sac may contain intestines. Pelvic relaxation can vary from minimal descent, causing few if any symptoms, to major descent in which one or more of the pelvic organs literally fall outside of the vagina causing significant health and personal comfort problems. The degree of descent often varies with position and activity level, increasing with standing and with exertion, and decreasing with lying down and resting.

Because the female genital tract and urinary tract share same pelvic connective supporting tissue (urogenital diaphragm)), pelvic relaxation can cause significant changes in urination. sStress urinary incontinence or USI (a leakage of urine from the urethra associated coughing or sneezing), to bladder retention and inability to empty the bladder of urine unless the prolapsed bladder is reintroduced deeper into the vagina. Pelvic reconstructive surgery can restore normal anatomy and function with the new surgical techniques. Non-operative treatment of pelvic relaxation is used when symptoms are minimal or when surgery cannot be performed because of the patient's state of health. Such conservative treatment options included change of activities, management of constipation and other conditions that increase abdominal pressure, pelvic floor muscle exercises (Kegel exercises), hormone replacement therapy, and pessaries. A pessary is essentially an artificial plug that is inserted into the vagina to act as a "strut" to help provide pelvic support. In many cases topical estrogen hormone therapy can help revitalize the aging pelvic tissue and reduce some intensity of symptoms.

For approximately 100 years, the repair of pelvic prolapse has relied on hysterectomy and the use of the patient's own tissues to create new support for the pelvic organs. This technique failed in up to 50% to 80 percent of cases within one to five years of surgery,

Repairing weakened connective tissue (fascia) of the urogenital diaphragm or pelvic floor causes contined failure. Dr. Purdy uses the latest techniques to repair the damaged connective tissue with insertion of fetal calf tissues called Xenform grafts by Boston Scientific corporation. Today, another approiach in pelvic floor repair relies on synthetic "mesh" material to reinforce a woman's normal supporting tissues. These meshes are made of various types of synthetic thread similar to fine fishing line, woven into fabric sheets and then sewn in place to repair the various types of pelvic floor support failures.

Uterine prolapse and repair

Uterine prolapse results from descent of the uterus and cervix because of weakness of their supporting structures. This condition is frequently called a "dropped uterus," Normally the cervix is located at the top of the vagina. As uterine prolapse progresses, the amount of descent into the vaginal canal will increase. Uterine prolapse is graded as follows:

Grade 1: mild descent of the cervix towards the vaginal opening with strain

Grade 2: the cervix reaches the vaginal opening with strain

Grade 3: the cervix reaches beyond the vaginal opening with strain

Grade 4: the cervix and uterus are outside the vaginal opening at all times (also called procedentia)

The symptoms of uterine prolapse are typically one or more of the following:

a bulge or lump protruding from the vagina
a sense of "dropping out" and lack of pelvic support
an involuntary loss of urine or the need to "manually reduce" (push back) the uterus in order to initiate voiding
kidney obstruction because of descent of bladder and ureters (tubes that drain urine from the kidney to the bladder)
vaginal pain with sitting and walking
painful intercourse
frequent urinary tract infections

Surgical repair is the best option.

Surgical repair of uterine prolapse:

Vaginal hysterectomy to remove the uterus (TVH)
Robotic laparoscopic assisted vaginal hysterectomy (RLAVH)
Rarely total abdominal hysterectomy (TAH)

Vaginal surgical procedures are associated with less pain after surgery, faster healing and a better cosmetic result.

Vaginal prolapse and repair

The two principle types of vaginal prolapse are cystocele, involving the bladder and front wall, rectocele, involving the rectum and back wall of the vagina and the enterocele. Most often, these defects or bulges exist in combination, frequently at least two at a time.

- Cystocele and repair

A cystocele occurs when the wall between a woman's bladder and her vagina weakens and allows the bladder to droop into the vagina. This condition may cause discomfort and problems with emptying the bladder. A bladder that has dropped from its normal position may cause two kinds of problems�unwanted urine leakage and incomplete emptying of the bladder. In some women, a fallen bladder pulls the urethra down away from the pubic bone and forms a straight line between the bladder thus causing urine leakage when the woman coughs, sneezes, laughs, or moves in any way that puts pressure on the bladder. This is a urethrocele and the symptom is call urinary stress incontinence (USI).

Cystoceles are graded as follows:

Grade 1: mild drooping of the bladder a short way into the vagina

Grade 2: the bladder sinks far enough to reach the opening of the vagina

Grade 3: the bladder bulges out through the opening of the vagina

The new surgical repair of cystoceles relies on the use of "biologic" or synthetic materials to provide strength and durability. These materials are used in place of a patient's own fascia. Biologics generally are derived from animal connective tissue that has been processed and sterilized and adapted for use in humans. One typical example is Xenform, derived from the tough skin of unborn calf tissue. The healing mechanism causes new reapir tissue to replace the graft over many months to a year - this is callled remodeling.

Dr. Purdy uses a special surgical instrument called the Capio system for placement of deep pelvic sutures in the dense and strong connective tissue of the pelvis. The graft materail is almost riveted to the pelvic side wall strong tissue by this system for lasting anchoring.

More commonly used today are synthetic materials called mesh, woven from various types of nylon thread. Most of these meshes have bands that hold them in place, pulled through various incisions in the patient's groin. Perigee and Prolift are two such products but more advanced systems are now available. Dr. Purdy does not use these two synthetic materail kits for repair and surgical correction.

Another mesh delivery system that do no require skin incisions in the groin. is fixated internally, leading to less post-operative pain and faster healing. Two of these systems are the Pinnacle and Elevate.

Urethrocele and urine leakage

A Urethrocele is a loss of support of the connective tissue surrouding the short female urethra as this tube exists the urogenital diaphragm. The herniation of the urethra causes the urethra to rotate away from the pubic bone and the axis with the bladder becomes more of a straight line. Coughing or increased intrabdominal pressure allows urine to spurt out of the drooping urethra and the condition is called urinary stress incontinence. Dr. Purdy uses a urethral sling to suport the drooping urethra and establish urinary control or continence. The surgical procedure is called a transobturator tape urethral sling procedure (TOT). The sling is a polypropylene mesh.

TOT urethral sling material

- Rectocele and repair

A rectocele occurs when the fascia � a wall of fibrous tissue separating the rectum from the vagina � becomes weakened, allowing the front wall of the rectum to bulge into the vagina. Childbirth and other processes that put pressure on the fascia can lead to a rectocele. Generally, rectoceles occur after menopause, when estrogen � which helps keep your pelvic tissues strong � decreases. Dr. Purdy uses topical estrogen creams or suppositories (Vagifem) before and after corrrective pelvic repair surgery to keep the tissue strong.

A small rectocele may cause no signs or symptoms. If a rectocele is large, it may create a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, and rarely this condition can causes sharp shooting rectal like pains. Women may complain of a sense of vaginal "pressure" or a feeling that something is falling out of the vagina with increasingly sever cases of rectocele. A woman with a very large rectocele might not be unable to defecate without placing downward pressure on the posterior vaginal wall with her fingers. This called splinting for a bowel movement.

The same principles of repair described for cystocele also apply to rectocele repair. Dr Purdy uses Xenform for rectocele and enterocele repairs. Beyond biologic materials available for repair, we also use synthetic mesh materials. The older systems with bands to anchor the mesh material in place include Prolift and Apogee. More recently, internal anchoring systems such as Pinnacle and Elevate have avoided the need for groin incisions.